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Contiguous Muscle Transfer for Reanimation of the Smile in Facial Paralysis: Long Term Outcomes in 105 Patients
Roger L. Simpson, MD, MBA, Jonathon Landon, MD.
Long Island Plastic Surgical Group, Garden City, NY, USA.

Reanimation of the unilateral paralyzed face using contiguous muscle transfer is a reproducible procedure with predictable long-standing dynamic results and a high degree of patient satisfaction.
The pre- and post surgical smiles of 105 patients with complete unilateral facial paralysis were reviewed. All patients underwent dynamic facial reanimation using contiguous muscle transfer of the Temporalis, or Temporalis and Masseter muscles. Length of follow-up ranged from 2 years to 40 years following reanimation. The cohort consisted of 69% females and 31% males. The mean age at surgery was 46.3 years. The etiology of the paralysis was acoustic neuroma in 47%, Bell’s palsy and viral origin in 24%, tumor involving the facial nerve in 18%, trauma 5%, and congenital 5%.
A grading system for objective assessment of the outcome was developed based on symmetry of subunits of the smile following reconstruction. The smile was divided into 3 main subunits: symmetrical teeth show demonstrating upper lip and commissure excursion during both the maximum smile and at rest, symmetry and depth of the nasal labial fold, and degree of downward motion of the lower lip. Points were assigned to each subunit with a maximum of 100 points awarded. Symmetry of teeth show while smiling was given the heaviest weighting. Grades of excellent, good, fair or poor were assigned based on total points, formulating the final smile grade. Photographic review was performed to determine the pre-operative to post-operative improvement of the smile. An independent review of the analysis was carried out by the surgeon, a resident, and a nurse. An interrater reliability analysis using the Kappa statistic was performed to determine consistency among raters.
One hundred five patients with complete, unilateral facial paralysis who underwent contiguous muscle facial reanimation surgery were subject to photographic review and analysis of a dynamic smile. Weighted scoring attributed 50% of the value to upper lip and commissure excursion (teeth show), 30% to symmetry and depth of the nasal labial fold, and 20% to dynamic position of the lower lip. Independent photographic reviews were consistently accurate. Sixty (57.14%) patients received a final smile grade of excellent, 25 (23.81%) good, 15 (14.29%) fair and 5 patients (4.76%) poor.
The grading system proved easy to apply and required no special instrumentation. Comparison of the reconstructed smile in both the resting position and at maximum excursion defined the dynamic component to lip motion in all reanimated patients in the series.

CONCLUSION: An objective grading system represents a simple, reliable, and reproducible process for assessing the results of the reanimated smile in complete unilateral facial paralysis. This process can be applied to any of the techniques of facial reanimation. The consistency of outcome of the reconstructed smile is an important criteria in selection of an operative technique for facial paralysis reanimation. Overall, 81% of patients undergoing reanimation using contiguous muscle transfer received an objective grade of excellent or good. This grading system clearly defines the reconstructed dynamic smile in relation to the opposite non paralyzed side.

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