OBJECTIVE: To compare the prevalence of mental health disorders in individuals with facial synkinesis, facial paralysis alone, and the general population.
METHODS: Retrospective cohort.
METHODS: Eighty-two health care organizations across the United States.
METHODS: The TriNetX Research Network was queried from 2011 to 2021 for patients with facial paralysis without synkinesis, facial paralysis and documented synkinesis, and controls, matched for age, sex, race, and ethnicity. Cases included infectious, iatrogenic, or idiopathic facial paralysis. Patients with pre-existing depression or anxiety were excluded. Two-year rates of newly diagnosed depression, anxiety, and mental health prescriptions were compared.
RESULTS: Among 127,573 patients with facial paralysis, 92.5% (n = 117,976) had facial paralysis alone, and 7.5% (n = 9597) also had documented synkinesis. Compared to controls, patients with facial paralysis alone had increased risks of new depression (8.9% vs 7.3%, P < .001) and anxiety (10.1% vs 9.6%, P < .001), with higher mental health medication rates (16.6% vs 13.1%, P < .001). Patients with documented synkinesis, in comparison to controls, had the highest risks of depression (19.8% vs 8.6%, P < .001), anxiety (20.5% vs 10.5%, P < .001), and prescriptions (28.1% vs 15.8%, P < .001). The 27.8% (n = 2669) of synkinetic patients treated with chemodenervation had lower rates of depression (8.5% vs 23.5%, P < .001), anxiety (9.0% vs 23.8%, P < .001), and prescriptions (21.6% vs 30.0%, P < .001) compared to synkinetic patients who were not.
CONCLUSIONS: Facial paralysis, particularly synkinesis, is linked to increased mental health disorders. Integrating mental health screening and treatment into a comprehensive approach is crucial. Chemodenervation is associated with decreased mental health disorders in synkinesis, highlighting its therapeutic potential.

Although patients with facial palsy often complain of disturbed eye blinking which may lead to visual impairment, a blinking analysis is not part of routine grading of facial palsy. Twenty minutes of spontaneous eye blinking at rest of 30 patients with facial palsy (6 with acute palsy; 24 patients with facial synkinesis; median age: 58 years, 67% female), and 30 matched healthy probands (median age: 57 years; 67% female) was smart phone video recorded. A custom computer program automatically extracted eye measures and determined the eye closure rate (eye aspect ratio [EAR]), blink frequency, and blink duration. Facial Clinimetric Evaluation (FaCE), Facial Disability Index (FDI) were assessed as patient-reported outcome measures. The minimal EAR, i.e., minimal visible eye surface during blinking, was significantly higher on the paretic side in patients with acute facial palsy than in patients with synkinesis or in healthy controls. The blinking frequency on the affected side was significantly lower in both patient groups compared to healthy controls. Vice versa, blink duration was longer in both patient groups. There was no clear correlation between the blinking values and FaCE and FDI. Blinking parameters are easy to estimate automatically and add a functionally important parameter to facial grading.

Background: Chemodenervation is an important means of treating oral-ocular synkinesis, but upper eyelid treatment is avoided due to risk of blepharoptosis. Objective: To measure the change in eyelid position among patients with oral-ocular synkinesis who received botulinum toxin to the upper eyelid orbicularis oculi compared with those who received lateral and lower eyelid treatment alone. Methods: In this retrospective clinical study, patients were categorized as having received lateral and lower eyelid botulinum toxin alone or having received upper eyelid botulinum toxin (to the preseptal and orbital orbicularis oculi) along with lateral and lower eyelid treatment. Pre- and posttreatment margin to reflex distance 1 (MRD1), margin to reflex distance 2 (MRD2), and palpebral height were measured using Emotrics software and compared using t tests and regression analysis. Results: Twenty-five patients were included. Mean age was 48.7 years and 24% were male. Mean duration of paralysis was 29 months (range 9-360 months). Posttreatment resting MRD1 (3.36) was not significantly different than pretreatment resting MRD1 (3.43) for patients who received upper eyelid botulinum toxin (p value = 0.60). Conclusion: Botulinum toxin to the upper eyelid orbicularis oculi injected superficially in small, concentrated aliquots did not result in blepharoptosis and was effective in reducing oral-ocular synkinesis.

A common sequela of peripheral nerve injury is aberrant regeneration and recovery. Aberrant regeneration of injured motor nerves can affect all aspects of the nerve circuit from the motor cortex to the target muscle. A more comprehensive term for the symptoms that develop after aberrant motor neuromuscular reinnervation is aberrant reinnervation syndrome (ARS). Injury to the facial nerve followed by aberrant reinnervation results in a spectrum of symptoms that has been called many things in the literature. The authors support that this commonly encountered sequela of facial nerve injury be called facial aberrant reinnervation syndrome (FARS), a term that is more descriptive of the underlying pathophysiology and more inclusive of the clinical symptoms: facial synkinesis, facial muscle hypertonicity, and facial muscle spasm/twitching, which occur following facial nerve injury and recovery. In the following article, we present the clinical manifestations and sequelae of facial nerve injury and recovery and briefly discuss our evolving understanding of the pathophysiology and treatment of FARS.

Importance: Cross-Facial Nerve Grafting (CFNG) for facial palsy offers potential to restore spontaneous facial expression, but specific indications and associated outcomes are limited. Updates to this technique have aided in its successful employment in select cases. This review aims to explore the context in which CFNG has been successfully utilized as a primary modality. Observations: Literature review was performed auditing all studies investigating CFNG as a primary modality, which reported outcomes. A total of 326 cases reporting outcomes for primary CFNG were included. Eye closure outcomes were 83.3% successful at ages 0-18, 77.3% successful at ages 19-40, and 57.1% successful at ages 41+. Smile outcomes were 73.7% successful at ages 0-18, 81.5% successful at ages 19-40, and 52.8% successful at ages 41+. For synkinesis, 89% of cases were considered successful; 100% successful at ages 0-18, and 78.4% successful in adults. Conclusions and Relevance: CFNG may offer return of spontaneous facial function in select cases. Higher percentages of successful outcomes are observed in younger patients, when performed in two stages, and when performed earlier from the onset of FP in cases of eye closure restoration. In the modern era, CFNG has been more commonly employed as an adjunctive procedure to other reanimation techniques.

BACKGROUND: Blepharoptosis is a common symptom in ophthalmology clinic, but eyelid retraction when smiling in a ptosis eye is a rare manifestation. Here we report a novel manifestation that eyelid retraction during smiling in a patient with monocular congenital ptosis.
METHODS: A 10-year-old girl with isolated and mild unilateral congenital ptosis showed eyelid retraction in ptotsis eye when smiling together with a lid lag on downgaze. She didn\'t have any systematic and ocular diseases other than myopia and astigmatism.Eyelid retraction during smiling is 5 mm, resulting in a significant difference in the height of bilateral palpebral fissures.As for ptosis, is mild.The margin to reflex distance 1 is 1.0 mm on the right eye(ptosis eye) and 3.0 mm on the left eye. A lid lag of 1.0 mm on downward gaze was noted on the right, she could close her eyes fully while sleeping.The ice pack test, laboratory test for thyroid function, whole-exome sequencing (WES) and magnetic resonance imaging(MRI) of the orbital and ocular motor nerves showed normal results.Her symptoms alleviated after 6 months, with the retraction of the right upper eyelid when smiling was approximately 3 mm, thus the difference in the palpebral fissure height when smiling was smaller than that at the initial presentation.
CONCLUSIONS: Blepharoptosis may accompanied with abnormal innervation like eyelid retraction, this phenomenon can be alleviated with age.The results of the levator muscle function test should be carefully examined to determine whether it is ptosis in an impaired innervation eyelid.

Facial synkinesis is characterized by unintentional contractions of facial musculature secondary to aberrant facial nerve healing. The associated impairment in facial functioning results in a significant decrease in patients\' quality of life. The mainstay treatment for postfacial paralysis synkinesis (PFPS) is chemodenervation and physiotherapy, which requires long-term maintenance neurotoxin injections. This can lead to treatment resistance. Selective neurectomy of the distal branches of the facial nerve has been suggested as an effective surgical treatment of PFPS. This study aims to provide a comprehensive systematic review evaluating the efficacy of selective neurectomy for patients presenting with PFPS. Ovid MEDLINE, Ovid Embase, PubMed, Web of Science, and CINAHL were searched from inception until July 2022. Studies that investigated postoperative outcomes of pediatric and/or adult patients who underwent selective neurectomy as a treatment for PFPS were included. The database search identified 1,967 studies, and 11 were ultimately included based on inclusion and exclusion criteria. These 11 studies represented 363 patients. Studies reported on outcomes following selective neurectomy with or without adjuvant therapies for patients with PFPS. The main outcome categories identified were clinician-reported outcomes and patient-reported outcomes. The studies that used clinician-reported outcomes found an improvement in both synkinesis and facial nerve paralysis (FNP) outcomes following selective neurectomy according to their respective grading systems. Three studies looked at patient-reported outcomes and found increased patient-reported quality of life and satisfaction following selective neurectomy. The most reported complications were upper lip contracture, uneven cheek surface, lagophthalmos, and temporary oral incompetence. Selective neurectomy has demonstrated stable or improved synkinesis, FNP, and quality of life outcomes in patients with PFPS. This approach should be considered for patients with PFPS, particularly for patients with refractory symptoms or those who are unable to undergo continued medical management.

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Facial palsy can result in a serious complication known as facial synkinesis, causing both physical and psychological harm to the patients. There is growing evidence that patients with facial synkinesis have brain abnormalities, but the brain mechanisms and underlying imaging biomarkers remain unclear. Here, we employed functional magnetic resonance imaging (fMRI) to investigate brain function in 31 unilateral post facial palsy synkinesis patients and 25 healthy controls during different facial expression movements and at rest. Combining surface-based mass-univariate analysis and multivariate pattern analysis, we identified diffused activation and intrinsic connection patterns in the primary motor cortex and the somatosensory cortex on the patient\'s affected side. Further, we classified post facial palsy synkinesis patients from healthy subjects with favorable accuracy using the support vector machine based on both task-related and resting-state functional magnetic resonance imaging data. Together, these findings indicate the potential of the identified functional reorganizations to serve as neuroimaging biomarkers for facial synkinesis diagnosis.

OBJECTIVE: Depressor anguli oris (DAO) excision can improve clinician-graded, objective, and patient-reported smile outcomes in patients with nonflaccid facial paralysis (NFFP). However, no prior research has studied changes in perceived emotions after surgery. This study quantifies changes in perceived emotions with smiling after DAO excision in the largest case series presented to date.
METHODS: Prospectively collected data from patients with NFFP who underwent DAO excision at a tertiary care facial nerve center were reviewed. Patient-reported, clinician-graded, and objective smile metrics were compared before and after surgery. Videos of faces at rest and while smiling were analyzed by artificial intelligence-derived facial expression analysis software to quantify perceived emotions.
RESULTS: Sixty-eight patients underwent isolated DAO excision between August 2021 and August 2023. Patients conveyed significantly more perceived happiness with smile and at rest after surgery (p < 0.001 and p = 0.012, respectively). DAO excision improved oral commissure excursion (p < 0.001), dental show (p < 0.001), and smile angle (p < 0.001) symmetry. Patients reported significant improvements in smiling and social function after surgery.
CONCLUSIONS: This study demonstrates DAO excision increases perceived happiness conveyed by patients with NFFP while smiling and at rest. It confirms improved objective, clinician-graded, and patient-reported smile outcomes after surgery.
METHODS: 4 Laryngoscope, 134:4028-4035, 2024.