Understanding the Relationship Between Facial Nerve Branch Sacrifice and Selective Neurectomy Outcome.

Introduction: While there is great interest in selective neurectomy (SN) for patients with synkinesis, outcomes can be inconsistent. Objective: To examine the relationships between intraoperative facial nerve branch transection and both postoperative outcome and functional deficits. Methods: SN cases, with minimal follow-up of 4 months, were retrospectively identified between 2019 and 2021; outcome was assessed using FaCE instrument, eFACE and Emotrics. Correlations between intraoperative facial nerve branch preservation or transection, and functional outcome and new functional deficits were examined. Results: Fifty-six cases were performed: 88% were females, and median age was 53 years (range 11-81). Mean follow-up was 19.5 months (range 4-42). Oral commissure excursion improved in patients where all smile branches were preserved, no vertical vector smile branches were transected, and more than three smile antagonist branches were transected. A linear trend between smile antagonist branch sacrifice and favorable smile outcome was found. Lower lip movement was improved in patients in whom more than half of the identified lower lip branches were transected. Thirty percent of patients experienced untoward postoperative functional deficits, from which 47% recovered with interventions. Conclusions: Several correlations between SN intra-operative decisions and outcome were identified; new or worsening functional deficit rate can be high. However, chemodenervation or fillers can help diminish these deficits.

Pre-Operative Factors May Predict Outcome in Selective Neurectomy for Synkinesis.

Background: While there has been great interest in offering selective neurectomy (SN) to patients with nonflaccid facial palsy (NFFP), postoperative outcomes are inconsistent. Objective: To assess overall SN outcome in NFFP patients and to examine correlation between preoperative factors and SN outcome. Methods: SN cases were retrospectively identified between 2019 and 2021. Patient factors and facial function were assessed using chart review, the Facial Clinimetric Evaluation (FaCE), the electronic clinician-graded facial function tool (eFACE), and an automated computer-aided facial assessment tool (Emotrics). Correlations between preoperative factors and patients outcome were established. Results: Fifty-eight SN cases were performed; 88% were females, and median age was 53 years (range 11-81). Outcome assessment was 8 months on average (1-24 months). Postoperatively, multiple eFACE and Emotrics parameters improved significantly, including ocular, perioral, and synkinesis metrics. In preoperative factors assessment, age >50, facial palsy (FP) duration >2 years, poor preoperative facial function, and nontrauma etiology all correlated with greater improvements compared with younger patients, those with shorter duration facial palsy, trauma etiology, and better preoperative facial function. Conclusions: SN can significantly improve facial function; we have identified several preoperative factors that correlated to outcome.

Lower Facial Nerve Nomenclature Clarification: Cervical Branch Controls Smile-Associated Lower Lip Depression and Dental Display.

OBJECTIVE: In head and neck ablative surgery, traditional teaching is that the key facial nerve branch to preserve along the plane of the lower border of the mandible is the marginal mandibular branch (MMb), which is considered to control all lower lip musculature. The depressor labii inferioris (DLI) is the muscle responsible for pleasing lower lip displacement and lower dental display during natural emotive smiling. STUDY DESIGN: To understand the structure/function relationships of the distal lower facial nerve branches and lower lip musculature. SETTING: In vivo extensive facial nerve dissections under general anesthesia. METHODS: Intraoperative mapping was performed in 60 cases, using branch stimulation and simultaneous movement videography. RESULTS: In nearly all cases, the MMb innervated the depressor anguli oris, lower orbicularis oris, and mentalis muscles. The nerve branches controlling DLI function were identified 2 ± 0.5 cm below the angle of the mandible, originating from a cervical branch, separately and inferior to MMb. In half of the cases, we identified at least 2 independent branches activating the DLI, both within the cervical region. CONCLUSION: An appreciation of this anatomical finding may help prevent lower lip weakness following neck surgery. Avoiding the functional and cosmetic consequences that accompany loss of DLI function would have a significant impact on the burden of potentially preventable sequelae that the head and neck surgical patient frequently carries.

Reliability Between In-Person and Still Photograph Assessment of Facial Function in Facial Paralysis Using the eFACE Facial Grading System.

Importance: Assessing facial function using high-quality photographs would improve long-term and objective outcomes tracking in facial palsy, facilitate automated facial grading using artificial intelligence algorithms, and allow for remote follow up. Objective: To determine agreement between in-person and photographic electronic facial function scale (eFACE) assessments, and evaluate inter-rater reliability of photographic eFACE evaluation. Design, Setting, and Participants: Retrospective review of eFACE scores from in-person interviews and standardized photographs using the Massachusetts Eye and Ear (MEE) Standard Facial Palsy Dataset. Main Outcomes and Measures: eFACE total scores and subset scores determined by two experienced facial reanimation surgeons in person and from photographs. Results: Intraclass correlation coefficients for eFACE scores were 0.96 (95% CI 0.94 to 0.97) for total scores, 0.99 (95% CI 0.989 to 0.995) for static scores, 0.82 (95% CI 0.74 to 0.88) for dynamic scores, and 0.98 (95% CI 0.97 to 0.99) for synkinesis scores. Photographic and in-person scores had a mean difference of -0.64 (95% CI -2.05 to 0.77; p = 0.37) for total score, -1.58 (95% CI -4.22 to 1.05; p = 0.24) for the static subset, 0.14 (95% CI -1.70 to 1.97; p = 0.88) for the dynamic subset, and -1.11 (95% CI -3.09 to 0.86; p = 0.26) for the synkinetic subset. Bland-Altman analysis showed no trend for increasing differences in total score or subset scores. Conclusions: eFACE assessment obtained via photographs exhibits excellent inter-rater reliability and strong agreement with in-person assessment, demonstrating facial symmetry in facial palsy patients can be monitored using standardized frontal photographs.

Five-Year Experience with Fifth-to-Seventh Nerve Transfer for Smile.

BACKGROUND: Masseteric- or deep temporal-to-facial nerve transfer (five-to-seven nerve transfer) is increasingly used in facial reanimation; however, the indications and clinical variables affecting outcomes for five-to-seven nerve transfer have not been defined. The authors describe their early experience with five-to-seven nerve transfer, reporting function and patient-reported outcomes, to identify potential parameters that are predictive of outcome. METHODS: The authors conducted a retrospective chart review of all patients who underwent five-to-seven nerve transfer for smile reanimation from 2012 to 2017. Age, sex, cause of facial paralysis, onset and duration of paralysis, history of adjuvant chemotherapy and/or radiation therapy, donor nerve used, adjunctive procedures, and final excursion were recorded. Standard photographs and videos, and data regarding clinical facial nerve function and patient-reported quality of life, were obtained preoperatively and postoperatively. RESULTS: Sixty patients were identified. Forty-seven had flaccid facial paralysis and 13 had postparalysis facial palsy. Among flaccid facial paralysis patients, masseteric nerve transfer was successful in 30 patients (88 percent) and deep temporal nerve transfer was successful in three cases (60 percent). Among postparalysis facial palsy patients, five-to-seven nerve transfer was successful in two patients (20 percent). Average quality-of-life scores improved significantly from preoperatively (46) to postoperatively (59) among flaccid facial paralysis patients with successful five-to-seven nerve transfer. CONCLUSIONS: Five-to-seven nerve transfer is a viable option in facial reanimation. Shorter denervation times and preoperative flaccidity are favorable predictors of outcome. Five-to-seven nerve transfer as an adjunct to primary repair appears highly effective for enhancing smile function. Five-to-seven nerve transfer results are not reliable in patients with postparalysis facial palsy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facial Soft-tissue Mobility: Baseline Dynamics of Patients with Unilateral Facial Paralysis.

BACKGROUND: The aims of this observational study were 2-fold: (1) To demonstrate a method and measures to quantify impaired facial soft-tissue movements in patients with facial paralysis; and (2) To quantify the differences in magnitude and velocity of facial soft-tissue movements between patients with facial paralysis and control participants. METHODS: The study sample that addressed both aims consisted of 20 adults with acute, unilateral, flaccid facial paralysis who presented at the onset of their paralysis, and a control group of 20 healthy adults. Dynamic 3D facial movement data were collected from each participant during 11 facial animations. To compare the movements between the patients and control participants, dynamic modeling comparisons of mean facial movements were computed as well as plots of movement vectors for each animation, in addition, measures of maximum displacement, movement velocity, and asymmetry were computed. RESULTS: Dynamic 3D modeling of critical facial landmarks provided precise profiles of zone-specific asymmetries and customized reporting that highlighted areas of importance for individual patients. The dynamic 3D movement data confirmed that the nonparalyzed side of patients' faces had abnormal directional movements. As expected, the controls had significantly higher excursive facial movements during all animations except during gentle eye closure, which was greater for the patients and the controls had significantly greater movement velocity than the patients. The patients had significantly greater asymmetry for all the animations, and the hierarchy of the asymmetry was such that maximum smile > lip purse > grimace > cheek puff. CONCLUSION: Dynamic 3D modeling appeared to be an effective tool to provide precise profiles of zone-specific asymmetries and customized reports for patients with facial paralysis.

Quantifying Soft Tissue Shape and Symmetry: Patients with Cleft Lip/Palate and Facial Paralysis.

BACKGROUND: The objective of this study was to demonstrate simple three-dimensional analyses of facial soft tissue shape and asymmetry. METHODS: There were 2 study samples: one retrospective comprised patients with repaired cleft lip and palate (CL/P) and control subjects; and the other prospective comprised patients with unilateral facial paralysis (FP) and control subjects. The data collected were digitized three-dimensional facial landmarks. Scores for shape and asymmetry of subjects' faces and for different facial regions were generated using Procrustes methods. Pivotal bootstrap methods and analysis of variance were used to test for significant differences in the scores between the patients and controls, and plots of the scores were generated to compare differences among the subjects. RESULTS: (1) Shape scores: The CL/P patients demonstrated significant overall and regional facial differences (P ≤ 0.01). The patients were further from the control mean, especially those with unilateral CL/P. Patients with FP demonstrated significant differences (P ≤ 0.05) for the lower face only. (2) Asymmetry scores: CL/P and FP patients demonstrated significant overall and regional facial differences (CL/P, P ≤ 0.0001; FP, P ≤ 0.01). CL/P and FP patients were more asymmetric and were further from the control mean, and patients with unilateral CL/P were more asymmetric than the bilateral CL/P patients. CONCLUSION: Clinicians can use the analyses to isolate differences and/or changes in the face due to shape or asymmetry, or a combination of both; based on the score plots, the extent of the shape and asymmetry differences can be compared among subjects and the extent of changes due to surgery measured.

Worldwide Testing of the eFACE Facial Nerve Clinician-Graded Scale.

BACKGROUND: The electronic, clinician-graded facial function scale (eFACE) is a potentially useful tool for assessing facial function. Beneficial features include its digital nature, use of visual analogue scales, and provision of graphic outputs and scores. The authors introduced the instrument to experienced facial nerve clinicians for feedback, and examined the effect of viewing a video tutorial on score agreement. METHODS: Videos of 30 patients with facial palsy were embedded in an Apple eFACE application. Facial nerve clinicians were invited to perform eFACE video rating and tutorial observation. Participants downloaded the application, viewed the clips, and applied the scoring. They then viewed the tutorial and rescored the clips. Analysis of mean, standard deviation, and confidence interval were performed. Values were compared before and after tutorial viewing, and against scores obtained by an experienced eFACE user. RESULTS: eFACE feedback was positive; participants reported eagerness to apply the instrument in clinical practice. Standard deviation decreased significantly in only two of the 16 categories after tutorial viewing. Subscores for static, dynamic, and synkinesis all demonstrated stable standard deviations, suggesting that the instrument is intuitive. Participants achieved posttutorial scores closer to the experienced eFACE user in 14 of 16 scores, although only a single score, nasolabial fold orientation with smiling, achieved statistically significant improvement. CONCLUSIONS: The eFACE may be a suitable, cross-platform, digital instrument for facial function assessment, and was well received by facial nerve experts. Tutorial viewing does not appear to be necessary to achieve agreement, although it does mildly improve agreement between occasional and frequent eFACE users.

Test-Retest Reliability and Agreement Between In-Person and Video Assessment of Facial Mimetic Function Using the eFACE Facial Grading System.

IMPORTANCE: Use of a robust high-resolution instrument for grading of facial symmetry would enhance reporting the outcomes of facial reanimation interventions. The eFACE is one such tool. OBJECTIVE: To determine test-retest reliability of the eFACE tool over time and agreement between eFACE assessments made in person vs those made using video of facial mimetic function. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study was conducted among 75 consecutive patients with varying degrees of facial palsy who presented between July 1 and December 31, 2014, to an academic tertiary referral hospital. Facial symmetry of all patients was graded in person and via standardized photographic and video documentation of facial mimetic function at the initial visit. Three months after initial presentation, eFACE scores were reassessed by the same raters using the videos of facial mimetic function documented at the initial visit. MAIN OUTCOMES AND MEASURES: Individual and subset eFACE scores assessed by 2 facial reanimation surgeons. RESULTS: Among the 75 patients in the study (mean [SD] age, 48.18 [16.60] years; 30 men and 45 women), agreement between in-person and video assessments of facial function using the eFACE scale was excellent (static subset score: mean difference, 0.19; 95% CI, -1.51 to 1.88; P = .83; intraclass correlation coefficient [ICC], 0.85; 95% CI, 0.80 to 0.89; dynamic subset score: mean difference, -0.51; 95% CI, -1.72 to 0.71; P = .41; ICC, 0.96; 95% CI, 0.94 to 0.97; synkinesis subset score: mean difference, -1.14; 95% CI, -2.87 to 0.59; P = .20; ICC, 0.90; 95% CI, 0.86 to 0.93; and composite score: mean difference, -0.41; 95% CI, -1.30 to 0.47; P = .36; ICC, 0.94; 95% CI, 0.92 to 0.96). Agreement between repeated eFACE assessments of video of facial function was excellent (static subset score: ICC, 0.93; 95% CI, 0.87 to 0.96; dynamic subset score: ICC, 0.88; 95% CI, 0.80 to 0.94; synkinesis subset score: ICC, 0.92; 95% CI, 0.86 to 0.96; and composite score: ICC, 0.96; 95% CI, 0.93 to 0.98). CONCLUSIONS AND RELEVANCE: Strong agreement exists between eFACE scores of facial function assessed in person and from video recordings. Test-retest reliability of eFACE scores is high. The eFACE is a reliable instrument for high-resolution assessment of facial mimetic function. LEVEL OF EVIDENCE: NA.

Steroid use in Lyme disease-associated facial palsy is associated with worse long-term outcomes.

OBJECTIVE: The purpose of this study was to determine whether differences in long-term facial function outcomes following acute Lyme disease-associated facial palsy (LDFP) exist between patients who received antibiotic monotherapy (MT); dual therapy (DT) with antibiotics and corticosteroids; and triple therapy (TT) with antibiotics, corticosteroids, and antivirals. STUDY DESIGN: Retrospective cohort. METHODS: All patients with a prior diagnosis of unilateral LDFP who presented to our center between 2002 and 2015 were retrospectively assessed for inclusion. Two blinded experts graded static, dynamic, and synkinesis parameters of facial functions using standardized video documentation of facial function. RESULTS: Fifty-one patients were included. The mean time of assessment following LDFP onset was 15.1 months (range 0.3-84 months). Significantly worse facial outcomes were seen among those who received DT and TT as compared to those who received MT, most pronounced among those assessed 12 months or later following onset of LDFP (Dynamic-P = 0.031, post hoc MT vs. TT: mean difference [MD], 15.83; 95% confidence interval [CI], 1.54-30.13; P = 0.030. Synkinesis-P = 0.026, post hoc MT vs. DT: MD, 21.50; 95% CI, 0.68-42.32; P = 0.043, post hoc MT vs. TT: MD, 19.22; 95% CI, 2.23-36.22; P = 0.027). CONCLUSION: An association between corticosteroid use in acute LDFP and worse long-term facial function outcomes has been demonstrated. Care should be taken in differentiating viral or idiopathic facial palsy (e.g., Bell palsy) from LDFP. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1451-1458, 2017.

Bilateral Facial Paralysis: A 13-Year Experience.

BACKGROUND: Bilateral facial palsy is a rare clinical entity caused by myriad disparate conditions requiring different treatment paradigms. Lyme disease, Guillain-Barré syndrome, and leukemia are several examples. In this article, the authors describe the cause, the initial diagnostic approach, and the management of long-term sequelae of bilateral paralysis that has evolved in the authors' center over the past 13 years. METHODS: A chart review was performed to identify all patients diagnosed with bilateral paralysis at the authors' center between January of 2002 and January of 2015. Demographics, signs and symptoms, diagnosis, initial medical treatment, interventions for facial reanimation, and outcomes were reviewed. RESULTS: Of the 2471 patients seen at the authors' center, 68 patients (3 percent) with bilateral facial paralysis were identified. Ten patients (15 percent) presented with bilateral facial paralysis caused by Lyme disease, nine (13 percent) with Möbius syndrome, nine (13 percent) with neurofibromatosis type 2, five (7 percent) with bilateral facial palsy caused by brain tumor, four (6 percent) with Melkersson-Rosenthal syndrome, three (4 percent) with bilateral temporal bone fractures, two (3 percent) with Guillain-Barré syndrome, one (2 percent) with central nervous system lymphoma, one (2 percent) with human immunodeficiency virus infection, and 24 (35 percent) with presumed Bell palsy. Treatment included pharmacologic therapy, physical therapy, chemodenervation, and surgical interventions. CONCLUSIONS: Bilateral facial palsy is a rare medical condition, and treatment often requires a multidisciplinary approach. The authors outline diagnostic and therapeutic algorithms of a tertiary care center to provide clinicians with a systematic approach to managing these complicated patients.

Emerging vs Time-Tested Methods of Facial Grading Among Patients With Facial Paralysis.

IMPORTANCE: Most rehabilitation specialists and many facial reanimation surgeons use the Sunnybrook Facial Grading System (FGS) to measure and detect changes in facial function. The eFACE, an electronic and digitally graded facial measurement scale, was recently created to provide similar information to the Sunnybrook FGS, but with scaling uniformity across all categories of facial function, graphical outputs, and easy-to-use visual analog scales. OBJECTIVES: To establish the correlation between the scores on the eFACE and the Sunnybrook FGS among patients with facial paralysis and to compare the reliability of the 2 scales. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of medical records identified 109 patients who were evaluated at a facial nerve center by physical therapists using the eFACE and the Sunnybrook FGS on the same day, between November 1, 2014, and May 31, 2015. The level of facial function predicted using the 2 scales was compared to study correlation between the scales. Data analysis was conducted from June 1 to September 1, 2015. MAIN OUTCOMES AND MEASURES: Correlation between the Sunnybrook FGS and the eFACE grading scale. METHODS: Two independent physical therapists evaluated patients using both the eFACE and the Sunnybrook FGS. Scores were compared and the Spearman rank correlation coefficient was calculated between the total scores and each of the 3 subscores, including static, dynamic, and synkinesis scores. The total Sunnybrook FGS synkinesis score (worst score, 15; perfect score, 0) and static score (worst score, 20; perfect score, 0) were normalized to a 100-point scale with the eFACE (perfect score, 100; worst score, 1). RESULTS: eFACE scores ranged from 48 to 100, and Sunnybrook FGS scores ranged from 0 to 100. Among 109 patients, there was a moderately strong correlation between eFACE and Sunnybrook FGS scores in both total and subcategory scores. The Spearman rank correlation coefficient of the total eFACE and Sunnybrook FGS was 0.75 (r < 0.0001). For the static scores, the correlation coefficient was -0.71 (r < 0.0001). The correlation coefficients for the dynamic and synkinesis scores were 0.77 (r < 0.0001) and -0.78 (r < 0.0001), respectively. CONCLUSIONS AND RELEVANCE: There is moderately good agreement between the Sunnybrook FGS and the eFACE. Given the ease of using the eFACE on mobile devices, as well as its additional functionality, it may represent a reasonable facial grading option across disciplines in the future. LEVEL OF EVIDENCE: NA.

Weighting of Facial Grading Variables to Disfigurement in Facial Palsy.

IMPORTANCE: A universal, health care professional-graded scale for facial assessment would be a useful tool for reporting, comparing, and assessing facial function among patients with facial paralysis. OBJECTIVES: To correlate scores of an assessment tool, the eFACE scale, with expert-rated facial disfigurement and to determine the relative contributions of facial features to facial palsy-related disfigurement. DESIGN, SETTING, AND PARTICIPANTS: The eFACE scale yields 15 individual variable scores, in addition to subscores for static, dynamic, and synkinesis elements, and a total score that is based on 100-point scales. Two hundred patients with varying degrees of unilateral facial palsy underwent independent eFACE assessment and assignment of a disfigurement score by 2 facial nerve surgeons. The mean scores were determined, and multivariate regression analysis was performed to fit eFACE subset scores (static, dynamic, and synkinesis) to disfigurement ratings. A hybrid regression model was then used to weight each of the 15 eFACE variables, using stepwise regression to control for the effect of the other variables. Scoring was performed during an 8-week period from March 16 to May 8, 2015. MAIN OUTCOME AND MEASURE: Use of the 100-point eFACE variables, together with a 100-point visual analog scale of disfigurement, with 0 representing the most extreme disfigurement possible from a facial nerve disorder and 100 representing no discernible facial disfigurement. RESULTS: In the 200 patients included in analysis (126 [63.0% female]; mean [SD] age, 46.5 [16.4] years]), predicted disfigurement scores based on eFACE subset scores demonstrated excellent agreement with surgeon-graded disfigurement severity (r2 = 0.79). Variable weighting demonstrated that the 6 key contributors to overall disfigurement were (in order of importance) nasolabial fold depth at rest (normalized coefficient [NC], 0.18; P < .001), oral commissure position at rest (NC, 0.15; P < .001), lower lip asymmetry while pronouncing the long /e/ (NC, 0.09; P < .001), palpebral fissure width at rest (NC, 0.09; P < .001), nasolabial fold orientation with smiling (NC, 0.08; P = .001), and palpebral fissure width during attempts at full eye closure (NC, 0.06; P = .03). CONCLUSIONS AND RELEVANCE: A mathematical association between eFACE-measured facial features and overall expert-graded disfigurement in facial paralysis has been established. For those using the eFACE grading scale, predictions of the specific effects of various interventions on expert-rated disfigurement are now possible and may guide therapy. LEVEL OF EVIDENCE: NA.

Asymmetry of Facial Mimicry and Emotion Perception in Patients With Unilateral Facial Paralysis.

IMPORTANCE: The ability of patients with unilateral facial paralysis to recognize and appropriately judge facial expressions remains underexplored. OBJECTIVE: To test the effects of unilateral facial paralysis on the recognition of and judgments about facial expressions of emotion and to evaluate the asymmetry of facial mimicry. DESIGN, SETTING, AND PARTICIPANTS: Patients with left or right unilateral facial paralysis at a university facial plastic surgery unit completed 2 computer tasks involving video facial expression recognition. Side of facial paralysis was used as a between-participant factor. Facial function and symmetry were verified electronically with the eFACE facial function scale. EXPOSURES: Across 2 tasks, short videos were shown on which facial expressions of happiness and anger unfolded earlier on one side of the face or morphed into each other. Patients indicated the moment or side of change between facial expressions and judged their authenticity. MAIN OUTCOMES AND MEASURES: Type, time, and accuracy of responses on a keyboard were analyzed. RESULTS: A total of 57 participants (36 women and 21 men) aged 20 to 76 years (mean age, 50.2 years) and with mild left or right unilateral facial paralysis were included in the study. Patients with right facial paralysis were faster (by about 150 milliseconds) and more accurate (mean number of errors, 1.9 vs 2.5) to detect expression onsets on the left side of the stimulus face, suggesting anatomical asymmetry of facial mimicry. Patients with left paralysis, however, showed more anomalous responses, which partly differed by emotion. CONCLUSIONS AND RELEVANCE: The findings favor the hypothesis of an anatomical asymmetry of facial mimicry and suggest that patients with a left hemiparalysis could be more at risk of developing a cluster of disabilities and psychological conditions including emotion-recognition impairments. LEVEL OF EVIDENCE: 3.

Clinician-Graded Electronic Facial Paralysis Assessment: The eFACE.

BACKGROUND: The subjective nature of facial aesthetics and the difficulties associated with quantifying facial function have made outcomes analysis in facial paralysis challenging. Clinicians rely on photographs, subjective descriptions, and scales, limiting assessment, communication among providers, and communication between providers and patients. The authors describe the development and validation of a comprehensive, electronic, clinician-graded facial function scale (eFACE), which generates an overall disfigurement score and offers simple graphic output for clinician communication, assessment of various interventions, and patient understanding. The eFACE application may be used in a variety of electronic devices, including smartphones, tablets, and computers. METHODS: An instrument consisting of 16 items in a visual analogue scale format was developed to assess facial function and symmetry (the eFACE). Video recordings of subjects performing facial expressions were viewed, and the eFACE instrument was applied, along with an overall facial disfigurement score. A multiple regression analysis was performed to determine the best linear relationship between overall expert-determined disfigurement and the eFACE items. The resulting equation was tested by three independent facial nerve clinicians, using an additional series of patients, to determine both interrater and intrarater reliability of the instrument. RESULTS: Multiple regression analysis produced good fit of eFACE parameters to overall expert-rated global facial disfigurement when dynamic parameters were weighted twice as heavily as static and synkinesis parameters. eFACE scores demonstrated very high interrater and intrarater reliability. CONCLUSION: The eFACE is a reliable, reproducible, and straightforward digital clinical measure with which to assess facial function and disfigurement in patients with facial paralysis.

Development and validation of a spontaneous smile assay.

IMPORTANCE: Smiling can be a voluntary or involuntary movement. Facial reanimation procedures differ in their ability to restore a spontaneous smile, and an assay designed to evoke and evaluate a spontaneous smile is not available. OBJECTIVE: To develop and validate an assay to assess the spontaneous smile of patients with facial paralysis. DESIGN, SETTING, AND PARTICIPANTS: This was an exploratory cohort study. A series of short video clips were administered to laypersons via an online survey service from January 1, 2014, to March 31, 2014. Respondents rated how funny each video was on a visual analog scale from 0 to 100. The 4 funniest videos were selected to generate a 1½-minute spontaneous smile assay. The assay was then administered from July 1, 2014, to December 31, 2014, to 2 different study groups: the first was composed of 100 healthy individuals (control group) and the second was composed of 30 patients with facial paralysis. We analyzed the capability of this assay to provoke at least 1 spontaneous smile and calculated smile excursion in both groups. Statistical analysis was performed using analysis of variance. INTERVENTION: Spontaneous smile assay administered to both healthy and diseased groups. MAIN OUTCOMES AND MEASURES: Ability of the assay to elicit smiles, as defined by an oral commissure excursion greater than 3 mm, as well as difference in commissure excursion. RESULTS: Ninety-five (95.0%) participants in the control group and 29 (96.7%) patients with facial paralysis experienced at least 1 oral commissure excursion that appeared to be a spontaneous smile while viewing the assay. Mean oral commissure excursion with spontaneous smile was 9.08 mm (95% CI, 2.77-15.39) in controls, 6.72 mm (95% CI, 3.13-10.31) on the healthy side in patients with flaccid facial paralysis (P=.004 vs controls), and 9.64 mm (95% CI, 3.52-15.76) on the healthy side in patients with nonflaccid facial paralysis (P=.74). Among patients with flaccid facial paralysis, a statistically significant difference was found between smile excursion of the affected and the unaffected sides (P = .03). There was no statistically significant difference in the measurement between sides for the control group (P = .67). CONCLUSIONS AND RELEVANCE: Although humor is a challenging construct to universalize, our assay was able to elicit a smile in almost all individuals in the group with facial paralysis and the control group. The spontaneous smile assay will facilitate future research on the ability of facial reanimation procedures and other interventions to restore a spontaneous smile. LEVEL OF EVIDENCE: NA.

Long-term functional recovery after facial nerve transection and repair in the rat.

BACKGROUND: The rodent model is commonly used to study facial nerve injury. Because of the exceptional regenerative capacity of the rodent facial nerve, it is essential to consider the timing when studying facial nerve regeneration and functional recovery. Short-term functional recovery data following transection and repair of the facial nerve has been documented by our laboratory. However, because of the limitations of the head fixation device, there is a lack of long-term data following facial nerve injury. The objective of this study was to elucidate the long-term time course and functional deficit following facial nerve transection and repair in a rodent model. METHODS: Adult rats were divided into group 1 (controls) and group 2 (experimental). Group 1 animals underwent head fixation, followed by a facial nerve injury, and functional testing was performed from day 7 to day 70. Group 2 animals underwent facial nerve injury, followed by delayed head fixation, and then underwent functional testing from months 6 to 8. RESULTS: There was no statistical difference between the average whisking amplitudes in group 1 and group 2 animals. CONCLUSION: Functional whisking recovery 6 months after facial nerve injury is comparable to recovery within 1 to 4 months of transection and repair, thus the ideal window for evaluating facial nerve recovery falls within the 4 months after injury.

Pediatric facial nerve rehabilitation.

Facial paralysis is a rare but severe condition in the pediatric population. Impaired facial movement has multiple causes and varied presentations, therefore individualized treatment plans are essential for optimal results. Advances in facial reanimation over the past 4 decades have given rise to new treatments designed to restore balance and function in pediatric patients with facial paralysis. This article provides a comprehensive review of pediatric facial rehabilitation and describes a zone-based approach to assessment and treatment of impaired facial movement.

Macrophage Infiltrate Is Elevated in CRSwNP Sinonasal Tissue Regardless of Atopic Status.

OBJECTIVE: Macrophages are major producers of inflammatory cytokines; however, their role in chronic rhinosinusitis (CRS) has not been clearly defined. The aim of this study was to quantify macrophages in sinus tissue of patients with various subtypes of CRS and determine the impact of atopic status on macrophage infiltrate. STUDY DESIGN: Prospective immunohistochemical study of human sinonasal tissue. SETTING: Academic medical center. SUBJECTS AND METHODS: Human sinonasal tissue was taken from patients with CRS with nasal polyposis (CRSwNP, n = 8), CRS without nasal polyposis (CRSsNP, n = 8), and controls (n = 8) undergoing surgery for CSF leak repair or endoscopic excision of non-secreting pituitary tumor. Samples were immunohistochemically stained for macrophage/monocyte markers Mac387 and CD68. RESULTS: CRSwNP patients had significantly increased numbers of Mac387 and CD68 cells compared to control patients (P < .05) or CRSsNP patients (P < .01). CRSsNP had significantly increased number of cells staining for CD68 compared to controls (P < .05). The increased presence of macrophages measured by either marker in CRSwNP was independent of atopic status. CONCLUSION: Macrophages are increased in CSRwNP patients regardless of atopic status and may contribute to the immunopathology of CRS.