IMPORTANCE Objective assessment of smile outcome after microvascular free gracilis transfer is challenging, and quantification of smile outcomes in the literature is inconsistent.OBJECTIVE To report objective excursion and symmetry outcomes from a series of free gracilis cases and investigate the predictive value of intraoperative measurements on final outcomes. DESIGN, SETTING, AND PARTICIPANTSA retrospective medical chart review was undertaken of all patients who underwent microvascular free gracilis transfer for smile at our institution over the past 10 years. MAIN OUTCOMES AND MEASURESOutcome measures included the following: smile excursion, angle of smile with respect to the vertical midline, and facial symmetry during repose and with smile. Measurements were obtained using an automated tool for assessment of facial landmarks (FACE-Gram). An exhaustive set of intraoperative parameters including degree of recoil of the gracilis muscle following harvest, the degree to which the muscle foreshortened during stimulation of the obturator nerve, final stretched length of the inset muscle, surgeon assessment of neurorrhaphy and pulse pressure, ischemia time, number of sutures used during neurorrhaphy, nerve used to innervate the flap, and surgeon assessment of oral commissure overcorrection were recorded and placed into a linear regression model to investigate correlations with smile. RESULTSFrom March 2003 to March 2013, 154 microvascular free gracilis transfers were performed for facial reanimation at our institution, 14 (9%) of which were deemed failures. Of the remaining 140 flaps, 127 fulfilled inclusion criteria and constituted the study cohort. Smile excursion, angle excursion, and symmetry of the oral commissure at repose and with smile all improved following gracilis free flap (P < .05). Associations between selected outcomes measures and intraoperative gracilis measurements were identified.CONCLUSIONS AND RELEVANCE Facial reanimation using free gracilis transfer results in quantifiable improvements in oral commissure excursion and facial symmetry both at rest and with smiling. Associations between contractility and internal recoil of the flap and final outcome were identified.LEVEL OF EVIDENCE 4.

We observed an accelerative recovery effect of either electrical nerve stimulation or massage of the whisker pad on whisking behavior. The combination of both interventions had a negating effect on the acceleration of recovery. The potential clinical utility of these modalities bears consideration, and their negating interaction warrants further study.

Free gracilis muscle transfer has become a mainstay in the management armamentarium for patients who develop severe reduction in oral commissure movement after facial nerve insult and recovery. The operation achieves a high overall success rate, and innovations involving transplanting thinner segments of muscle avoid a cosmetic deformity secondary to excess bulk. This study demonstrates a quantitative improvement in QOL and facial function after free gracilis muscle transfer in patients who failed to achieve a meaningful smile after physical therapy.

ver the past several decades, clinical outcomes research in facial paralysis has been hampered by a lack of objective and quantitative evaluation of facial function. Ideally, a standard and systematic model for evaluating patient outcomes would exist for patients with facial paralysis. Such a model has been generically described in a recent Outcomes Measure Framework whitepaper 1 for the Agency for Healthcare Research and Quality and was adapted for use in facial plastic surgery and facial paralysis. The components of this model include characteristics of the patient, features of their facial paralysis, and treating health care providers. In addition, the elements of treatment, including types and intent, and their outcomes are recorded. Effective evaluation of facial outcomes following treatment requires both clinician-reported and patient-reported measures of function and well-being. Clinician-reported scales, such as the Sunnybrook Facial Grading System 2 and the modified House-Brackmann grading scale, 3 provide one necessary component of evaluation. Similarly, validated software tools (Facial Assessment by Computer Evaluation program [FACE-gram]) 4 for evaluating facial movement from images also exist and play an important role in treatment planning and assessment. 5 Finally, several relevant patient-reported outcomes measures now exist for facial paralysis such as the Facial Clinimetric Evaluation (FaCE) Scale, 6 the NOSE Scale, 7 and the Synkinesis Assessment Questionnaire. 8 Moving from model to implementation requires the development of both processes and technology to collect, manage, and interpret data. At the Massachusetts Eye and Ear Infirmary (MEEI), we have treated over 2000 patients with facial nerve injury since 2002. To better quantify and improve our outcomes, we have over the years developed what we now believe represents a systematic method for the previsit evaluation, intake, management, and follow-up of our patients with facial nerve injury to optimize data collection for the purposes of clinical studies. However, because standard and systematic data collection for many clinical entities has only recently been introduced, statistically valid conclusions will arise from analysis of data over IMPORTANCE Assessment of outcomes in patients with facial paralysis is challenging owing to the lack of objective tools to evaluate facial function and suboptimal data collection. OBJECTIVE To describe a methodology for prospective evaluation of patients with facial paralysis that permits optimal assessment of clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS At the Massachusetts Eye and Ear Infirmary, we have treated over 2000 patients with facial nerve injury since 2002. To better quantify and improve our outcomes, we have developed what we now believe represents a systematic method for the previsit evaluation, intake, management, and follow-up of our facial nerve patients to optimize data collection for the purposes of clinical outcome studies, as detailed in this retrospective descriptive study. RE...