Masseteric-zygomatic nerve transfer for the management of eye closure-smile excursion synkinesis

Objective: The purpose of this study is to illustrate the efficacy of masseteric-to-zygomatic nerve transfer to address eye closure-smile excursion synkinesis after facial nerve paralysis. Background: Synkinesis after facial nerve paralysis represents a wide range of facial movement disability. One manifestation is involuntary smiling with eye closure and a concomitant reduction of oral commissure movement with attempted smile ("frozen smile") - arising as a result of aberrant fibers populating the zygomatic branch-muscle complex. This is a particularly difficult area to treat with conservative management. We propose a single-stage procedure to sever the dysfunctional zygomatic nerve and perform a masseteric-zygomatic nerve coaptation to recover a voluntary smile. Methods: We present a case series of eight patients with eye closure/smile excursion synkinesis who underwent single-stage masseteric-zygomatic nerve transfer by a single surgeon. The surgical technique and indications for surgery were reviewed. Patients underwent facial movement analysis using Emotrics. Results: We analyzed the pre- and post- surgical photographic images of 8 patients with synkinesis (7 female, 1 male). Masseteric-facial nerve transfer was performed from 18 months to 22 years after the initial facial paralysis. Eyelid and brow positioning were more symmetric after surgery, with discrepancy between affected and unaffected side decreasing from 2.1 to 1.0 mm (p < .05) and 1.74 to 1.29 mm (p < .05), respectively. Symmetry of smile excursion postoperatively was also improved with commissure excursion discrepancy decreasing from 8.8 to 3.78 mm (p < .05). Discrepancy in the smile angle when comparing affected to unaffected side improved postoperatively from 10.3 to 5.2 degrees (p < .05). Improvement in oral commissure height was noted, but not statistically significant. Conclusions: The masseteric-zygomatic nerve transfer is a useful technique for the treatment of eye closure/smile excursion synkinesis after failure of chemodenervation and/or physical therapy.