JAMA Facial Plastic Surgery
Journal Club Slides:
Objective Assessment of Smile Outcomes
Bhama PK, Weinberg JS, Lindsay RW, Hohman MH, Cheney
ML, Hadlock TA. Objective outcomes analysis following
microvascular gracilis transfer for facial reanimation: a review
of 10 years’ experience. JAMA Facial Plast Surg. Published
online January 30, 2014. doi:10.1001/jamafacial.2013.2463.
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Introduction
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Gracilis free tissue transfer (GFTT) is the gold standard for dynamic
reanimation of the oral commissure.
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Objective assessment of smile outcome after microvascular free gracilis
transfer is challenging, and quantification of smile outcomes in the literature
is inconsistent.
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Lack of objective outcomes measurements makes it challenging to predict
outcomes based on patient characteristics and intraoperative events.
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Purpose
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The purpose of this study was to quantify smile outcomes in patients
following GFTT and find relationships between intraoperative parameters
and outcomes.
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Relevance to Clinical Practice
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The advancement of facial reanimation treatment is dependent on the ability
of facial plastic surgeons to reliably quantify results so that comparisons
between current treatments and novel procedures can be made.
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If associations between perioperative parameters and ultimate outcomes
can be determined, clinicians can more accurately educate and prepare
patients for the results of their interventions.
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Description of Evidence
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All patients who underwent GFTT at the Massachusetts Eye and Ear
Infirmary from March 2003 to March 2013 were included in the study.
Patients with flap failure and patients who were still in the process of
recovery were excluded.
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Description of Evidence
Face-GRAM software used to
make facial measurements.
1, Horizontal interpupillary
line; 2, vertical line bisecting
and perpendicular to
horizontal interpupillary line;
A, intersection of line 2 and
vermilliocutaneous border of
lower lip; B, oral commisure;
3, line with distance spanning
points A and B; and a, angle
between line 2 and line 3.
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Description of Evidence
Gracilis muscle
following inset.
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Description of Evidence
Preoperative and
postoperative gracilis
recipients. Left column
represents trigeminally
innervated flaps; right
column represents flaps
innervated by contralateral
facial nerve.
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Description of Evidence
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Description of Evidence
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Description of Evidence
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Controversies and Consensus
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Our data only reflect 2-dimensional measurements of facial movement and
do not account for the Z plane, which is an important metric.
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The average postoperative excursion in our study was 8 mm, which is
similar to smile excursion in the normal population.
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Excursion in trigeminally innervated flaps is greater than in flaps innervated
by the contralateral facial nerve.
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Comment
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Larger, prospective studies are indicated to better define associations
between intraoperative gracilis muscle parameters and outcomes.
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It is important to investigate quality-of-life changes following GFTT to
determine whether associations between quality of life and objective
measurements exist.
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Conclusions
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GFTT is a reliable procedure for dynamic reanimation of the paralyzed oral
commissure and results in measureable improvements in smile excursion
and oral commissure symmetry.
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Contact Information
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If you have questions, please contact the corresponding author:
– Prabhat K. Bhama, MD, Division of Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology, Harvard Medical
School/Massachusetts Eye and Ear Infirmary, Harvard School of Public
Health, 243 Charles St, Boston, MA 02114 (pbhama@gmail.com).
Funding/Support
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This research was supported by grant R01NS071067 from the National
Institutes of Health.
Conflict of Interest Disclosures
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None reported.
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