Outcome of the Smile in Facial Paralysis Reanimation - an Objective Evaluation of Post Surgical Results
Jonathan Landon, MD, Roger L. Simpson, MD, MBA.
Long Island Plastic Surgical Group, Garden City, NY, USA.
Analysis of the surgically reconstructed smile following facial paralysis reanimation will provide significant criteria in selection of the reanimation technique. Classification of the reanimated smile in complete unilateral facial paralysis must be an easy to apply, reproducible, and reliable process.
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. 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%. Photographic analysis focused on the pre-operative to post-operative improvement of the smile. Independent review of the analysis was carried out by the surgeon and 3 individuals to assess consistency of the evaluation process.
A grading system 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 the maximum smile, symmetry and depth of the nasal labial fold, and degree of normal 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.
One hundred five patients with complete, unilateral facial paralysis who underwent 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. Overall, 81% of patients undergoing reanimation using contiguous muscle transfer received a grade of excellent or good.
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.
An objective grading system for the smile represents a simple, reliable, and reproducible process for assessing the results of the reanimated smile in complete unilateral facial paralysis. The objective process can be applied to any of the techniques of facial reanimation. The outcome of the reconstructed smile dynamics, along with the choice of motor reanimation, is an important criteria in selection of an operative technique for facial paralysis reanimation. This grading system clearly defines the reconstructed dynamic smile in relation to the opposite non paralyzed side.
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