Facial Synkinesis Research Articles

Orbicularis Oculi Myectomy as an Adjunctive Procedure to Modified Selective Neurectomy for Postparalysis Facial Synkinesis: Technical and Safety Considerations.

Orbicularis Oculi Myectomy as an Adjunctive Procedure to Modified Selective Neurectomy for Postparalysis Facial Synkinesis: Technical and Safety Considerations.

Surgical Treatments for Facial Aberrant Reinnervation Syndrome: A Systematic Review.

Background: Facial aberrant reinnervation syndrome is characterized by aberrant facial muscle reinnervation after facial nerve injury producing facial synkinesis, hypertonicity, and muscle spasm. Objective: To systematically review the surgical treatments for facial aberrant reinnervation syndrome and assess their effectiveness as measured by patient-reported outcomes, physician-graded outcomes, or computer-automated grading systems. Methods: We conducted a systematic review using PubMed, Embase, and Cochrane CENTRAL in accordance with PRISMA guidelines. Texts reporting outcomes of any surgical treatment for facial aberrant reinnervation syndrome from 2003 to 2023 were included. Results: After screening, 25 studies with 731 patients were included. Surgical procedures included selective neurectomy (SN), selective myectomy (SM), cross-facial nerve graft, masseter nerve transfer, and gracilis muscle transfer. All surgical techniques and combinations showed significant improvement in at least one clinical outcome measure from baseline (p < 0.05), although one study found no significant improvement. Thirty different outcome measures were used, the most common being the FaCE and eFACE scales (seven studies each). Conclusions: All surgical procedures in this review yield improved clinical outcome measures for facial aberrant reinnervation syndrome, with SN and SM being the dominant surgical treatments. Standardized outcome assessment and more nuanced patient evaluation are necessary to determine the most effective surgical treatments.

Compare the Effectiveness of Mime Therapy on Facial Synkinesis in Idiopathic and Traumatic Lower Motor Neuron Facial Palsy

Background: The seventh cranial nerve has a core function of regulating emotional displays and speech. Facial paralysis, characterized by the loss of voluntary motor control on one or both sides, is commonly attributed to Bell’s palsy which accounts for 50-75% of cases and trauma responsible for 10-23% of cases. Various rehabilitation methods, including Mime Therapy, are employed to enhance facial muscle function. Objective: This study aims to compare Mime Therapy's impact to reduce the synkinesis of a face in individuals with idiopathic and traumatic lower motor neuron facial nerve palsy. Study Design: Experimental, Comparative Study Study Setting: Physiotherapy OPD, Neurology ward, and ENT ward of Himalayan Hospital, Dehradun Participant: This study involved 30 patients, with 20 in Group A (Idiopathic) and 10 in Group B (Traumatic), all of whom had House-Brackmann Scores of 3-5. The patient’s ages ranged from 20 to 70. Outcome Measure: Two outcome measures were used: House Brackmann Score and Sunnybrook Facial Grading System. Result: A noticeable difference in both outcome measures was observed. In the House Brackmann Score for group A (p-value &lt;0.001) and B (p-value=0.016), In Sunnybrook Facial Grading System for group A (p-value&lt;0.001) and B (p-value=0.002). However, when comparing the post-intervention results of both groups, no distinct variation was found in the outcome variables (p-value&gt;0.05). Conclusion: The study provides evidence demonstrating that Mime Therapy has been successful in effectively reducing Facial Synkinesis in patients with both idiopathic and traumatic LMN Facial Palsy. The results indicate a significant improvement in the condition, suggesting that Mime therapy can be an efficacious treatment approach for this type of facial paralysis. KEYWORDS: Mime Therapy, Facial Synkinesis, Idiopathic LMN Facial palsy, Traumatic LMN facial palsy, Bell’s palsy.

Effects of Kabat rehabilitation versus mime therapy on facial disability and synkinesis in patients of Bell's palsy.

To compare the effects of Kabat rehabilitation and Mime therapy on facial disability and synkinesis in patients with Bell's palsy. The single-blind, randomised clinical trial was conducted at the Physiotherapy Department of the University of Lahore Teaching Hospital, Lahore, Pakistan, from May to October 2023, and comprised adults of either gender aged 25-50 years having sub-acute or chronic unilateral Bell's palsy of non-congenital origin. The patients were randomised into Kabat rehabilitation group A and mime therapy group B. Conventional physical therapy was given to both groups additionally. Facial disability was assessed using the Facial Disability Index scale, and synkinesis was observed using the House-Brackmann Facial Nerve Grading Scale. Data was analysed using SPSS 25. Of the 72 patients, 41(56.9%) were females and 31(43.1%) were males. The overall mean age was 37.77±6.98 years, mean body mass index was 25.71±5.71kg/m2 and 41(56.9%) patients had left-sided palsy. Facial disability and synkinesis were significantly different in both groups post-intervention (p<0.001), while intergroup differences were significant in the 3rd and 6th weeks (p<0.001). Kabat rehabilitation led to more significant improvements in synkinesis and facial disability compared to mime therapy. Clinical trials.gov registration id: NCT06029855.

Electro-Stimulation System with Artificial-Intelligence-Based Auricular-Triggered Algorithm to Support Facial Movements in Peripheral Facial Palsy: A Simulation Pilot Study.

Facial palsy causes severe functional disorders and impairs quality of life. Disturbing challenges for patients with acute facial palsy, but also with those with chronic facial palsy with synkinesis, are the loss of the ability to smile and insufficient eyelid closure. A potential treatment for these conditions could be a closed-loop electro-stimulation system that stimulates the facial muscles on the paretic side as needed to elicit eye closure, eye blink and smile in a manner similar to the healthy side. This study focuses on the development and evaluation of such a system. An artificial intelligence (AI)-based auricular-triggered algorithm is used to classify the intended facial movements. This classification is based on surface electromyography (EMG) recordings of the extrinsic auricular muscles, specifically the anterior, superior, and posterior auricular muscle on the paretic side. The system then delivers targeted surface electrical stimulation to contract the appropriate facial muscles. The evaluation of the system was conducted with 17 patients with facial synkinesis, who performed various facial movements according to a paradigm video. The system's performance was evaluated through a simulation, using previously captured data as the inputs. The performance was evaluated by means of the median macro F1-score, which was calculated based on the stimulation signal (output of the system) and the actual movements the patients performed. This study showed that such a system, using an AI-based auricular-triggered algorithm, can support with a median macro F1-score of 0.602 for the facial movements on the synkinetic side in patients with unilateral chronic facial palsy with synkinesis.

The Association of Mental Health Disorders with the Effectiveness of Treating Facial Synkinesis with Chemodenervation Using Botulinum Toxin A.

Background: Studies suggest that mood disorders may affect perception of facial synkinesis, though none have analyzed effects on perceived benefit from chemodenervation. Objective: To measure the effect of depression, appearance anxiety, and other variables on chemodenervation benefit among patients with post-paralytic facial synkinesis. Design Type: Prospective cohort. Methods: Patients volunteered and completed: Synkinesis Assessment Questionnaire (SAQ), Facial Clinimetric Evaluation Scale (FaCE), Center for Epidemiological Studies Depression Scale (CES-D), and Fear of Negative Appearance Evaluation Scale (FNAES). Multivariate regression was used to analyze the effect of CES-D, FNAES, and demographics on pre- and post-chemodenervation SAQ and FaCE. Results: In total, 100 patients participated, 90% were female. Mean age was 56.4 (SD 12.3) years. The most common paralysis etiology was idiopathic (47%). Average synkinesis duration was 7.6 (6.2) years and treatment duration 4.9 (4.8) years. Older age and prior treatment (p < 0.05) were associated with reduced SAQ improvement; worse CES-D approached significance (p = 0.09). Reported history of anxiety was associated with greater SAQ improvement (p = 0.05). Factors associated with reduced FaCE improvement included higher baseline CES-D and prior treatment (p < 0.05). Conclusions: Older age, worse depression scores, and prior treatments may be associated with reduced patient-graded improvement following chemodenervation. History of anxiety may be associated with greater improvement.

Epineurectomy of extracranial facial nerve trunk for non-flaccid sequelae following Bell's palsy: A single-arm trial.

Non-flaccid facial palsy sequelae manifest as sequelae following Bell's palsy. Currently, there are no effective remedies for addressing this issue. In this study, we proposed a new surgical solution, epineurectomy of the extracranial facial nerve trunk, and assessed its safety and efficacy as a potential remedy.. In this single-arm trial, adult patients with non-flaccid facial palsy sequelae were enrolled and subjected to epineurectomy of the extracranial facial nerve trunk. The primary efficacy endpoint was the Sunnybrook scores at months 12 postoperatively. The secondary endpoints included non-flaccid facial palsy sequelae symptom scores, such as facial tightness or facial stiffness, facial synkinesis, eyefissures narrowing or difficulty in opening the eyes, House-Brackmann grade scale, and Facial Disability Index. A total of 22 patients were enrolled between July 2020 and January 2021. One patient was lost to follow up. One year after surgery, the Sunnybrook score was 72.0 (63.0 - 75.0) at 12 months versus 68.0 (58.0 - 70.8) at baseline. The mean difference was -5.4 (-7.2 to -3.6). The scores of facial tightness or facial stiffness, synkinesis, eye fissures narrowing or difficulty in opening eyes were 0.0 (0.0 - 1.0), 1.0 (1.0 - 1.0), 1.0 (1.0 - 2.0) at 12 months versus 3.0 (1.3 - 3.0), 2.0 (1.0 - 2.8), 2.0 (2.0 - 3.0) at baseline, respectively. The median (IQR) values of the Facial Disability Index physical function were 92.0 (90.0 - 95.0) at months 12, and the mean difference (95% CI) was -32 (-38 to -26) compared to baseline. The mean difference (95% CI) in the Facial Disability Index social/well-being function between month 12 and baseline was -38 (-46 to -31). Epineurectomy of the extracranial facial nerve trunk can effectively and safely alleviate the sequelae of non-flaccid facial palsy.

Combining early lower eyelid surgery with neuromuscular retraining for synkinesis prevention after facial palsy: the role of the eye in aberrant facial nerve regeneration.

Facial synkinesis (FS) is a distressing sequela of facial palsy (FP) characterized by involuntary, simultaneous movements of facial muscles occurring during voluntary facial expressions. Treatment of synkinesis is challenging, and preventive methods are needed. This study evaluated the efficacy of physical facial nerve rehabilitation (PFNR) therapy alone vs. PNFR with eyelid surgery to correct lagophthalmos and prevent the onset of synkinesis. Twenty five outpatients were randomized to receive either PFNR alone (neuromuscular retraining and Kabat proprioceptive neuromuscular facilitation) or PNFR and early (90 days after FP onset) eyelid surgery (involving a conservative oculoplastic correction for lagophthalmos with epiphora or ectropion). Comprehensive otolaryngological assessments and Magnetic Resonance Imaging (MRI) were conducted. Synkinesis progression was measured using Another Disease Scale (ADS) at baseline, 3-, 6-, 12-, and 24-months post-treatment. The data were analyzed with ANOVA, τ-test, Chi-Square analyses. Patients undergoing eyelid surgery with PFNR showed faster (p < 0.001) and better recovery of facial movements (p < 0.05) than patients receiving PFNR alone comparing T0 and T12 (p < 0.0001). No synkinesis were observed in the PFNR plus surgery group while 37% of patients in PFNR alone had synkinesis (p = 0.03). At 24 months, none of the patients in the surgery group presented synkinesis. Combining early surgical treatment of paralytic lagophthalmos or epiphora with PFNR accelerated functional recovery and reduced synkinesis in patients with FP compared to facial rehabilitation alone. Further investigations in larger populations with long-term follow-up are needed. https://clinicaltrials.gov/study/NCT06538103, NCT06538103.

The Role of Botulinum Toxin A Neuromodulator in the Management of Synkinesis in Facial Palsy.

Facial palsy describes the denervation of the facial nerve leading to difficulty in facial animation and expression. Facial synkinesis is the result of complex pathological nerve regeneration following damage to the facial nerve axons. Synkinesis in facial palsy can be managed using facial neuromuscular rehabilitation, botulinum toxin neuromodulators, and surgical treatment options. Botulinum toxin A can be used as an adjunct to other treatment options to manage synkinesis. This article will explore the role of botulinum toxin A in the management of synkinesis in facial palsy including the clinical assessment, injection location (muscles targeted), dosages, treatment interval, and long-term results. It will also include surgical management options.

Chemodenervation is Associated With Reduced Mental Health Disorders in Patients With Synkinesis.

To compare the prevalence of mental health disorders in individuals with facial synkinesis, facial paralysis alone, and the general population. Retrospective cohort. Eighty-two health care organizations across the United States. The TriNetX Research Network was queried from 2011 to 2021 for patients with facial paralysis without synkinesis, facial paralysis and documented synkinesis, and controls, matched for age, sex, race, and ethnicity. Cases included infectious, iatrogenic, or idiopathic facial paralysis. Patients with pre-existing depression or anxiety were excluded. Two-year rates of newly diagnosed depression, anxiety, and mental health prescriptions were compared. Among 127,573 patients with facial paralysis, 92.5% (n = 117,976) had facial paralysis alone, and 7.5% (n = 9597) also had documented synkinesis. Compared to controls, patients with facial paralysis alone had increased risks of new depression (8.9% vs 7.3%, P < .001) and anxiety (10.1% vs 9.6%, P < .001), with higher mental health medication rates (16.6% vs 13.1%, P < .001). Patients with documented synkinesis, in comparison to controls, had the highest risks of depression (19.8% vs 8.6%, P < .001), anxiety (20.5% vs 10.5%, P < .001), and prescriptions (28.1% vs 15.8%, P < .001). The 27.8% (n = 2669) of synkinetic patients treated with chemodenervation had lower rates of depression (8.5% vs 23.5%, P < .001), anxiety (9.0% vs 23.8%, P < .001), and prescriptions (21.6% vs 30.0%, P < .001) compared to synkinetic patients who were not. Facial paralysis, particularly synkinesis, is linked to increased mental health disorders. Integrating mental health screening and treatment into a comprehensive approach is crucial. Chemodenervation is associated with decreased mental health disorders in synkinesis, highlighting its therapeutic potential.

Botulinum toxin application to the buccinator muscle in the treatment of facial synkinesis: a prospective cohort study

Botulinum toxin application to the buccinator muscle in the treatment of facial synkinesis: a prospective cohort study

Automated analysis of spontaneous eye blinking in patients with acute facial palsy or facial synkinesis

Although patients with facial palsy often complain of disturbed eye blinking which may lead to visual impairment, a blinking analysis is not part of routine grading of facial palsy. Twenty minutes of spontaneous eye blinking at rest of 30 patients with facial palsy (6 with acute palsy; 24 patients with facial synkinesis; median age: 58 years, 67% female), and 30 matched healthy probands (median age: 57 years; 67% female) was smart phone video recorded. A custom computer program automatically extracted eye measures and determined the eye closure rate (eye aspect ratio [EAR]), blink frequency, and blink duration. Facial Clinimetric Evaluation (FaCE), Facial Disability Index (FDI) were assessed as patient-reported outcome measures. The minimal EAR, i.e., minimal visible eye surface during blinking, was significantly higher on the paretic side in patients with acute facial palsy than in patients with synkinesis or in healthy controls. The blinking frequency on the affected side was significantly lower in both patient groups compared to healthy controls. Vice versa, blink duration was longer in both patient groups. There was no clear correlation between the blinking values and FaCE and FDI. Blinking parameters are easy to estimate automatically and add a functionally important parameter to facial grading.

Surgical Pearls for Safe and Precise Decision-Making during Modified Selective Neurectomy Surgery.

In this short communication: (1) A transcutaneous electrical nerve stimulaton stimulator is a cost-effective solution for the predictable stimulation of mimicry and for precise decision-making. (2) Positioning a simple shatterproof mirror in front of an operated facial half enables the primary surgeon to simultaneously see and stimulate at the operative site and to scrutinize the mimicry for decision-making. (3) A misconception in the literature regarding colors used for tagging "branches for transection" and "branches for preservation" is clarified, and a third tag-color is suggested for times of ambiguity. (4) The principle of distal execution of the surgery and technical considerations are underlined for maximal transection and maximal preservation. The modified selective neurectomy surgery is the current golden standard of post facial paralysis synkinesis treatment, and developing a learning curve in this type of surgery is like walking a tightrope, where the surgeon must keep pushing the limits with precise decision-making and a small margin of error. It is important to be reminded that the first aim is primum non nocere, and the second aim is to improve the condition of patients as much as possible. The above-mentioned principles and solutions increase precision and safety, assisting surgeons to achieve better outcomes.

Facial Aberrant Reinnervation Syndrome Following Facial Nerve Injury and Recovery.

A common sequela of peripheral nerve injury is aberrant regeneration and recovery. Aberrant regeneration of injured motor nerves can affect all aspects of the nerve circuit from the motor cortex to the target muscle. A more comprehensive term for the symptoms that develop after aberrant motor neuromuscular reinnervation is aberrant reinnervation syndrome (ARS). Injury to the facial nerve followed by aberrant reinnervation results in a spectrum of symptoms that has been called many things in the literature. The authors support that this commonly encountered sequela of facial nerve injury be called facial aberrant reinnervation syndrome (FARS), a term that is more descriptive of the underlying pathophysiology and more inclusive of the clinical symptoms: facial synkinesis, facial muscle hypertonicity, and facial muscle spasm/twitching, which occur following facial nerve injury and recovery. In the following article, we present the clinical manifestations and sequelae of facial nerve injury and recovery and briefly discuss our evolving understanding of the pathophysiology and treatment of FARS.

Approaches to the Management of Synkinesis: A Scoping Review.

Postparalysis facial synkinesis (PPFS) can develop in any facial palsy and is associated with significant functional and psychosocial consequences for affected patients. While the prevention of synkinesis especially after Bell's palsy has been well examined, much less evidence exists regarding the management of patients with already established synkinesis. Therefore, the purpose of this review is to summarize the available literature and to provide an overview of the current therapeutic options for facial palsy patients with established synkinesis. A systematic literature review was undertaken, following the Preferred Reporting Items of Systematic Reviews and Meta-analyses 2020 guidelines. MEDLINE via PubMed and Cochrane Library were searched using the following strategy: ([facial palsy] OR [facial paralysis] OR [facial paresis]) AND (synkinesis) AND ([management] OR [guidelines] OR [treatment]). The initial search yielded 201 articles of which 36 original papers and 2 meta-analyses met the criteria for inclusion. Overall, the included articles provided original outcome data on 1,408 patients. Articles were divided into the following treatment categories: chemodenervation (12 studies, 536 patients), facial therapy (5 studies, 206 patients), surgical (10 studies, 389 patients), and combination therapy (9 studies, 278 patients). Results are analyzed and discussed accordingly. Significant heterogeneity in study population and design, lack of control groups, differences in postoperative follow-up, as well as the use of a variety of subjective and objective assessment tools to quantify synkinesis prevent direct comparison between treatment modalities. To date, there is no consensus on how PPFS is best treated. The lack of comparative studies and standardized outcome reporting hinder our understanding of this complex condition. Until higher quality scientific evidence is available, it remains a challenge best approached in an interdisciplinary team. An individualized multimodal therapeutic concept consisting of facial therapy, chemodenervation, and surgery should be tailored to meet the specific needs of the patient.

Evaluating Neck Pain in Patients with Facial Synkinesis Using Patient Responses to the Synkinesis Assessment Questionnaire and Neck Disability Index.

Evaluating Neck Pain in Patients with Facial Synkinesis Using Patient Responses to the Synkinesis Assessment Questionnaire and Neck Disability Index.

Spatial functional reorganizations can serve as potential biomarkers of post facial palsy synkinesis.

Facial palsy can result in a serious complication known as facial synkinesis, causing both physical and psychological harm to the patients. There is growing evidence that patients with facial synkinesis have brain abnormalities, but the brain mechanisms and underlying imaging biomarkers remain unclear. Here, we employed functional magnetic resonance imaging (fMRI) to investigate brain function in 31 unilateral post facial palsy synkinesis patients and 25 healthy controls during different facial expression movements and at rest. Combining surface-based mass-univariate analysis and multivariate pattern analysis, we identified diffused activation and intrinsic connection patterns in the primary motor cortex and the somatosensory cortex on the patient's affected side. Further, we classified post facial palsy synkinesis patients from healthy subjects with favorable accuracy using the support vector machine based on both task-related and resting-state functional magnetic resonance imaging data. Together, these findings indicate the potential of the identified functional reorganizations to serve as neuroimaging biomarkers for facial synkinesis diagnosis.

Effect of Underlying Mental Health Disorders on the Correlation Between Patient- and Surgeon-Graded Synkinesis Scores.

Background: Little is known about how depression and appearance anxiety affect patient reporting of synkinesis severity. Learning/Study Objective: Measure prevalence of depression and appearance anxiety in facial synkinesis and correlations between subjective and surgeon-graded synkinesis severity. Design Type: Prospective cohort. Methods: Patients with synkinesis volunteered and completed: Synkinesis Assessment Questionnaire (SAQ), facial clinimetric evaluation (FaCE) scale, Center for Epidemiological Studies Depression Scale (CES-D), and Fear of Negative Appearance Evaluation Scale (FNAES). Standardized videos were scored by facial plastic surgeons using Sunnybrook Scale and eFaCE. Multivariate linear regression was used to compare patient- and surgeon-graded metrics. Results: One hundred patients participated, 91 were female. Mean age was 56.4 (12.3). Eight percent identified as Black and 87% White. The most common nerve injury etiology was idiopathic (47%). Mean synkinesis duration was 7.6 years (6.2). Twenty percent and 15% reported history of an anxiety or depressive disorder, respectively. Patient (SAQ, FaCE) and clinician (Sunnybrook, eFaCE) scores were correlated (Pearson's r 0.223-0.294, p < 0.05). Upon adjusting for CES-D/FNAES, correlations between most patient and clinician metrics became stronger. As CES-D and FNAES worsened, patient-clinician correlations weakened. Conclusions: Depression and appearance anxiety may affect patient reporting of synkinesis severity. Worse mental health scores may decorrelate patient and clinician synkinesis assessments.

Negative Impact of Synkinetic Mentalis Muscle on Smile Quality: Pathomechanism and Treatment with Mentalis-Targeted Selective Neurectomies.

The treatment of postparetic facial synkinesis is based on a combination of nonsurgical and surgical strategies. Improvements toward the restoration of a natural smile have been obtained with selective neurectomies and depressor anguli oris myectomy, but the lower lip frequently remains asymmetric and cranially displaced. The aim of this study was to evaluate the effect of the mentalis muscle on the position and symmetry of the lower lip in patients with synkinesis and to assess the added benefit of neurectomies of nerves innervating the mentalis muscle in improving the lower lip configuration and mandibular teeth show. A retrospective cohort study of all patients with postparetic synkinesis was performed at the authors' institution. A nonmentalis neurectomy group including 12 patients treated with selective neurectomies without targeting the branches to mentalis muscle was compared with a mentalis neurectomy group including 16 patients who underwent additional specific mentalis branches neurectomies. All patients underwent depressor anguli oris myectomy. Analyses of standardized images were performed with ImageJ software. Postoperative comparisons between the 2 groups showed superior and significant improvements in the mentalis neurectomy group across all measures, including lower and upper border deviation ( P = 0.035 and P = 0.004, respectively), inclination of the lower lip ( P = 0.019), and lower quadrant dental show ( P = 0.004). The addition of targeted selective neurectomies to the branches innervating the mentalis muscle significantly improved dental show and caudal position and symmetry of the lower lip during open-mouth smile. Therapeutic, III.

Facial Paralysis Treatment Using Selective Neurectomy: A Comprehensive Review.

Facial paralysis can affect patients undergoing full mouth rehabilitation, regardless of what caused their paralysis. A procedure known as modified selective neurectomy of the facial nerve can enhance the movement of facial muscles in individuals with facial synkinesis safely and effectively. This approach is proposed as an alternative to more invasive surgical options when used independently as a treatment for incomplete facial palsy. Selective neurectomy offers a promising surgical option for managing nonflaccid facial paralysis and synkinesis, enhancing patients' quality of life. However, treatment plans should be individually tailored considering the complexity of facial paralysis and the unique needs of each patient, taking into account the timing and type of treatment. The objective of this review is to explore the use of selective neurectomy as a treatment for facial paralysis based on previously published papers.