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      Qualitative and Quantitative Analysis of Smile Excursion in Facial Reanimation: A Systematic Review and Meta-analysis of 1- versus 2-stage Procedures


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          Free functional muscle transfer has become a common treatment modality for smile restoration in long-lasting facial paralysis, but the selection of surgical strategy between a 1-stage and a 2-stage procedure has remained a matter of debate. The aim of this study was to compare the quantitative and qualitative outcomes of smile excursion between 1-stage and 2-stage free muscle transfers in the literature.


          A comprehensive review of the published literature between 1975 and end of January 2017 was conducted.


          The abstracts or titles of 2,743 articles were screened. A total of 24 articles met our inclusion criteria of performing a quantitative or qualitative evaluation of a free-functioning muscle transfer for smile restoration. For the purpose of meta-analysis, 7 articles providing quantitative data on a total of 254 patients were included. When comparing muscle excursion between 1-stage and 2-stage procedures, the average range of smile excursion was 11.5 mm versus 6.6 mm, respectively. For the purpose of systematic review, 17 articles were included. The result of the systematic review suggested a tendency toward superior functional results for the 1-stage procedure when comparing the quality of smile.


          The results of this review must be interpreted with great caution. Quantitative analysis suggests that 1-stage procedures produce better excursion than 2-stage procedures. Qualitative analysis suggests that 1-stage procedures might also produce superior results when based on excursion and symmetry alone, but these comparisons do not include one important variable dictating the quality of a smile—the spontaneity of the smile. The difficulty in comparing published results calls for a consensus classification system for facial palsy.

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          Most cited references 33

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          Expression of emotion and quality of life after facial nerve paralysis.

          To investigate the facial expression of emotion and quality of life in patients after long-term facial nerve paralysis. Cross-sectional. Facial nerve paralysis clinic. Twenty-four patients with facial nerve paralysis and 24 significant others (partner, relative, friend). Patients were assessed using Sunnybrook, Sydney, and House-Brackmann grading scales and SF-36, Glasgow Benefit Inventory, and Facial Disability Index quality-of-life measures. When patients identified themselves as either effective or not effective at facially communicating each of Ekman's primary emotions (happiness, disgust, surprise, anger, sadness, and fear), 50% classified themselves as not effective at expressing one or more of the six emotions. Significant others of the not effective patients rated the emotions as more difficult for their partner-patients to communicate facially than did the significant others of effective patients. The SF-36 quality-of-life survey revealed lower social functioning relative to physical functioning for not effective patients. From the Sunnybrook Facial Grading System, more synkinesis was found for those patients not effective at expressing happiness, less brow and eye movement for patients not effective at expressing sadness, and less voluntary movement for those not effective with surprise. Movement deficits associated with expressing specific emotions and an association with quality-of-life measures were identified in patients with long-term facial nerve paralysis who saw themselves as not effective at facial expression of emotions. To improve management of emotional expression in patients with facial nerve paralysis, a broader approach is recommended, linking the practitioner's treatment goals with patient-driven outcome goals.
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            Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation.

            This study assesses the ability of the masseter motor nerve-innervated microneurovascular muscle transfer to produce an effective smile in adult patients with bilateral and unilateral facial paralysis. The operation consists of a one-stage microneurovascular transfer of a portion of the gracilis muscle that is innervated with the masseter motor nerve. The muscle is inserted into the cheek and attached to the mouth to produce a smile. The outcomes assessed were the amount of movement of the transferred muscle; the aesthetic quality of the smile; the control, use, and spontaneity of the smile; and the functional effects on eating, drinking, and speech. The study included 27 patients aged 16 to 61 years who received 45 muscle transfers. All 45 muscle transfers developed movement. The commissure movement averaged 13.0 +/- 4.7 mm at an angle of 47 +/- 15 degrees above the horizontal, and the mid upper lip movement averaged 8.3 +/- 3.0 mm at 42 +/- 17 degrees. Age did not affect the amount of movement. Patients older than 50 years had the same amount of movement as patients younger than 26 years (p = 0.605). Ninety-six percent of patients were satisfied with their smile. A spontaneous smile, the ability to smile without thinking about it, occurred routinely in 59 percent and occasionally in 29 percent of patients. Eighty-five percent of patients learned to smile without biting. Age did not affect the degree of spontaneity of smiling or the patient's ability to smile without biting.
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              Sural nerve donor-site morbidity: thirty-four years of follow-up.

              This study presents a long-term evaluation of sural nerve donor-site morbidity in patients with at least 15 years' follow-up (mean 26 years) after sural nerve harvesting for peripheral nerve repair. Twenty-nine patients (mean age 30 years at time of surgery) participated in a retrospective analysis using a questionnaire. The subjective patient evaluations indicated a significant recovery of the sural nerve donor site with regard to sensory loss, pain, and cold sensitivity over time. Beyond 5 years, no further improvement is to be expected. Our findings provide a guideline for general patient information regarding sural nerve donor-site morbidity. An area of sensory loss of approximately the size of 5 x 6 cm is to be expected, and 20%-30% of the patients experienced minimal levels of pain, cold sensitivity, functional impairment, and scar discomfort. The latter 2 were confined to inconvenience with bumping of the donor site and putting on shoes.

                Author and article information

                Plast Reconstr Surg Glob Open
                Plast Reconstr Surg Glob Open
                Plastic and Reconstructive Surgery Global Open
                Wolters Kluwer Health
                28 December 2017
                December 2017
                : 5
                : 12
                From the [* ]Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden; []Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden; and []Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.
                Author notes
                Hamidreza Natghian, MD, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Sjukhusvagen 10, 751 85 Uppsala, Sweden, E-mail: Hamidreza.natghian@ 123456gmail.com
                Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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