Rethinking Oncologic Facial Nerve Reconstruction in the Acute Phase Through Classification of the Level of Injury.

Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors breakdown oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and nonfacial donor nerves (hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.

Ultrasound-Guided Injections for Treatment of Facial Paralysis Sequelae: A Randomized Study on Body Donors.

BACKGROUND: Botulinum toxin injection is the accepted standard treatment for synkinesis and gustatory hyperlacrimation in patients with facial paralysis. However, poor injection accuracy can result in inconsistent treatment outcomes, variable treatment durations, and complications. Ultrasound guidance should increase injection accuracy in the facial region; however, this has not been proven. METHODS: Twenty-six hemifaces of nonembalmed cadavers were studied in a randomized split-face manner. Ink was injected with ultrasound or landmark guidance into the lacrimal gland and three common synkinetic muscles: the orbicularis oculi, depressor anguli oris, and mentalis. Injection accuracy was evaluated using several measures. RESULTS: Using ultrasound guidance, most ink (>50%) was found inside the correct target in 88% of cases, compared with 50% using landmark guidance ( P < 0.001). This was most pronounced in the lacrimal gland (62% versus 8%), depressor anguli oris (100% versus 46%), and mentalis (100% versus 54%) ( P < 0.05). All ink was found inside the correct target (no ink outside) in 65% using ultrasound guidance versus 29% without ( P < 0.001). Injection accuracy (any ink in target) was 100% when using ultrasound guidance versus 83% without ( P < 0.01). Twenty-three percent of the landmark-guided depressor anguli oris injections stained the facial artery ( P = 0.22). CONCLUSIONS: Ultrasound guidance significantly increased injection accuracy and reduced the amount of ink lost in the surrounding tissue compared with landmark guidance. Clinical trials are needed to explore the effects of ultrasound guidance on treatment outcome, duration, and complications in patients with facial paralysis.

Preoperative assessment of depressor anguli oris to prevent myectomy failure: An anatomical study using high-resolution ultrasound.

BACKGROUND: Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies. METHODS: Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection. RESULTS: The ultrasound and dissection measurements showed the DAO muscle width to be 16.2 ± 2.9 versus 14.5 ± 2.5 mm, respectively, and the location of the lateral muscle border 54.4 ± 5.7 versus 52.3 ± 5.4 mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced. CONCLUSIONS: High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.

Early Second Free Flap is Required in Osteoradionecrosis-related Nonunion after Primary Mandible Reconstruction.

Osteoradionecrosis (ORN) manifested as symptomatic nonunion between primary free flap and native mandible after primary bony reconstruction of the mandible is an entity not included in current conventional ORN staging guidelines. This article reports on and proposes early management of this debilitating condition using a chimeric scapular tip free flap (STFF). Methods: A retrospective review was performed examining cases with bony nonunion at the junction of primary free fibula flap (FFF) and native mandible at a single center over a 10-year duration, which required a second free bone flap. Details of each case (patient demographics, oncological details, primary surgery, presentation, and secondary surgery) were documented and analyzed. Outcomes of the treatment were assessed. Results: Four patients (two men and two women; age range, 42-73 years) out of a total of 46 primary FFF were identified. All patients presented with symptoms of low-grade ORN and radiological signs of nonunion. All cases were reconstructed with chimeric STFF. The duration of follow-up ranged from 5 to 20 months. All patients reported resolution of symptoms and radiological evidence of union. Two of four patients subsequently received osseointegrated dental implants. Conclusions: Institutional rate of nonunion after primary FFF requiring a second free bone flap is 8.7%. All the patients of this cohort presented with a similar clinical entity easily discounted as an infected nonunion postosseous flap reconstruction. There is no ORN grading system that currently guides the management of this cohort. Good outcomes are possible with early surgical intervention with a chimeric STFF.

Selective ansa cervicalis nerve transfer to the marginal mandibular nerve for lower lip reanimation: An anatomical study in cadavers and a case report.

BACKGROUND: Donor nerve options for lower lip reanimation are limited in patients undergoing oncological resection of the facial nerve. The ansa cervicalis nerve (ACN) is an advantageously situated donor with great potential but has not been examined in detail. In the current study, the anatomical technical feasibility of selective ACN to marginal mandibular nerve (MMN) transfer for restoration of lower lip tone and symmetry was explored. A clinical case is presented. METHODS: Dissections were conducted in 21 hemifaces in non-embalmed human cadavers. The maximal harvestable length of ACN was measured and transfer to MMN was simulated. A 28-year-old male underwent ACN-MMN transfer after parotidectomy (carcinoma) and was evaluated 12 months post-operatively (modified Terzis' Lower Lip Grading Scale [25 observers] and photogrammetry). RESULTS: The harvestable length of ACN was 100 ± 12 mm. A clinically significant anatomical variant ("short ansa") was present in 33% of cases (length: 37 ± 12 mm). Tensionless coaptation was possible in all cases only when using a modification of the surgical technique in "short ansa" cases (using an infrahyoid muscle nerve branch as an extension). The post-operative course of the clinical case was uneventful without complications, with improvement in tone, symmetry, and function at the lower lip at 12-month post-operative follow-up. CONCLUSIONS: Selective ACN-MMN nerve transfer is anatomically feasible in facial paralysis following oncological ablative procedures. It allows direct nerve coaptation without significant donor site morbidity. The clinical case showed good outcomes 12 months post-operatively. A strategy when encountering the "short ansa" anatomical variant in clinical cases is proposed.

Challenges in the Management of Kidney Allograft Herniation With a Single-stage Pedicled Anterolateral Thigh Flap.

Wound complications are the most common surgical complication after kidney allograft transplantation. Total wound rupture exposing the entire kidney is a rare and not well-described event. We present a successful treatment of this complication in a patient admitted to our unit. A single-stage procedure was performed combining debridement and reconstruction with a pedicled anterolateral thigh flap and an iliotibial band transferring. A short literature review is performed comparing the different treatment strategies and results.

Five-Step Scapula Tip Flap Harvesting for Oromaxillofacial Defects Reconstruction.

SUMMARY: In the last 10 years, there has been an increased focus on the scapula tip free flap for head and neck reconstructions. Its several advantages make it a versatile and reliable reconstructive option for patients with orofacial compound defects. The aim of this article is to present a systematic surgical approach for the harvesting of the scapula tip free flap. Herein, a step-by-step surgical approach and some technical tips are described to make the scapula tip flap dissection simpler, safer, and more straightforward.

Anatomical Features in Lower-Lip Depressor Muscles for Optimization of Myectomies in Marginal Mandibular Nerve Palsy.

INTRODUCTION: Myectomies of the lower-lip depressor muscles, with the aim to improve facial balance in unilateral facial paralysis, have unexplained high recurrence rates. A potential explanation is that these recurrences are due to inadequate resection through the muscle width, leaving lateral muscle fibers intact. AIM: Revisit the anatomy of the lower-lip depressor muscles and suggest an optimization of the surgical technique. Perform a literature review to identify recurrence rates and surgical technique of the procedure. MATERIALS AND METHODS: Ten fresh hemifaces were dissected. The following measurements of depressor labii inferioris and depressor anguli oris were made: the widths of the muscles, the distance from the mandibular midline to the lateral borders of the muscles, and the intraoral distance from the lateral canine to the lateral border of depressor anguli oris. A literature review was performed. RESULTS: The width of depressor labii inferioris was 20 ±â€Š4 mm and depressor anguli oris 14 ±â€Š3 mm. The distance from the midline to the lateral border of depressor labii inferioris was 32 ±â€Š4 mm and 54 ±â€Š4 mm for depressor anguli oris. The literature review revealed a mean recurrence rate of 21%. DISCUSSION: A potential optimization of the surgical technique in lower-lip depressor myectomies is to extend the muscle resection laterally. To ensure inclusion of the whole width of the depressor muscles and decrease the recurrence rates of the procedure, the measurements presented in this study should be kept in mind during surgery.

Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies.

Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients. METHODS: Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey. RESULTS: Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest. CONCLUSION: The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

Deep inferior epigastric artery perforator free flap in head and neck reconstruction: A systematic review.

BACKGROUND: Perforator flaps yield the best results for the patient with the least morbidity, and they should be considered the gold standard in head and neck reconstruction. Although deep inferior epigastric perforator (DIEP) flap is considered as the gold standard in breast reconstruction, its use in head and neck reconstructive surgery does not seem so widespread. The objective of this study is to conduct a systematic review of the use, applications and results of the DIEP flap in the head and neck area. METHODS: Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through meta-searcher Trip Database with deep inferior epigastric perforator flap AND head neck keywords. Studies on animal and human experiments published in peer-reviewed journals, where investigators assessed the use of DIEP flap, according to the Koshima criteria, in the head and neck area were considered. RESULTS: A total of 31 articles and 185 flaps with 95% of survival were found. Thrombosis or venous stasis is the most frequent cause of flap loss and 16.1% presented some type of complication, the most frequent being the dehiscence. The most use was in the reconstruction of glossectomy defect secondary to squamous cell carcinoma (30.51%), being able potentially to re-establish sensory innervation in oral cavity. The assessment of risk bias (National Institutes of Health) highlights the lack of uniformity, with no standardisation of the outcome variable collection and monitoring. DISCUSSION: By virtue of its versatility, reliable vascular supply and high flap survival rate, the DIEP flap reconstruction could be an option in complicated 3-dimensional head and neck defects while maintaining the standard of low donor site morbidity.

Usefulness of a template-based anterolateral thigh flap for reconstruction of head and neck defects.

BACKGROUND: One of the challenges in head and neck reconstruction is to have an adequate understanding of the three-dimensionalities of the defects created after resections due to the high variability of clinical scenarios. Consequently, it is essential to design the flap to match the requirements of the defect in order to facilitate the insetting and to achieve a successful outcome. The anterolateral thigh flap (ALT) is a robust and versatile flap commonly used in head and neck reconstruction. In this study the authors use a hand-made template as a tool to customize ALT flaps and its variations to fit more accurately the different shapes, volume, and components of the resulting defects. The aim of this study is to describe in detail this surgical approach and present the clinical experience in 100 consecutive cases using a template-based ALT flaps in head and neck reconstruction. METHODS: A retrospective review was performed on all microvascular head and neck reconstruction cases between January 2013 and December 2017 in our institution where a template-based ALT flap design was performed. We describe in detail the surgical technique used and present the clinical outcomes. In addition, we analyzed the use of different designs of the ALT flaps including different flap components in relation to the location of the defect. RESULTS: One hundred reconstructions for head and neck defects were performed in 97 patients. Seven types of ALT free flaps were performed: fasciocutaneous (46%), suprafascial (8%), adipofascial (9%), vastus lateralis muscle (3%), composite fasciocutaneous/adipofascial (9%), chimeric flaps (21%), and vascularized nerve grafts (4%). Oropharyngeal and periauricular defects were mostly reconstructed with fasciocutanoues design. In more complex three-dimensional defects such as skull base or midface defects, a chimeric flap was selected. In all cases the used of template facilitated the insetting of the free flap. The total flap loss was 2%. CONCLUSIONS: Customization of ALT flaps using intraoperative templates is a useful method for flap design which facilitates fitting of the flap to a variety of defects in head and neck reconstruction.

Microsurgical Salvage of Acute Lower Limb Ischemia after Iatrogenic Femoral Injury during Orthopedic Surgery in a Pediatric Patient.

Acute lower limb ischemia (ALLI) in the pediatric population is rare but may lead to limb loss and life-long complications. We report the technique and outcomes of microsurgical salvage of ALLI in a preterm newborn after open reduction of congenital hip dysplasia. A 2-month-old girl was born premature at week 36 with congenital bilateral hip dysplasia. The initial management attempted was conservative and entailed placement of bilateral Von Rosen splints. The treatment was successful on the left side, but the patient had recurrent unstable hip dislocation on the right side. Subsequently, 2 attempts at close reduction under general anesthesia were done and both were unsuccessful in maintaining the right hip in the acetabulum. Therefore, an open reduction of the right hip was planned through a medial/obturator approach. During the surgical procedure, the neurovascular femoral bundle (including the superficial femoral artery [SFA], femoral vein [FV], and femoral nerve) was accidently transected with subsequent development of ALLI. Therefore, the FV was harvested distally to the injury site and a 4-cm long healthy segment was obtained. It was reversed, flushed with heparin, spatulated at both extremities, and interposed to the SFA in end-to-end fashion using two 9/0 polypropylene interrupted sutures under microscope. Reperfusion of the limb was noted immediately after releasing the vascular clamps. The final ischemia time at completion of the surgical procedure was 6 hr. Thereby, prophylactic 4-compartment fasciotomies were performed in the right leg. The patient tolerated the procedure well and the postoperative clinical course was free from adverse events. Duplex ultrasound examination at 6 weeks after the intervention confirmed sustained clinical success and showed no signs of venous thromboembolism. At the same time, X-ray examination of the right hip confirmed adequate and stable reduction of the joint in the acetabulum. ALLI due to accidental arterial injury during orthopedic surgical procedures for congenital defects in newborns is a rare but potentially devastating complication. Microsurgical salvage is a safe, feasible, and effective option to restore limb flow. Multidisciplinary expertise and meticulous technique are mandatory in order to achieve satisfactory and durable outcomes.

Endoscopic assisted insetting of free flaps in anterior skull base reconstruction: A preliminary report of five cases.

INTRODUCTION: Free vascularized tissue may provide a robust reconstruction after anterior skull base surgery. We report our technique and outcomes of the endoscopic inset of free flaps in anterior skull base reconstructions. METHODS: Between 2016 and 2018, endoscopic tumor removal and reconstruction of anterior skull base pathology was performed in five patients aged 20-72 years old (four male, one female). The tumors included three neuroblastomas, a carcinoma, an adenoma, and a melanoma. The median size of the defect was 3.7 × 6.6 cm. Transmaxillary access was gained through the upper sulcus and an anterior and medial maxillectomy. The flap inset was facilitated by the endoscope. The donor vessels were tunneled through the sinus and through the cheek to the facial vessels without the use of the endoscope. RESULTS: In three cases a vastus lateralis flap was used, in one case an adipofascial ALT flap and in one case an adipofascial radial forearm flap. Separation of intracranial and sinonasal spaces was confirmed by radiological and endoscopic examinations. There was no flap failure and one case with partial necrosis. One of the flaps needed to be trimmed as it obliterated the nasal cavity and in one of the cases the flap was repositioned postoperatively. Two cases had infectious complications. The mean follow-up of the patients was 13.8 months. CONCLUSIONS: Endoscopic assisted inset of a free flap in the anterior skull base was feasible in the five cases we present. A dedicated, multidisciplinary approach is mandatory for surgical innovation like this.

Contemporary Concepts of Primary Dynamic Facial Nerve Reconstruction in the Oncologic Patient.

Transection of the facial nerve and its branches during extensive ablative procedures in the oncologic patient causes loss of control of facial mimetic muscles with severe functional and aesthetic sequelae. In such patients with advanced tumorous disease, copious comorbidities, and poor prognosis, rehabilitation of the facial nerve has long been considered of secondary priority. However, recent advances in primary facial nerve reconstruction after extensive resection demonstrated encouraging results focusing on rapid and reliable restoration of facial functions. The authors summarize 3 innovative approaches of primary dynamic facial nerve reconstruction by using vascularized nerve grafts, dual innervation concepts, and intra-facial nerve transfers.

Oculo-zygomatic nerve transfer for facial synkinesis: An anatomical feasibility study.

BACKGROUND: Patients with severe oro-ocular synkinesis often present with concomitant inefficient smile excursion on the affected site. In theory, oculo-zygomatic nerve transfer may decrease synkinesis and improve smile by redirecting nerve fibers to their target muscle. The aim of this study was to explore the feasibility of nerve transfer in human cadavers between a caudal branch innervating the orbicularis oculi to a cephalad branch innervating the zygomaticus major muscles. METHODS: Eighteen hemi-faces were dissected. Reach for direct coaptation of a caudal nerve branch innervating the orbicularis oculi muscle to a cephalad nerve branch innervating the zygomaticus major muscle was assessed. Measurements included total number of nerve branches as well as maximum dissection length. Nerve samples were taken from both branches at the site of coaptation and histomorphometric analysis for axonal count was performed. RESULTS: The number of sub-branches to the orbicularis oculi muscle was 3.1 ± 1.0 and to the zygomaticus major muscle 4.7 ± 1.2. The maximal length of dissection of the caudal nerve branch to the orbicularis oculi muscle was 28.3 ± 7.3 mm and for the cranial nerve branch to the zygomaticus major muscle 23.8 ± 6.5 mm. Transection and tension-free coaptation was possible in all cases but one. The average myelinated fiber counts per mm2 was of 5,173 ± 2,293 for the caudal orbicularis oculi branch and 5,256 ± 1,774 for the cephalad zygomaticus major branch. CONCLUSION: Oculo-zygomatic nerve transfer is an anatomically feasible procedure. The clinical value of this procedure, however, remains to be proven.

Relational Anatomy of the Mimetic Muscles and Its Implications on Free Functional Muscle Inset in Facial Reanimation.

BACKGROUND: The human smile is a complex coordinated activity of mimetic muscles predominantly recognizable by a superolateral pull at the commissure and elevation of the upper lip. The aim of this study was to revisit the muscles of facial expression responsible for these motions, evaluate their relational anatomy and orientation, and relate this to optimal positioning of free muscle transfer in smile reanimation. METHODS: Nineteen hemifaces from fresh cadaveric specimens were dissected. A subsuperficial muscular aponeurotic system skin flap was elevated to expose the zygomaticus major, zygomaticus minor, levator labii superioris, and levator labii superioris alaeque nasi. Muscle location, length, width, angle of pull, and any anatomic variation were noted. RESULTS: All specimens had zygomaticus major, levator labii superioris, and levator labii superioris alaeque nasi muscles present bilaterally. Conversely, the zygomaticus minor was present in only 10 of 19 hemifaces. There was no significant difference in muscle length, width, or line of pull between specimen sides. Of all the assessed muscles, the zygomaticus minor had the most transverse line of pull, at 31.6°; the zygomaticus major was more oblique with a line of pull of 55.5°; and the levator labii superioris and levator labii superioris alaeque nasi were oriented almost vertically with angles of 74.7° and 79.0°, respectively. CONCLUSIONS: The mimetic muscle vector is quite vertical in comparison to the angle obtained by traditional dynamic smile reconstruction surgeries. A more vertical vector, especially at the upper lip, should be considered in smile reconstruction.

Cranial Nerve Coactivation and Implication for Nerve Transfers to the Facial Nerve.

In reanimation surgery, effortless smile can be achieved by a nonfacial donor nerve. The underlying mechanisms for this smile development, and which is the best nonfacial neurotizer, need further clarification. The aim of the present study was therefore to further explore the natural coactivation between facial mimic muscles and muscles innervated by the most common donor nerves used in smile reanimation. The study was conducted in 10 healthy adults. Correlation between voluntary facial muscle movements and simultaneous electromyographic activity in muscles innervated by the masseter, hypoglossal, and spinal accessory nerves was assessed. The association between voluntary movements in the latter muscles and simultaneous electromyographic activity in facial muscles was also studied. Smile coactivated the masseter and tongue muscles equally. During the seven mimic movements, the masseter muscle had fewer electromyographically measured coactivations compared with the tongue (two of seven versus five of seven). The trapezius muscle demonstrated no coactivation during mimic movements. Movements of the masseter, tongue, and trapezius muscles induced electromyographically recorded coactivation in the facial muscles. Bite resulted in the strongest coactivation of the zygomaticus major muscle. The authors demonstrated coactivation between voluntary smile and the masseter and tongue muscles. During voluntary bite, strong coactivation of the zygomaticus major muscle was noted. The narrower coactivation pattern in the masseter muscle may be advantageous for central relearning and the development of a spontaneous smile. The strong coactivation between the masseter muscle and the zygomaticus major indicates that the masseter nerve may be preferred in smile reanimation.

Reconstruction of late esophagus perforation after anterior cervical spine fusion with an adipofascial anterolateral thigh free flap: A case report.

Reconstruction of late esophageal perforation usually requires flap surgery to achieve wound healing. However, restoring the continuity between the digestive tract and retropharyngeal space to allow for normal swallowing remains a technical challenge. In this report, we describe the use of a thin and pliable free adipofascial anterolateral thigh (ALT) flap in a 47-year-old tetraplegic man with a history of C5-C6 fracture presented with a large posterior esophagus wall perforation allowing an easier flap insetting for a successful wound closure. The postoperative course was uneventful and mucosalization of the flap was confirmed by esophagoscopy 4 weeks postsurgery. The patient tolerated normal diet and maintained normal swallowing during a follow-up of 3 years postoperatively. The adipofascial ALT flap may provide easier insetting due to the thin and pliable layer of adipofascial tissue for reconstructing large defects of the posterior wall of the esophagus by filling the retroesophageal space.

Qualitative and Quantitative Analysis of Smile Excursion in Facial Reanimation: A Systematic Review and Meta-analysis of 1- versus 2-stage Procedures.

BACKGROUND: Free functional muscle transfer has become a common treatment modality for smile restoration in long-lasting facial paralysis, but the selection of surgical strategy between a 1-stage and a 2-stage procedure has remained a matter of debate. The aim of this study was to compare the quantitative and qualitative outcomes of smile excursion between 1-stage and 2-stage free muscle transfers in the literature. METHODS: A comprehensive review of the published literature between 1975 and end of January 2017 was conducted. RESULTS: The abstracts or titles of 2,743 articles were screened. A total of 24 articles met our inclusion criteria of performing a quantitative or qualitative evaluation of a free-functioning muscle transfer for smile restoration. For the purpose of meta-analysis, 7 articles providing quantitative data on a total of 254 patients were included. When comparing muscle excursion between 1-stage and 2-stage procedures, the average range of smile excursion was 11.5 mm versus 6.6 mm, respectively. For the purpose of systematic review, 17 articles were included. The result of the systematic review suggested a tendency toward superior functional results for the 1-stage procedure when comparing the quality of smile. CONCLUSIONS: The results of this review must be interpreted with great caution. Quantitative analysis suggests that 1-stage procedures produce better excursion than 2-stage procedures. Qualitative analysis suggests that 1-stage procedures might also produce superior results when based on excursion and symmetry alone, but these comparisons do not include one important variable dictating the quality of a smile-the spontaneity of the smile. The difficulty in comparing published results calls for a consensus classification system for facial palsy.