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Plastic and Reconstructive Surgery • May 2019

Video 1. Supplemental Digital Content 1 demonstrates a patient undergoing right modified selective neurectomy. The video demon strates intraoperative nerve stimulation with split face showing the elicited facial movement. The lower buccal, cervical, and marginal mandibular nerves have been identified in this video. The first facial movement is elicited by stimulating a lower buccal nerve, which elevates the lower lip and depresses the upper lip with lateral oral commissure movement. This nerve is a candidate for neurectomy. The second stimulation is a distal branch that mobilizes the men talis. This nerve will be sacrificed. The third nerve is another buccal branch that also elevates the lower lip and depresses the upper lip, thereby counteracting a wide smile. The last split screen shows the depressor labii inferioris activation from stimulation of the marginal mandibular nerve. This nerve will be preserved, http://links.lww. com/PRS/D438 . (Courtesy Facial Paralysis Institute.)

1 month postoperatively, with the goal of reestab lishing and coordinating the facial muscle activity and reducing hypercontracted zygomatic major/ minor and levator labii/anguli muscles. 14,21 Study Design All patients in this study were from the private practice of the senior author (B.A.). No patients or patient records included in this report were associated with any academic institutions at the time of the study; thus, institutional review board approval was not obtained. Written informed con sent was obtained for each procedure from all patients, and the present review adheres to the standards of the Declaration of Helsinki and com plies with the Health Insurance Portability and Accountability Act of 1996. Medical records of patients who underwent modified selective neurectomy between June 20, 2013, and August 12, 2017, were reviewed retrospectively. The subset of patients who con currently underwent rhytidectomy and direct zygomatic major/minor neurotization or end-to side nerve coaptation to the zygomatic branch by a cross-facial nerve graft or the proximal portion

branches are often transected. In addition, other buccal and cervical peripheral nerve branches that were not identified in the initial surgery need to be uncovered and transected. Occasionally, the transected buccal branch is rerouted to the zygo matic major/minor (direct muscle neurotization) or zygomatic branch (end-to-side coaptation) to increase neural input into the smile elevators. This approach is used mainly for patients who intraop eratively do not demonstrate adequate superior excursion of the modiolus with direct nerve stim ulation. 20 Platysmal myotomy is performed from the lateral edge of the platysma to the medial border approximately 3 cm below the border of the mandible, avoiding the marginal mandibular nerve (Fig. 3, below ). At the conclusion, the SMAS is returned to its native position. If the patient is undergoing a simultaneous rhytidectomy, the SMAS is sus pended in the appropriate superolateral vector and a deep plane rhytidectomy is performed on the contralateral side. Patients usually return to social function in 7 to 14 days and may obtain botulinum toxin type A as needed. Neuromuscular retraining may begin

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