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Patient with global facial paralysis (House-Brackmann V) due to Bell's palsy. a, Preoperative image, aged 12. B, postoperative image, aged 16, following 3-stage procedure: (1) Placement of 2 cFngs, to buccal and MMB nerves; (2) free-gracilis transfer; (3) aBDM transfer.
Source publication
Background:
Lower lip depression was historically regarded a neglected area of facial paralysis, but, with refinement of techniques, has gained increasing attention. We present the first detailed description and evaluation of a 2-stage technique, using first cross facial nerve graft and then the anterior belly of digastric muscle (ABDM), innervate...
Context in source publication
Context 1
... was a greater mean improvement in appearance in the isolated MMB palsy group (+1.5) compared with those with more extensive paralysis (partial +0.7, global +1.1) (Fig. 6). A number of cases are shown in Video 2. (See Video 2 [online], which displays pre-and postoperative smiles demonstrated side-by-side for comparison, and spontaneous smile of the patient shown in Fig. 7.) Table 4 summarizes photogrammetric (Emotrics) results. The number of patients with complete sets for repose, open-lip smile, and ...
Similar publications
Citations
... Improvements upon this concept have included double-and multi-paddle flaps, as well as dual-innervation to improve control of the muscle flap with acceptable results for smile outcomes. [21][22][23][24] In addition to free-muscle transfer, attempts at reanimation of the paralyzed face has expanded into the fields of materials science and electrical engineering. Developed by SRI International research laboratory, artificial muscle comprised of dielectric elastomers stretch in response to high-voltage current. ...
Facial palsy, or weakness of the facial muscles, arises from injury to the facial nerve and can lead to debilitating morbidity by affecting facial expression, speech, and daily activities. Playing a wind instrument, such as the saxophone, requires formation of an airtight seal with the instrument’s mouthpiece through a coordinated effort of facial muscles known as embouchure. Consequently, facial palsy can impair a musician’s ability to play a wind instrument. To address this functional disability, we present a novel 3D-printed embouchure-assistive device designed for application in saxophone players with facial palsy. Quantitative and qualitative metrics were recorded, demonstrating improved duration of note sustain, increased mean air pressure within the mouthpiece during play, and subjectively improved patient comfort and overall tone quality with use of the device. We also include design iterations of the prototype device as they may serve as a template for broader applications in musicians with facial palsy.
... Emotrics possesses a significant advantage in automatically evaluating the differences in landmark positions between two images. It has been utilized in assessing the effectiveness of various plastic surgeries and rehabilitation treatments [9,[12][13][14]. However, since it was not originally designed for the purpose of the facial palsy severity scale, there is insufficient evidence to support the reliability and validity of its automatic evaluation, particularly when compared to manual evaluation methods or the HB grades. ...
... A previous study confirmed the improvement of BH and PF using Emotrics, displaying improved eye function after plastic surgery on the eyelids that did not close in facial palsy [9]. Previous studies have also shown improvements in SA, CE, and DS using this program, representing oral functions, as well as additional progress in other indicators after rehabilitation treatment or plastic surgery that enabled spontaneous smiling [12][13][14]. Based on these studies, Emotrics parameters are well-reflected by clinical improvements. ...
The globally accepted evaluation method for facial palsy is the House–Brackmann facial grading system; however, it does not reflect minute changes. Several methods have been attempted, but there is no universally accepted evaluation method that is non-time-consuming and quantitative. Recently, Emotrics, a two-dimensional analysis that incorporates machine-learning techniques, has been used in various clinical fields. However, its reliability and validity have not yet been determined. Therefore, this study aimed to examine and establish the reliability and validity of Emotrics. All patients had previously received speech therapy for facial palsy at our hospital between January and November 2022. In speech therapy at our hospital, Emotrics was routinely used to measure the state of the patient’s facial palsy. A frame was created to standardize and overcome the limitation of the two-dimensional analysis. Interrater, intrarater, and intrasubject reliability were evaluated with intraclass correlation coefficients (ICC) by measuring the indicators that reflect eye and mouth functions. Validity was evaluated using Spearman’s correlation for each Emotrics parameter and the House–Brackmann facial grading system. A total of 23 patients were included in this study. For all parameters, there was significant interrater and intrarater reliability (ICC, 0.61 to 0.99). Intrasubject reliability showed significant reliability in most parameters (ICC, 0.68 to 0.88). Validity showed a significant correlation in two parameters (p-value < 0.001). This single-center study suggests that Emotrics could be a quantitative and efficient facial-palsy evaluation method with good reliability. Therefore, Emotrics is expected to play a key role in assessing facial palsy and in monitoring treatment effects more accurately and precisely.
... Among the facial nerve branches, the marginal mandibular branch of the facial nerve (MMN) has often been neglected in facial reanimation (Mandlik et al., 2019;Terzis & Kalantarian, 2000), but has received increasing attention in recent years (Tzafetta et al., 2021). ...
... The photographs were analyzed with photogrammetry (Emotrics;Guarin et al., 2018), where facial landmarks were marked to calculate objective differences in symmetry between facial halves. Analysis was also performed using the version of Terzis' Lower Lip Grading Scale(Terzis & Kalantarian, 2000) modified byTzafetta et al. (2021) (lower lip function rated from 1 (poor outcome) to 5 (excellent outcome)). Both videos were graded by 25 independent observers (plastic surgery residents and specialists, medical interns, and nurses and physiotherapists from the facial palsy clinic) with 50 separate gradings in total (25 at 1 month, 25 at 12 months).The post-operative course was uneventful, and no donor site morbidity or clinically significant complications were seen. ...
Background
Donor nerve options for lower lip reanimation are limited in patients undergoing oncological resection of the facial nerve. The ansa cervicalis nerve (ACN) is an advantageously situated donor with great potential but has not been examined in detail. In the current study, the anatomical technical feasibility of selective ACN to marginal mandibular nerve (MMN) transfer for restoration of lower lip tone and symmetry was explored. A clinical case is presented.
Methods
Dissections were conducted in 21 hemifaces in non-embalmed human cadavers. The maximal harvestable length of ACN was measured and transfer to MMN was simulated. A 28-year-old male underwent ACN-MMN transfer after parotidectomy (carcinoma) and was evaluated 12 months post-operatively (modified Terzis' Lower Lip Grading Scale [25 observers] and photogrammetry).
Results
The harvestable length of ACN was 100 ± 12 mm. A clinically significant anatomical variant (“short ansa”) was present in 33% of cases (length: 37 ± 12 mm). Tensionless coaptation was possible in all cases only when using a modification of the surgical technique in “short ansa” cases (using an infrahyoid muscle nerve branch as an extension). The post-operative course of the clinical case was uneventful without complications, with improvement in tone, symmetry, and function at the lower lip at 12-month post-operative follow-up.
Conclusions
Selective ACN-MMN nerve transfer is anatomically feasible in facial paralysis following oncological ablative procedures. It allows direct nerve coaptation without significant donor site morbidity. The clinical case showed good outcomes 12 months post-operatively. A strategy when encountering the “short ansa” anatomical variant in clinical cases is proposed.
... When the anterior belly of the digastric transfer (ABDT) is accomplished in a single operation, innervation by the trigeminal nerve is maintained, but this does not allow for spontaneous facial reanimation [14]. Accordingly, nerve reeducation is generally required to obtain symmetry and emotionally responsive contraction [14,16]. ABDT is more successfully performed using a two-stage technique, where a cross-facial nerve graft enables innervation of the ABDM by the facial nerve [16] This procedure is significantly more invasive and cannot be performed using endoscopic approaches; thus, there is an inherent trade-off [14,16]. ...
... Accordingly, nerve reeducation is generally required to obtain symmetry and emotionally responsive contraction [14,16]. ABDT is more successfully performed using a two-stage technique, where a cross-facial nerve graft enables innervation of the ABDM by the facial nerve [16] This procedure is significantly more invasive and cannot be performed using endoscopic approaches; thus, there is an inherent trade-off [14,16]. ...
... Accordingly, nerve reeducation is generally required to obtain symmetry and emotionally responsive contraction [14,16]. ABDT is more successfully performed using a two-stage technique, where a cross-facial nerve graft enables innervation of the ABDM by the facial nerve [16] This procedure is significantly more invasive and cannot be performed using endoscopic approaches; thus, there is an inherent trade-off [14,16]. ...
Background
Congenital unilateral lower lip palsy (CULLP), also referred to as congenital asymmetric crying facies (ACF), is a rare condition that causes pronounced depression of the unaffected lower lip when crying, despite symmetric appearance of the mouth and lips at rest. Unlike the acquired form of ACF, CULLP is idiopathic and often involves permanent defect.Methods and resultsWe present a case-based review of CULLP, including a thorough analysis of the relevant literature and a discussion of the exemplary case of 5-year-old patient presenting with unilateral facial asymmetry resulting from left-sided facial weakness. The patient was diagnosed with ACF at birth, and documentation from a previous neurologic consultation specifies the root cause of the asymmetry as developmental aplasia of the left depressor anguli oris muscle (DAOM). However, there is no record of electrodiagnostic testing or B-scan ultrasound imaging that would support this conclusion, and the patient’s dysarthric speech may suggest lower motor neuron involvement. Botox chemodenervation of the right, unaffected side was recommended to deanimate the contralateral lower lip and achieve facial symmetry, in addition to potentially resolving some of the patient’s speech difficulties.Conclusions
There are several approaches, both surgical and non-surgical, to the management and correction of CULLP. These include weakening the muscles of the contralateral side or increasing muscular tension on the ipsilateral side, referred to as deanimation and reanimation procedures, respectively.
... Cross facial nerve grafts (CFNGs) are one of the most ubiquitous and time-honored surgical tools used in facial reanimation. [1][2][3][4][5] They may be used for targeting different mimetic muscles in varied facial subunits, such as the periorbita, midface, and lower lip, [6][7][8][9][10] in both the acute and subacute settings, complementing "babysitter" strategies, or for innervating free functional muscle transfers (FFMTs) and even grafts in long-standing paralysis. [11][12][13][14] Traditionally, CFNG is transferred to the contralateral face through the upper lip in a subcutaneous, submucosal, [15][16][17] or periosteal tunnel 12,18 and banked directly in front of the preauricular incision in a straight line, usually tagged and tacked in place with a large identifiable permanent suture. ...
Cross facial nerve grafts (CFNGs) are one of the most ubiquitous and time-honored surgical tools used in facial reanimation. They may be used for targeting different mimetic muscles in the subacute setting as well as to innervate newly placed muscle flaps in varied facial subunits. In our experience, when used specifically for smile reanimation in two-stage strategies with either traditional "babysitting" approaches in nerve transfers or free functional muscle transfers, the second stage may present some challenges in CFNG identification as well as injury to the previously banked nerve graft. We present some technical modifications in the first-stage CFNG inset that can make the second stage easier and safer. These modifications include: (1) marking the course of the nerve graft with surgical metal clips and inserting loose circumferential sutures throughout the distal course of the nerve in the recipient area to avoid displacement; (2) transferring the nerve graft through the nasal sills rather than lips, protecting it from damage during insertion of free functional muscle transfer; and (3) routing the nerve from the lateral nose to the preauricular area over the zygomatic arch, allowing easier dissection and banking of adequate graft length to provide tension-free coaptation with the flexibility of nerve coaptation in variable positions.
... In the case of longstanding lower lip paralysis, Tzafetta et al. recommend a two-stage technique, first using a cross-facial nerve graft and then the transposition of the anterior belly of the digastric muscle (ABDM), innervated by the cross-facial nerve graft [62]. The authors managed to significantly improve lower lip height and symmetry, smile angle, and dental show [63]. ...
... Lower lip depressors are responsible for the subtle movement of the lower lip, playing a significant role in full-denture smiles and phonetics [63]. Contemporary management of lip depressor palsy depends on whether flaccid paralysis or synkinetic (non-flaccid) palsy is present [81,82]. ...
... Although there are numerous hypothesized mechanisms for synkinesis, nonspecific aberrant regeneration of nerves due to ineffective myelination and reorganization of neural networks during regrowth is the predominant theory [73,74]. Synkinetic lower lip depressor muscles can be managed with ipsilateral weakening of the depressor anguli oris muscle, either through botulinum toxin injections, marginal mandibular nerve neurectomy, or depressor labii inferioris myomectomy [1,63]. Botulinum toxin type A (BTX-A) injections impermanently paralyze muscles by blocking acetylcholine release at the neuromuscular junction, allowing one to improve synkinesis on the affected side and reduce hyperkinesis of the face on the unaffected side [81,82]. ...
Purpose:
To create a systematic overview of the available reconstructive techniques, facial nerve grading scales, physical evaluation, the reversibility of paralysis, non-reconstructive procedures and medical therapy, physical therapy, the psychological aspect of facial paralysis, and the prevention of facial nerve injury in order to elucidate the gaps in the knowledge and discuss potential research aims in this area. A further aim was to propose an algorithm simplifying the selection of reconstructive strategies, given the variety of available reconstructive methods and the abundance of factors influencing the selection.
Methodological approach:
A total of 2439 papers were retrieved from the Medline/Pubmed and Cochrane databases and Google Scholar. Additional research added 21 articles. The primary selection had no limitations regarding the publication date. We considered only papers written in English. Single-case reports were excluded. Screening for duplicates and their removal resulted in a total of 1980 articles. Subsequently, we excluded 778 articles due to the language and study design. The titles or abstracts of 1068 articles were screened, and 134 papers not meeting any exclusion criterion were obtained. After a full-text evaluation, we excluded 15 papers due to the lack of information on preoperative facial nerve function and the follow-up period. This led to the inclusion of 119 articles.
Conclusions:
A thorough clinical examination supported by advanced imaging modalities and electromyographic examination provides sufficient information to determine the cause of facial palsy. Considering the abundance of facial nerve grading scales, there is an evident need for clear guidelines regarding which scale is recommended, as well as when the postoperative evaluation should be carried out. Static procedures allow the restoral of facial symmetry at rest, whereas dynamic reanimation aims to restore facial movement. The modern approach to facial paralysis involves neurotization procedures (nerve transfers and cross-facial nerve grafts), muscle transpositions, and microsurgical free muscle transfers. Rehabilitation provides patients with the possibility of effectively controlling their symptoms and improving their facial function, even in cases of longstanding paresis. Considering the mental health problems and significant social impediments, more attention should be devoted to the role of psychological interventions. Given that each technique has its advantages and pitfalls, the selection of the treatment approach should be individualized in the case of each patient.
... In longstanding cases with no chance of neural recovery and where motor end plates have fibrosed, cross-face nerve graft (CFNG)-powered muscle replacements are well described for both upper and lower lip indications. Free functional gracilis muscle transfer (FFGMT) 1 for upper lip and pedicled anterior belly of digastric muscle transfer (AB-DMT) [2][3][4][5][6][7][8][9][10][11][12] for lower lip are well established techniques. Since upper and lower lip mimetic muscles each have different facial nerve branch inputs and opposing vectors of pull, two different muscle transfers may be required to recreate the vectors faithfully. ...
... There were six males (60%) and four females (40%). The median denervation time up to stage I (CFNG) was 7.75 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) years. ...
Background
One approach to reanimating both upper and lower lips following facial palsy is through staged surgery: cross-face nerve grafting at stage I, free gracilis muscle transfer to levators at stage II and pedicled anterior belly of digastric muscle transfer (ABDMT) to depressors at stage III. The results of this approach were hitherto unquantified.
Methods
This study retrospectively assessed peer-reviewed, patient-rated and objective outcomes following staged reanimation in adults between 2010-2020. Demographics, palsy characteristics and surgery details were recorded. Pre and postoperative videos were rated by independent assessors using Terzis’ aesthetic and symmetry scale. Photographs were analysed using Emotrics and patients completed the Glasgow Benefit inventory (GBI) patient-rated outcome measure.
Results
Ten patients [mean age 34 (SD 12.48)] were eligible. All regained lip elevation and depression. All markers of symmetry improved after gracilis transfer. All markers were also improved after ABDMT except for lower lip height when smiling with teeth showing (p>0.05). Five patients (50%) responded to the GBI (mean score +39.44). No patients reported detriment from the reanimations. Mean Terzis scores preoperatively and after stages II and III were 1.5, 2.26 and 2.39 respectively (p<0.05). Nine patients underwent aesthetic refinements [lipofilling to lower lip notches (n=5), debulking of gracilis bulk (n=6), repositioning of muscle insertion (n=5) and facelifts (n=2)].
Conclusion
The outcomes were positive objectively and as judged by peers and patients themselves. Aesthetic refinements may also be required to enhance these results.
... The senior author has preferentially offered two-stage lower lip reanimations to physiologically fit patients requiring permanent lower lip animation after long denervation times. 20 The second stage consists of ABDM transposition and neurotisation by a CFNG coapted to a redundant CNVII branch at stage one. ...
... The authors' previously published peer-rated (21 raters using the Terzis scale) and photogrammetric (Emotrics) outcomes in patients who had undergone two-stage reanimations up to 2018. 20 The current analysis presents patient-rated outcomes following both single-and two-stage ABDM lower lip reanimations to 2020 at the authors' institution. ...
... All patients regained a degree of spontaneous or facial nerve-controlled lower lip depression as judged by facial palsy physiotherapists, and objectively using Emotrics and 21 independent raters as previously published. 20 The overall mean total GBI was +33.3. Twenty patients reported overall improvement whereas one patient felt the reanimation had been detrimental. ...
Background
The authors previously published positive peer-reviewed (21 raters using the Terzis scale) and photogrammetric (Emotrics) outcomes in patients who had undergone two-stage lower lip reanimations up to 2018. Other series have published surgeon and peer-rated results but only two series (n=12) assessed patient’s views using patient satisfaction surveys.
Aims
This paper presents patient-rated outcomes (PROMS) in an 11-year series of both single- and two-stage ABDM lower lip reanimations.
Methods
Demographics, paralysis characteristics, operative details and complications were recorded. Patients were telephoned and requested to complete the Glasgow Benefit Inventory (GBI) to assess patient-rated outcomes.
Results
Thirty-two patients were eligible (mean age 36.4 years). Twenty-one patients (63.6%) completed the GBI (mean score +33.3). More patients reported benefit than did detriment (95.2% vs.4.8%). Complications were infrequent and included three superficial infections, and one dermatitis. Four patients (12.5%) underwent minor revisions, mostly lipofilling of lip notches. The median duration of follow up was 2.8 years (0.3 – 8.5).
Conclusions
Anterior belly of digastric transfer for lower lip reanimation is a safe, low morbidity procedure which enhances the psychological wellbeing of patients with facial palsy.
