Spontaneity Assessment in Dually Innervated Gracilis Smile Reanimation Surgery

Key Points

Question  Can a video time-stamping method be used to measure spontaneity of smile after dually innervated gracilis smile reanimation surgery?

Findings  In this cohort study of 25 patients treated with dually innervated gracilis free muscle transfers vs 24 patients treated with masseteric nerve–driven transfers (n = 11) or cross-face nerve graft–driven gracilis (n = 13), a spontaneous smile was present in a median of 33% of smiles, which was more than was present in masseteric nerve–driven transfers (20%) but less than in cross-face nerve graft–driven smile reanimation surgery (75%).

Meaning  Dual innervation may improve synchronicity compared with masseteric nerve transfer but not to the level of cross-face nerve graft–driven gracilis free muscle transfer.

Importance  Surgeons have sought to optimize outcomes of smile reanimation surgery by combining inputs from nerve-to-masseter and cross-face nerve grafts. An objective assessment tool could help surgeons evaluate outcomes to determine the optimal neural sources for smile reanimation.

Objective  To evaluate the use of a novel video time-stamping method and standard outcome measurement tools to assess outcomes of facial reanimation surgery using various innervation strategies.

Design, Setting, and Participants  Cohort study assessing the outcomes of dually innervated gracilis free muscle transfers vs single-source innervated gracilis transfer performed at a tertiary care facial nerve center between 2007 and 2017 using a novel, video time-stamping spontaneity assessment method. The statistical analyses were performed in 2018.

Interventions  Dually innervated gracilis free muscle transfers or single-source innervated gracilis transfer.

Main Outcomes and Measures  Spontaneous smiling was assessed by clinicians and quantified using blinded time-stamped video recordings of smiling elicited while viewing humorous video clips.

Results  This retrospective cohort study included 25 patients (12 men and 13 women; median [range] age, 38.4 [29.3-46.0] years) treated with dually innervated gracilis free functional muscle graft for unilateral facial palsy between 2007 and 2017. Smile spontaneity assessment was performed in 17 patients and was compared with assessment performed in 24 patients treated with single-source innervated gracilis transfer (ie, nerve-to-masseter–driven or cross-face nerve graft–driven gracilis [n = 13]) (demographic data not available for NTM and CFNG cohorts). The use of time-stamped video assessment revealed that spontaneous synchronous oral commissure movement in a median percentage of smiles was 33% in patients with dually innervated gracilis (interquartile range [IQR], 0%-71%), 20% of smiles in patients with nerve-to-masseter–driven gracilis (IQR, 0%-50%), and 75% of smiles in patients with cross-face nerve graft–driven gracilis (IQR, 0%-100%). Clinicians graded smile spontaneity in dually innervated cases as absent in 40% (n = 6 of 15), trace in 33% (n = 5 of 15) and present in 27% (n = 4 of 15). No association was demonstrated between clinician-reported spontaneity and objectively measured synchronicity.

Conclusions and Relevance  Dually innervated gracilis free muscle transfers may improve smile spontaneity compared with masseteric nerve–driven transfers but not to the level of cross-face nerve graft–driven gracilis transfers. Quantifying spontaneity is notoriously difficult, and most authors rely on clinical assessment. Our results suggest that clinicians may rate presence of spontaneity higher than objective measures, highlighting the importance of standardized assessment techniques.

Level of Evidence  4.

Original Article