Facial Reanimation Research Articles

Intraoral temporalis transposition for facial reanimation: A novel technique in facial nerve palsy

BackgroundFacial palsy patients require reconstructive surgery because they suffer from an expressionless and deformed appearance especially during smiling. To gain a natural smile, various dynamic procedures rather than static procedures are performed. Through cadaveric studies with clinical implications on temporalis muscle and intraoral transposition, we were able to come up with a more effective and less invasive procedure than the conventional temporalis muscle transposition or lengthening temporalis myoplasty. The aim of this study is to describe our novel surgical technique for facial reanimation and evaluate its efficacy. MethodTwo intraoral incisions were made. Through the posterior incision, the tendinous portion of the temporalis was separated from the coronoid process and anterior border of the ramus. Through the anterior incision, submucosa tunneling was performed to fixate the temporalis tendon onto the new perioral site. Results14 patients with facial palsy underwent intraoral temporalis transposition and their mouth corner excursion was measured for objective assessment after surgery. At resting state, mouth and cheek drooping was improved. At smiling, the excursion of the unaffected side was 10–17 mm. For the reconstructed side, 8 cases were considered excellent (exceeding 75% of normal side), 5 cases were considered good (exceeding 50%), and 1 case fair (exceeding 25%). ConclusionThis temporalis transposition through the intraoral approach is a novel technique for facial reanimation reconstruction. It is s less invasive, immediately effective method with rapid recovery and minimal donor site morbidity without visible scar. Level of evidenceIV.

One-stage free transfer of latissimus dorsi-serratus anterior combined muscle flap with dual innervation for smile reanimation in established facial paralysis

Microneurovascular free muscle transfer is the gold-standard surgical procedure for the reanimation of established facial paralysis. However, the innervation of the transferred muscle by the contralateral facial nerve is usually insufficient to produce a stable smile. Besides, the corner of the mouth sometimes moves unnaturally as if it were being pulled up because of the single-direction movement. Thus, we propose one-stage facial reanimation using free latissimus dorsi (LD)-serratus anterior (SA) combined muscle flap transfer with dual innervation. The LD-SA combined muscle flap was harvested with the thoracodorsal artery and vein as common vessels to move the corner of the mouth bidirectionally for natural smiling. The LD muscle was located in the same direction as the zygomaticus major muscle and reinnervated by dual innervation. The contralateral facial nerve was coapted with the thoracodorsal nerve, and the ipsilateral masseter motor nerve was inserted into the LD muscle by intramuscular neurotization. The 6th or 7th SA muscle was located in the same direction as the risorius muscle and reinnervated by neurorrhaphy of the long thoracic nerve and the thin branch of the ipsilateral masseter motor nerve. Since 2015, seven patients have been treated with this method without complications. On average, SA muscle movement was detected in voluntary biting at 3.1 months, and spontaneous smiling occurred 7.7 months after surgery. All patients developed a spontaneous natural smile. This method for established facial paralysis has the potential to improve the quality of the reconstructed smile and the unstable results of conventional single-innervation-single-muscle transfer.

The temporalis muscle and its relationship to the accessory attachments and the main pedicle—a cadaveric study

Lengthening temporalis myoplasty, described by Daniel Labbe in 1997, is a facial reanimation procedure for the treatment of facial nerve palsy. It involves the mobilization of temporalis muscle antero-inferiorly, and the insertion of its tendon at the nasolabial fold-oral commissure region. Knowledge of the temporalis muscle is crucial in performing this procedure; however, previous anatomical studies are limited. This study on cadavers, aimed to describe the anatomical location of the temporalis muscle insertion in relation to the adjacent structures, and its main pedicle to aid surgeons in performing this procedure. Twenty-four temporalis muscles were dissected in 12 fresh frozen cadavers. The anatomical location of the temporalis muscle insertion, accessory attachments, the emergence of the posterior deep temporal artery, and the distance of sliding movements from the coronoid process to the nasolabial fold were recorded. In addition to its origin from the temporalis fossa and its insertion at the coronoid process, the temporalis muscle was found to have multiple accessory attachments to adjacent structures. These findings explain the challenges in performing the sliding action without releasing the accessory attachments to the masseter and pterygoid muscles. The deep posterior temporal artery is located inferoposteriorly in relation to the muscle. Therefore, the muscle elevation maneuver performed without direct vision can be done with minimal risk to the muscle pedicle. The knowledge of temporalis muscle insertion, its accessory attachments, and its main pedicle will facilitate surgeons in performing the lengthening temporalis myoplasty more confidently.

A nasolabial fold reset technique for enhancing midface lifts in facial reanimation: Three-dimensional volumetric analysis

Despite successfully gaining excursion after free muscle transfer for facial palsy, soft tissue asymmetry, especially around the nasolabial fold (NLF) and medial cheek, is a troublesome problem in elderly patients. An NLF reset technique that enhances midface lifts has been introduced to overcome this problem.Our study included 43 consecutive patients who underwent facial reanimation surgery with free functional muscle transfer between March 2015 and July 2017. Of these, 20 patients underwent conventional procedures and 23 underwent our NLF reset technique. Postoperative oral commissure excursion and symmetry at rest and while smiling were quantified using FACEgram (Facial Assessment by Computer Evaluation) software. To detect soft-tissue changes after surgery, three-dimensional analysis was performed using Morpheus®, a 3D, LED-based, white-structured-light scanner.The NLF group had a significantly larger postoperative mean excursion at rest (control 25.32 ± 2.80 mm vs NLF 27.42 ± 3.60 mm; p = 0.047). The mean horizontal length ratios (affected-to-healthy) revealed better symmetry in the NLF group (resting 1.05 ± 0.22, smiling 0.97 ± 0.19; p = 0.201). The three-dimensional midface volume difference was significantly lower in the NLF group. The NLF reset technique produced improved surgical outcomes.An incision made along a mirrored NLF can influence midface lifting in patients with facial palsy, with the soft tissue concentrated in the lower face mobilized superomedially.

Electromyographic evaluation of the facial and motor donor nerves before facial reanimation surgery in Moebius syndrome.

Moebius syndrome is a clinical entity characterized by bilateral facial and abducens nerve palsies; other cranial nerver might be affected as well. So far, no studies have reported the electromyographic responses of the facial musculature in this group of patients. The objective of our study is to describe the electromyographic responses of the facial muscle and the main donor nerves for facial reanimation in patients with Moebius syndrome. We analyzed electromyographies from the facial, hypoglossal, masseterine (trigeminal) and accessory nerves from patients with Moebius syndrome treated between 2010 and 2016. Results are presented as percentages and central tendency measures. 24 patients were included, mean age 11.79 ± 9.39 years. The facial nerve showed complete unilateral recruitment in 4 patients, partial bilaterally in 11, 7 showed no activity bilaterally and two had unilateral inactivity. The masseterine was normal in 14 patients, had partial recruitment bilaterally in 4 and unilaterally in 4 cases. The accessory nerve was normal in 20 patients, showed partial recruitment bilaterally in 3 and unilaterally in 1 patients. The hypoglossal was normal in 22 patients, and altered in 2 cases. Patients with Moebius syndrome show several degrees of alteration in electromyographic evaluation of the facial nerve. Electromyography is a useful tool in evaluating potential motor donor nerves for facial reanimation surgery.

Comparison between VII-to-VII and XII-to-VII coaptation techniques for early facial nerve reanimation after surgical intra-cranial injuries: a systematic review and pooled analysis of the functional outcomes

The surgical injury of the intracranial portion of the facial nerve (FN) is a severe complication of many skull base procedures, and it represents a relevant issue in terms of patients' discomfort, social interactions, risk for depression, and social costs. The aim of this study was to investigate the surgical and functional outcomes of the most common facial nerve rehabilitation techniques. The present study is a systematic review of the pertinent literature, according to the PRISMA guidelines. Two different online medical databases (PubMed, Scopus) were screened for studies reporting the functional outcome, measured by the House-Brackman (HB) scale, and complications, in FN early reanimation, following surgical injuries on its intracranial portion. Data on the VII-to-VII and XII-to-VII coaptation, the surgical technique, the use of a nerve graft, the duration of the deficit, and complications were collected and pooled. The XII-to-VII end-to-side coaptation seems to provide higher chances for functional restoration (HB 1-3) than the VII-to-VII (68.8% vs 60.6%), regardless of the duration of the palsy deficit, the use or not of a nerve graft, and the use of stitches or glues. However, its complication rate was as high as 28.6%, and a second procedure is then often needed. The XII-to-VII side-to-end coaptation is the most effective in providing a functional outcome (HB 1-3), even though it is associated to a higher complication rate. Further trials are needed to better investigate this relevant topic, in terms of health-related social costs and patients' quality of life.

Acute Peripheral Facial Palsy: Recent Guidelines and a Systematic Review of the Literature.

BackgroundThis study reviews recent literature on facial palsy guidelines and provides systematic reviews on related topics of interest.MethodsAn electronic database search was performed to identify recent guidelines dealing with facial nerve palsy, systematic reviews and recent meta-analysis published between 2011 and 2019 (inclusive). The literature search used the search terms “Bell's palsy,” “Ramsay-Hunt syndrome,” “Facial palsy,” “Facial paralysis,” “Facial paresis,” “Guideline,” “Meta-analysis,” “Systematic review,” and “Randomized controlled trial.” Only studies written in English were used.ResultsThe characteristics of treatment trends for facial palsy have been reviewed over the past decade. The most prominent change noted may be the shift from the conventional House-Brackmann facial nerve grading system to the Sunnybrook and eFACE systems. In addition, the results of serial meta-analyses indicate increasing agreement with the use of surgical decompression of the facial nerve. Beyond steroids or combined steroid-antiviral treatment, various novel drugs and treatments have been tried. For long-standing facial paralysis and postparetic synkinesis sequelae after facial palsy, facial reanimation has been highlighted and the necessity of new paradigms have been raised.ConclusionFor peripheral facial paralysis, various changes have been made, not only in the facial nerve grading systems, but also in medical treatments, from surgical procedures to rehabilitation, during the last decade.

Current landscape in motoneuron regeneration and reconstruction for motor cranial nerve injuries.

The intricate anatomy and physiology of cranial nerves have inspired clinicians and scientists to study their roles in the nervous system. Damage to motor cranial nerves may result from a variety of organic or iatrogenic insults and causes devastating functional impairment and disfigurement. Surgical innovations directed towards restoring function to injured motor cranial nerves and their associated organs have evolved to include nerve repair, grafting, substitution, and muscle transposition. In parallel with this progress, research on tissue-engineered constructs, development of bioelectrical interfaces, and modulation of the regenerative milieu through cellular, immunomodulatory, or neurotrophic mechanisms has proliferated to enhance the available repertoire of clinically applicable reconstructive options. Despite these advances, patients continue to suffer from functional limitations relating to inadequate cranial nerve regeneration, aberrant reinnervation, or incomplete recovery of neuromuscular function. These shortfalls have profound quality of life ramifications and provide an impetus to further elucidate mechanisms underlying cranial nerve denervation and to improve repair. In this review, we summarize the literature on reconstruction and regeneration of motor cranial nerves following various injury patterns. We focus on seven cranial nerves with predominantly efferent functions and highlight shared patterns of injuries and clinical manifestations. We also present an overview of the existing reconstructive approaches, from facial reanimation, laryngeal reinnervation, to variations of interposition nerve grafts for reconstruction. We discuss ongoing endeavors to promote nerve regeneration and to suppress aberrant reinnervation and the development of synkinesis. Insights from these studies will shed light on recent progress and new horizons in understanding the biomechanics of peripheral nerve neurobiology, with emphasis on promising strategies for optimizing neural regeneration and identifying future directions in the field of motor cranial neuron research.

Dual Coaptation of Facial Nerve Using Masseteric Branch of Trigeminal Nerve for Iatrogenic Facial Palsy: Preliminary Reports.

Immediate facial nerve substitution or graft technique has been used for the repair of facial nerve defects occurring as a result of tumour dissection. However, some patients report unsatisfactory outcomes, such as difficulty in maintaining resting or smiling symmetry, due to persistent flaccid facial palsy. Here we evaluated the functional outcomes of transferring the masseteric branch of the trigeminal nerve to the facial nerve adjunct to facial nerve graft. We reviewed the medical records of seven patients who underwent facial reanimation surgery between 2014 and 2016. The patients were divided into two groups according to the type of facial reanimation surgery: group A, masseteric nerve innervation with interposition graft; group B, interposition graft only. The postoperative resting symmetry and dynamic movement were compared. Facial contraction was first observed in group A at 4 months and in group B at 7.3 months. Most of the patients achieved reliable resting symmetry; however, one patient in group B exhibited unsatisfactory facial weakness on the affected side. Group A patients showed better dynamic movement than group B patients. Eye closure, oral excursion and oral continence were better in group A than in group B patients. Smile symmetry in both groups was similar due to hyperkinetic movement in group A patients and flaccidity in group B patients. Dual innervation of the masseteric branch of the trigeminal nerve improves the dynamic movement of paralysed facial muscles and shortens the recovery period in patients with iatrogenic facial palsy.

Masseteric-Facial Nerve Anastomosis: Surgical Techniques and Outcomes-A Pilot Indian study.

Masseteric-facial anastomosis has gained popularity in recent days compared to the facial-hypoglossal anastomosis. Masseteric nerve has numerous advantages like its proximity to the facial nerve, stronger motor impulse, its reliability, low morbidity in harvesting and sacrificing the nerve and faster re-innervation that is achievable in most patients. The present case series demonstrate the surgical technique and the effectiveness of the masseteric nerve as donor for early facial reanimation. Between January 2017 and February 2019, 6 patients (2 male, 4 female) with iatrogenic unilateral complete facial paralysis (grade VI, House Brackmann scale) who underwent masseteric-facial nerve anastomosis were included in the study. The time interval between the onset of paralysis and surgery ranged from 4 to 18months (mean 8.5months). In all patients pre-operative electromyography had facial mimetic muscle fibrillation potentials. All patients underwent end to end anastomosis except for one patient where greater auricular interposition graft was used. In all cases, the facial muscles showed earliest sign of recovery at 2-5months. These movements were first noticed on the cheek musculature when the patients activated their masseter muscle. Eye movements started appearing at 6-9months (in 3 cases) and forehead movements at 18months (in 1 case). According to the modified House-Brackmann grading scale, one patient had Grade I function, two patients had Grade II function, and three had Grade V function. There was no morbidity except one patient who underwent interposition graft had numbness in the ear lobule. None of the patients could feel the loss of masseteric nerve function. Masseteric facial nerve anastomosis is a versatile, powerful early facial dynamic reanimation tool with almost negligible morbidity compared to other neurotization procedures for patients with complete facial nerve paralysis.

Significance of the Marginal Mandibular Branch in Relation to Facial Palsy Reconstruction

The marginal mandibular branch (MMB) of the facial nerve provides lower lip symmetry apparent during human smile or crying and is mandatory for vocal phonation. In treating facial palsy patients, so far, little attention is directed at the MMB in facial reanimation surgery. However, isolated paralysis may occur congenital, in Bell's palsy or iatrogenic during surgery, prone to its anatomical course. A variety of therapies address symmetry with either weakening of the functional side or reconstruction of the paralyzed side. To further clarify the histoanatomic basis of facial reanimation procedures using nerve transfers, we conducted a human cadaver study examining macroanatomical and microanatomical features of the MMB including its axonal capacity. Nerve biopsies of the MMB were available from 96 facial halves. Histological processing, digitalization, nerve morphometry investigation, and semiautomated axonal quantification were performed. Statistical analysis was conducted with P < 0.05 as level of significance. The main branch of 96 specimens contained an average of 3.72 fascicles 1 to 12, and the axonal capacity was 1603 ± 849 (398-5110, n = 85). Differences were found for sex (P = 0.018), not for facial sides (P = 0.687). Diameters were measured with 1130 ± 327 μm (643-2139, n = 79). A significant difference was noted between sexes (P = 0.029), not for facial sides (P = 0.512.) One millimeter in diameter corresponded to 1480 ± 630 axons (n = 71). A number of 900 axons was correlated with 0.97 mm (specificity, 90%; sensitivity, 72%). Our morphometric results for the MMB provide basic information for further investigations, among dealing with functional reconstructive procedures such as nerve transfers, nerve grafting for direct neurotization or babysitter procedures, and neurectomies to provide ideal power and authenticity.

Spontaneity Assessment in Dually Innervated Gracilis Smile Reanimation Surgery.

Surgeons have sought to optimize outcomes of smile reanimation surgery by combining inputs from nerve-to-masseter and cross-face nerve grafts. An objective assessment tool could help surgeons evaluate outcomes to determine the optimal neural sources for smile reanimation. To evaluate the use of a novel video time-stamping method and standard outcome measurement tools to assess outcomes of facial reanimation surgery using various innervation strategies. Cohort study assessing the outcomes of dually innervated gracilis free muscle transfers vs single-source innervated gracilis transfer performed at a tertiary care facial nerve center between 2007 and 2017 using a novel, video time-stamping spontaneity assessment method. The statistical analyses were performed in 2018. Dually innervated gracilis free muscle transfers or single-source innervated gracilis transfer. Spontaneous smiling was assessed by clinicians and quantified using blinded time-stamped video recordings of smiling elicited while viewing humorous video clips. This retrospective cohort study included 25 patients (12 men and 13 women; median [range] age, 38.4 [29.3-46.0] years) treated with dually innervated gracilis free functional muscle graft for unilateral facial palsy between 2007 and 2017. Smile spontaneity assessment was performed in 17 patients and was compared with assessment performed in 24 patients treated with single-source innervated gracilis transfer (ie, nerve-to-masseter-driven or cross-face nerve graft-driven gracilis [n = 13]) (demographic data not available for NTM and CFNG cohorts). The use of time-stamped video assessment revealed that spontaneous synchronous oral commissure movement in a median percentage of smiles was 33% in patients with dually innervated gracilis (interquartile range [IQR], 0%-71%), 20% of smiles in patients with nerve-to-masseter-driven gracilis (IQR, 0%-50%), and 75% of smiles in patients with cross-face nerve graft-driven gracilis (IQR, 0%-100%). Clinicians graded smile spontaneity in dually innervated cases as absent in 40% (n = 6 of 15), trace in 33% (n = 5 of 15) and present in 27% (n = 4 of 15). No association was demonstrated between clinician-reported spontaneity and objectively measured synchronicity. Dually innervated gracilis free muscle transfers may improve smile spontaneity compared with masseteric nerve-driven transfers but not to the level of cross-face nerve graft-driven gracilis transfers. Quantifying spontaneity is notoriously difficult, and most authors rely on clinical assessment. Our results suggest that clinicians may rate presence of spontaneity higher than objective measures, highlighting the importance of standardized assessment techniques. 4.

M-Mode Echomyography of Facial Muscle Function Following Facial Reanimation with Temporalis Muscle Galea Pedicled Flap: Analysis of Ten Cases with Review of Literature.

Facial palsy is a condition where the patients lack voluntary movement on the affected side of the face and are not able to convey their emotions. Besides that, they also succumb themselves to social isolation. Various techniques have been devised to overcome this devastating problem. The aim of this article is to evaluate and compare facial muscle function before and after facial reanimation with temporalis muscle galea pedicled flap by motion mode echomyography in patients with long-standing facial paralysis. Ten patients with long-standing facial paralysis were included in the study (six patients with LMN palsy and four patients with facial weakness involving specific peripheral branches), and they subsequently underwent facial reanimation surgery with temporalis galea pedicled flap. These patients were followed postoperatively for a period of 1-2years and were subjectively graded as excellent, good, fair and poor and objectively evaluated by M-mode echomyography, and the results were evaluated and statistically analyzed. Subjectively, out of 6 patients with LMN palsy, results were graded as excellent in 2 cases, good in 3 cases, fair in 1 case, and out of 4 patients with weakness in specific facial nerve branches, the subjective results were excellent in 2 cases, good in 1 case and fair in 1 case. Objectively, the effect of transposed temporalis galea on orbicularis occuli, levator labii superioris and orbicularis oris was found to be statistically significant in patients with LMN palsy. Our study proves the versatility of temporalis muscle galea pedicled flap in cases of long-standing facial paralysis by motion mode echomyography.

Novel Method of Double Innervated Free Gracilis Muscle Functional Transfer for Facial Reanimation

PURPOSE: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate free gracilis muscle has been reported in various configurations, with the goal of providing both spontaneity from the CFNG and strong innervation from the masseteric nerve. We report a novel modification to the existing nerve configuration, with presentation of outcomes of our case series. METHODS: A total of 8 patients received free gracilis muscle transfer using the new double innervation method between September 2014 and December 2017. The CFNG, which was performed 9 months prior, was sutured in an end-to-end fashion to the obturator nerve. The ipsilateral masseter nerve was coapted to a nerve graft obtained from extra length of obturator nerve obtained during the harvest of the gracilis muscle. This nerve graft was then sutured in an end-to-side fashion to the sural nerve graft proximal to the end-to-end obturator coaptation (Figure will be provided during presentation). Video analysis was performed on preoperative and all postoperative follow-up. Two independent experienced raters performed Terzis 5 stages classification on the videos. Time to smile with biting down and time to natural smile were also assessed. RESULT: All patients recover smile function with teeth clenching (average, 7.5 months; range, 3–12). Two patients did not recover smile function at 4 and 8 months follow-up, but achieved smile at their 10 and 12 months follow-up. Seven of 8 patients recover spontaneous smile by average of 8.4 months (range, 7–12), with 1 patient having no function after 12 months of follow-up. Average follow-up time was 22 months. Based on the Terzis reanimation grading, 4 patients achieved moderate result, 2 achieved good result, and 2 achieved excellent result. CONCLUSION: Our new novel method of dual gracilis innervation represents a viable technique that does not risk denervation of the gracilis muscle, and provide good spontaneous emotional smile and esthetic symmetry. We hypothesize that placing the masseter nerve at a disadvantage by using the extra nerve graft which requires the signal to go through 3 anastomosis, the CFNG has more time to provide a stronger signal without being taken over by the masseter.

Facial reanimation: an update on nerve transfers in facial paralysis.

The aim of this article is to review the recent literature on nerve transfers in facial paralysis. The discussion focuses on direct nerve repair and three types of nerve transfers, cross facial nerve graft, hypoglossal, and masseter nerve transfers. Masseteric nerve transfers have a high probability of creating significant movement, although tone is poor. The hypoglossal to facial nerve transfer is reliable in affording facial tone and has been updated to involve a transposition technique that offers good results with minimal morbidity. Combination nerve transfer techniques using multiple cranial nerves or cross-face nerves are increasingly described. Reinnervation of the facial nerve and neural regeneration in general are areas of intense research and novel surgical approaches continue to be explored. Although direct nerve repair is the most ideal, other nerve transfers can be performed with good results. More specifically, the masseteric nerve transfer can provide excellent movement and the hypoglossal transfer good tone. Combination transfers may afford the benefits of multiple nerves.

Craniofacial Fellowship Trained Surgeons: Where Are They Now?

INTRODUCTION: There are currently 29 craniofacial surgery fellowship training programs in the United States and Canada endorsed by the American Society of Craniofacial Surgeons and participating in the San Francisco Match. This number has increased over the last decade despite limited demand. The authors sought to evaluate the practice types and patterns of craniofacial fellowship trained surgeons. METHODS: After Institutional Review Board approval, a 20-question survey was designed to evaluate craniofacial surgeons and their practice patterns. The survey was sent to surgeons who completed accredited craniofacial fellowships in the United States or Canada from 2010 to 2018. The survey was created and distributed electronically through a private survey research center. RESULTS: There were 61 respondents (26.5% response rate), 68.8% male, and 85.2% 36–45 years old. 54.1% trained in integrated plastic surgery residency before fellowship, and 39.1% trained in general surgery followed by plastic surgery fellowship. Some had previously completed fellowships: 8 (13.1%) pediatric plastic surgery, 5 (8.2%) microsurgery, 4 (6.6%) esthetic surgery, 3 (4.9%) hand surgery, and 2 (3.3%) burn surgery. Forty-five surgeons (75%) have been in practice ≤5 years. Practice profiles were academic (49.2%), private (23.0%), and hospital employed (9.8%) with 18% in various hybrid practices. Percentage of practice dedicated to craniofacial surgery was <25% for 21 (34.4%), 25%–50% for 10 (16.4%), 51%–75% for 13 (21.3%), and >76% for 17 surgeons (27.9%) with 63.8% desiring an increase in craniofacial case volume. Surgeons’ patient populations are 14.8% pediatric only, 6.6% adult only, and 78.7% combined. They perform craniofacial trauma reconstruction (88.5%), general plastic surgery reconstruction (83.6%), cleft lip and palate repair (75.4%), craniosynostosis reconstruction (68.9%), breast surgery (54.1%), microtia reconstruction (50.8%), orthognathic surgery (50.8%), cosmetic surgery (50.8%), microsurgery (45.9%), hand surgery (36.1%), and facial reanimation (32.7%). Forty-six (75.4%) work as members of a craniofacial team. Twenty-six (42.6%) do not have any craniofacial trained partners. Twelve surgeons (19.7%) had jobs secured before beginning craniofacial fellowship, and 44 (72.1%) were able to find jobs in their desired geographic area. Forty-one (67.2%) would recommend completing a craniofacial fellowship. CONCLUSION: Craniofacial surgeons trained within the last decade are primarily in academic practice, operate on adults and children, and perform a variety of procedures. Limitations include low response rate and likelihood that surgeons who do not perform craniofacial surgery did not respond. Respondents were able to find employment in their desired location, work on a craniofacial team, and would recommend a craniofacial fellowship.

S8B-02 SESSION 8B: FACE RESEARCH - PART I TOWARD AN OBJECTIVE OUTCOME IN FACIAL REANIMATION SURGERY: AN EYETRACKING STUDY

Introduction: The availability of an objective outcome measure for facial reconstructive surgery remains elusive. Evaluations submitted by external raters or by patient self-report may be influenced by expert knowledge, emotional antecedent, or implicit attitude. These types of subjective ratings, or objective measures such as anthropometric analysis, may unreliably convey how one is perceived by others. We are interested in observers’ instantaneous, reflexive responses to the human face, and how those instinctive responses relate to subjective judgment of a given face. Methods: We explored the visual markers that lead to differential perception of patients before and after facial reanimation surgery. By examining the early stages of visual processing that occur, we intended to measure changes in the focus of impression formation, thereby helping surgeons and their patients prioritize areas for reconstruction. Pre and post operation (>3 months) photographs from 10 patients with unilateral facial nerve palsy who underwent cross facial nerve graft and free gracillis muscle transfer were obtained.40 observers examined each image while an infrared eye-tracking camera continuously recorded their eye movements. The observers were then asked to rate the image for character attributes (attractiveness, trustworthiness, sociability, healthy, and capability, 1–7 scale). Results: (i) The surgical intervention was found to decrease the observers’ attention to the upper lip on the unaffected (non palsy) side, thus equalizing attention to both sides of the lips. (ii) The surgical intervention was found to significantly increase the character ratings for all five attributes compared to pre op controls: (sociable 3.2 to 3.6, trustworthy 3.42 to 3.61, attractive 2.96 to 3.2, health 3.37 to 3.54, p<0.05. (iii) For those pre-operative images of facial palsy, observers’ attention was overwhelming drawn to the area of disproportion. (iv) Our eye tracking methodology clearly reflects a trend towards normalization of gaze attention following surgical intervention. This finding was associated with the improvement in character assessment of the images in the post-op cohort of images. Conclusion: We provide data illustrating a novel and objective technique to evaluate the effect of reconstructive intervention for facial palsy. This information may be used to inform patients about how these areas of facial difference/aging are perceived, and the potential effect that surgical intervention may have on others’ perception of them. This work may assist patients and their surgeons to more meaningfully focus their surgical decision-making priorities.

Revision Surgery Following Gracilis Transplantation for Pediatric Facial Reanimation

Revision Surgery Following Gracilis Transplantation for Pediatric Facial Reanimation

Hypoglossal Facial Nerve Anastomosis for Post-Operative and Post-Traumatic Complete Facial Nerve Paralysis.

AIM:This study aims to evaluate the outcome of patients with complete facial paralysis following surgery to cerebellopontine angle tumours or following traumatic petrous bone fractures after reanimation by hypoglossal-facial anastomosis as regards clinical improvement of facial asymmetry and facial muscle contractility as well as complications associated with hypoglossal-facial reanimation procedure.METHODS:This thesis included a prospective study to be carried out on 15 patients with unilateral complete lower motor neuron facial paralysis (11 patients after cerebellopontine angle tumour resection and 4 patients after traumatic transverse petrous bone fracture) operated upon by end to end hypoglossal-facial nerve anastomosis in Cairo university hospitals in the period between June 2015 and January 2017.RESULTS:At one year follow up the improvement of facial nerve functions were as follows: Three cases (20%) had improved to House Hrackmann grade II, eleven cases (73.33%) had improved to grade III, and one patient (6.66%) had improved to House Brackmann grade IV.CONCLUSION:Despite the various techniques in facial reanimation following facial nerve paralysis, the end to end hypoglossal-facial nerve anastomosis remains the gold standard procedure with satisfying results in cases of the viable distal facial stump and non-atrophic muscles. Early hypoglossal-facial anastomotic repair after acute facial nerve injury is associated with better long-term facial function outcomes and should be considered in the management algorithm.

Functional results after facial reanimation in iatrogenic facial palsy.

Iatrogenic facial nerve injury is a common cause of long-standing facial palsy. This study aimed to assess functional results after facial reanimation in iatrogenic facial palsy and to determine correlating patient factors. The data of 128 iatrogenic facial palsy patients were analyzed for this case series. Inclusion criteria for assessment of facial function by three-dimensional video analysis were preoperative and postoperative (>18 months) video sets for facial marker tracking, which were available in 63 patients. Demographic factors and treatment concepts were analyzed and correlations to functional outcomes calculated. One hundred and twenty-eight patients with iatrogenic facial palsy underwent facial reanimation procedures and were included in this study. The mean duration of facial palsy was 7.8 years. The most common procedures leading to iatrogenic facial palsy were acoustic neuroma resection (29.7%), parotidectomy (21.1%), and brainstem/cerebellopontine angle tumor resection (21.1%). Selected functional results were significantly improved after facial reanimation surgery. The mean lagophthalmos during eyelid closure reduced from 7.3 ± 4.1 mm to 5.4 ± 4 mm (p < .001). The function of the mouth was significantly improved, both statically (static asymmetry: 10.3 ± 7.6 mm preoperatively, 0.8 ± 9.5 mm postoperatively; p < .001), and during smile movement ("Dynamic Symmetry Index": 0.16 preoperatively, 0.39 postoperatively; p < .001). The mean duration of facial palsy correlated with postoperative smiling function (r = .358, p = .011). Facial reanimation significantly improves facial function in iatrogenic facial palsy. Early referral to a facial nerve center is crucial as duration of facial palsy influences functional outcomes.