Quantitative Evaluation of Palatal Lengthening After Cleft Palate Repair When a Buccal Flap Is Routinely Combined With Furlow's Z-Plasty.

INTRODUCTION: The use of a buccinator myomucosal flap in combination with Furlow's Z-plasty during primary and secondary palatal repairs has been proposed by many authors to overcome some of the limitations of Furlow's technique. However, there have been no studies that quantitatively measured the effective palatal lengthening when the buccal flap is added. PATIENTS AND METHODS: The buccal flap is routinely used during primary palate repair in order to fill the gap between the hard palate and reoriented palatal muscle sling. The soft palatal length was measured in the midline from the posterior edge of the hard palate to the base of the uvula. All patients were measured before starting the surgery and just after palatal closure in the standard position for cleft palate repair. RESULTS: Seventy-three patients with cleft palate who were candidates for primary repair were included. The mean age at the time of operation was 11.4 ± 3.5 months. The mean preoperative palatal length was 21.36 ± 3.529 mm, whereas the mean postoperative palatal length was 29.64 ± 4.171) mm. The mean palatal length change was 8.29 ± 2.514 mm (P < 0.000). CONCLUSIONS: The Combined use of a buccinator myomucosal flap with modified Furlow's Z-plasty in primary cleft palate repair has proven effective for palatal lengthening and achieved tensionless closure without the need for relaxing incision. It also provided a pliable soft tissue attachment of the palatal muscles to the hard palate allowing for better muscle function and mobility.

Facial Nerve Injury and Repair: A Practical Review for Cutaneous Surgery.

BACKGROUND: The facial nerve and its branches are at risk of injury during dermatologic surgery. Few publications in the dermatologic literature discuss facial nerve injury and management. OBJECTIVE: To review facial nerve injury and management, including static and dynamic repair techniques, and to review outcomes in facial nerve reconstruction. METHODS: Two detailed literature reviews were performed using PubMed. First, articles reporting facial nerve injury and/or management in the dermatologic literature were identified. In addition, articles pertaining to outcomes in facial nerve reconstruction with a minimum of 20 patients were included. RESULTS: Fifty-three articles reporting outcomes in facial nerve reconstruction were identified and consist of retrospective reviews and case series. Most patients achieve improvement in facial symmetry and movement with nerve repair. CONCLUSION: Timing of facial nerve repair is an important consideration in management of facial nerve injury, with earlier repairs achieving better outcomes. Facial nerve repair does not result in normal facial movement, and improvements may require a year or more to be realized. Many options exist for facial nerve reconstruction, and patients with long-standing facial nerve injuries may still benefit from treatment.

Unilateral Buccinator Flap for Lengthening of Short Palate.

BACKGROUND: Velopharyngeal insufficiency is one of the most frequent complications after cleft palate repair. PURPOSE: To evaluate the results and complications of unilateral Buccinator flap (BMF) in velopharyngeal insufficiency. MATERIALS AND METHODS: During 4 years the authors performed unilateral BMF in all short palates. Age, sex, demographic data, length of palate, cause of short palate, nasopharyngoscopy and videofluroscopy results, hyper nasality, nasal escape, nasal emission, nasal fluid leak, speech evaluation and results, outcome and complications of the treatment were surveyed before surgery and in 1, 3, 6 months after treatment. RESULTS: The authors had 43 patients, 29 below 8 years old and 14 adults. Velopharyngeal gap was between 10 and 27 mm, mean 21 mm. Buccinator flap were measuring 15 to 19 mm in width and 32 to 56 mm in length. The operation time was 80 to 100 minutes, mean 86 minutes.Nasal emission, nasal escape, and nasal leak were treated in all patients.Hyper nasality was completely improved in all of the patients below 8 years old (29 patients) and in 10 patients of the adults (totally 39 patients, 90.6%). And it was improved significantly in other 4 patients (9.4%). The speech evaluation reported between 70% and 86% improvements.The lengthening of the palate was between 12 and 19 mm, mean 17 mm.The satisfaction of the patients was as 0% poor, 2.3% fair, 72.1% good, and 25.6% excellent. CONCLUSION: Unilateral BMF is reliable, promising, and safe flap for lengthening of short palate and it can lengthen the palate up to 19 mm. The time of surgery is very short compared with other methods. It is an anatomical treatment versus pharyngeal flap which is not an anatomical one. Speech improvement will achieve in 70% to 86% patients.

Fascial Graft Repair of Wide Bilateral Cleft Lip Deformity.

Wide bilateral cleft lip deformity reconstruction represents a special difficulty as it affects the lip, nose, and maxillary segments making single-stage reconstruction sometimes unobtainable. Many surgical and nonsurgical techniques have been prescribed to facilitate the definitive repair. Although some of these techniques proved to be useful, they have their inherent limitations and add another treatment step with all its possible complications and costs. The authors present a new method to address muscle layer repair in 1-stage procedure. It entails using fascial graft obtained from the temporalis muscle fascia or fascia lata, to reconstruct orbicularis oris lip muscle. Seven patients of wide bilateral cleft lip deformity (mean 17 mm) with a mean age of 4.4 months were subjected to single-stage lip reconstruction. After measuring the defect between both lateral muscle segments in front of the premaxilla intraoperatively ensuring that direct muscle repair could not be obtained, a fascial graft was harvested and sutured to both muscle edges. The authors found that, regardless the defect size or premaxilla protrusion, all wide clefts could be reconstructed satisfactorily in 1 stage procedure. No serious postoperative complications have been encountered in the lip or donor areas. Early follow-up reporting of the patients revealed stable repair. However more follow-up is still needed to assess late sequelae. In conclusion, fascial graft muscle repair of wide bilateral cleft lip deformity enables early 1-stage lip reconstruction without tension. The added donor morbidity is minimal and well tolerated.

The Arterialized Facial Artery Musculo-Mucosal Island Flap for Post-Oncological Tongue Reconstruction.

BACKGROUND: In 1992, Pribaz described the facial artery musculomucosal flap (FAMM), an axial musculomucosal flap based on the facial artery. The FAMM flap, a modification of the nasolabial and buccal mucosal flaps, is widely used in the reconstruction of defects in the oral cavity. Many modifications of this flap have been described in the literature. Here we aimed to explore the use of an arterialized tunnelized FAMM island flap (a-FAMMIF) for the reconstruction tongue defects after tumor resection. METHOD: From January 2015 to December 2016, five cases of tongue cancer were selected for the use of arterialized FAMMIF flap to reconstruct defects after tumor resection. RESULTS: Reconstruction was successful in all cases, except one case of total flap necrosis; partial necrosis of the flap occurred in two patients, which were solved with medications. CONCLUSION: The authors consider the a-FAMMIF an unreliable flap in the reconstruction of tongue defects.The authors recommend avoiding tunneling and island modification when the vein is not included in the pedicle.

Modified Composite-Flap Facelift Combined With Finger-Assisted Malar Elevation (FAME): A Cadaver Study.

BACKGROUND: Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches. OBJECTIVES: In the authors' surgical practice for modified composite flap rhytidectomy, the authors employed the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. The aim was to evaluate the anatomical basis and safety measures of this technique through a cadaveric dissection study. METHODS: Modified composite-flap facelift with the FAME technique was carried out in 22 fresh cadaver hemi-faces. All facial nerve subbranches were dissected thoroughly to assess for any evidence of injury during facelift, and to evaluate the safety of the operation. The relations among the facial nerve, zygomatic cutaneous and masseteric ligaments, orbicularis oculi muscle, and malar fat pad were investigated. RESULTS: Finger dissection of the prezygomatic space allows safe release of the zygomatic cutaneous ligaments as well as adequate entry to a proper surgical plane above the zygomatici muscles under direct vision, while leaving the malar fat pad and overlying structures attached to the skin without the need of a transblepharoplasty approach. CONCLUSIONS: This study by the authors shows that a modified composite-flap facelift with FAME technique is a safe procedure that allows adequate and effective repositioning of an en-bloc composite flap that produces balanced and harmonious rejuvenation of the midface and lower face without the need of a separate midface lift.

A Systematic Review of Lower Lip Anatomy, Mechanics of Local Flaps, and Special Considerations for Lower Lip Reconstruction.

Reconstruction of defects of the lower lip can be very challenging. The aim of this review is to analyze the unique characteristics of lower lip anatomy and provide a systematic approach for lower lip reconstruction. A review of current literature was performed using the PubMed database. Articles analyzing the anatomic and histologic characteristics of the lower lip, mechanics of local faps, and different lower lip reconistruction techniques were included. Articles focused on lower lip reconstruction with free faps were excluded. The orbicularis oris has been described as the main supportive mechanism, however, a number of other structures have been shown to provide mechanical support to the lower lip, including septations of connective tissue extending from the epithelium to the orbicularis oris, a fbroelastic meshwork located in the mentolabial sulcus, and subdermal muscular fibers with dermal terminations in the area of the modiolus. Depending on the location, size, and depth of the wound, a number of reconstruction options are available. Preservation of the competency of orbicularis oris, relation-ship of the modiolus with associated muscles, and sensation, are critical components of functional reconstruction. Primary closure and local faps are assessed for these 3 components and analysis is provided. In conclusion, knowledge of the static and dynamic structural support of the lower lip, as well as the characteristics of different reconstructive options, is imperative for optimal functional and aesthetic outcomes.

Autologous Tissue Graft in Revision Medial Epicanthoplasty Using Subciliary Fat and Orbicularis Oculi Muscle.

The medial epicanthal fold is one of the racial anatomic characteristics of Asians. As medial epicanthoplasty has become one of the most common cosmetic surgeries among Asians, the need for revision of overcorrected medial epicanthus also increased. In revision medial epicanthoplasty, an autologous tissue graft to the subcutaneous plane is used to reduce postoperative scar. Medial epicanthoplasty, using V-Y advancement and rotation flap, was performed in 93 patients (revision medial epicanthoplasty with autologous tissue graft, 60 patients; revision medial epicanthoplasty only, 33 patients). A V-Y and rotation flap was designed to cover the overexposed lacrimal lake. A small amount of fat tissue and orbicularis oculi muscle were harvested from the upper eyelid through the double-fold line and grafted to the subcutaneous space of the medial epicanthal area. We evaluated the patients' satisfaction with the overall outcome and scar. The mean intercanthal distance increased from 32.3 mm before surgery to 34.6 mm after surgery. Satisfaction with the scar and overall outcome was higher in the patient group who underwent medial epicanthoplasty with autologous tissue graft. No complication was observed in the autologous tissue graft group, whereas 1 patient who underwent medial epicanthoplasty without autologous tissue graft showed recurrence of the medial epicanthal fold, 5 months after surgery. Medial epicanthoplasty with autologous tissue graft is a simple and reliable method to repair the overcorrected medial epicanthus that can efficiently increase the intercanthal distance and prevent scar contracture.

Single-Stage Reconstruction of Eyebrow Defect Using a V-Y Advancement Pedicle Flap Based on the Orbicularis Oculi Muscle.

Eyebrows play an important role in face expression and facial mimics by virtue of muscle contraction. Defects or deformity of the eyebrows result in abnormal facial expressions, and may lead to aesthetic issues for patients. The objective of this study is to report the case of a patient, with a congenital skin pigmented nevus at the right side of the eyebrow treated with direct surgical resection and followed by immediate reconstruction of the eyebrow with a V-Y advancement pedicle flap based on the orbicularis oculi muscle.

The Dilator Naris Muscle as a Reporter of Facial Nerve Regeneration in a Rat Model.

OBJECTIVE: Many investigators study facial nerve regeneration using the rat whisker pad model, although widely standardized outcomes measures of facial nerve regeneration in the rodent have not yet been developed. The intrinsic whisker pad "sling" muscles producing whisker protraction, situated at the base of each individual whisker, are extremely small and difficult to study en bloc. Here, we compare the functional innervation of 2 potential reporter muscles for whisker pad innervation: the dilator naris (DN) and the levator labii superioris (LLS), to characterize facial nerve regeneration. METHODS: Motor supply of the DN and LLS was elucidated by measuring contraction force and compound muscle action potentials during stimulation of individual facial nerve branches, and by measuring whisking amplitude before and after DN distal tendon release. RESULTS: The pattern of DN innervation matched that of the intrinsic whisker pad musculature (ie, via the buccal and marginal mandibular branches of the facial nerve), whereas the LLS seemed to be innervated almost entirely by the zygomatic branch, whose primary target is the orbicularis oculi muscle. CONCLUSIONS: Although the LLS has been commonly used as a reporter muscle of whisker pad innervation, the present data show that its innervation pattern does not overlap substantially with the muscles producing whisker protraction. The DN muscle may serve as a more appropriate reporter for whisker pad innervation because it is innervated by the same facial nerve branches as the intrinsic whisker pad musculature, making structure/function correlations more accurate, and more relevant to investigators studying facial nerve regeneration.

Comparison of Clinical Outcome of Facial Artery Myomucosal Flap and Tongue Flap for Closure of Large Anterior Palatal Fistulas.

Closure of large anterior palatal fistula has high recurrence rate. The objective of this study was to compare the clinical outcome of facial artery myomucosal flap (FAMM flap) and tongue flap used for closure of large anterior palatal fistula. This study was conducted from March 2008 to March 2014. Thirty-nine patients, aged 2 to 40 years, who had anterior palatal fistula 5 to 20 mm in width with associated alveolar cleft and repaired with either a tongue flap or FAMM flap were included. Patients were excluded if they had adequate local palatal tissue for closure, mid, posterior or multiple fistulae, fistula width >20 mm. Closure was performed in 2 layers. Turndown flap of oral mucoperiosteum was used to reconstruct nasal layer and oral layer was reconstructed with FAMM flap in 16 and tongue flap in 23 patients. Mean(SD) pain score was 3(1) and 7(1) in FAMM flap and tongue flap groups respectively with a P value <0.096. All patients in tongue flap group experienced difficulty in speaking and eating whereas in FAMM flap group 2 had eating problem and 2 experienced speech difficulty. Mean(SD) total operative times for FAMM flap and tongue flap were 155(38) and 242(10) minutes, respectively, P value <0.002. There was no difference for other complications and no recurrence at 1 year follow-up in both groups. The authors concluded that FAMM flap should be considered first choice for closure of large anterior palatal fistulas associated with alveolar cleft as it requires less total operative time and has less early postoperative complications.

The Buccinator Mucomuscular Flap: An In-Depth Analysis and Evaluation of Its Role in the Management of Velopharyngeal Dysfunction.

BACKGROUND: A significant proportion of patients with cleft palate experience persisting velopharyngeal dysfunction (VPD) after primary surgery. Pharyngoplasty is the most common procedure to correct inadequate velopharyngeal closure. Although it is often effective, it poses a risk for postoperative airway obstruction. The mucomuscular buccinator flap is a more recent alternative: In the largest case series to date, we outline its use and evaluate its effectiveness in managing persistent VPD. METHODS: Over 9 years, 103 buccinator flap procedures were performed by the Cambridge group to improve velar function. Clinical records were retrospectively assessed: 60 patients were analyzed by two expert speech and language therapists external to the group using the Cleft Audit Protocol for Speech-Augmented. In a subset of patients, the buccinator flap was interpolated between the limbs of a large mucosal Z-plasty. Consensus listening was undertaken, and interrater reliability was calculated for 24.17% of the cohort. The remaining samples were assessed by a single listener following calibrated consensus listening. RESULTS: There was a significant reduction in VPD (P < .001). Preoperatively, 68.5% of patients demonstrated marked VPD, falling to 24.1% postoperatively. The buccinator procedure demonstrated significant improvement for three of four individual speech parameters: hypernasality, passive cleft speech characteristics, and audible nasal emission. Overall, 13.5% of patients required further corrective speech surgery. CONCLUSIONS: The buccinator mucomuscular flap reliably and effectively improves velar function in the management of VPD and has low complication rates. We therefore recommend the use of the buccinator flap in primary surgical management of persisting VPD.

Small-incision frontalis muscle transposition flap for lateral eyebrow ptosis repair.

PURPOSE: To describe a novel technique to correct lateral eyebrow ptosis using a frontalis muscle transposition flap. METHODS: The charts of all patients undergoing eyebrow ptosis repair using a frontalis muscle transposition flap from December 2013 through April 2014 were reviewed to describe the surgical technique. RESULTS: Sixteen patients underwent eyebrow ptosis repair using a frontalis muscle pedicle flap during the study period. Briefly, after local infiltration, a lateral forehead rhytid was marked and incised for approximately 1.5 cm. Blunt dissection exposed the frontalis-orbicularis angle, the frontalis-orbicularis insertion, and the lateral extent of the frontalis muscle. A pedicle flap of lateral frontalis muscle was created, trimmed, and transposed laterally in graded fashion to achieve the optimal eyebrow height and contour. The incision was closed with 5-0 polypropylene suture. All patients reported improvement in eyebrow position. CONCLUSIONS: This novel technique provides frontalis muscle elevatory force to the lateral eyebrow through a small incision to improve eyebrow ptosis. Further study, including objective measures of long-term results, is required.

Comparison of Subciliary Approaches in Orbito-Zygomatic Fractures: Skin Flap Versus Skin-Muscle Flap.

BACKGROUND: Because of the complications of classical subciliary incision, some modified subciliary approaches have been described in recent literature. OBJECTIVES: The aim of this study was to compare 2 commonly used subciliary approaches according to development of postoperative complications (scar formation, and ectropion). MATERIALS AND METHODS: Ninety patients were included in this retrospective study. Subciliary skin flap technique (SF group) was performed to 39 patients, while the others were operated by using skin-muscle (stepped) flap technique (SMF group). Fitzpatrick skin types, genders, ages, scar scores, and ectropion scores of the patients also were recorded. RESULTS: The mean age of the patients was 39.3 (18-99) years, and the mean follow-up period was 2.1 (1-6) years. Fitzpatrick skin-type levels were between 2 and 4 (median = 3). No difference was found between 2 groups in terms of age, follow-up period, and Fitzpatrick skin-type levels. However, the scar values of the SMF group were significantly lower than the SF group statistically. Also, there was no significant difference between males and females in SF and SMF groups in terms of scar and ectropion formation. On the other hand, scar values were lower in SMF groups rather than SF group in males. Although ectropion values were not different between SF and SMF groups in females, ectropion values of SMF group were significantly lower than SF group in males statistically. CONCLUSION: Subciliary skin-muscle (stepped) flap technique can be more reliable than subciliary skin flap technique for approach to orbitozygomatic fractures.

Functional Sharing of the Upper Orbicularis Oris Muscle for the Reconstruction of the Lower Lip.

The lip reconstruction is a very controversial topic in plastic surgery and many flaps have been described for this purpose. Despite all of the interventions, some patients still have problems such as drooling and gingival show that decrease their quality of life. In this study, the authors report a patient whose lower lip was resected totally for squamous cell carcinoma. His lip was reconstructed with radial forearm flap and the patient was referred to our clinic with the aforementioned complaints. A portion of the orbicularis oris muscle of the upper lip was designed as a bipedicled flap, and it was transposed to the lower lip to make the initial flap functional. After the operation, the sphincteric function of the lip was better, and the problems as drooling and gingival show were absent. In conclusion, this flap can be a good option to make the initial nonfunctional flaps (such as radial forearm flap), functional in the aspect of lower lip reconstruction. It has a function, and it is concordant with the principle of "reconstructing like with like." The native muscle tissue of the upper lip can be transferred partially to maintain physiologic oral competency.

Dynamic muscle transfer in facial nerve palsy: the use of contralateral orbicularis oculi muscle.

The aim of the study is to describe the results of dynamic muscle transfer with an orbicularis oculi muscle flap from the contralateral side to the paralyzed side in patients with House-Brackmann grade 6 facial nerve palsy. This case series included six patients who underwent dynamic muscle transfer with a flap of healthy orbicularis oculi muscle fibers from the contralateral side into the paralyzed orbicularis oculi muscle. All patients had a House-Brackmann grade 6 facial nerve palsy. They all had previous multiple surgical procedures to improve the eyelid function. In spite of this, they were all symptomatic in terms of corneal exposure before orbicularis muscle transfer. All patients had postoperative follow up in excess of 2 years after the procedure. All patients improved symptomatically and had clinically reduced lagophthalmos postoperatively. Five patients who had an absent blink reflex showed a significant improvement in their blink reflex postoperatively. No complications occurred at the donor site. All patients showed a significant improvement of their symptoms and their lagophthalmos reduced postoperatively. Most importantly, the blink occurred involuntarily at the same time as the blink on the normal side. The authors propose that a dynamic muscle transfer using the contralateral orbicularis muscle may be considered to improve the voluntary lid closure and spontaneous blink reflex to improve corneal exposure in patients with grade 6 facial palsy who have not benefited from conventional surgical procedures.

Using platysma myocutaneous flap with Z-plasty for head and neck reconstruction.

Cheek or head cancer and its treatments are difficult for head and neck surgeons. Large tumor resection can leave extensive defects in the facial region. Technique difficulties are always possible to cover existing defects. We are presenting a different platysma myocutaneous flap with Z-plasty.

Cross-face neurotized platysmal muscular graft for upper eyelid reanimation: an anatomic feasibility study.

BACKGROUND: Upper eyelid reanimation is one of the most important aspects of facial paralysis. The ideal method would be one that provided dynamic restoration of voluntary eye closure, involuntary blinking, and corneal reflex. Innervation to the platysma has shown to be relatively consistent, which would allow its use as a muscle graft neurotized by the contralateral healthy facial nerve for eyelid reanimation. METHODS: Six fresh cadavers, 12 sides, were studied by dissecting the main trunk of the facial nerve and its cervicofacial division. Special attention was paid at the emergence of cervical branches to the platysma and its distribution on the undersurface of the muscle as well as its relationships with regional anatomic references. RESULTS: One major branch with 1 or 2 accessory branches was found to emerge from the cervicofacial division, 1.5 cm distal to its origin in the facial nerve trunk. The major branch showed an oblique course, starting approximately 1 cm below the angle of the mandible and coursing toward the inferomedial border of the muscle. Harvest of a 3 × 2 muscle piece with a 10-cm-long neural pedicle was possible in all specimens. When presented over the superior eyelid, the nerve branch was found to reach the contralateral frontal branch of the facial nerve. CONCLUSIONS: Innervation to the platysma muscle is relatively constant and consists of 1 major branch accompanied by 1 or 2 accessory branches. Harvest of a muscle flap with a neural pedicle long enough to reach the contralateral healthy side is anatomically feasible.

Reconstruction of the lower vermilion with a musculomucosal flap from the upper lip in the repair of extensive lower lip and chin defects.

In the repair of extensive lower lip and chin defects, the reconstruction of vermilion at the same time is a great challenge to plastic surgeons. We describe a novel method for the reconstruction of lower vermilion with musculomucosal flap from the upper lip in the repair of extensive lower lip and chin defects. Two patients underwent extensive lower lip and chin reconstruction together with vermilion reconstruction. This technique used 3 basic components: musculomucosal flap from the upper lip, buccal mucosal advancement flap, and cutaneous rotational flap from the neck. All the flaps survived without significant complications. Labial function in the motions of expression and speaking was maintained. The patients could basically close their mouths completely, and there were no drooping or small-mouth deformities postoperatively. Functional and cosmetically acceptable lower-lip and chin reconstructions in both patients were achieved.

Facial reanimation utilizing combined orthodromic temporalis muscle flap and end-to-side cross-face nerve grafts.

BACKGROUND: Individuals with facial paralysis of 6 months or more without evidence of clinical or electromyographic improvement have been successfully reanimated utilizing an orthodromic temporalis transfer in conjunction with end-to-side cross-face nerve grafts. The temporalis muscle insertion is released from the coronoid process of the mandible and sutured to a fascia lata graft that is secured distally to the commissure and paralyzed hemilip. The orthodromic transfer of the temporalis muscle overcomes the concave temporal deformity and zygomatic fullness produced by the turning down of the central third of the muscle (Gillies procedure) while yielding stronger muscle contraction and a more symmetric smile. The muscle flap is combined with cross-face sural nerve grafts utilizing end-to-side neurorrhaphies to import myelinated motor fibers to the paralyzed muscles of facial expression in the midface and perioral region. Cross-face nerve grafting provides the potential for true spontaneous facial motion. We feel that the synergy created by the combination of techniques can perhaps produce a more symmetrical and synchronized smile than either procedure in isolation. METHODS: Nineteen patients underwent an orthodromic temporalis muscle flap in conjunction with cross-face (buccal-buccal with end-to-side neurorrhaphy) nerve grafts. To evaluate the symmetry of the smile, we measured the length of the two hemilips (normal and affected) using the CorelDRAW X3 software. Measurements were obtained in the pre- and postoperative period and compared for symmetry. RESULTS: There was significant improvement in smile symmetry in 89.5 % of patients. CONCLUSION: Orthodromic temporalis muscle transfer in conjunction with cross face nerve grafts creates a synergistic effect frequently producing an aesthetic, symmetric smile. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .