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IMPORTANCE Facial paralysis can contribute to disfigurement, psychological difficulties, and an inability to convey emotion via facial expression. In patients unable to perform a meaningful smile, free gracilis muscle transfer (FGMT) can often restore smile function. However, little is known about the impact on disease-specific quality of life.OBJECTIVE To determine quantitatively whether FGMT improves quality of life in patients with facial paralysis. DESIGN, SETTING, AND PARTICIPANTS Prospective evaluation of 154 FGMTs performed at a facial nerve center on 148 patients with facial paralysis. The Facial Clinimetric Evaluation (FaCE) survey and Facial Assessment by Computer Evaluation software (FACE-gram) were used to quantify quality-of-life improvement, oral commissure excursion, and symmetry with smile. INTERVENTION Free gracilis muscle transfer. MAIN OUTCOMES AND MEASURES Change in FaCE score, oral commissure excursion, and symmetry with smile. RESULTS There were 127 successful FGMTs on 124 patients and 14 failed procedures on 13 patients. Mean (SD) FaCE score increased significantly after successful FGMT (42.30 [15.9] vs 58.5 [17.60]; paired 2-tailed t test, P < .001). Mean (SD) FACE scores improved significantly in all subgroups (nonflaccid cohort, 37.8 [19.9] vs 52.9 [19.3]; P = .02; flaccid cohort, 43.1 [15.1] vs 59.6 [17.2]; P < .001; trigeminal innervation cohort, 38.9 [14.6] vs 55.2 [18.2]; P < .001; cross-face nerve graft cohort, 47.3 [16.6] vs 61.7 [16.9]; P < .001) except the failure cohort (36.5 [20.8] vs 33.5 [17.9]; Wilcoxon signed-rank test, P = .15). Analysis of 40 patients' photographs revealed a mean (SD) preoperative and postoperative excursion on the affected side of −0.88 (3.79) and 7.68 (3.38), respectively (P < .001); symmetry with smile improved from a mean (SD) of 13.8 (7.46) to 4.88 (3.47) (P < .001). CONCLUSIONS AND RELEVANCEFree gracilis muscle transfer has become a mainstay in the management armamentarium for patients with severe reduction in oral commissure movement after facial nerve insult and recovery. We found a quantitative improvement in quality of life after FGMT in patients who could not recover a meaningful smile after facial nerve insult. Quality-of-life improvement was not statistically different between donor nerve groups or facial paralysis types.LEVEL OF EVIDENCE 3.
IMPORTANCE Facial paralysis can contribute to disfigurement, psychological difficulties, and an inability to convey emotion via facial expression. In patients unable to perform a meaningful smile, free gracilis muscle transfer (FGMT) can often restore smile function. However, little is known about the impact on disease-specific quality of life.OBJECTIVE To determine quantitatively whether FGMT improves quality of life in patients with facial paralysis. DESIGN, SETTING, AND PARTICIPANTS Prospective evaluation of 154 FGMTs performed at a facial nerve center on 148 patients with facial paralysis. The Facial Clinimetric Evaluation (FaCE) survey and Facial Assessment by Computer Evaluation software (FACE-gram) were used to quantify quality-of-life improvement, oral commissure excursion, and symmetry with smile. INTERVENTION Free gracilis muscle transfer. MAIN OUTCOMES AND MEASURES Change in FaCE score, oral commissure excursion, and symmetry with smile. RESULTS There were 127 successful FGMTs on 124 patients and 14 failed procedures on 13 patients. Mean (SD) FaCE score increased significantly after successful FGMT (42.30 [15.9] vs 58.5 [17.60]; paired 2-tailed t test, P < .001). Mean (SD) FACE scores improved significantly in all subgroups (nonflaccid cohort, 37.8 [19.9] vs 52.9 [19.3]; P = .02; flaccid cohort, 43.1 [15.1] vs 59.6 [17.2]; P < .001; trigeminal innervation cohort, 38.9 [14.6] vs 55.2 [18.2]; P < .001; cross-face nerve graft cohort, 47.3 [16.6] vs 61.7 [16.9]; P < .001) except the failure cohort (36.5 [20.8] vs 33.5 [17.9]; Wilcoxon signed-rank test, P = .15). Analysis of 40 patients' photographs revealed a mean (SD) preoperative and postoperative excursion on the affected side of −0.88 (3.79) and 7.68 (3.38), respectively (P < .001); symmetry with smile improved from a mean (SD) of 13.8 (7.46) to 4.88 (3.47) (P < .001). CONCLUSIONS AND RELEVANCEFree gracilis muscle transfer has become a mainstay in the management armamentarium for patients with severe reduction in oral commissure movement after facial nerve insult and recovery. We found a quantitative improvement in quality of life after FGMT in patients who could not recover a meaningful smile after facial nerve insult. Quality-of-life improvement was not statistically different between donor nerve groups or facial paralysis types.LEVEL OF EVIDENCE 3.
In the setting of facial paralysis, inadequate eyelid closure and lower eyelid ectropion can lead to corneal exposure and impaired quality of life. Repair of paralytic ectropion is challenging, and an ideal surgical approach for all cases has not been identified. OBJECTIVE To assess the patient-reported outcomes and eyelid position improvement in patients with flaccid facial paralysis undergoing lateral eyelid coupling with a tarsal strip canthoplasty and modified tarsoconjunctival flap to correct eyelid malposition. DESIGN, SETTING, AND PARTICIPANTS Review of medical records of adults with flaccid facial paralysis who underwent a single-stage tarsal strip canthoplasty and modified tarsoconjunctival flap at a tertiary academic center. Inclusion criteria included a minimum of 3 months of follow-up. INTERVENTION The lateral upper and lower eyelid are coupled with the hybrid tarsoconjunctival flap. MAIN OUTCOMES AND MEASURES Patient-reported outcome measures and objective photograph analysis. Preoperative and postoperative Facial Clinimetric Evaluation (FaCE) scores and Moe Ectropion Grading Scale scores were compared. The relationship between radiation therapy (RT) and outcomes was analyzed. RESULTS Sixteen patients (8 [50%] female; mean [SD] age at surgery, 71.5 [9.6] years) were identified between January 2014 and August 2017. Twelve (75%) had paralysis from facial nerve sacrifice during cancer ablation. The mean time between paralysis and referral for surgical repair of ectropion was 23 months (range, 0-151 months) and mean follow-up after surgery was 9.8 months (range, 3-39 months). The most common symptom was epiphora, which was significantly reduced after surgery (75% vs 25%; P = .01). Median Moe Ectropion Grading Scale score improved from 3 (interquartile range, 2-3) to 0 (interquartile range, 0-1; P < .001). Quality of life measured using the FaCE scale demonstrated a significant improvement in mean eye comfort (from 18.8 [95% CI, 2.3-35.2] to 47.9 [95% CI, 31.9-63.9]; P = .01) and lacrimal control scores (from 12.5 [95% CI, 0-29.2] to 45.8 [95% CI, 29.3-62.3]; P = .03) in the 6 patients in the RT group, but no difference in the 4 patients in the non-RT group. CONCLUSIONS AND RELEVANCE Ocular symptoms, eyelid appearance, and quality of life were improved after lateral eyelid coupling among patients with flaccid facial paralysis and paralytic ectropion. The tarsoconjunctival flap does limit peripheral vision, but is reversible if dynamic eyelid closure is returned with nerve grafting. LEVEL OF EVIDENCE 4.
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