RECONSTRUCTIVE Therapeutic Strategies in Post–Facial Paralysis Synkinesis in Adult Patients

RECONSTRUCTIVE

Therapeutic Strategies in Post–Facial ParalysisSynkinesis in Adult Patients

Julia K. Terzis, M.D., Ph.D.Dimitrios Karypidis, M.D.

Norfolk, Va.

Background: Facial synkinesis comprises unwanted facial muscle contractionsin different facial muscle groups following voluntary ones, in cases of incompleterecovery from facial paralysis. Facial expressivity and function are impaired, andthe psychological integrity of the patients is seriously affected.Methods: Thirty-one adult patients (older than 18 years) presenting with post–facial paralysis synkinesis were included in this study. The mean patient age was39.6 years and the mean denervation time was 124 months.Results: There were five patient groups. Group A (n � 9) underwent cross-facialnerve grafting and secondary microcoaptations. Group B (n � 8) had cross-facialnerve grafting, secondary microcoaptations, and botulinum toxin type A injec-tions. Group C (n � 6) received cross-facial nerve grafting, secondary micro-coaptations, botulinum toxin type A, and selective neurectomies. Group D(n � 2) underwent cross-facial nerve grafting, direct muscle neurotization, andbotulinum toxin type A. Group E underwent other means of treating synkinesis(n � 6), such as botulinum injections alone (n � 1), biofeedback alone (n � 2),biofeedback with selective neurectomies and myectomies (n � 2), and biofeed-back and botulinum injections (n � 1). Group B had the highest synkinesisimprovement (100 percent), followed by groups A and C (66 percent). Func-tional results were improved, with smile improvement being higher in group Cand eye closure being higher in groups A, B, and E.Conclusion: Meticulous patient selection and evaluation followed by an in-dividualized form of treatment, most frequently including cross-facial nervegrafting and secondary microcoaptations along with botulinum toxin type Aand biofeedback including facial muscle retraining, constitute an effectiveand reliable methodology with which to combat post–facial paralysissynkinesis. (Plast. Reconstr. Surg. 128: 1, 2011.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Synkinesis consists of abnormal, undesiredfacial contractions that accompany volun-tary facial movements during recovery

from facial nerve injury.1 Persisting synkinesismay lead to facial expression impairment, dis-rupted resting facial posture, and unpredictablepsychological consequences for patients recov-ering from facial palsy.2 The incidence of post–facial palsy synkinesis ranges from 15 to 55 per-cent of patients.3–5

Beurskens et al.6 reported on the location andfrequency of synkinesis in patients recovering

from facial nerve lesions. They observed that in-voluntary mouth-corner lifting was coupled withvoluntary brow lift or eye closure (85 to 90 per-cent) and that voluntary lip puckering evoked the

From the Department of Surgery, Division of Plastic andReconstructive Surgery, Microsurgery Program, Eastern Vir-ginia Medical School.Received for publication March 9, 2011; accepted May 11,2011.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318230e758

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

Supplemental digital content is available forthis article. Direct URL citations appear in anAppendix at the end of the printed text; sim-ply type the URL address into any Webbrowser to access this content. Clickable linksto the material are provided in the HTML textof this article on the Journal’s Web site(www.PRSJournal.com).

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most severe and disturbing synkinesis, to the pa-tient’s eye.

Yamada et al.7 investigated the incidence offacial synkinesis and facial nerve fiber misdirec-tion after clamping at the intratemporal or extra-temporal portion of the facial nerve in guineapigs. The reorganization of the facial nucleus wasobserved using retrograde fluorescent tracersshowing that disturbed somatotopic organization,misdirected regenerating axons, and synkinesisoccurred almost exclusively in the subjects withthe intratemporal lesions. It was therefore sug-gested that the more proximal the lesion, thehigher the incidence and the severity of synkinesis.

Celik et al.8 applied facial nerve stimulation in34 patients within the first 5 days after the onset offacial palsy. Facial movement responses, the ap-pearance and spread of synkinetic movements,were recorded clinically and electrophysiologi-cally. Clinical synkinesis developed in 78 percentof patients with low direct response to stimulationcompared with 18.7 percent of patients with a highpoststimulation response, suggesting that peoplerecovering from facial palsy who also have a lowresponse to early facial nerve stimulation couldconstitute a high-risk group for the developmentof clinical synkinesis.

Bajaj-Luthra et al.9 studied 78 patients withclinically diagnosed ocular to oral synkinesis andquantified facial motion during eye closure andsmile suggesting that movement of the unaffectedside is influenced by the synkinetic movements ofthe affected side. Maeyama et al.,10 by performingelectroneurography and blink reflex evaluation in114 patients, showed that synkinesis could be de-termined by the blink reflex.

The prevalent pathogenesis theory of synkinesissuggests that aberrant facial nerve regeneration fol-lowing trauma, lesion, and/or disease occurs inwhich axons are misdirected and grow to undesiredperipheral muscle groups. Consequently, voluntaryfacial movement may be accompanied by un-wanted contractions of different muscle groupsbecause of the abnormal innervation of differentmuscle targets that would normally contract inde-pendently. By using retrograde fluorescent tracertechniques in a rat model, it was shown that ab-errant axonal development occurred throughoutthe length of the facial nerve and not at the site ofthe lesion alone.11

According to the second theory, because ofthe initially ineffective myelination of the nervefibers following a lesion, neighboring nerve fibersmay come into contact, leading to the incorrecttransfer of nerve signals along undesired neural

pathways.12 The third theory suggests that nuclearhypersensitivity to neurotransmitters develops be-cause of the postlesion axonal degeneration andthe resulting lack of peripheral input. Hypersen-sitivity may this way lead to the creation of unde-sired and uncoordinated movements.13 All of theaforementioned theories have both advantagesand disadvantages, and the combination of severalpathogenesis mechanisms is more likely to be re-sponsible for synkinesis.

PATIENTS AND METHODSData collection included the retrospectively

reviewed medical charts of 50 facial palsy patientswho received treatment for synkinesis betweenJanuary of 1982 and January of 2008. Thirty-oneadult patients were included in this study. Com-plete patient history, follow-up of at least 18months, and full preoperative physical examina-tion and neurologic investigation of the patientsconstituted the inclusion criteria. Nerve conduc-tion studies and needle electromyography werealways included. Computed tomography or mag-netic resonance imaging of the facial canal andtemporal bone bilaterally was performed whenindicated. No patients with immediate post-trauma or post–tumor extirpation facial palsy orwith ongoing radiation therapy were included.The demographic details of the patients arelisted in Table 1.

Eye closure and smile evaluation were per-formed as indicated by the standardized protocolin our center.14 Video documentation of eye clo-sure required each patient to be in a seated po-sition with the head stabilized. Each patient wasthen asked to close his or her eyes lightly and thentightly several times looking straight at the camera.Video documentation of smile required patientsto demonstrate first a slight smile and then a fullsmile several times. Emotional-involuntary facialmovements were videotaped for further evalua-tion while patients were talking and watching a

Table 1. Patient Demographics

Value

No. of patients 31Sex

Male 9Female 20

Mean age, years 39.5 � 13Mean DT, months 119.9LFP 14RFP 15DT, denervation time; LFP, left facial paralysis; RFP, right facialparalysis.

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humorous video. For eye closure and smile eval-uation, the established grading systems are listedin Tables 2 and 3. Synkinesis evaluation was per-formed using the component for synkinesis grad-ing in the Facial Grading System by Ross et al.,15

which is a practical and validated system used infacial palsy patients without specific training re-quirements for the user (Table 4).

The same series of detailed examinations andstandardized video recording took place at thepreoperative and postoperative visits for each pa-tient. All video recordings were reviewed sepa-rately by three independent investigators whorated eye closure, smile, and synkinesis. Final post-operative evaluation concerned the last follow-upvisit scoring of each patient, following completionof synkinesis treatment and not earlier than 18months postoperatively. The independent inves-tigators did not participate in patient investigationand treatment. The senior author (J.K.T.) did notparticipate in eye closure, smile, or synkinesis eval-uation. Video recordings and evaluation were per-formed under standardized and protocol-specificconditions.16,17 A considerable degree of agree-ment was noted among the independent investi-gators as determined by an intraclass correlationcoefficient of 0.91.

Patients were divided into five groups depend-ing on the treatment they received. Group A (n �9) included patients who underwent cross-facialnerve grafting and secondary microcoaptations.Group B (n � 8) included patients who underwentcross-facial nerve grafting, secondary microcoap-tations, and botulinum toxin type A injections.Group C (n � 6) consisted of patients who un-derwent cross-facial nerve grafting, secondary mi-crocoaptations, botulinum toxin type A injections,

and selective neurectomies. Group D (n � 2) in-cluded patients who underwent cross-facial nervegrafting, direct muscle neurotization, and botuli-num toxin type A injections. Group E includedpatients who underwent other means of treatingsynkinesis (n � 5), such as botulinum toxin typeA injections alone (n � 1), biofeedback alone (n �2), biofeedback with selective neurectomies andmyectomies (n � 2), and biofeedback and botu-linum toxin type A injections (n � 1). Biofeedbackwas followed consistently by every patient accord-ing to the protocol in our center. Therefore, theeffect of biofeedback concerned all patients re-gardless of any additional procedure that was ap-plied to treat synkinesis. Consequently, biofeed-back was a constant factor in all patient groups thatwas consistently taken under consideration in allpatients during evaluation and analysis.

Treatment ModalitiesThe cross-facial nerve grafting procedure in-

volves placement of a cross-facial nerve graft in-tended for eye reanimation, a second cross-facialnerve graft for smile restoration, and a third cross-

Table 2. Scoring System for Eye Closure

Group Grade Designation Description

I 1 Poor No eye closure (no contraction); maximal scleral showII 2 Fair Poor eye closure (minimal contraction); two-thirds scleral showIII 3 Moderate Incomplete eye closure; one-third scleral showIV 4 Good Nearly complete eye closure; minimal scleral showV 5 Excellent Complete eye closure; no scleral showFrom Terzis JK, Bruno W. Outcomes with eye reanimation microsurgery. Facial Plast Surg. 2002;18:101–112.

Table 3. Aesthetic and Functional Grading System Used for Smile

Group Grading Result Description

I 1 Poor Deformity, no contractionII 2 Fair No symmetry, bulk, minimal contractionIII 3 Moderate Moderate symmetry and contraction, mass movementIV 4 Good Symmetry, nearly full contractionV 5 Excellent Symmetrical smile with teeth showing, full contractionFrom Terzis JK, Noah ME. Analysis of 100 cases of free-muscle transplantation for facial paralysis. Plast Reconstr Surg. 1997;99:1905–1921.

Table 4. Grading System Used for Synkinesis*

Grade Designation Description

0 None No synkinesis or mass movementI Mild Slight synkinesisII Moderate Obvious but not disfiguring

synkinesisIII Severe Disfiguring synkinesis, gross mass

movement of several muscles*The component for synkinesis rating in the Facial Grading Systemby Ross et al. (Ross BG, Fradet G, Nedzelski JM. Development of asensitive clinical facial grading system. Otolaryngol Head Neck Surg.1996;114:380–386.)

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facial nerve graft for depressor complex. Aftercompletion of nerve regeneration along the cross-facial nerve grafts, secondary microcoaptationswith the corresponding branches of the contralat-eral diseased or injured facial nerve are performedto “slave” the paralyzed eye-sphincter, smile mus-cles, and depressor complex to the seventh nervemotor fibers supplying the normal correspondingmuscles of the contralateral side.18 As a result, the“synkinesis” cycle is broken by “slaving” the para-lyzed facial muscle to signals that control the con-tralateral corresponding facial muscle, thus “es-caping” the abnormal volleys of stimuli from theipsilateral diseased facial nerve.18

Direct muscle neurotization includes the directimplantation of the cross-facial nerve graft into thesubstance of the muscle. The distal end, which isdestined to neurotize the muscle, is split into sev-eral fascicles, and each fascicle is implantedthrough individual incisions in the epimysium.17

Consequently, a new motor nerve supply is madeavailable, augmenting facial muscle contractionand coupling it with the contralateral normal mus-cle function.17

Botulinum toxin type A injections temporarilyparalyze selected muscle fiber groups, reducingsynkinetic movements. Because of the short du-ration of the effect of botulinum toxin type A,patients have to undergo repeated injections every3 to 4 months.19,20 Conversely, in selective neurec-tomies and myectomies, specific facial nervebranches and muscle groups are excised respec-tively. Detailed preoperative electromyographicand nerve conduction studies and intraoperativemapping indicate the selected nerve or muscletargets to be excised. Results are permanent.21

During biofeedback training, the patient learnsto actively sense facial muscle contraction using ei-ther electromyographic or mirror feedback or both.Sound signals indicating the time and intensity ofmuscle contraction while looking in the mirror helpthe patient regain conscious control of symmetricfacial movements and achieve improvement ofsynkinesis.

The choice of the appropriate treatment in-cluded a detailed, individualized approach takinginto consideration the clinical, psychological, anddemographic characteristics of each patient. Gen-eral guidelines regarding surgical decision makingin synkinesis treatment in our center include thefollowing:

1. Cross-facial nerve grafting and secondary mi-crocoaptations (group A) is the treatment ofchoice in cases of severe synkinesis (grade �

2) and high denervation time when, tobreak the synkinesis cycle, facial muscles ofthe affected side are connected to signalsfrom the unaffected side and are effectivelydisengaged from the abnormal stimuli fromthe ipsilateral diseased facial nerve. In themost severe cases (grade 3 with very highdenervation time), this method is accompa-nied by botulinum toxin type A injections(group B) to further block the abnormallystimulated facial muscles and improve theoverall outcome of cross-facial nerve graft-ing. Selective neurectomies (group C) wereused when a more permanent result thanthe one achieved with botulinum toxin typeA injections was required (e.g., in cases ofdiminished botulinum toxin type A actionbecause of numerous previous uses).

2. Direct muscle neurotization (group D) wasused in less severe cases of synkinesis (1 �grade �2) in which facial muscle primary in-nervation was preserved (no microcoaptationsbetween ipsilateral facial nerve branches andcross-facial nerve grafts) and their functionwas augmented and coordinated with thefunction of the contralateral unaffected side.Invariably, botulinum toxin type A injectionsare used to further improve synkinesis.

3. Patients with mild synkinesis (grade �1, groupE) were treated with either nonsurgical inter-ventions (botulinum toxin type A) or with aminor to intermediate surgical procedure (se-lective neurectomy, myectomy) without un-dergoing several hours of surgery such as ma-jor nerve transfer procedures (cross-facialnerve grafting and direct muscle neurotiza-tion). Selective neurectomies and myectomieswere preferred over botulinum toxin type Ainjections when the latter did not have thedesired effect in synkinesis improvement.

Injections of the orbicularis oculi muscle in-volved 10 injection sites in the upper lateral quad-rant of the eye sphincter and 10 injection sites inthe lower lateral quadrant. Each site received 1unit of botulinum toxin type A. Injections of thelip and commissure elevators consisted of 25 in-jections lateral and superior to the nasolabial foldto include the zygomaticus major and lip elevators.Once more, each injection site received 1 unit ofbotulinum toxin type A.

Statistical AnalysisBecause all synkinesis and functional evalua-

tion scores correspond to Likert type scales (Ta-


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bles 2 through 4), nonparametric statistical anal-ysis was performed using the Wilcoxon signedpaired test when comparing preoperative andpostoperative scores (median values). Correla-tions between two variables in the matched pairsdata were tested using the Spearman rank corre-lation coefficient (�s is correct) based on � � 0.05and the number of patients in each group underinvestigation. Results were statistically significantfor values of � � 0.05.

RESULTSThe differences between preoperative and

postoperative synkinesis scores corresponded tothe improvement following treatment. The me-dian value of all the aforementioned differenceswas 1 on the synkinesis grading scale (Table 4),with � � 0.05 showing that treatment resulted inan improvement of 33 percent. Overall functionalimprovement was 20 percent for both eye closureand smile (Table 5). The side of paralysis and thetype of synkinesis yielded no statistically significantdifferences in posttreatment synkinesis improve-ment (p � 0.77 and p � 0.32, respectively). Therewas no correlation between the age of the patientsand eye closure (0.22), smile (0.15), and synkine-sis (0.03) following treatment improvement. Pre-operative and postoperative functional (eye clo-sure and smile) and synkinesis scores in eachpatient treatment group are shown in Tables 6 and7, respectively. Posttreatment functional and syn-

kinesis improvement in each facial palsy causegroup are shown in Tables 8 and 9, respectively.

In all patient groups, a negative correlationwas observed between denervation time and syn-kinesis, eye closure, and smile improvement. Ta-ble 10 lists the aforementioned correlations ineach patient group.

Types of synkinesis (oro-ocular and oculo-oral) and improvement in each patient group arelisted in Table 11. Correlation of synkinesis im-provement and eye closure in each group was 0.66(p � 0.03) in group A, 0.72 (p � 0.02) in groupB, and 0.75 (p � 0.04) in group C. Similarly, cor-relation of synkinesis improvement and smile iseach patient group was 0.83 (p � 0.005) in groupA, 0.79 (p � 0.009) in group B, and 0.88 (p � 0.01)

Table 5. Functional and Synkinesis Overall Preoperative and Postoperative Scores in the Adult Population*

Preoperative† Postoperative‡ Improvement (%)§ Normal�Eye closure 4 5 1 (20) 5Smile 3 4 1 (20) 5Synkinesis 2 1 1 (33) 0*Scores represent functional and synkinesis grades as shown in the grading scales in Tables 2 through 4. All patients underwent biofeedbackpostoperatively.†Median pretreatment synkinesis, eye closure and smile scores.‡Median posttreatment synkinesis, eye closure, and smile scores.§Improvement represented by the difference between median pretreatment and posttreatment scores and percentage conversion.�Score for full smile, optimum eye closure, and no synkinesis, respectively (� � 0.05 for all pairs).

Table 6. Synkinesis Treatment, Denervation Time, and Functional Results*

Eye Closure Smile

Group No. DT (mo) Pre Post Imp Pre Post Imp Normal

A 9 133.75 4 5 1 3 4 1 5B 8 67.125 4 5 1 2 3 1C 6 89.5 5 5 0 3 5 2D 2 131 3 3 0 3 4 1E 6 214.6 4 5 1 3 4 1DT, mean denervation time; Pre, preoperative synkinesis score; Post, postoperative synkinesis score; Imp, functional improvement (thedifference between preoperative and postoperative median scores).*Scores represent functional results as shown in the grading scales in Tables 2 and 3. All patients underwent biofeedback postoperatively.

Table 7. Synkinesis Treatment and Preoperative andPostoperative Scores

Group* No. DT Pre Post Imp (%) Normal†

A 9 67.125 2 0 2 (66) 0B 8 133.75 3 0 3 (100)C 6 89.5 2 0 2 (66)D 2 131 2 1 1 (33)E 6 214.6 1 0 1 (33)DT, mean denervation time; Pre, median preoperative synkinesisscore; Post, median postoperative synkinesis score; Imp, improve-ment in synkinesis (the difference between preoperative and post-operative median scores and the percentage conversion).*Patient groups include patients who underwent different treatmentmodalities as described in the text. All patients underwent biofeed-back postoperatively.†Score for no synkinesis.


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in group C. The aforementioned correlationswere not statistically significant in group D and E.Representative cases depicting preoperative ver-sus postoperative synkinesis and functional scoreimprovement are shown in Figures 1 through 10.(See Videos, Supplemental Digital Content 1through 10; hyperlinks to view videos and descrip-tions are available in Appendix 1.) Details of thehistory, additional procedures, type of synkinesis,and treatment group of patients shown in Figures1 through 10 are listed in Table 12.

DISCUSSIONIt was noted that synkinesis improvement con-

sistently accompanied functional improvement asindicated by the high positive correlations be-tween synkinesis and eye closure and smile im-provement. It can therefore be suggested that therestoration of coordinated symmetrical facial mus-cle contractions and the reduction of abnormalvolleys of unwanted movements increase the effi-ciency of normal facial muscle functions and en-able clear and natural facial expressions.

No correlation was noted between the age ofthe patients and their functional and synkinesis

improvement. Age has been shown to be a factorof major importance in nerve regeneration.22

There are a number of parameters that are morefrequently present in aged patients and have anegative effect on nerve regeneration. At a pe-ripheral level, these parameters include the im-pairment of axonal sprouting caused by myelinpersistence in the distal segment, and the pro-longation of the inflammatory phase, whichleads to increased intraneural scarring and theincreased number of misrouted axons and col-lateral branches that often fail to reach the targetmuscle.22 Centrally, brainstem somatotopic orga-nization of the corresponding motoneurons in-side the facial nucleus following a lesion is poorerin the aged.23 Finally, at the level of the neuro-muscular junction, advancing age is associatedwith decreased quality of cell differentiation,lower efficiency of cell interaction and connec-tion, and lower concentration of adhesion mole-cules at the site of the neuromuscular junction.24

Nevertheless, in our series, all patients were adults,having already exceeded the age of the suggestedage-related advantageous potential (mean age,39.6 � 13 years).

There was a high negative correlation betweendenervation time and both functional and synki-nesis improvement in all patient groups. Althoughin all cases facial paralysis was partial and there wasno facial muscle atrophy, our findings were inagreement with the fact that prolonged even par-tial denervation has a negative effect on the qualityof reinnervation by subsequent nerve reconstruc-tion. The cause and the pathogenesis of facialparalysis did not have an effect on functional andsynkinesis improvement, probably because thereare no specific cause-related factors associatingthe cause of facial paralysis in this series of patientswith the severity of their synkinesis.

Cross-facial nerve grafting with secondary mi-crocoaptations and botulinum toxin type A injec-

Table 8. Facial Palsy Cause, Denervation Time, and Functional Results*

Eye Closure Smile

Cause No. DT Pre Post Imp Pre Post Imp Normal

Traumatic 6 132 3 4 1 3 4 1 5Developmental 1 384 5 5 0 3 3 0Tumor† 2 146.41 4 5 1 3 4 1Iatrogenic 12 27 4 4 0 3 4 1Bell palsy 7 52 5 5 0 3 4 1RHS 1 98 5 5 0 3 3 0DT, denervation time; Pre, median preoperative synkinesis score; Post, median postoperative synkinesis score; Imp, functional improvement(the difference between preoperative and postoperative median scores); RHS, Ramsey Hunt syndrome.*Scores represent functional results as shown in the grading scales in Tables 2 and 3.†Posttumor extirpation.

Table 9. Facial Palsy Cause, Denervation Time, andSynkinesis Results*

Synkinesis Scores

Cause No. DT Pre Post Imp Normal†

Traumatic 6 132 3 1 2 0Developmental 1 384 1 0 1Tumor 2 146.41 2 0 2Iatrogenic 12 27 1 0 1Bell palsy 7 52 2 1 1RHS 1 98 2 0 2DT, denervation time; Pre, median preoperative synkinesis score;Post, median postoperative synkinesis score; Imp, synkinesis improve-ment (� � 0.05 for all pairs); RHS, Ramsey Hunt syndrome.*Scores represent functional results as shown in the grading scale inTable 4).†Score for no synkinesis.


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tions had the highest improvement. It was thetreatment modality that was chosen for patientswith the most severe synkinesis and resulted in fullrestoration. It can be suggested that the combina-tion of restoring normal, coordinated, symmetricfunction by coupling it with that of the unaffectedside along with the decrease of undesired move-ments using botulinum toxin type A injections con-stituted the most successful and reliable modality intreating severe synkinesis. Direct muscle neurotiza-tion had improvement similar to that achieved withthe non–nerve transfer modalities (33 percent) (Ta-ble 7) but was reserved for patients with more severepretreatment synkinesis than the ones treated withnon–nerve transfer modalities.

Guerrissi21 achieved satisfactory results in sixpatients with postparetic oro-ocular synkinesis us-ing myectomy in the perioral muscle groups. How-ever, these results were neither quantified norcompared with other synkinesis patients who were

also included in the study but did not undergosurgery. No other treatment modality or facialmuscle training was mentioned.

Mountain et al.25 treated four post–facial paral-ysis patients with botulinum toxin type A injectionsalone and achieved significant improvement. Nev-ertheless, surgical modalities were not included inthe study, and the decision to repeat injections basedon the duration of the results was not fully justified.

Armstrong et al.26 achieved improvement in 24patients with synkinesis using botulinum toxintype A injections and analyzed the minimum re-quired dose for their optimum results. Surgicalmodalities and adequate comparative outcomequantification were not included.

Wang, who trained as a fellow in our centerduring the period 2006 to 2007, applied the conceptof cross-facial nerve grafting, which was originallyestablished in our center in the early 1980s, in thetreatment of 11 patients with post–facial palsy oculo-oral synkinesis.27 Although the applied method ofevaluation was different and no direct comparisonwould be possible, the maximum reported improve-ment was 28 percent, whereas in our series, the im-provement was threefold higher. Technique-relateddetails and successful combination of surgical andnonsurgical modalities could be the reason for thesuperior results in our center.

Physical therapy, biofeedback, and retraininghave a role in synkinesis treatment, as they increasethe patient’s awareness of the intensity, timing, andsymmetry of facial muscle contractions. In addition,they augment the potential gained by surgical treat-ment and accelerate recovery.28

CONCLUSIONSPreoperative synkinesis severity and dener-

vation time play a central role in surgical plan-

Table 10. Correlations between Denervation Time and Synkinesis, Eye Closure, and Smile Improvement in theEach Patient Group

Denervation Time

Eye Closure Improvement Smile Improvement Synkinesis Improvement

Group* Correlation p Correlation p Correlation p

A –0.83 0.01 –0.81 0.01 –0.72 0.044B –0.93 0.004 –0.85 0.07 –0.76 0.03C –0.7 0.05 –0.84 0.01 –0.78 0.03D† NS NS NS NS NS NSE –0.79 0.05 –0.82 0.04 –0.78 0.05NS, not significant.*Patient groups, including patients as described in the text.†Nonsignificant values in patient group D are attributable to the small sample (n � 2); values of p � 0.05 are considered statisticallysignificant.

Table 11. Type of Synkinesis and Improvement

Type of Synkinesis

Oro-Ocular Oculo-Oral Both

Group*A 2 3 4B 5 1 2C 3 1 2D 0 1 1E 2 2 2Total 12 8 11

Synkinesis scores†Preoperative 2 2 2Postoperative 1 1 1Improvement 1 1 1

*Patient groups include patients who underwent different treatmentmodalities as described in the text.†Median preoperative and postoperative synkinesis scores as shownin Table 4; Improvement is the improvement in synkinesis (thedifference between preoperative and postoperative median scoresand the percentage conversion).


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ning, and in the majority of cases it is the suc-cessful implementation of a combination oftreatment modalities that yields the superior re-sults. The greatest contribution from our center

is the introduction over the past three decadesof the cross-facial nerve grafting procedure tocombat synkinesis, as it has the capabilities ofrestoring coordinated function on both sides of

Fig. 1. (Left) A 46-year-old woman from treatment group B presented with oro-ocular syn-kinesisandpartialparesisontherightface.(Right)Noteimprovementinsynkinesisandoverallfunction and aesthetics. The patient’s history and treatment details are listed in Table 12.

Fig. 2. (Left) A 47-year-old man from treatment group B presented with severe oro-ocularsynkinesis and weakness of the right face. (Right) At the last office visit, 7 years later, there wasmajor improvement in his synkinesis, function, and aesthetics. Treatment and history detailsare listed in Table 12.


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Fig. 3. (Left) A 33-year-old woman from group B presented with severe left oro-ocularsynkinesis. (Right) Note improvement in synkinesis and overall function and aes-thetics 3 years after her treatment. Treatment and history details are listed inTable 12.

Fig. 4. (Left) A 44-year-old woman from treatment group B presented with severe oro-ocular synkinesis and weakness of the left face. (Right) At the last office visit, 2 years later,there was significant improvement in her synkinesis, function, and aesthetics. Treatmentand history details are listed in Table 12.


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the face and eliminates the signals from thediseased or affected facial nerve by slaving thesynkinetic target to the normal impulses ofthe contralateral side. Combination of cross-fa-

cial nerve grafting with other modalities has per-manently limited involuntary movements andproved to be a reliable and effective way of com-bating synkinesis.

Fig. 5. (Left) A 60-year-old woman from treatment group C presented with severe oro-ocular synkinesis and weakness of the right face. (Right) At the last office visit, 5 years later,there is significant improvement in her synkinesis, function, and aesthetics. Treatmentand history details are listed in Table 12.

Fig. 6. (Left) A 35-year-old woman from group A presented with severe right synkinesis. Noteright paresis, oculo-oral synkinesis, and weakness of the right depressor complex. (Right) Noteimprovement in synkinesis and overall function and aesthetics 3 years after her treatment. Treat-ment and history details are listed in Table 12.


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Fig. 7. (Left) A 39-year-old woman from group A presented with right synkinesis.Note right paresis, oro-ocular synkinesis, and weakness of the right depressor com-plex. (Right) Note improvement in synkinesis and overall function and aesthetics2 years after her treatment. Treatment and history details are listed inTable 12.

Fig. 8. (Left) A 47-year-old man from group B presented with right oculo-oral synkinesisand paresis. (Right) Note improvement in synkinesis at his last office visit 9 years later.Additional treatment and history details are listed in Table 12.


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Fig. 9. (Left) A 63-year-old woman from group D presented with left oculo-oral synkinesisand paresis. (Right) Note improvement in synkinesis at the last office visit. Treatment andhistory details listed in Table 12.

Fig. 10. (Left) A 61-year-old man from group B presented with severe left oro-ocularsynkinesis. (Right) Note improvement in synkinesis and overall function and aes-thetics 3 years after his treatment. Treatment and history details are listed inTable 12.


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APPENDIX 1Supplemental Digital Content 1 and 2 corre-

spond to the patient shown in Figure 1. In thepreoperative video, Supplemental Digital Content1, http://links.lww.com/PRS/A396, the patientwho presented with oro-ocular synkinesis andparesis on the right face is shown. In the post-operative video, Supplemental Digital Content2, http://links.lww.com/PRS/A397, the synkinesishas been addressed by a combination of thecross-facial nerve grafting procedure combinedwith botulinum toxin type A injections to theupper and lower right eye sphincter.

Supplemental Digital Content 3 and 4 cor-respond to the patient shown in Figure 2. Thepreoperative video, Supplemental Digital Con-tent 3, http://links.lww.com/PRS/A398, shows se-vere oro-ocular synkinesis as a result of recov-ering Bell palsy on the right face. In thepostoperative video, Supplemental Digital Con-tent 4, http://links.lww.com/PRS/A399, improve-ment in synkinesis is apparent, along with amore symmetrical smile and overall aesthetics.

Supplemental Digital Content 5 and 6 corre-spond to the patient shown in Figure 3. The pre-operative video, Supplemental Digital Content 5,http://links.lww.com/PRS/A400, was obtained fol-lowing recovering Bell paralysis synkinesis in ayoung woman during the third trimester of preg-

nancy. Note the patient’s inability to keep herright eye open every time she attempts to smile. Inthe postoperative video, Supplemental DigitalContent 6, http://links.lww.com/PRS/A401, the pa-tient is seen at her last office visit after the cross-facial nerve grafting procedure, selective neurec-tomies, and crushing of selected branches of theright facial nerve and injection of botulinum toxintype A. Note improvement in synkinesis, function,and aesthetics.

Supplemental Digital Content 7 and 8 corre-spond to the patient shown in Figure 4. In the pre-operative video, Supplemental Digital Content 7,http://links.lww.com/PRS/A402, the patient, who pre-sented with recovering left facial paralysis that shesustained 8 years previously, is shown. Note synki-nesis, retractor paresis, and weakness of the left de-pressor. In the postoperative video, SupplementalDigital Content 8, http://links.lww.com/PRS/A403,the synkinesis has been addressed by the upper cross-facial nerve graft carrying fibers from the contralat-eral normal eye to the affected side. She also hadtransposition of the left platysma for strengtheningof the left depressor. Note improvement in synki-nesis, function, and aesthetics.

Supplemental Digital Content 9 and 10 corre-spond to the patient shown in Figure 5. The preop-erative video, Supplemental Digital Content 9,http://links.lww.com/PRS/A404, shows late presenta-

Table 12. Treatment Groups, Type of Synkinesis, and History of the Patients Shown in Figures 1 through 10

FigureTreatment

Group Synkinesis History Additional Procedures

1 B Right oro-ocular 46-yr-old woman, right mastoidsurgery to treat cholesteatoma

Bilateral upper eyelid blepharoplasty, chincontour correction

2 B Right oro-ocular 47-yr-old man, right mastoid surgery Right mini-temporalis to right commissure3 B Left oro-ocular 33-yr-old woman, Bell palsy during

third trimester of pregnancyLeft SMAS elevation for contour symmetry

restoration, MAC facelift4 B Left oro-ocular 44-yr-old woman, insect bite left

preauricular area (infection),preeclampsia

BTX-A preoperatively, left platysmatransfer for depressor substitution, MACfacelift, fat injection (upper lateraleyelids, nasojugal areas)

5 C Right oro-ocular 60-yr-old woman, right pontine angletumor extirpation (schwannoma)

Right mini-temporalis to right commissure,platysma selective myectomies,blepharoplasty, chin contour correction

6 A Right oro-ocular 35-yr-old woman, rightlymphangioma of the neck

Right mini-temporalis to right commissure,right digastric for depressor substitution

7 A Right oro-ocular 39-yr-old woman, right Bell palsy Free gracilis to (right) cheek, minifacelifts, bilateral neck liposuction

8 B Right oculo-oral 47-yr-old man, right Bell palsy Mini-temporalis to (right) commissure,right platysma transfer for rightdepressor substitution

9 D Right oculo-oral 63-yr-old woman, left parotidectomy,Fry syndrome

Mini-temporalis to (left) commissure, leftsuperficial temporal fascia flap to leftcheek

10 B Left oculo-oral 61-yr-old male, left Bell palsy Mini-tendon graft for left lower lidsuspension, gold weight left uppereyelid, lateral canthopexy

SMAS, superficial musculoaponeurotic system; MAC, minimal access cranial suspension; BTX-A, botulinum toxin type A.


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AQ: 7


http://links.lww.com/PRS/A396









tion of recovering right facial paralysis followinglarge pontine angle tumor extirpation, with associatedsynkinesis.Thepostoperativevideo,SupplementalDig-ital Content 10, http://links.lww.com/PRS/A405, showsthe patient following treatment with cross-facialnerve grafting (three times), secondary microco-aptations, and botulinum toxin type A injections.The patient’s appearance during final follow-up isshown. Note improvement in synkinesis, function,and aesthetics.

Supplemental Digital Content 11 and 12 corre-spond to the patient shown in Figure 6. The preop-erative video, Supplemental Digital Content 11,http://links.lww.com/PRS/A406, shows a 35-year-oldwoman with right facial palsy following removal oflymphangioma in the right neck when she was 7months of age. Note right paresis, oro-ocular synk-inesis, and weakness of the right depressor complex.The postoperative video, Supplemental Digital Con-tent 12, http://links.lww.com/PRS/A407, shows the pa-tient following treatment with the two-stage cross-facial nerve grafting (four times) procedure, rightmini-temporalis to right commissure, and pedicledigastric transfer to substitute for the paretic rightdepressor complex. Appearance during the last of-fice visit is shown. Note improvement in synkinesis,function, and aesthetics.

Supplemental Digital Content 13 and 14 cor-respond to the patient shown in Figure 7. Thepreoperative video, Supplemental Digital Content13, http://links.lww.com/PRS/A408, shows a 39-year-old woman with late presentation from sequelae ofBell palsy during pregnancy. Note severe synkinesis,right facial paresis, and weakness of the right de-pressor. The postoperative video, SupplementalDigital Content 14, http://links.lww.com/PRS/A409,shows the patient following treatment with the two-stage cross-facial nerve grafting (four times) proce-dure, free mini-gracilis to the right cheek, bilateralmini-facelifts, and neck liposuction. Note improve-ment in synkinesis, function, and aesthetics.

Supplemental Digital Content 15 and 16 cor-respond to the patient shown in Figure 8. Thepreoperative video, Supplemental Digital Content15, http://links.lww.com/PRS/A410, shows a 47-year-old man with oculo-oral synkinesis and rightfacial paresis secondary to right Bell palsy. Thepostoperative video, Supplemental Digital Con-tent 16, http://links.lww.com/PRS/A411, shows thepatient following treatment with the two-stagecross-facial nerve grafting (three times) proce-dure, injection of botulinum toxin type A, mini-temporalis to the right commissure, and right plat-ysma transfer for depressor restoration. Noteimprovement in synkinesis 9 years later.

Supplemental Digital Content 17 and 18 cor-respond to the patient shown in Figure 9. Thepreoperative video, Supplemental Digital Content17, http://links.lww.com/PRS/A412, shows late pre-sentation of left facial paralysis with oculo-oralsynkinesis in a 63-year-old woman following leftparotidectomy. Note uncontrollable elevationof left upper lip on eye closure. In the postop-erative video, Supplemental Digital Content 18,http://links.lww.com/PRS/A413, the patient isseen after a two-stage cross-facial nerve graftingprocedure, minitemporalis to left commissure,and direct muscle neurotization. Note improve-ment in synkinesis and overall aesthetics.

Supplemental Digital Content 19 and 20 cor-respond to the patient shown in Figure 10. Thepreoperative video, Supplemental Digital Con-tent 19, http://links.lww.com/PRS/A414, shows a61-year-old man with synkinesis developing afterhe was diagnosed with Bell palsy. The postop-erative video, Supplemental Digital Content 20,http://links.lww.com/PRS/A415, shows the pa-tient following treatment with the cross-facialnerve grafting (three times) two-stage proce-dure, left mini-hypoglossal–to–left cervicofacialnerve transfer, and static procedures to the lefteye. Appearance of the patient during the finaloffice visit is shown. Note improvement in syn-kinesis, function, and aesthetics.

Julia K. Terzis, M.D., Ph.D.Department of Surgery

Division of Plastic and Reconstructive SurgeryEastern Virginia Medical School

700 Olney Road, LH 2055Norfolk, Va. 23501

[email protected]

PATIENT CONSENTPatients provided written consent for the use of their

images.

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JOBNAME: AUTHOR QUERIES PAGE: 1 SESS: 3 OUTPUT: Mon Oct 10 08:19:02 2011/rich3/zpr-prs/zpr-prs/zpr01211/zpr5083-11z

AQ1: AUTHOR—Sentence that begins “They observed”: Correct as edited (“the most severe anddisturbing synkinesis, to the patient’s eye”)? If not, please revise as needed.

AQ2: AUTHOR—Please respond to the following question from the PRS Staff Editor: Table 1 saysthat there were 31 patients, but Male and Female add up to 29, as do LFP and RFP. Similarly,there are 31 patients in Tables 6, 7, and 11, but 29 patients in Tables 8 and 9. Please checkthroughout, with whatever changes or clarifications are necessary.

AQ3: AUTHOR—IMPORTANT: When returning proof corrections, please supply a copy of theletter granting permission to reproduce Table 2.

AQ4: AUTHOR—IMPORTANT: When returning proof corrections, please include the lettergranting permission to reproduce Table 4.

AQ5: AUTHOR—Please verify that the Spearman rank correlation coefficient symbol is correct astypeset.

AQ6: AUTHOR—For Tables 6 through 12, please confirm placement of the value in the “Normal”column. As wanted throughout? Please advise.

AQ7: AUTHOR—Footnote to Table 12: MAC spelled out correctly as minimal access cranialsuspension? If not, please supply the correct expansion.

AUTHOR QUERIES

AUTHOR PLEASE ANSWER ALL QUERIES 1

RECONSTRUCTIVE Therapeutic Strategies in Post–Facial Paralysis Synkinesis in Adult Patients

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