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Special Communication Clinical Review & Education

A Contemporary Approach to Facial Reanimation

Figure 5. Dynamic Reanimation of Smile in Nonflaccid and Flaccid Facial Palsy

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Conclusions The initial management of FP involves establishment of the correct diagnosis, followed by medical or surgical interventions in addition to physical therapy. The management of long-standing FP entails physical therapy, injectables, and surgical reanimation procedures. The facial reanimation surgeon, backed by amultidisciplinary team of physical therapists, nurses, and assistants, is skilled in zonal as sessment of the paretic face and in procedures to protect the eye, reduce facial fatigue and discomfort, optimize facial symmetry, and restore meaningful smile. musculature in flaccid facial palsy. Twelve months following resection of an acoustic neuroma with an anatomically intact facial nerve, the patient demonstrates persistent flaccid facial palsy with effacement of the nasolabial fold and inferiorly malpositioned oral commissure on the affected side at rest (E) and absence of commissure movement with smile (F). Eight months following combined cross facial nerve grafting and masseteric nerve transfer to a large mid-facial branch, rest appearance appears mostly unchanged (G), with significant improvement in smile symmetry demonstrated with light-effort (H).

Dynamic reanimationof the affected lower lipusingdigastricmuscle transfer or platysma transfer hasbeendescribedbut hasnot achieved widespreaduse due to the high success rate of contralateral depres sor labii inferiorisweakening. 45 Synkineticmentalis dimplingandpla tysmal synkinesis are common inNFFP and aremanagedwith botu linum toxin injection. Refractory platysmal synkinesis is managed with platysmectomy, which may be achieved using local anesthe sia by removing a 2-cmor greater strip spanning the entirewidth of the muscle. 46 Correction of platysmal synkinesis reduces facial fa tigue and may result in improvements in smile aesthetics second ary to elimination of an inferior vector of pull resulting from inser tion of platysmal fibers to the modiolus and lower lip. A-D, Cross-facial nerve graft transfer to a free-gracilis muscle for dynamic reanimation of smile. The patient presented with nonflaccid facial palsy 2 years following resection of a temporal bone facial schwannoma with cable grafting, having symmetry at rest (A) with severe limitation of commissure excursion with full-effort smile (B). The patient underwent cross facial nerve grafting transfer to free-gracilis muscle three years later. On follow-up 18 months later, the midface remains symmetrical at rest (C), while significant improvement in symmetry is seen with smile (D). E-H, Nerve transfer to native facial

5 . Lindsay RW, Bhama P, Weinberg J, Hadlock TA. The success of free gracilis muscle transfer to restore smile in patients with nonflaccid facial paralysis. Ann Plast Surg . 2014;73(2):177-182. 6 . Hadlock TA, Malo JS, Cheney ML, Henstrom DK. Free gracilis transfer for smile in children: the Massachusetts Eye and Ear Infirmary experience in excursion and quality-of-life changes. Arch Facial Plast Surg . 2011;13(3):190-194. 7 . Henstrom DK, Lindsay RW, Cheney ML, Hadlock TA. Surgical treatment of the periocular complex and improvement of quality of life in patients with facial paralysis. Arch Facial Plast Surg . 2011;13(2): 125-128.

REFERENCES 1 . Darwin C. The Expression of the Emotions in Man and Animals. London, England: J Murray; 1872. 2 . Hohman MH, Hadlock TA. Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope . 2014;124(7): E283-E293. doi:10.1002/lary.24542. 3 . Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB, McKenna MJ. Validation of a patient-graded instrument for facial nerve paralysis: the FaCE Scale. Laryngoscope . 2001;111(3):387-398. 4 . Lindsay RW, Bhama P, Hadlock TA. Quality-of-life improvement after free gracilis muscle transfer for smile restoration in patients with facial paralysis. JAMA Facial Plast Surg . 2014;16(6):419-424.

ARTICLE INFORMATION Accepted for Publication: March 16, 2015.

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Published Online: June 4, 2015. doi:10.1001/jamafacial.2015.0399.

Author Affiliations: Facial Nerve Center and Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston (Jowett, Hadlock); Harvard Medical School, Boston, Massachusetts (Jowett, Hadlock). Conflict of Interest Disclosures: None reported. Correction: The CME questions for this article in the July/August print version of the journal are incorrect. The questions were corrected online on August 17, 2015.

(Reprinted) JAMA Facial Plastic Surgery July/August 2015 Volume 17, Number 4

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