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20. Terzis JK, Wang W, Zhao Y. Effect of axonal load on the functional and aesthetic outcomes of the cross-facial nerve graft procedure for facial reanimation. Plast Reconstr Surg . 2009;124(5):1499–1512. 21. Terzis JK, Noah ME. Analysis of 100 cases of free-muscle transplantation for facial paralysis. Plast Reconstr Surg. 1997;99(7):1905–1921. 22. Jacobs JM, Laing JHE, Harrison DH. Regeneration through a long nerve graft used in the correction of facial palsy: a qualitative and quantitative study. Brain . 1996;119(1):271–279. 23. Mohan S, Herna´ndez IC, Wang W, et al. Fluorescent reporter mice for nerve guidance conduit assessment: a high-throughput in vivo model. Laryngoscope . 2018;128(11):E386–E392.

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DOI: 10.1089/fpsam.2022.0027

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INVITED COMMENTARY

Facial Nerve

Commentary on: ‘‘The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?’’ by Greene et al Babak Azizzadeh, MD * and Adrian E. House, MD

short sural nerve grafts (extending to the contralateral oral commissure), and high axonal load of the donor facial nerve. 5,6 Although the Tinel sign is the most common signal to determine the success of CFNG, it is inherently subjective, and no studies have examined it critically as it relates to successful smile outcomes after secondary FGMT. Most surgeons, including myself, do biopsy of the CFNG intraoperatively before proceeding with FGMT; however, the use of histopathology to assess CFNG myelination density has only been previously compared with masseteric nerve and not examined for determining the outcome of FGMT. 3 The findings of this study are very interesting. The most clinically relevant information is that several pati ents (all pediatric) with negative Tinel sign had

We would like to congratulate Dr. Greene and her colleagues on a very informative article about an impor tant issue that most contemporary facial reanimation surgeons consider routinely in their clinical practice. This is a well-written article examining the usefulness of the Tinel sign and the presence of myelinated axons in cross-face sural nerve grafts (CFNGs) in predicting smile outcomes after second-stage free gracilis muscle transfer (FGMT). 1 FGMT powered by CFNG is a favored method and one of my own personal preferred reanima tion techniques for patients with complete facial paralysis desiring a natural and spontaneous smile outcome. 2–4 There are currently no reliable methods for predicting the success of FGMT based on CFNG criteria. Factors considered to predict success are a positive Tinel sign, Downloaded by Kaiser Permanente from www.liebertpub.com at 01/09/23. For personal use only.

Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA.

*Address correspondence to: Babak Azizzadeh, MD, Center for Advanced Facial Plastic Surgery, 9401 Wilshire Boulevard, Suite #650, Beverly Hills, CA 90212, USA, Email: drazizzadeh@gmail.com