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Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: A literature review
Accepted Manuscript Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: a literature review Anson Dong, MD(c), MBA(c), Kevin J. Zuo, MD, Georgina Papadopoulos-Nydam, MSc, Jaret Olson, MD, FRSC(C), Gordon Wilkes, MD, FRCS(C), Jana Rieger, PhD PII:
S1010-5182(18)30072-6
DOI:
10.1016/j.jcms.2018.03.008
Reference:
YJCMS 2926
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 14 October 2017 Revised Date:
20 February 2018
Accepted Date: 13 March 2018
Please cite this article as: Dong A, Zuo KJ, Papadopoulos-Nydam G, Olson J, Wilkes G, Rieger J, Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: a literature review, Journal of Cranio-Maxillofacial Surgery (2018), doi: 10.1016/ j.jcms.2018.03.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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b. Division of Plastic & Reconstructive Surgery Department of Surgery, Faculty of Medicine University of Toronto, Toronto, ON, Canada
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a. Faculty of Medicine and Dentistry & Alberta School of Business University of Alberta, Edmonton, AB, Canada
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Author and Affiliationss: • Anson Dong, MD(c), MBA(c)a • Kevin J. Zuo, MDb • Georgina Papadopoulos-Nydam, MScc, e • Jaret Olson, MD, FRSC(C)d • Gordon Wilkes, MD, FRCS(C)d, e • Jana Rieger, PhDc, e
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Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: a literature review
c. Department of Communication Sciences and Disorders, Faculty of Rehabilitation Medicine University of Alberta, Edmonton, AB, Canada d. Division of Plastic & Reconstructive Surgery Department of Surgery, Faculty of Medicine and Dentistry University of Alberta, Edmonton, AB, Canada
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e. Institute for Reconstructive Sciences in Medicine Misericordia Community Hospital, Edmonton, AB, Canada
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Institution: Faculty of Rehabilitation Medicine University of Alberta 8205 114 Street 3-48 Corbett Hall Edmonton, AB, Canada
Corresponding Author: Jana Rieger Professor of Rehabilitation Medicine- Communication Sciences and Disorders University of Alberta Faculty of Rehabilitation Medicine 6-131 Clinical Sciences University of Alberta Edmonton, Alberta T6G 2G4 Phone: 780-492-4992 Fax: 780-492-9333 Email: [email protected]
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Sources of Funding: No sources of grant funding or other funding from external sources were utilized in the authoring of this manuscript.
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Contributions Anson Dong: lead author, idea conception, data collection, data analysis, drafting manuscript, revising manuscript Kevin Zuo: idea conception, data collection, data analysis, drafting manuscript, revising manuscript
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Jaret Olson: expert appraisal, manuscript reviewer
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Georgina Papadopoulos-Nydam: idea conception, data collection, data analysis, drafting manuscript, revising manuscript
Gordon Wilkes: expert appraisal, manuscript reviewer
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Jana Rieger: supervising author, idea conception, data analysis, manuscript reviewer
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Introduction Chronic facial paralysis is a devastating condition that compromises basic human functions such as emotional expression, verbal communication, and oral competence, leading to decreased quality of
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life (Coulson et al., 2004; Ryzenman et al., 2005). Clinicians have sought innovative means of restoring facial function through both static and dynamic reconstructive strategies. Major advancements in microsurgery in the 1970s led to new options in dynamic reconstruction for smile function. Today, the
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gold standard for dynamic reconstruction of oral commissure excursion in patients with chronic facial paralysis is microneurovascular free muscle transfer. Despite these advancements, robust holistic
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assessments of functional outcomes for patients are lacking, with no universally accepted assessment strategy (Niziol et al., 2015). The majority of reports focus on evaluation of pre- and postoperative measures of smile. Although facial expression is indeed a major function of the human face, a dynamic facial musculature system is also vital for speech, oral competence, mastication, deglutition, and overall
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quality of life. These endpoints are uncommonly reported in the literature and characterized by considerable heterogeneity. The purpose of this study was to undertake a literature review of methods
Methods
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of evaluating functional outcomes following dynamic free muscle facial reanimation.
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A literature search was performed in PubMed, Medline, Embase, CINAHL, and Cochrane database for articles reporting functional outcomes of dynamic facial reanimation with free muscle transfer in at least 10 patients per study, and that were published in English from January 1989 to July 2017. The following key words and Medical Subject Heading (MeSH) terms were used:
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(face or facial) and (paralysis or palsy) and (reanimation or animation or dynamic or free muscle) and (outcome or aesthetic or symmetry or smile or swallow or mastication or chew or speech or EMG or excursion or quality of life or satisfaction or complication)
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Additional articles were identified through bibliographic screening of relevant papers. Results were screened by two independent reviewers (KZ, GP) with arbitration of discrepancies by the supervising author (JR). The initial screen involved elimination of results based on titles and abstracts.
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The remaining results were then read in entirety for eligibility for inclusion.
Exclusion criteria included reports with fewer than 10 patients, acute facial palsy, upper face
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(brow and orbicularis oculi) reanimation only, non-specific outcome measures, and review articles. The basis for elimination of articles with fewer than 10 patients was the plethora of articles describing experimental or uncommonly applied techniques in case studies or small case series studies. Furthermore, to avoid redundancy in patient outcomes from ongoing case series studies in a specific
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institution, only the most recent article, or article with the largest patient sample, was included in data collection.
Included articles were examined for number of patients, age and gender, etiology of facial palsy,
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side affected, duration from deficit to reconstruction, muscle transferred, method of reconstruction,
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rehabilitation, complications, and quantitative and qualitative functional outcome measures.
Results
We identified 1465 articles in the primary search. After the initial screen, 95 articles were
retained, and an additional 15 potentially suitable articles were identified by bibliographic cross-review and expert suggestion. After full text review, 37 articles fulfilling the inclusion criteria were included.
Patient Demographics
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Across the 37 studies (Table 1), the most commonly employed reconstructive method was two-stage cross face nerve grafting (CFNG) with free muscle transfer. Other popular choices included one-stage free latissimus dorsi transfer to facial nerve and one-stage free muscle transfer to masseteric nerve.
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Small samples of numerous other dynamic reanimation techniques have been described. The aggregate patient study population was equally distributed between males and females, with slightly more reported female patients (percentage). The major etiologies of facial paralysis were iatrogenic,
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neoplastic, congenital causes, Bell’s palsy, and trauma. Mean patient age was 31.8 years and mean
Functional Outcomes: General Trends
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follow up 23.5 months.
Facial expression was the most commonly measured functional outcome, with 33 of 37 articles evaluating oral commissure excursion using subjective (20 papers), objective (five papers), or combined
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(eight papers) methods (Figure 1). Other functional outcomes that were measured included oral competence (six papers), speech (four papers), and patient satisfaction and quality of life (13 papers) (Table 1). Subjective questionnaires developed by the reporting institution were the most common
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method of measurement.
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Facial Expression: Objective Evaluation
Five studies used objective methods only to assess smile excursion (Table 2). These consisted of
a variety of computer analysis software programs to plot and measure changes in key landmarks on digital photographs of patients. The different computer programs included the FaceMS and FACIAL CLIMA programs (Manktelow et al., 2006; Hontanilla et al., 2013). These groups reported positive post reconstruction excursion with superior results for one-stage masseter innervation and good results for two-stage CFNG reconstruction. Another group used the Scaled Measurement of Improvement in Lip
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Excursion (SMILE) software to analyze photos for scaled measurements in lip excursion standardized to iris diameter (Snyder-Warwick et al., 2015). One group manually measured excursion from the tragion to the commissure in repose and animation, and reported better results in reconstruction with the
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masseteric nerve compared with CFNG (Bae et al., 2006). However, they noted poorer spontaneity with the former. Finally, another group used electromyography (EMG) to assess the number and duration of
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recruited motor units during smiling (Sassoon et al., 1991).
Facial Expression: Subjective Evaluation
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Twenty articles used subjective methods only to assess facial expression (Table 3). Facial movements were graded by researchers based on institution-specific criteria. The rating scales focused predominantly on symmetry and tone, but some considered other variables such as contraction and spontaneity. These scales include Hay’s scale, the Terzis scale, Harii’s 4-scale, Harii’s 6-scale, O’Brien’s 4-
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point scale, and the Toronto Facial Grading System. Results revealed that most patients had satisfactory to good postoperative facial expressions (Harii, 1988; O'Brien et al., 1990; Harii et al., 1998; Kumar et al., 2002; Cuccia et al., 2005; Huang et al., 2009; Terzis et al., 2009a; Terzis et al., 2009b; Woollard et al.,
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2010; Biglioli et al., 2012; Harrison et al., 2012; Liu et al., 2012). Other researchers developed their own scales, such as Faria’s facial grading system and Chuang’s Smile Excursion System, to look at teeth
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exposure (Faria et al., 2007; Chuang et al., 2013). Two research groups employed the House-Brackmann scale instead, looking at dysfunction, and found that 40% of patients had moderately severe to severe facial dysfunction postoperatively (Yla-Kotola et al., 2004; Sforza et al., 2015). Finally, one group relied solely on clinical examination rather than a standardized assessment scale, finding satisfactory results for 92% of patients and 8% having no movement (Yang et al., 2006).
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Facial Expression: Both Objective and Subjective Evaluation Eight studies used both objective and subjective measurements to assess facial expression outcomes (Table 4). Three groups used, respectively: a combination of objective measurements and
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O’Brien’s scale; the FACEgram, the Sunnybrook Facial Grading System (FGS), and the FaCE scale; and the Commissural Excursion Indices in combination with subjective assessments to evaluate facial expression (Bianchi et al., 2010; Krishnan et al., 2010; Lindsay et al., 2014). Schliephake used a similar system to
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Johnson’s metrical system and used Harii’s (1998) scale to evaluate facial expression, where seven patients were noted to have good symmetry and three patients to have acceptable symmetry
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(Schliephake et al., 2000). Frey used three-dimensional video to objectively assess commissure excursion pre and post-treatment, and to observe the presence of facial dyskinesias during expressions, finding that despite commissural excursion improvement, 10 out of 31 patients had dyskinesias (Frey et al., 2008). Faria assessed oral commissure excursion pre- and post-surgery, and also used a scale to assess
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intensity and shape of smile, to compare the success of two intervention groups (Faria et al., 2007). Finally, one group created a 5-grade scale based on clinical examination and EMG findings to stratify
al., 2013).
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Oral Competence
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facial expression outcomes, finding that most patients had good-to-excellent outcomes (Takushima et
Six articles (Table 5) measured functional outcomes related to chewing and swallowing.
Investigators administered patient questionnaires (O'Brien et al., 1990; Kumar et al., 2002; Manktelow et al., 2006), used direct questioning (Bianchi et al., 2010), or conducted video analysis for synkinesis (Rozen et al., 2013). One group utilized a semi-structured interview process consisting of 32 open-ended questions (Bradbury et al., 2006). Participants in the Bianchi study reported absence of drooling and adequate oral control on fluid intake post-reconstruction (Bianchi et al., 2010). Participants in four
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studies (O'Brien et al., 1990; Kumar et al., 2002; Bradbury et al., 2006; Manktelow et al., 2006) mentioned improvements in eating and drinking issues after their surgery, more so with unilateral than with bilateral reconstruction. In addition, one study mentioned that 90% of participants reported
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improvement in their chewing abilities and reduced synkinesis during mastication (Rozen et al., 2013). All six groups that assessed chewing ability reported an increased functional capacity to chew, with 80– 100% of patients reporting improved eating and 90% with improved mastication (O'Brien et al., 1990;
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Kumar et al., 2002; Bradbury et al., 2006; Manktelow et al., 2006; Bianchi et al., 2010; Rozen et al.,
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2013).
Speech
Four articles measured functional speech outcomes (Table 6). Two of these used speech-
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language pathologist assessment (Kumar et al., 2002; Bianchi et al., 2010) and reported slightly greater speech improvement in two-stage reconstruction patients as well as improvement in patient articulation and pronunciation of bilabial phonemes postoperatively. The other two papers focused on using patient
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questionnaires such as the Masseter Questionnaire for Speech and Swallowing to assess speech (O'Brien et al., 1990; Manktelow et al., 2006). These groups found speech difficulties to be reduced more for
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patients with unilateral facial reconstruction compared with bilateral reconstruction, along with an overall patient-reported improvement in speech. Patient Satisfaction and QoL
Thirteen articles measured patient satisfaction outcomes (Table 7), relating to: the level of satisfaction for smile outcomes; their quality of life; the presence of anxiety and/or depression in their lives after surgery (Bradbury et al., 2006); and surgical complications such as pain and edema (Sassoon
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et al., 1991; Schliephake et al., 2000). Participants were given questionnaires (Manktelow et al., 2006) or were interviewed (Bradbury et al., 2006) in relation to their expected outcomes after surgery. More than half of the participants were satisfied with results of the reanimation, expressing good-to-excellent
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results for their smile outcomes and quality of life. However, in one study (Bradbury et al., 2006), eight out of ten participants were identified as suffering from mild depression disorders, whilst 15–21 out of 38 participants were identified as suffering from mild-to-moderate anxiety disorders after their surgery.
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The most recent article used a self-reported facial disability index (FDI) (Bianchi et al., 2017), measuring satisfaction with physical (oromotor and periocular) and social (stress, sleep/anxiety, mood, and social
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isolation) functions.
Discussion
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Microvascular free muscle transfer is the gold standard for dynamic reconstruction of longstanding facial paralysis. Various methods of functioning muscle transfer and neurotisation have been described in the literature, along with a range of strategies for functional outcome assessment
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(Fattah et al., 2012). Although restoration of smile function remains the primary objective of facial reanimation, there is an increasing interest in assessing improvements in other functional outcomes,
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such as speech, swallowing, and quality of life (Rieger et al., 2007; Dziegielewski et al., 2013; Al-Qahtani et al., 2015). The involvement of rehabilitation therapists after surgical intervention is of critical importance for muscle retraining. Unfortunately, reporting of these outcomes is sparse in the facial reanimation literature.
The success of facial reanimation is typically graded by quantitatively evaluating commissure excursion, for which numerous methods have been developed. The advent of computerized facial analysis programs such as SMILE software, FaceMS, and FACIAL CLIMA has permitted more objective
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methods of quantification. Although practical and precise, these programs may be expensive, have limited availability and accessibility, and depend on high-quality photographs; thus, subjective patient and observer scales remain the simplest and most commonly employed methods. Furthermore, the
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ability to evaluate and ensure spontaneity of smile remains elusive. The use of preoperative functional MRI has potential, as do other methods under development, such as EMG to identify whether techniques such as free muscle transfer to masseter muscle have potential for spontaneous smiling in
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selected patients (Romeo et al., 2013; DRKS, 2016). The different definitions of ‘excellent’ or ‘good’ results developed by different groups unfortunately lead to wide variation in grading scales, making it
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challenging to compare results between centres. Facial reanimation studies could benefit from a unification of facial expression outcome evaluation tools through vigorous validation studies, so that appropriate surgical intervention protocols can be developed and tailored to each patient. Despite the significant number of papers assessing facial muscle excursion, few groups have
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assessed outcomes related to oral competence for eating and chewing. Like facial expression, oral competence serves an important role in human socialization, because drooling or loss of food during mastication can be stigmatizing. Our review of the literature identified only five articles that provided
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indirect functional outcomes for oral competence through eating and chewing. Although all of these reported improvements, the methodology was heterogeneous, including questionnaires, interviews,
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and physician observation. None of the articles utilized swallowing imaging, despite its routine use in other facial surgeries such as head and neck oncologic reconstruction (Pauloski, 2008). The ability to eat normally results not only in less social anxiety, but also improved satisfaction. Although the improved outcomes for post-reconstruction oral competence are promising, the development of more standardized assessment methods should be a priority. Similar to the reporting of facial expressions, increased standardization is required so that surgical techniques can be compared between centres.
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Similarly, speech outcomes were reportedly rarely in the literature. Given the importance of speech in social functioning (Gomersall et al., 2015), the paucity of literature highlights the need for more comprehensive outcome reporting in facial reanimation. Results varied, with one paper reporting
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improvement in speech intelligibility ranging from 25% to 53% (O'Brien et al., 1990). Only one paper reported outcomes measured by a speech-language pathologist, with just seven patients in that study having improved articulation, particularly in bilabial phoneme pronunciation (Bianchi et al., 2010). While
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most physicians may not be equipped to evaluate speech, the increased prevalence of interdisciplinary care allows the inclusion of more collaborative assessments by speech-language pathologists.
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Furthermore, there is room for improved reporting on speech through the creation of mixed-method systems to assess patient speech, relying on objective and subjective outcomes as well as a mix of patient and physician questionnaires.
Another important outcome is patient quality of life and satisfaction. Several studies
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investigated patient satisfaction with surgical results, focusing on facial symmetry and smile function. Although aesthetics and elementary movement are important parts of patient satisfaction in reconstructive surgery, this bias in emphasis may divert attention from other domains of patient
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satisfaction. For example, patient satisfaction may reveal dissatisfaction in reconstructive methods such as the use of the masseter nerve for innervation, where poor spontaneity of smile may impede
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performance in social situations. As such, increased acceptance of more psychosocial aspects of patient satisfaction and quality of life functional outcomes is needed in order to provide better patient-centered intervention. The development of standardized quality-of-life scales would help reduce the amount of variability and provide more consistent and reliable results to help evaluate future interventions for facial paralysis. The groups reporting on this outcome provide a promising foundation for highlighting important domains of the patient experience from which to structure these standardized tools. Regardless, further investigation would be required in order strengthen the sensitivity and specificity of
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questions used to assess these domains of patient satisfaction. As patient satisfaction and quality of life often encompass multifactorial dimensions, including the aforementioned outcomes, a broader look at
generalized outlook on recovery from facial paralysis.
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functional outcomes from the patient’s perspective can provide an improved capacity to gain a
Facial reanimation is a transforming procedure for individuals affected by facial paralysis. Functional outcome evaluations have focused heavily on assessment of facial expression, with fewer
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studies recording other outcomes such as oral competence, speech, and patient satisfaction. There is increasing recognition of the importance of patient-reported outcomes in reconstructive surgery,
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ranging from pediatric cleft to breast reconstruction to hand deformities (Pusic et al., 2009; Wong et al., 2013; Griffiths et al.; Johnson et al., 2015; Klassen et al., 2016a; Klassen et al., 2016b). An increased appreciation for more holistic outcomes and an awareness of patient-reported outcomes should be
Conclusion
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prioritized by reconstructive microsurgeons restoring function to patients with facial paralysis.
Facial expression is the most commonly assessed functional outcome after facial reanimation.
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However, there is methodological heterogeneity, with a plethora of subjective and objective methods for assessing facial expression, speech, oral competence, and quality of life. Standardized functional
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outcome assessments for multiple facial functions — not just facial expression — should be developed to enable more comprehensive functional assessment following facial reanimation in the future, and to improve reconstructive techniques.
Acknowledgements and Conflict of Interests We would like to acknowledge the University of Alberta (U of A) and the Institute for Reconstructive Sciences in Medicine (IRSM) for their continued support and assistance.
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Ryzenman JM, Pensak ML, Tew JM, Jr.: Facial paralysis and surgical rehabilitation: a quality of life analysis in a cohort of 1,595 patients after acoustic neuroma surgery. Otology & Neurotology 26:516– 521; discussion 521, 2005.
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Sassoon EM, Poole MD, Rushworth G: Reanimation for facial palsy using gracilis muscle grafts. British Journal of Plastic Surgery 44:195–200, 1991.
Schliephake H, Schmelzeisen R, Troger M: Revascularized muscle transfer for facial reanimation after
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long-standing facial paralysis. Int J Oral Maxillofac Surg 29:243–249, 2000.
Sforza C, Frigerio A, Mapelli A, Tarabbia F, Annoni I, Colombo V, Latiff M, Pimenta Ferreira CL, Rabbiosi
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D, Sidequersky FV, Zago M, Biglioli F: Double-powered free gracilis muscle transfer for smile reanimation: a longitudinal optoelectronic study. Journal of Plastic, Reconstructive & Aesthetic Surgery 68:930–939, 2015.
Snyder-Warwick AK, Fattah AY, Zive L, Halliday W, Borschel GH, Zuker RM: The degree of facial
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movement following microvascular muscle transfer in pediatric facial reanimation depends on donor motor nerve axonal density. Plastic and Reconstructive Surgery 135:e370–381, 2015. Takushima A, Harii K, Asato H, Kurita M, Shiraishi T: Fifteen-year survey of one-stage latissimus dorsi
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muscle transfer for treatment of longstanding facial paralysis. Journal of Plastic, Reconstructive & Aesthetic Surgery 66:29–36, 2013.
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Terzis JK, Karypidis D: Outcomes of direct muscle neurotization in pediatric patients with facial paralysis. Plastic and Reconstructive Surgery 124:1486-1498, 2009a. Terzis JK, Olivares FS: Long-term outcomes of free-muscle transfer for smile restoration in adults. Plastic and Reconstructive Surgery 123:877–888, 2009b. Tzou CH, Chuang DC, Chen HH: Facial paralysis grading system: a new and simple smile excursion score for evaluating facial reanimation surgery. Annals of Plastic Surgery 74:210–213, 2015.
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Reconstructive & Aesthetic Surgery. 63:1557–1560, 2010.
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Woollard ACS, Harrison DH, Grobbelaar AO: An approach to bilateral facial paralysis. Journal of Plastic,
Yang D, Morris SF, Tang M, Geddes CR: A modified longitudinally split segmental rectus femoris muscle flap transfer for facial reanimation: anatomic basis and clinical applications. Journal of Plastic,
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Reconstructive & Aesthetic Surgery 59:807–814, 2006.
Yla-Kotola TM, Kauhanen MS, Asko-Seljavaara SL: Facial reanimation by transplantation of a
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microneurovascular muscle: long-term follow-up. Scandinavian Journal of Plastic and Reconstructive
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Surgery and Hand Surgery 38:272–276, 2004.
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Table 1: Functional outcome assessments for selected articles # pts
F:M
Free muscle transfer
Innervation
FU (mo)
Functional outcomes
Bae 2006
120
50:70
Gracilis
CFNG, Masseter
N/A
Facial expression
48
25:23
Gracilis
CFNG, masseter
Bianchi 2010
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Article
≥12
42
22:20
Gracilis
CFNG
12
QoL
Bianchi 2017
20
8:12
Gracilis
Masseter
≥14
Patient satisfaction/QoL
Biglioli 2012
50
14:36
Gracilis, LD
Masseter, LD (1-stage)
12
Facial expression
Bradbury 2006
106
72:34
N/A
N/A
≥12
Chewing/swallowing, patient satisfaction/QoL
Braig 2016
22
11:11
Gracilis
Masseter, CFNG
≥6
Facial expression
Chuang 2013
36
17:19
Gracilis
CN XI (1-stage)
≥12
Facial expression, patient satisfaction/QoL
Cuccia 2005
11
N/A
LD
LD (1-stage)
18
Facial expression
Faria 2007
91
62:29
CFNG (2-stage), LD, masseter
>18
Facial expression
Frey 2008
31
N/A
Gracilis
CFNG
24
Facial expression
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Facial expression, chewing/swallowing, speech, patient satisfaction/QoL
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Gracilis, LD
Gur 2010
60
N/A
Gracilis
CFNG, masseter, CN7 stump
N/A
Facial expression
Hadlock 2011
17
N/A
Gracilis
CFNG, masseter
N/A
Facial expression, patient satisfaction/QoL
Harii, 1988
76
N/A
Gracilis
CFNG
N/A
Facial expression
Harii 1998
24
N/A
LD
LD
N/A
Facial expression
Harrison 2012
561
316:245
Pec minor, LD, gracilis, EDB
CFNG
23.8
Facial expression
1
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47
28:19
Gracilis
CFNG, masseter
33.2– 38.4
Facial expression
Hontanilla 2016
66
31:35
Gracilis
Masseter, masseteric to facial nerve transfer
≥6
Facial expression
Huang 2009
26
16:10
EDB, EHB
Masseter
≥6
Facial expression
Krishnan 2010
17
14:03
Gracilis, serratus, LD
Masseter
Kumar 2002
25
15:10
Gracilis
CFNG (1- and 2-stage)
Lindsay 2014
20
16:04
Gracilis
CFNG, masseter
>6
Facial expression, patient satisfaction/QoL
Liu 2012
45
21:24
Abductor hallucis
Ipsilateral V3, CN7
54.6
Facial expression
Manktelow 2006
27
18:09
Gracilis
CFNG, masseter
50
Facial expression, chewing/swallowing, speech, patient satisfaction/QoL
O’Brien 1990
69
N/A
Gracilis, EDB, serratus
CFNG, ipsilateral CN 7
N/A
Facial expression, chewing/swallowing, speech, patient satisfaction/QoL
Rozen 2013
18
10:07
Gracilis
Masseter
≥24
Chewing/swallowing
Sassoon 1991
12
N/A
Gracilis
CFNG
≥24
Facial expression, patient satisfaction/QoL
Schliephake 2000
15
07:08
Gracilis
CFNG, CNXII
49.3
Facial expression, patient satisfaction/QoL
Sforza 2015
26
10:03
Gracilis
Masseter, CFNG
17
Facial expression
Snyder-Warwick 2015
25
N/A
Gracilis
Masseter, CFNG
N/A
Facial expression
Takushima 2013
344
211:133
LD
Thoracodorsal nerve
≥24
Facial expression
Terzis 2009 (adults)
24
18:06
Gracilis, pec minor, rectus abdo
CFNG, CNXII, rectus abdo
≥60
Facial expression
Terzis 2009 (children)
37
20:17
Gracilis, pec minor
CFNG, CN XII, CN XI, masseter
≥18
Facial expression
Tzou 2015
329
N/A
CFNG, CNXI, masseter, facial nerve
N/A
Facial expression
Gracilis, pectoralis, serratus
26.4
Facial expression, patient satisfaction/QoL
>36
Facial expression, chewing/swallowing, speech
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Hontanilla 2013
2
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anterior, rectus femoris 19
11:08
Gracilis, LD,
CFNG, masseter
≥24
Facial expression
Yang 2006
25
16:09
Rectus femoris
CFNG
>15
Facial expression
Yla-Kotola 2004
15
11:4
Gracilis, LD, serratus
CFNG
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Woollard 2010
102
Facial expression, patient satisfaction/QoL
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CFNG — cross face nerve graft; LD — latissimus dorsi; CN — cranial nerve; QoL — quality of life; FU — follow up; F — female; M — male; N/A — not reported by authors
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Table 2: Objective measurements of facial expression Author
Objective Methods
Mean commissure excursion (postoperative)
Commissure excursion
7.9 mm (CFNG), 14.2 mm (masseter)
Hontanilla, 2013
Commissure excursion (FACIAL CLIMA program)
Average mean commissural displacement 61.1% (CFNG) and 90.6% (masseter) of contralateral side
Manktelow, 2006
Commissure excursion (FaceMS program)
13.0 mm
Sassoon 1991
EMG — number and duration of motor units
Increased number of motor units during smiling
Snyder-Warwick 2015
Scaled Measurement in Lip Excursion software to analyze photos
Greater gains 8.1 ± 4.0 mm (masseteric nerve) compared with 4.1 ± 2.9 mm (CFNG)
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Bae, 2006
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CFNG — cross face nerve graft; LD — latissimus dorsi
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Table 3: Subjective measurements of facial expression Subjective measurements-scales used
Results (subjective)
Biglioli, 2012
Terzis & Noah (1997)
30% excellent results, 50% good results, and 20% average results
Braig 2016
Projected distance between tragion and commissure set at 100%
Significant commissure movement of the reanimated side while smiling
Chuang, 2013
Smile excursion (tooth exposure) scoring system
Preoperative mean score 0.5 and postoperative mean score 3.45
Cuccia, 2005
Harii’s scale (1998)
Postoperative mean score 3.6
Faria, 2007
Smile grading scale
Gur, 2010
Symmetry scale
Harii, 1988
4-scale
68.4% good, 21.1% satisfactory, 6.6% fair, 3.9% poor results
Harii, 1998
6-scale
85% excellent/satisfactory results
Harrison, 2012
Hay’s score scale (1970)
63% symmetry in smile
Huang, 2009
Hay’s score scale (1970)
88% symmetry in smile
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Author
53.4–86.3% of the three groups had excellent to good results
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94% excellent to good results
60% had good results (Stage I), 73.3% had good results (Stage II)
Liu, 2012
Toronto Facial Grading System (Kayhan 2000)
Average mean score 21.2 preoperative and 50.6 postoperative
O'Brien 1990
4-point scale
4% excellent and 47% good results
House Brackmann scale
Preoperative 69.23% smile, postoperative 75% smile, and 91% smile with teeth clenching
Terzis 2009 (adults)
Facial Grading Scale (Terzis 1997)
More than 70% with good/excellent results
Terzis 2009 (children)
Facial Grading Scale (Terzis 1997)
1 participant 100% and 12 participants 86% with moderate/better results
Tzou 2015
Smile Excursion Score System
Interrater reliability with an average intraclass correlation coefficient of 0.948 (excellent) for smile
Woollard, 2010
Hay’s score scale (1970)
Improvement from mean 9 (preoperative) to mean 2.8 (postoperative)
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Sforza 2015
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O’Brien’s scale modified (1990)
Kumar, 2002
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Clinical examination
Satisfactory results for facial animation in 92% and no movement noted in 8%
Yla-Kotola 2004
House Brackmann scale
18.5% had mild dysfunction after surgery, 40% moderate, 29% moderately severe, and 11% severe dysfunction
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CFNG — cross face nerve graft; LD — latissimus dorsi
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Yang 2006
6
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Table 4: Combined objective and subjective measurements of facial expression
Frey, 2008
Commissure excursion (three-dimensional video)
Hadlock 2011
Commissure excursion (SMILE program)
Hontanilla 20016
FACIAL CLIMA, EMG
Krishnan, 2010
Commissure excursion (commissural excursion indices)
Commissure excursion (FACEgram)
Commissure excursion (by Johnson 1998, 1997)
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Schliephake, 2000
Takushima, 2013
Group I: −0.06 mm and group II: 0.11 mm
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Lindsay, 2014
Results
13 mm (CFNG) and 16 mm (masseter)
O’Brien evaluation criteria (1990)
87% had good symmetry
Group I: 0.55 mm and group II: 0.68 mm
Presence of dyskinesis
10/31 had dyskinesis while smiling and at rest
Postoperative
8.8 mm
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Commissure excursion
Preoperative
Subjective measurements
−1.36 mm
1.89 mm
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Bianchi, 2010
Commissure excursion results
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Objective measurements
FaCE scale
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Author
25.93 mm (affected side)
32.09 mm (affected side)
63.7% vertical and 65.5% horizontal improvement
Graded scale (clinical exam and EMG) assessing symmetry, facial tone at rest, muscle contraction, synchronous smile, and EMG high potentials
CFNG — cross face nerve graft; LD — latissimus dorsi
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Score improved from 51.3 to 65.7
Questionnaire filled by relative for spontaneity of smile
Higher recovery of spontaneity in women than men
Researchers’ observations
59% had a natural smile
Sunnybrook Facial Grading System (FGS) and FaCE scale
Preoperative smile 1.58 and postoperative smile 3.26 using the FGS Preoperative FaCE scale 44.14 and postoperative 57.89
Scale from Harii (1998)
Seven had good symmetry and three had acceptable symmetry
Grading scale
51.6% had excellent results (grade 5), 28.8% had good results (grade 4)
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Table 5: Oral competence outcomes Author
Types of assessment
Oral competence outcomes — results
Bianchi 2010
Questionnaire
Bradbury 2006
Semi-structured interview
Kumar 2002
Questionnaire
100% of patients (stage 1) and 85% (stage 2) reported no eating difficulties
Manktelow 2006
Questionnaire
75% of patients with unilateral reconstruction observed that difficulty with eating and drinking was reduced to 38%, while 22% of patients with bilateral reconstruction difficulties observed a reduction to 50%
O’Brien 1990
Questionnaire
64% of patients noted improvement in eating and 36% no improvement
Rozen 2013
Questionnaire and mastication video analysis
Patients noted no drooling and adequate oral fluid control
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Most patients observed improvement in eating and dribbling
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Involuntary movement in all cases, but only 60% detected by nonmedical experts. 90% reported improvement in mastication and 40% reported problems
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Table 6. Speech outcomes Author
Types of Assessment
Speech outcome results
Bianchi 2010
Articulation assessment
Kumar 2002
Questionnaire
25% of stage 1 patients and 31% of stage 2 patients showed speech improvement
Manktelow 2006
Questionnaire
Incidence of difficulty in speaking reduced from 67% to 11% for unilateral patients and 87% to 53% for bilateral patients
O’Brien 1990
Questionnaire
Speech improved in 53% of patients and did not improve in 47%
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Postoperative assessment showed that seven patients had improvement in articulation (particularly bilabial phoneme pronunciation)
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Table 7. Patient satisfaction outcomes Author
Types of assessment
Patient satisfaction/QoL results
Questionnaire
80% of patients observed improvement in self-esteem and QoL
Bianchi 2016
Questionnaire
Preoperative mean score 29.0 and postoperative mean score 36.55 showing improvement in QoL
Bianchi 2017
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Bianchi 2010
Self-reported satisfaction on physical and social function: preoperative mean score 31.0 and postoperative mean score 36.5
Questionnaire
Hospital Anxiety & Depression Scale; semi-structured interview
Eight patients diagnosed with mild depressive disorder, one with moderate depressive disorder, and one with severe depressive disorder
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Bradbury 2006
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Most significant improvements in oral competence and anxiety, but change in social function/isolation less clear
21 patients diagnosed with mild anxiety disorder, 15 with moderate anxiety disorder, and two with severe anxiety disorder Three patients were satisfied; 27 patients accepted the outcomes but agreed to minor improvement
Chuang 2013
Questionnaire
Hadlock 2011
FaCE instrument self-evaluation
Krishnan 2010
Questionnaire
Lindsay 2014
FaCE instrument self-evaluation
Average mean incorporated facial expression as well
Manktelow 2006
Questionnaire
74% of patients good/very good outcomes, 15% okay, 11% not very good
O’Brien 1990
Questionnaire
Satisfied with smile symmetry: 11% excellent, 57% good, 25% fair, 9% poor smile outcome
Sassoon 1991
Questionnaire
Six patients very satisfied (50%), five patients fairly satisfied (41.6%), one patient fairly unsatisfied (8.3%)
Self-administered SF-36 questionnaire
Comparable average values for every category, reduced score for physical functioning and general health perception, pain, social function, and role limitation
Questionnaire
78% of patients noted improved QoL, whereas 22% noted no change
Yla-Kotola 2004
47% of patients reported normal function of their smile
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Schliephake 2000
Preoperative score 51.3 and postoperative score 65.7
QoL — quality of life
10
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20 15 10
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Number of Articles (#)
25
5
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0
Outcome Measures
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Figure 1: Distribution of functional outcomes classified by category and methodology, as reported in selected articles featuring free muscle transfer facial reanimation
S1010-5182(18)30072-6
DOI:
10.1016/j.jcms.2018.03.008
Reference:
YJCMS 2926
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 14 October 2017 Revised Date:
20 February 2018
Accepted Date: 13 March 2018
Please cite this article as: Dong A, Zuo KJ, Papadopoulos-Nydam G, Olson J, Wilkes G, Rieger J, Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: a literature review, Journal of Cranio-Maxillofacial Surgery (2018), doi: 10.1016/ j.jcms.2018.03.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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b. Division of Plastic & Reconstructive Surgery Department of Surgery, Faculty of Medicine University of Toronto, Toronto, ON, Canada
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a. Faculty of Medicine and Dentistry & Alberta School of Business University of Alberta, Edmonton, AB, Canada
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Author and Affiliationss: • Anson Dong, MD(c), MBA(c)a • Kevin J. Zuo, MDb • Georgina Papadopoulos-Nydam, MScc, e • Jaret Olson, MD, FRSC(C)d • Gordon Wilkes, MD, FRCS(C)d, e • Jana Rieger, PhDc, e
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Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: a literature review
c. Department of Communication Sciences and Disorders, Faculty of Rehabilitation Medicine University of Alberta, Edmonton, AB, Canada d. Division of Plastic & Reconstructive Surgery Department of Surgery, Faculty of Medicine and Dentistry University of Alberta, Edmonton, AB, Canada
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e. Institute for Reconstructive Sciences in Medicine Misericordia Community Hospital, Edmonton, AB, Canada
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Institution: Faculty of Rehabilitation Medicine University of Alberta 8205 114 Street 3-48 Corbett Hall Edmonton, AB, Canada
Corresponding Author: Jana Rieger Professor of Rehabilitation Medicine- Communication Sciences and Disorders University of Alberta Faculty of Rehabilitation Medicine 6-131 Clinical Sciences University of Alberta Edmonton, Alberta T6G 2G4 Phone: 780-492-4992 Fax: 780-492-9333 Email: [email protected]
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Sources of Funding: No sources of grant funding or other funding from external sources were utilized in the authoring of this manuscript.
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Contributions Anson Dong: lead author, idea conception, data collection, data analysis, drafting manuscript, revising manuscript Kevin Zuo: idea conception, data collection, data analysis, drafting manuscript, revising manuscript
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Jaret Olson: expert appraisal, manuscript reviewer
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Georgina Papadopoulos-Nydam: idea conception, data collection, data analysis, drafting manuscript, revising manuscript
Gordon Wilkes: expert appraisal, manuscript reviewer
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Jana Rieger: supervising author, idea conception, data analysis, manuscript reviewer
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Introduction Chronic facial paralysis is a devastating condition that compromises basic human functions such as emotional expression, verbal communication, and oral competence, leading to decreased quality of
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life (Coulson et al., 2004; Ryzenman et al., 2005). Clinicians have sought innovative means of restoring facial function through both static and dynamic reconstructive strategies. Major advancements in microsurgery in the 1970s led to new options in dynamic reconstruction for smile function. Today, the
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gold standard for dynamic reconstruction of oral commissure excursion in patients with chronic facial paralysis is microneurovascular free muscle transfer. Despite these advancements, robust holistic
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assessments of functional outcomes for patients are lacking, with no universally accepted assessment strategy (Niziol et al., 2015). The majority of reports focus on evaluation of pre- and postoperative measures of smile. Although facial expression is indeed a major function of the human face, a dynamic facial musculature system is also vital for speech, oral competence, mastication, deglutition, and overall
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quality of life. These endpoints are uncommonly reported in the literature and characterized by considerable heterogeneity. The purpose of this study was to undertake a literature review of methods
Methods
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of evaluating functional outcomes following dynamic free muscle facial reanimation.
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A literature search was performed in PubMed, Medline, Embase, CINAHL, and Cochrane database for articles reporting functional outcomes of dynamic facial reanimation with free muscle transfer in at least 10 patients per study, and that were published in English from January 1989 to July 2017. The following key words and Medical Subject Heading (MeSH) terms were used:
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(face or facial) and (paralysis or palsy) and (reanimation or animation or dynamic or free muscle) and (outcome or aesthetic or symmetry or smile or swallow or mastication or chew or speech or EMG or excursion or quality of life or satisfaction or complication)
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Additional articles were identified through bibliographic screening of relevant papers. Results were screened by two independent reviewers (KZ, GP) with arbitration of discrepancies by the supervising author (JR). The initial screen involved elimination of results based on titles and abstracts.
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The remaining results were then read in entirety for eligibility for inclusion.
Exclusion criteria included reports with fewer than 10 patients, acute facial palsy, upper face
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(brow and orbicularis oculi) reanimation only, non-specific outcome measures, and review articles. The basis for elimination of articles with fewer than 10 patients was the plethora of articles describing experimental or uncommonly applied techniques in case studies or small case series studies. Furthermore, to avoid redundancy in patient outcomes from ongoing case series studies in a specific
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institution, only the most recent article, or article with the largest patient sample, was included in data collection.
Included articles were examined for number of patients, age and gender, etiology of facial palsy,
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side affected, duration from deficit to reconstruction, muscle transferred, method of reconstruction,
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rehabilitation, complications, and quantitative and qualitative functional outcome measures.
Results
We identified 1465 articles in the primary search. After the initial screen, 95 articles were
retained, and an additional 15 potentially suitable articles were identified by bibliographic cross-review and expert suggestion. After full text review, 37 articles fulfilling the inclusion criteria were included.
Patient Demographics
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Across the 37 studies (Table 1), the most commonly employed reconstructive method was two-stage cross face nerve grafting (CFNG) with free muscle transfer. Other popular choices included one-stage free latissimus dorsi transfer to facial nerve and one-stage free muscle transfer to masseteric nerve.
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Small samples of numerous other dynamic reanimation techniques have been described. The aggregate patient study population was equally distributed between males and females, with slightly more reported female patients (percentage). The major etiologies of facial paralysis were iatrogenic,
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neoplastic, congenital causes, Bell’s palsy, and trauma. Mean patient age was 31.8 years and mean
Functional Outcomes: General Trends
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follow up 23.5 months.
Facial expression was the most commonly measured functional outcome, with 33 of 37 articles evaluating oral commissure excursion using subjective (20 papers), objective (five papers), or combined
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(eight papers) methods (Figure 1). Other functional outcomes that were measured included oral competence (six papers), speech (four papers), and patient satisfaction and quality of life (13 papers) (Table 1). Subjective questionnaires developed by the reporting institution were the most common
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method of measurement.
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Facial Expression: Objective Evaluation
Five studies used objective methods only to assess smile excursion (Table 2). These consisted of
a variety of computer analysis software programs to plot and measure changes in key landmarks on digital photographs of patients. The different computer programs included the FaceMS and FACIAL CLIMA programs (Manktelow et al., 2006; Hontanilla et al., 2013). These groups reported positive post reconstruction excursion with superior results for one-stage masseter innervation and good results for two-stage CFNG reconstruction. Another group used the Scaled Measurement of Improvement in Lip
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Excursion (SMILE) software to analyze photos for scaled measurements in lip excursion standardized to iris diameter (Snyder-Warwick et al., 2015). One group manually measured excursion from the tragion to the commissure in repose and animation, and reported better results in reconstruction with the
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masseteric nerve compared with CFNG (Bae et al., 2006). However, they noted poorer spontaneity with the former. Finally, another group used electromyography (EMG) to assess the number and duration of
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recruited motor units during smiling (Sassoon et al., 1991).
Facial Expression: Subjective Evaluation
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Twenty articles used subjective methods only to assess facial expression (Table 3). Facial movements were graded by researchers based on institution-specific criteria. The rating scales focused predominantly on symmetry and tone, but some considered other variables such as contraction and spontaneity. These scales include Hay’s scale, the Terzis scale, Harii’s 4-scale, Harii’s 6-scale, O’Brien’s 4-
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point scale, and the Toronto Facial Grading System. Results revealed that most patients had satisfactory to good postoperative facial expressions (Harii, 1988; O'Brien et al., 1990; Harii et al., 1998; Kumar et al., 2002; Cuccia et al., 2005; Huang et al., 2009; Terzis et al., 2009a; Terzis et al., 2009b; Woollard et al.,
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2010; Biglioli et al., 2012; Harrison et al., 2012; Liu et al., 2012). Other researchers developed their own scales, such as Faria’s facial grading system and Chuang’s Smile Excursion System, to look at teeth
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exposure (Faria et al., 2007; Chuang et al., 2013). Two research groups employed the House-Brackmann scale instead, looking at dysfunction, and found that 40% of patients had moderately severe to severe facial dysfunction postoperatively (Yla-Kotola et al., 2004; Sforza et al., 2015). Finally, one group relied solely on clinical examination rather than a standardized assessment scale, finding satisfactory results for 92% of patients and 8% having no movement (Yang et al., 2006).
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Facial Expression: Both Objective and Subjective Evaluation Eight studies used both objective and subjective measurements to assess facial expression outcomes (Table 4). Three groups used, respectively: a combination of objective measurements and
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O’Brien’s scale; the FACEgram, the Sunnybrook Facial Grading System (FGS), and the FaCE scale; and the Commissural Excursion Indices in combination with subjective assessments to evaluate facial expression (Bianchi et al., 2010; Krishnan et al., 2010; Lindsay et al., 2014). Schliephake used a similar system to
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Johnson’s metrical system and used Harii’s (1998) scale to evaluate facial expression, where seven patients were noted to have good symmetry and three patients to have acceptable symmetry
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(Schliephake et al., 2000). Frey used three-dimensional video to objectively assess commissure excursion pre and post-treatment, and to observe the presence of facial dyskinesias during expressions, finding that despite commissural excursion improvement, 10 out of 31 patients had dyskinesias (Frey et al., 2008). Faria assessed oral commissure excursion pre- and post-surgery, and also used a scale to assess
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intensity and shape of smile, to compare the success of two intervention groups (Faria et al., 2007). Finally, one group created a 5-grade scale based on clinical examination and EMG findings to stratify
al., 2013).
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Oral Competence
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facial expression outcomes, finding that most patients had good-to-excellent outcomes (Takushima et
Six articles (Table 5) measured functional outcomes related to chewing and swallowing.
Investigators administered patient questionnaires (O'Brien et al., 1990; Kumar et al., 2002; Manktelow et al., 2006), used direct questioning (Bianchi et al., 2010), or conducted video analysis for synkinesis (Rozen et al., 2013). One group utilized a semi-structured interview process consisting of 32 open-ended questions (Bradbury et al., 2006). Participants in the Bianchi study reported absence of drooling and adequate oral control on fluid intake post-reconstruction (Bianchi et al., 2010). Participants in four
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studies (O'Brien et al., 1990; Kumar et al., 2002; Bradbury et al., 2006; Manktelow et al., 2006) mentioned improvements in eating and drinking issues after their surgery, more so with unilateral than with bilateral reconstruction. In addition, one study mentioned that 90% of participants reported
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improvement in their chewing abilities and reduced synkinesis during mastication (Rozen et al., 2013). All six groups that assessed chewing ability reported an increased functional capacity to chew, with 80– 100% of patients reporting improved eating and 90% with improved mastication (O'Brien et al., 1990;
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Kumar et al., 2002; Bradbury et al., 2006; Manktelow et al., 2006; Bianchi et al., 2010; Rozen et al.,
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2013).
Speech
Four articles measured functional speech outcomes (Table 6). Two of these used speech-
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language pathologist assessment (Kumar et al., 2002; Bianchi et al., 2010) and reported slightly greater speech improvement in two-stage reconstruction patients as well as improvement in patient articulation and pronunciation of bilabial phonemes postoperatively. The other two papers focused on using patient
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questionnaires such as the Masseter Questionnaire for Speech and Swallowing to assess speech (O'Brien et al., 1990; Manktelow et al., 2006). These groups found speech difficulties to be reduced more for
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patients with unilateral facial reconstruction compared with bilateral reconstruction, along with an overall patient-reported improvement in speech. Patient Satisfaction and QoL
Thirteen articles measured patient satisfaction outcomes (Table 7), relating to: the level of satisfaction for smile outcomes; their quality of life; the presence of anxiety and/or depression in their lives after surgery (Bradbury et al., 2006); and surgical complications such as pain and edema (Sassoon
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et al., 1991; Schliephake et al., 2000). Participants were given questionnaires (Manktelow et al., 2006) or were interviewed (Bradbury et al., 2006) in relation to their expected outcomes after surgery. More than half of the participants were satisfied with results of the reanimation, expressing good-to-excellent
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results for their smile outcomes and quality of life. However, in one study (Bradbury et al., 2006), eight out of ten participants were identified as suffering from mild depression disorders, whilst 15–21 out of 38 participants were identified as suffering from mild-to-moderate anxiety disorders after their surgery.
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The most recent article used a self-reported facial disability index (FDI) (Bianchi et al., 2017), measuring satisfaction with physical (oromotor and periocular) and social (stress, sleep/anxiety, mood, and social
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isolation) functions.
Discussion
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Microvascular free muscle transfer is the gold standard for dynamic reconstruction of longstanding facial paralysis. Various methods of functioning muscle transfer and neurotisation have been described in the literature, along with a range of strategies for functional outcome assessment
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(Fattah et al., 2012). Although restoration of smile function remains the primary objective of facial reanimation, there is an increasing interest in assessing improvements in other functional outcomes,
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such as speech, swallowing, and quality of life (Rieger et al., 2007; Dziegielewski et al., 2013; Al-Qahtani et al., 2015). The involvement of rehabilitation therapists after surgical intervention is of critical importance for muscle retraining. Unfortunately, reporting of these outcomes is sparse in the facial reanimation literature.
The success of facial reanimation is typically graded by quantitatively evaluating commissure excursion, for which numerous methods have been developed. The advent of computerized facial analysis programs such as SMILE software, FaceMS, and FACIAL CLIMA has permitted more objective
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methods of quantification. Although practical and precise, these programs may be expensive, have limited availability and accessibility, and depend on high-quality photographs; thus, subjective patient and observer scales remain the simplest and most commonly employed methods. Furthermore, the
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ability to evaluate and ensure spontaneity of smile remains elusive. The use of preoperative functional MRI has potential, as do other methods under development, such as EMG to identify whether techniques such as free muscle transfer to masseter muscle have potential for spontaneous smiling in
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selected patients (Romeo et al., 2013; DRKS, 2016). The different definitions of ‘excellent’ or ‘good’ results developed by different groups unfortunately lead to wide variation in grading scales, making it
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challenging to compare results between centres. Facial reanimation studies could benefit from a unification of facial expression outcome evaluation tools through vigorous validation studies, so that appropriate surgical intervention protocols can be developed and tailored to each patient. Despite the significant number of papers assessing facial muscle excursion, few groups have
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assessed outcomes related to oral competence for eating and chewing. Like facial expression, oral competence serves an important role in human socialization, because drooling or loss of food during mastication can be stigmatizing. Our review of the literature identified only five articles that provided
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indirect functional outcomes for oral competence through eating and chewing. Although all of these reported improvements, the methodology was heterogeneous, including questionnaires, interviews,
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and physician observation. None of the articles utilized swallowing imaging, despite its routine use in other facial surgeries such as head and neck oncologic reconstruction (Pauloski, 2008). The ability to eat normally results not only in less social anxiety, but also improved satisfaction. Although the improved outcomes for post-reconstruction oral competence are promising, the development of more standardized assessment methods should be a priority. Similar to the reporting of facial expressions, increased standardization is required so that surgical techniques can be compared between centres.
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Similarly, speech outcomes were reportedly rarely in the literature. Given the importance of speech in social functioning (Gomersall et al., 2015), the paucity of literature highlights the need for more comprehensive outcome reporting in facial reanimation. Results varied, with one paper reporting
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improvement in speech intelligibility ranging from 25% to 53% (O'Brien et al., 1990). Only one paper reported outcomes measured by a speech-language pathologist, with just seven patients in that study having improved articulation, particularly in bilabial phoneme pronunciation (Bianchi et al., 2010). While
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most physicians may not be equipped to evaluate speech, the increased prevalence of interdisciplinary care allows the inclusion of more collaborative assessments by speech-language pathologists.
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Furthermore, there is room for improved reporting on speech through the creation of mixed-method systems to assess patient speech, relying on objective and subjective outcomes as well as a mix of patient and physician questionnaires.
Another important outcome is patient quality of life and satisfaction. Several studies
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investigated patient satisfaction with surgical results, focusing on facial symmetry and smile function. Although aesthetics and elementary movement are important parts of patient satisfaction in reconstructive surgery, this bias in emphasis may divert attention from other domains of patient
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satisfaction. For example, patient satisfaction may reveal dissatisfaction in reconstructive methods such as the use of the masseter nerve for innervation, where poor spontaneity of smile may impede
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performance in social situations. As such, increased acceptance of more psychosocial aspects of patient satisfaction and quality of life functional outcomes is needed in order to provide better patient-centered intervention. The development of standardized quality-of-life scales would help reduce the amount of variability and provide more consistent and reliable results to help evaluate future interventions for facial paralysis. The groups reporting on this outcome provide a promising foundation for highlighting important domains of the patient experience from which to structure these standardized tools. Regardless, further investigation would be required in order strengthen the sensitivity and specificity of
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questions used to assess these domains of patient satisfaction. As patient satisfaction and quality of life often encompass multifactorial dimensions, including the aforementioned outcomes, a broader look at
generalized outlook on recovery from facial paralysis.
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functional outcomes from the patient’s perspective can provide an improved capacity to gain a
Facial reanimation is a transforming procedure for individuals affected by facial paralysis. Functional outcome evaluations have focused heavily on assessment of facial expression, with fewer
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studies recording other outcomes such as oral competence, speech, and patient satisfaction. There is increasing recognition of the importance of patient-reported outcomes in reconstructive surgery,
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ranging from pediatric cleft to breast reconstruction to hand deformities (Pusic et al., 2009; Wong et al., 2013; Griffiths et al.; Johnson et al., 2015; Klassen et al., 2016a; Klassen et al., 2016b). An increased appreciation for more holistic outcomes and an awareness of patient-reported outcomes should be
Conclusion
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prioritized by reconstructive microsurgeons restoring function to patients with facial paralysis.
Facial expression is the most commonly assessed functional outcome after facial reanimation.
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However, there is methodological heterogeneity, with a plethora of subjective and objective methods for assessing facial expression, speech, oral competence, and quality of life. Standardized functional
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outcome assessments for multiple facial functions — not just facial expression — should be developed to enable more comprehensive functional assessment following facial reanimation in the future, and to improve reconstructive techniques.
Acknowledgements and Conflict of Interests We would like to acknowledge the University of Alberta (U of A) and the Institute for Reconstructive Sciences in Medicine (IRSM) for their continued support and assistance.
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Table 1: Functional outcome assessments for selected articles # pts
F:M
Free muscle transfer
Innervation
FU (mo)
Functional outcomes
Bae 2006
120
50:70
Gracilis
CFNG, Masseter
N/A
Facial expression
48
25:23
Gracilis
CFNG, masseter
Bianchi 2010
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Article
≥12
42
22:20
Gracilis
CFNG
12
QoL
Bianchi 2017
20
8:12
Gracilis
Masseter
≥14
Patient satisfaction/QoL
Biglioli 2012
50
14:36
Gracilis, LD
Masseter, LD (1-stage)
12
Facial expression
Bradbury 2006
106
72:34
N/A
N/A
≥12
Chewing/swallowing, patient satisfaction/QoL
Braig 2016
22
11:11
Gracilis
Masseter, CFNG
≥6
Facial expression
Chuang 2013
36
17:19
Gracilis
CN XI (1-stage)
≥12
Facial expression, patient satisfaction/QoL
Cuccia 2005
11
N/A
LD
LD (1-stage)
18
Facial expression
Faria 2007
91
62:29
CFNG (2-stage), LD, masseter
>18
Facial expression
Frey 2008
31
N/A
Gracilis
CFNG
24
Facial expression
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Bianchi 2016
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Facial expression, chewing/swallowing, speech, patient satisfaction/QoL
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Gracilis, LD
Gur 2010
60
N/A
Gracilis
CFNG, masseter, CN7 stump
N/A
Facial expression
Hadlock 2011
17
N/A
Gracilis
CFNG, masseter
N/A
Facial expression, patient satisfaction/QoL
Harii, 1988
76
N/A
Gracilis
CFNG
N/A
Facial expression
Harii 1998
24
N/A
LD
LD
N/A
Facial expression
Harrison 2012
561
316:245
Pec minor, LD, gracilis, EDB
CFNG
23.8
Facial expression
1
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47
28:19
Gracilis
CFNG, masseter
33.2– 38.4
Facial expression
Hontanilla 2016
66
31:35
Gracilis
Masseter, masseteric to facial nerve transfer
≥6
Facial expression
Huang 2009
26
16:10
EDB, EHB
Masseter
≥6
Facial expression
Krishnan 2010
17
14:03
Gracilis, serratus, LD
Masseter
Kumar 2002
25
15:10
Gracilis
CFNG (1- and 2-stage)
Lindsay 2014
20
16:04
Gracilis
CFNG, masseter
>6
Facial expression, patient satisfaction/QoL
Liu 2012
45
21:24
Abductor hallucis
Ipsilateral V3, CN7
54.6
Facial expression
Manktelow 2006
27
18:09
Gracilis
CFNG, masseter
50
Facial expression, chewing/swallowing, speech, patient satisfaction/QoL
O’Brien 1990
69
N/A
Gracilis, EDB, serratus
CFNG, ipsilateral CN 7
N/A
Facial expression, chewing/swallowing, speech, patient satisfaction/QoL
Rozen 2013
18
10:07
Gracilis
Masseter
≥24
Chewing/swallowing
Sassoon 1991
12
N/A
Gracilis
CFNG
≥24
Facial expression, patient satisfaction/QoL
Schliephake 2000
15
07:08
Gracilis
CFNG, CNXII
49.3
Facial expression, patient satisfaction/QoL
Sforza 2015
26
10:03
Gracilis
Masseter, CFNG
17
Facial expression
Snyder-Warwick 2015
25
N/A
Gracilis
Masseter, CFNG
N/A
Facial expression
Takushima 2013
344
211:133
LD
Thoracodorsal nerve
≥24
Facial expression
Terzis 2009 (adults)
24
18:06
Gracilis, pec minor, rectus abdo
CFNG, CNXII, rectus abdo
≥60
Facial expression
Terzis 2009 (children)
37
20:17
Gracilis, pec minor
CFNG, CN XII, CN XI, masseter
≥18
Facial expression
Tzou 2015
329
N/A
CFNG, CNXI, masseter, facial nerve
N/A
Facial expression
Gracilis, pectoralis, serratus
26.4
Facial expression, patient satisfaction/QoL
>36
Facial expression, chewing/swallowing, speech
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Hontanilla 2013
2
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anterior, rectus femoris 19
11:08
Gracilis, LD,
CFNG, masseter
≥24
Facial expression
Yang 2006
25
16:09
Rectus femoris
CFNG
>15
Facial expression
Yla-Kotola 2004
15
11:4
Gracilis, LD, serratus
CFNG
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Woollard 2010
102
Facial expression, patient satisfaction/QoL
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CFNG — cross face nerve graft; LD — latissimus dorsi; CN — cranial nerve; QoL — quality of life; FU — follow up; F — female; M — male; N/A — not reported by authors
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Table 2: Objective measurements of facial expression Author
Objective Methods
Mean commissure excursion (postoperative)
Commissure excursion
7.9 mm (CFNG), 14.2 mm (masseter)
Hontanilla, 2013
Commissure excursion (FACIAL CLIMA program)
Average mean commissural displacement 61.1% (CFNG) and 90.6% (masseter) of contralateral side
Manktelow, 2006
Commissure excursion (FaceMS program)
13.0 mm
Sassoon 1991
EMG — number and duration of motor units
Increased number of motor units during smiling
Snyder-Warwick 2015
Scaled Measurement in Lip Excursion software to analyze photos
Greater gains 8.1 ± 4.0 mm (masseteric nerve) compared with 4.1 ± 2.9 mm (CFNG)
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Bae, 2006
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CFNG — cross face nerve graft; LD — latissimus dorsi
4
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Table 3: Subjective measurements of facial expression Subjective measurements-scales used
Results (subjective)
Biglioli, 2012
Terzis & Noah (1997)
30% excellent results, 50% good results, and 20% average results
Braig 2016
Projected distance between tragion and commissure set at 100%
Significant commissure movement of the reanimated side while smiling
Chuang, 2013
Smile excursion (tooth exposure) scoring system
Preoperative mean score 0.5 and postoperative mean score 3.45
Cuccia, 2005
Harii’s scale (1998)
Postoperative mean score 3.6
Faria, 2007
Smile grading scale
Gur, 2010
Symmetry scale
Harii, 1988
4-scale
68.4% good, 21.1% satisfactory, 6.6% fair, 3.9% poor results
Harii, 1998
6-scale
85% excellent/satisfactory results
Harrison, 2012
Hay’s score scale (1970)
63% symmetry in smile
Huang, 2009
Hay’s score scale (1970)
88% symmetry in smile
SC
RI PT
Author
53.4–86.3% of the three groups had excellent to good results
M AN U
94% excellent to good results
60% had good results (Stage I), 73.3% had good results (Stage II)
Liu, 2012
Toronto Facial Grading System (Kayhan 2000)
Average mean score 21.2 preoperative and 50.6 postoperative
O'Brien 1990
4-point scale
4% excellent and 47% good results
House Brackmann scale
Preoperative 69.23% smile, postoperative 75% smile, and 91% smile with teeth clenching
Terzis 2009 (adults)
Facial Grading Scale (Terzis 1997)
More than 70% with good/excellent results
Terzis 2009 (children)
Facial Grading Scale (Terzis 1997)
1 participant 100% and 12 participants 86% with moderate/better results
Tzou 2015
Smile Excursion Score System
Interrater reliability with an average intraclass correlation coefficient of 0.948 (excellent) for smile
Woollard, 2010
Hay’s score scale (1970)
Improvement from mean 9 (preoperative) to mean 2.8 (postoperative)
EP
AC C
Sforza 2015
TE D
O’Brien’s scale modified (1990)
Kumar, 2002
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Clinical examination
Satisfactory results for facial animation in 92% and no movement noted in 8%
Yla-Kotola 2004
House Brackmann scale
18.5% had mild dysfunction after surgery, 40% moderate, 29% moderately severe, and 11% severe dysfunction
AC C
EP
TE D
M AN U
SC
CFNG — cross face nerve graft; LD — latissimus dorsi
RI PT
Yang 2006
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Table 4: Combined objective and subjective measurements of facial expression
Frey, 2008
Commissure excursion (three-dimensional video)
Hadlock 2011
Commissure excursion (SMILE program)
Hontanilla 20016
FACIAL CLIMA, EMG
Krishnan, 2010
Commissure excursion (commissural excursion indices)
Commissure excursion (FACEgram)
Commissure excursion (by Johnson 1998, 1997)
AC C
Schliephake, 2000
Takushima, 2013
Group I: −0.06 mm and group II: 0.11 mm
EP
Lindsay, 2014
Results
13 mm (CFNG) and 16 mm (masseter)
O’Brien evaluation criteria (1990)
87% had good symmetry
Group I: 0.55 mm and group II: 0.68 mm
Presence of dyskinesis
10/31 had dyskinesis while smiling and at rest
Postoperative
8.8 mm
RI PT
Commissure excursion
Preoperative
Subjective measurements
−1.36 mm
1.89 mm
TE D
Bianchi, 2010
Commissure excursion results
SC
Objective measurements
FaCE scale
M AN U
Author
25.93 mm (affected side)
32.09 mm (affected side)
63.7% vertical and 65.5% horizontal improvement
Graded scale (clinical exam and EMG) assessing symmetry, facial tone at rest, muscle contraction, synchronous smile, and EMG high potentials
CFNG — cross face nerve graft; LD — latissimus dorsi
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Score improved from 51.3 to 65.7
Questionnaire filled by relative for spontaneity of smile
Higher recovery of spontaneity in women than men
Researchers’ observations
59% had a natural smile
Sunnybrook Facial Grading System (FGS) and FaCE scale
Preoperative smile 1.58 and postoperative smile 3.26 using the FGS Preoperative FaCE scale 44.14 and postoperative 57.89
Scale from Harii (1998)
Seven had good symmetry and three had acceptable symmetry
Grading scale
51.6% had excellent results (grade 5), 28.8% had good results (grade 4)
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Table 5: Oral competence outcomes Author
Types of assessment
Oral competence outcomes — results
Bianchi 2010
Questionnaire
Bradbury 2006
Semi-structured interview
Kumar 2002
Questionnaire
100% of patients (stage 1) and 85% (stage 2) reported no eating difficulties
Manktelow 2006
Questionnaire
75% of patients with unilateral reconstruction observed that difficulty with eating and drinking was reduced to 38%, while 22% of patients with bilateral reconstruction difficulties observed a reduction to 50%
O’Brien 1990
Questionnaire
64% of patients noted improvement in eating and 36% no improvement
Rozen 2013
Questionnaire and mastication video analysis
Patients noted no drooling and adequate oral fluid control
SC
RI PT
Most patients observed improvement in eating and dribbling
AC C
EP
TE D
M AN U
Involuntary movement in all cases, but only 60% detected by nonmedical experts. 90% reported improvement in mastication and 40% reported problems
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Table 6. Speech outcomes Author
Types of Assessment
Speech outcome results
Bianchi 2010
Articulation assessment
Kumar 2002
Questionnaire
25% of stage 1 patients and 31% of stage 2 patients showed speech improvement
Manktelow 2006
Questionnaire
Incidence of difficulty in speaking reduced from 67% to 11% for unilateral patients and 87% to 53% for bilateral patients
O’Brien 1990
Questionnaire
Speech improved in 53% of patients and did not improve in 47%
AC C
EP
TE D
M AN U
SC
RI PT
Postoperative assessment showed that seven patients had improvement in articulation (particularly bilabial phoneme pronunciation)
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Table 7. Patient satisfaction outcomes Author
Types of assessment
Patient satisfaction/QoL results
Questionnaire
80% of patients observed improvement in self-esteem and QoL
Bianchi 2016
Questionnaire
Preoperative mean score 29.0 and postoperative mean score 36.55 showing improvement in QoL
Bianchi 2017
RI PT
Bianchi 2010
Self-reported satisfaction on physical and social function: preoperative mean score 31.0 and postoperative mean score 36.5
Questionnaire
Hospital Anxiety & Depression Scale; semi-structured interview
Eight patients diagnosed with mild depressive disorder, one with moderate depressive disorder, and one with severe depressive disorder
M AN U
Bradbury 2006
SC
Most significant improvements in oral competence and anxiety, but change in social function/isolation less clear
21 patients diagnosed with mild anxiety disorder, 15 with moderate anxiety disorder, and two with severe anxiety disorder Three patients were satisfied; 27 patients accepted the outcomes but agreed to minor improvement
Chuang 2013
Questionnaire
Hadlock 2011
FaCE instrument self-evaluation
Krishnan 2010
Questionnaire
Lindsay 2014
FaCE instrument self-evaluation
Average mean incorporated facial expression as well
Manktelow 2006
Questionnaire
74% of patients good/very good outcomes, 15% okay, 11% not very good
O’Brien 1990
Questionnaire
Satisfied with smile symmetry: 11% excellent, 57% good, 25% fair, 9% poor smile outcome
Sassoon 1991
Questionnaire
Six patients very satisfied (50%), five patients fairly satisfied (41.6%), one patient fairly unsatisfied (8.3%)
Self-administered SF-36 questionnaire
Comparable average values for every category, reduced score for physical functioning and general health perception, pain, social function, and role limitation
Questionnaire
78% of patients noted improved QoL, whereas 22% noted no change
Yla-Kotola 2004
47% of patients reported normal function of their smile
TE D
EP
AC C
Schliephake 2000
Preoperative score 51.3 and postoperative score 65.7
QoL — quality of life
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20 15 10
RI PT
Number of Articles (#)
25
5
M AN U
SC
0
Outcome Measures
AC C
EP
TE D
Figure 1: Distribution of functional outcomes classified by category and methodology, as reported in selected articles featuring free muscle transfer facial reanimation