Postparalysis Facial Synkinesis

Abstract

Background: Postparalysis facial synkinesis (PPFS) can occur after any cause of facial palsy. Current treatments are still inadequate. Surgical intervention, instead of Botox and rehabilitation only, for different degrees of PPFS was proposed. Methods: Seventy patients (43 females and 27 males) with PPFS were enrolled since 1986. They were divided into 4 patterns based on quality of smile and severity of synkinesis. Data collection for clinically various presentations was made: pattern I (n = 14) with good smile but synkinesis, pattern II (n = 17) with acceptable smile but dominant synkinesis, pattern III (n = 34) unacceptable smile and dominant synkinesis, and pattern IV (n = 5) poor smile and synkinesis. Surgical interventions were based on patterns of PPFS. Selective myectomy and some cosmetic procedures were performed for pattern I and II patients. Extensive myectomy and neurectomy of the involved muscles and nerves followed by functioning free-muscle transplantation for facial reanimation in 1- or 2-stage procedure were performed for pattern III and many pattern II patients. A classic 2-stage procedure for facial reanimation was performed for pattern IV patients. Results: Minor aesthetic procedures provided some help to pattern I patients but did not cure the problem. They all had short follow-up. Most patients in patterns II (14/17, 82%) and III (34/34, 100%) showed a significant improvement of eye and smile appearance and significant decrease in synkinetic movements following the aggressively major surgical intervention. Nearly, all of the patients treated by the authors did not need repeated botulinum toxin A injection nor require a profound rehabilitation program in the follow-up period. Conclusions: Treatment of PPFS remains a challenging problem. Major surgical reconstruction showed more promising and long-lasting results than botulinum toxin A and/or rehabilitation on pattern III and II patients.

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www.PRSGlobalOpen.com 1
Postparalysis facial synkinesis (PPFS) represents
a wide spectrum of unwanted facial movements
after recovery of facial palsy from any etiology.
The possible pathogenesis of synkinesis is cross-talks
in brain cortex, facial motor neurons, or facial nerve
fibers.1–6 Hypothesis of aberrant reinnervation among
facial nerve fibers following nerve injury is more pre-
ferred.1,3,6 PPFS should be clearly differentiated from
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Kluwer Health, Inc. on behalf of The American Society of
Plastic Surgeons. All rights reserved. This is an open-access
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Attribution-NonCommercial-NoDerivatives 3.0 License, where
it is permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or used
commercially.
DOI: 10.1097/GOX.0000000000000283
From the Department of Plastic Surgery, Chang Gung Me-
morial Hospital, Chang Gung University, Taipei-Linkou,
Taiwan.
Received for publication February 5, 2014; accepted Janu-
ary 7, 2015.
Presented, in part, at the Annual Meeting of the Ameri-
can Society for Reconstructive Microsurgery, January 13,
2013, Naples, Fla.; the 12th International Facial Nerve
Symposium, June 29, 2013, Boston, Mass.; and the 7th
World Society for Reconstructive Microsurgery, July 13,
2013, Chicago, Ill.
Background: Postparalysis facial synkinesis (PPFS) can occur after any
cause of facial palsy. Current treatments are still inadequate. Surgical inter-
vention, instead of Botox and rehabilitation only, for different degrees of
PPFS was proposed.
Methods: Seventy patients (43 females and 27 males) with PPFS were en-
rolled since 1986. They were divided into 4 patterns based on quality of
smile and severity of synkinesis. Data collection for clinically various pre-
sentations was made: pattern I (n = 14) with good smile but synkinesis,
pattern II (n = 17) with acceptable smile but dominant synkinesis, pattern
III (n = 34) unacceptable smile and dominant synkinesis, and pattern IV
(n = 5) poor smile and synkinesis. Surgical interventions were based on
patterns of PPFS. Selective myectomy and some cosmetic procedures were
performed for pattern I and II patients. Extensive myectomy and neurec-
tomy of the involved muscles and nerves followed by functioning free-mus-
cle transplantation for facial reanimation in 1- or 2-stage procedure were
performed for pattern III and many pattern II patients. A classic 2-stage
procedure for facial reanimation was performed for pattern IV patients.
Results: Minor aesthetic procedures provided some help to pattern I pa-
tients but did not cure the problem. They all had short follow-up. Most
patients in patterns II (14/17, 82%) and III (34/34, 100%) showed a signif-
icant improvement of eye and smile appearance and significant decrease
in synkinetic movements following the aggressively major surgical inter-
vention. Nearly, all of the patients treated by the authors did not need re-
peated botulinum toxin A injection nor require a profound rehabilitation
program in the follow-up period.
Conclusions: Treatment of PPFS remains a challenging problem. Major sur-
gical reconstruction showed more promising and long-lasting results than
botulinum toxin A and/or rehabilitation on pattern III and II patients. (Plast
Reconstr Surg Glob Open 2015;3:e320; doi: 10.1097/GOX.0000000000000283;
Published online 6 March 2015.)
David Chwei-Chin Chuang,
MD
Tommy Nai-Jen Chang, MD
Johnny Chuieng-Yi Lu, MD
Postparalysis Facial Synkinesis: Clinical
Classification and Surgical Strategies
Postparalysis Facial Synkinesis
Chuang et al.
xxx
xxx
XXX
Mythili
Plastic & Reconstructive Surgery-Global Open
2015
XXX
Original Article
10.1097/GOX.0000000000000283
© 2015 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American
Society of Plastic Surgeons. All rights reserved.
Cosmetic
ORIGINAL ARTICLE

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All rights reserved.
PRS Global Open • 2015
2
hemifacial spasm,7,8 which is caused by vascular loop
compression of the facial nerve at facial nerve exit
zone from the brain stem, and facial muscle tethering
after facial trauma, which causes adhesion between
eye and cheek muscles.
PPFS occurs not only always during facial expres-
sion but also at rest (intermittent blinking reflex
causes intermittent cheek muscles twitching) and at
sleeping (upper and lower lip constantly retracted),
which are often not noticed by the patients. Long-
term unresolved synkinesis may result in permanent
contracture, such as hypertrophy of corrugator mus-
cle, deep nasolabial fold, lower lip retraction, chin
skin dimples, and neck bands. (See Video 1, Supple-
mental Digital Content 1, which shows a patient who
had right facial palsy caused by parotid gland tumor
resection for 2 years and developed right PPFS. The
video showed her preoperative facial expression and
will be available in the “Related Videos” section of
the full-text article on http://links.lww.com/PRSGO/
A92.) These will disrupt the resting facial posture
and the involved face and neck will become tight
and sore. Those symptoms and signs make patients
with PPFS distressed with severe emotional sequelae.
Several treatments have been proposed, includ-
ing facial rehabilitation,9–12 botulinum toxin A (BTX-
A) injections,13–17 and minor surgical procedures,
such as selective myectomy17–21 and neurectomy.19,22,23
However, these treatments were all inadequate and
not convincing. The aim of this article was to give
a comprehensive overview of our surgical interven-
tions based on different patterns of PPFS.
MATERIALS AND METHODS
A retrospective review was performed from 1986
to 2012 (a 27-year period). A total of 343 facial palsy
patients were reconstructed by functioning free-mus-
cle transplantation (FFMT) for facial reanimation.
Ninety-nine percent of FFMT utilized gracilis mus-
cle. They all were operated on by the senior surgeon
(D.C.-C.C.). Fifty-three were patients with PPFS. Inci-
dence of PPFS was at least 15% (53/343).
Seventy patients with PPFS were randomly en-
rolled for clinical evaluation and classification. Pa-
tients’ demographics including mean age at time of
first clinic visit, sex, involved side, and etiology are
shown in Table 1.
Clinically, PPFS involves 2 movements: trigger
and synkinesis movements.
The trigger muscle(s) may be active or paralytic,
but synkinetic muscle(s) is always active. There are
basically 5 trigger and 6 synkinesis movements. The
5 trigger movements, which were regularly ordered
to the patients, include forehead raise, eye closure,
smile, lower lip pulled down, and lip pout or whis-
tling. The 6 synkinetic movements, following the or-
dered movements, involve corrugators, eye, cheek,
lower lip, chin skin, and platysma synkinesis. Since
2002, we have designed an examination sheet for
PPFS, which was renewed in 2010 (Table 2).
Through that, patients were divided into 4 patterns
based on quality of smile and degree of synkinesis.
Table 3 shows the characteristics of different patterns
of PPFS following the above patients’ evaluation.
Pattern I: Good Smile but Synkinesis
In pattern I, patients were aware of their altered
facial expression, but observers including physicians
might not fully recognize the problems due to their
mildness. Patients themselves were even not aware that
Table 1. Patient Demographics
Total no. patients 70
Mean age (range), y 30 (5–72)
Gender (male:female) 27:43
Left:right 39:31
Etiology: Bell’s:traffic:infection:tumor:
facial nerve repair:herpes zoster 30:19:7:6:4:4
Total no. FFMTs 53
Disclosure: The authors have no financial interest to
declare in relation to the content of this article. The Ar-
ticle Processing Charge was paid for by PRS GO at the
discretion of the Editor-in-Chief.
Supplemental digital content is available for this
article. Clickable URL citations appear in the text.
Video 1. See video, Supplemental Digital Content 1, which
shows a patient who had right facial palsy caused by parotid
gland tumor resection for 2 years and developed right PPFPS.
The video showed her preoperative facial expression and will
be available in the “Related Videos” section of the full-text ar-
ticle on http://www.PRSGO.com or available at http://links.
lww.com/PRSGO/A92.

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Chuang et al. • Postparalysis Facial Synkinesis
3
Table 2. PPFS Examination Sheet (Chang Gung Memorial Hospital, 2010)

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PRS Global Open • 2015
4
they had synkinesis. Their big smile could always show
at least 4 teeth. However, they always had intermittent
perioral twitching following eye blinking. Some pa-
tients had an unique synkinesis with bizarre facial ex-
pression, such as lip pouting–induced eye narrowing
on the affected side (oral-eye synkinesis) during spit-
ting or whistling. Pattern I patients were mostly con-
cerned more with cosmetic problems than synkinesis.
Pattern II: Acceptable Smile but Moderate-to-severe
Synkinesis
In pattern II, patients were classified as having an
acceptable smile but with moderate-to-severe synki-
nesis. (See Video 1, Supplemental Digital Content 1,
which shows a patient who had right facial palsy
caused by parotid gland tumor resection for 2 years
and developed right PPFPS. The video showed her
preoperative facial expression and will be available in
the “Related Videos” section of the full-text article on
http://www.PRSGO.com or available at http://links.
lww.com/PRSGO/A92.) Facial disfiguration in pat-
tern II majority came from synkinesis. Their big smile
could usually show 0-1 tooth. Such synkinesis could
not be cured or improved by cosmetic surgery. Some
aesthetic surgery might even make the appearance
worse.
Pattern III: Unacceptable Smile and Severe Synkinesis
In pattern III, patients were classified as having a
poor smile and severe synkinesis. They had lagoph-
thalmos with weak eye closure, poor smile with one
or no tooth visible, hypertrophic corrugators, narrow
eye, dominant nasolabial fold, chin skin dimples, and
neck bands on the affected side. Patients in this pat-
tern all demonstrated more courage to accept more
aggressive procedures to correct their disfigures.
Pattern IV: Poor Smile and Mild Synkinesis
In pattern IV, patients were classified as having a
poor smile and synkinesis. The patients’ complaints in
this pattern were focused on the paralytic face, less on
the synkinetic movements. All patients in this pattern
requested more aggressive procedures for correction.
SURGICAL PROCEDURES
Myectomy
Orbicularis Oculi Muscle
In PPFS, orbicularis oculi muscle is the most trig-
ger and/or synkinetic muscle. Myectomy of the or-
bicularis oculi muscle, upper and lower eyelids, can
reduce the synkinesis (Fig. 1). There were 2 incisions,
upper incision along the upper lid crease if present
and lower incision along and 2 mm below the lower
Table 3. Characteristics of Dierent Patterns of Patients with PPFS
Pattern I
(Data from 13 Patients)
Pattern II
(Data from 18 Patients)
Pattern III
(Data from 31 Patients)
Pattern IV
(Data from 5 Patients)
Mean age (range) 35 (14–53) 29 (20–50) 33 (16–72) 24 (5–43)
Mean interval of symptoms
and signs (range) 10 y (1–49) 10.6 y (0.5–27) 11.6 y (0.4–40) 7.6 y (3–21)
Rest status Grossly, natural, or normal Grossly, acceptable, or okay Asymmetry, moderate
to severe 100%, sad on the affected side
Detailedly, 60%, tension on
affected side Detailedly, 100%, sad on the affected
side 100%, sad on the affected side Asymmetry, moderate to severe
Asymmetry: mild Some, contracture Some, contracture
Asymmetry: moderate
Forehead raise Okay or weak Palsy or weak Most are paralytic, but will
trigger synkinesis All are paralytic
Most, reactor; few, a starter A starter (some, a dominant starter)
Eye closure Okay (lagophthalmos: 0 mm) Okay or weak (lagophthalmos: 0–1 mm) Lagophthalmos, >1 mm Lagophthalmos, > 2 mm
A dominant starter to upper lip
(blinking trigger) A dominant starter to upper lip, chin,
and neck A dominant starter to forehead,
upper lip, chin, and neck A weak starter to mouth, chin,
and neck
Oral smiling Natural, 4 teeth visible Weak, 3-2 teeth visible Paresis, 1-0 teeth visible Palsy, 1 or no tooth visible
A weak starter: to eye or neck A dominant starter to eye and chin and
neck A dominant starter to eye, chin
and, neck A weak starter
Lower lip pulled down Natural or weak Weak or palsy Palsy or contracture Palsy
A weak starter to neck A weak starter A dominant starter Most, weak starter
Whistling Okay or weak Weak or palsy Palsy Palsy
Some, a strong starter to eye A weak starter to eye or corrugators A dominant starter

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Chuang et al. • Postparalysis Facial Synkinesis
5
lid margin, to expose the orbicularis oculi muscle. Or-
bicularis oculi muscle has 3 components: pretarsus,
preseptum, and preorbital portions. Only segmental
resection of the former 2 portions in the upper and
lower eyelids is enough to decrease synkinesis. It was a
new procedure performed in recent 2 years.
Platysma Muscle
Platysma muscle on the affected side is quite often
a synkinetic muscle. Myectomy of the platysma can
decrease synkinesis. Two parallel incisions, 1 subman-
dibular and 1 above clavicle, to nearly total resection
of the platysma were regularly performed (Fig. 1).
Corrugator Muscle
Hypertrophy or involuntary movement of the cor-
rugators would cause bizarre appearance when smil-
ing. BTX-A injection is effective, but more patients
will request myectomy for one procedure with per-
manent result. Suprabrow incision along the medial
upper margin of the eyebrow to expose the corruga-
tor muscle and nearly total resection of the muscle
were performed.
A 2-stage Procedure
First stage involves short cross-face nerve graft
(CFNG); second stage (6–9 months later) involves
Fig. 1. A, A 47-year-old woman (patient 13, Table4) has developed left PPFPS, pattern I and II, due to Bell’s palsy for 2 years.
She presented left face with narrow eye, dominant nasolabial fold, chin dimples, and neck bands when she was smiling. B,
She received myectomy of the orbicularis oculi (upper and lower lids) and platysma, blepharoplasty, and late rigotomy and
fat grafts for nasolabial fold and chin. C, The results showed much improvement of smile and decreased left facial synkinesis
1 year postoperatively.
Table 4. Pattern I Patients
Patient Botox Injection (Site) Blepharoplasty
Platysma
Resection
Corrugator
Resection
Orbicularis Oculi
Resection
Other
Procedures
1 Yes (lower lip)
2 Yes (lower lip)
3 Yes (corrugators)
4 Yes (orbicularis oculi) Yes Browlift
5 Yes (orbicularis oculi)
6 Yes (orbicularis oculi) Yes Yes Change hair style
7 Platysma transfer
8 Yes (upper
and lower
blepharoplasty)
Yes Yes
9 Yes (orbicularis oculi) Fat grafts
10 Yes (orbicularis oculi) Yes Browlift
11 Yes
12 Yes (lip depressor) Yes Yes
13* (Fig. 1) Yes Yes Fat graft for deep
nasolabial fold
and chin
14 No treatment
* Patient shown in figures or supplemental videos.

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PRS Global Open • 2015
6
extensive myectomy of the cheek and platysma
muscles, neurectomy of the zygomatic, buccal and
cervical facial nerve branches, and gracilis FFMT for
facial reanimation.
In the first stage, short CFNG has been evolved
(since 2001).24,25 Sural nerve was placed subcutane-
ously from the preauricular wound on the intact
side to the nasolabial fold small wound on the affect-
ed side. One stump was coapted to the facial nerve
branches under microscopy, and the other stump
was sutured to the dermis of the nasolabial fold. (See
Video 2, Supplemental Digital Content 2, which shows
a patient who received extensive myectomy and neu-
rectomy and reconstruction by CFNG-innervated
gracilis, a 2-stage procedure. The video showed excel-
lent results of 1 year after free-muscle transplantation
and is available in the “Related Videos” section of the
full-text article on http://links.lww.com/PRSGO/A93.)
In the second stage, 1 small upper lip wound was
made to identify the CFNG stump. A long second
preauricular wound down to submandibular exten-
sion was made, and subcutaneous facelift from the
upper zygomatic arch to the upper and lower lip
was performed. All peripheral branches of the fa-
cial nerve should be identified. All zygomatic and
buccal branches and their innervated muscles in
the cheek area were excised en bloc (Fig. 2). The
excision should be as extensive as possible down to
the oral mucosa attachment to avoid late residual
synkinetic movements. The neck cervical branch of
the facial nerve and platysma were removed simul-
taneously. Stenson’s duct should be preserved. The
frontal and mandibular branches were preserved
if possible to preserve some function on eye and
lower lip.
A gracilis muscle from the contralateral thigh was
trimmed,25 harvested, and transferred to the face. Ves-
sels were anastomosed to the facial artery and vein. The
motor nerve of the gracilis muscle which was passing
under the muscle to the upper lip wound was coapted
to the previous CFNG under the operative microscope.
A 1-stage Procedure
Extensive Myectomy and Neurectomy and Gracilis FFMT
Innervated by the Spinal Accessory or Masseter (V3) Nerve
Simultaneously
The spinal accessory (XI) nerve was found on the
anterior margin of the trapezius muscle through a
posterior neck incision.26 Dissection of the XI nerve
should be as distal as possible, divided, and trans-
ferred to the mandibular angle.
The V3 nerve was found at the posterior margin of
the masseter muscle just below the zygomatic arch.27
A 1–1.5 cm of the nerve was dissected, divided, and
transferred for nerve coaptation. Facelift, myectomy
and neurectomy, gracilis FFMT, vessel anastomoses,
and nerve coaptation were performed as described.
Postoperative Rehabilitation
CFNG-innervated and V3-innervated gracilis
needed no splint immobilization. However, XI-in-
nervated gracilis required face and neck splint im-
mobilization for 3 weeks. Three weeks after surgery,
electric stimulation was started. At approximately 4
months postoperatively, “induction exercise”3,26 was
initiated. Once the transferred muscle achieved up-
per lip movement, “smile training”26 was prescribed
Fig. 2. Sample of myectomy of cheek muscles and platysma
and neurectomy of whole zygomatic and buccal facial nerve
branches. B indicates buccal; C&M, cervical and mandibular
branch; Z, upper and lower zygomatic.
Video 2. See video, Supplemental Digital Content 2, which
shows a patient who received extensive myectomy and neu-
rectomy and reconstruction by CFNG-innervated gracilis, a
2-stage procedure. The video showed excellent results of 1
year after free-muscle transplantation and is available in the
“Related Videos” section of the full-text article on http://www.
PRSGO.com or available at http://links.lww.com/PRSGO/A93.

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Chuang et al. • Postparalysis Facial Synkinesis
7
to achieve independent and spontaneous move-
ment. This smile training should be performed in
front of a mirror.
OUTCOME ASSESSMENT
All treated patients were closely followed a mini-
mum of 1 year. Outcomes were assessed in terms of
success of decreasing synkinesis and achieving facial
symmetry at rest and smiling. There were 4 methods
that were used for outcome assessment26,28,29:
1. Smiling Score is a score system (0–4) based on
how many teeth expose during smile: score 0, no
or partial first incisor visible; score 1, the full first
incisor visible; score 2, 2 teeth visible, and so forth.
A maximum score of 4 is given if at least 4 teeth
are visible. If reaching ≥score 2, it was acceptable.
2. Cortical Adaption Stage System (I–V) is a sys-
tem to evaluate functional recovery of an FFMT:
no movement (stage I), dependent movement
(stage II), independent movement (stage III),
spontaneous but with involuntary movement
(stage IV), and spontaneous with little or no
involuntary movement (stage V). If reaching
≥stage III, it was acceptable.
3. Synkinesis Grading System is utilized: mild, mod-
erate, and severe synkinesis.30 Only the mild one
was acceptable in outcome result.
4. Satisfactory Score, a questionnaire to evaluate
patient satisfaction was performed, including
patient’s complaint, self-image, use of the newly
acquired smile, the possible complications, and
symptoms by donor nerve transfer.26 Finally, a
“satisfactory score” was made: score 1, not accept-
able and regret surgery; score 2, not acceptable
but did not regret surgery; score 3, acceptable
but required further refinement surgery; score 4,
satisfied but request minor procedure to improve
the results; and score 5, completely satisfied.
RESULTS
Pattern I (n = 14)
BTX-A injection at eyelid muscle (1 shot at up-
per, 2 shots at lower eyelid; Botox, 0.025 ml = 1.0
IU/shot, 100 IU/2.5 ml), lower lip depressors (af-
fected side or nonaffected side, 5–6 shots, 0.05 ml
= 2 IU/shot), and corrugator muscle (2 shots,
0.05 ml = 2 IU/shot) was the most common pro-
cedure for pattern I patients (Table 4). They all
achieved temporary decrease of synkinesis, but
were not completely satisfied. Changing hair style
or wearing glasses to cover the synkinesis was ad-
vised with some help. Myectomy of the orbicularis
oculi showed some help to decrease synkinesis and
decrease requirement of the repeated BTX-A in-
jection (Fig. 1) (patient 13, Table 4). One patient
(patient 7, Table 4) had platysma muscle transfer
to the ipsilateral weak lower lip for balance. Many
pattern I patients knew that the synkinesis could
not be cured by such minor procedures and tend-
ed to stop clinical follow-up after a short time of
visiting. A few patients chose no treatment at all
(patient 14, Table 4).
Pattern II (n = 17)
Fourteen patients (82%) requested more aggres-
sive surgical procedures after explanation (Table 5).
All were treated with extensive myectomy and neu-
rectomy and reconstructed by CFNG-innervated
gracilis. They achieved a more symmetric smile
(smile score from average 2.6 preoperatively to 4.0
postoperatively, Table 7) and significantly decreased
synkinetic movements (from moderate or severe
down to mild, P < 0.001; Table 7). The cortical adap-
tation was all scored at stage V (spontaneous smile).
Clinically, it was more witnessed in eye opening and
teeth visibility (Fig. 3). Adjuvant surgeries includ-
ed lip revision, blepharoplasty, tensor fasciae latae
sling, or fat grafts to improve results. Most of them
received no more BT-A injection. Satisfactory Score
showed at least score 3. Six patients had lip contrac-
ture and required release procedure. Two patients
(patients 2 and 6, Table 5) required lip adhesion
(Fig. 4) for 1 year to overcome the lip contracture.
Two patients (patients 15 and 16, Table 5) only ac-
cepted minor procedures with repeated BT-A injec-
tions. One patient (patient 17, Table 5) refused the
treatment after explanation.
Pattern III (n = 34)
All patients accepted and received the extensive
surgical procedures for treatment (Table 6). Similar
to the pattern II surgical-treated patients, the most im-
proved parts with less synkinesis were eye opening and
teeth visibility (Figs. 5–7). The smile score improved
from an average 0.86 preoperatively to 3.57 postop-
eratively in the CFNG-innervated gracilis series (21 pa-
tients) and from an average 0.6 preoperatively to 3.5
postoperatively in the XI-innervated gracilis series (12
patients). The cortical adaptation stage showed at least
stage III. The synkinesis was significantly improved in
all from grade II or III down to I (P < 0.001, Table 7).
One patient was an exceptional child, 6 years old when
he was surgically treated by CFNG-innervated gracilis,
with near 10-year follow-up (patient 8, Table 6; Fig. 6).
In 1 girl patient (patient 23, Table 6) after CFNG-in-
nervated gracilis, although showing little movement of
the transferred muscle (smile score 1) after 2-year fol-
low-up with unknown reason, her synkinesis grading

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PRS Global Open • 2015
8
Table 5. Pattern II Patients
Patients Myectomy Neurectomy
Facial
Reanimation
(Neurotizer-
innervated
Muscle)
Blepharo-
plasty
Lip
Revision
Rigotomy
+ Fat
Injection
Other
Procedures
Smile
Score (0–4)
Preoperative→
Postoperative
Cortical
Adaptation
Stage (I–V)
Synkinesis
Grading (I–III)
Preoperative→
Postoperative
Satisfactory
Score (1–5)
1* (Fig. 3) Ch, Pl Z, B, C CFNG-gracilis Ye s TFL sling for
deep NLF 2→4Yes III→I 4
2 Ch, Pl Z, B, C CFNG-gracilis Yes Yes (lip
contracture
release
and lip
adhesion)
Yes 3→4Yes III→I3
3 Ch Z, B, C CFNG-gracilis Yes (lip
contracture
release)
2→4Yes II→I4
4 Ch, Pl Z, B, C CFNG-gracilis 3→4Yes II→I5
5 Ch, Pl Z, B, C CFNG-gracilis 2→4Yes II→I5
6 Ch, Pl Z, B, C CFNG-gracilis Yes (lip
contracture
release and
lip adhesion)
4→4Yes III→I3
7 Ch, Pl Z, B, C CFNG-gracilis Yes Yes (lip
contracture
release)
Yes Rigotomy and
fat graft 4→4Yes II→I4
8 Ch, Pl Z, B, C CFNG-gracilis Yes Yes (lip
contracture
release)
TFL sling for
deep NLF
Temporalis for
lagophthalmos
Rigotomy and
fat grafts
4→4Yes III→I4
9 Ch, Pl, Co Z, B, C CFNG-gracilis TFL sling for
deep NLF 3→4Yes III→I4
10 Ch, Pl Z, B, C CFNG-gracilis 2→4Yes II→I5
11 Ch, Pl Z, B, C CFNG-gracilis Yes Breast
augmentation
Rigotomy and
fat grafts
2→4Yes II→I4
12 Ch, Pl Z, B, C CFNG-gracilis TFL sling for
deep NLF 3→4Yes II→I5
13 Ch, Pl Z, B, C CFNG-gracilis Yes Yes (lip
contracture
release)
Rigotomy and
fat grafts 2→4Ye s III→I4
14* (Video
1 and 2,
Supplemental
Digital
Content)
Ch, Pl, Oo Z, B, C CFNG-gracilis Yes Lower lip
thinning 3→4Yes III→I5
15 Pl, Co. — — Yes Browlift 3→3Nil III→III 3
Botox injection
(×6)
16 Pl, Oo — Yes Browlift 2→2Nil III→II 3
17 No treatment
B, buccal branch; C, cervical branch; Ch, cheek muscles; Co, corrugator muscle; NLF, nasolabial fold; Oo, orbicularis oculi; Pl, platysma muscle; TFL, tensor fasciae latae; Z, zygomatic branch.
* Patient shown in figures or supplemental videos.

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Chuang et al. • Postparalysis Facial Synkinesis
9
improved. Another patient (patient 29, Table 6) who
had failed CFNG-innervated gracilis for 1 year received
masseter-innervated second gracilis for reconstruction
and showed improving results (Fig. 7). From Satisfac-
tory Score, 33 patients showed significant improve-
ment of their synkinesis (P < 0.001, Table 7) and more
tooth exposure when smiling. The Satisfactory Score
was at least 3. The eye appeared as the most improved
part with a more natural look. One patient (patient
14, Table 6) was considered as a fair result due to up-
per lip contracture. Four patients had lip contracture
and required lip adhesion (patients 8, 10, 14, and 17,
Table 6). No patient regretted having such complex
surgical procedures.
Fig. 3. A, A 31-year-old man (patient 1, Table5) had left Bell’s palsy for 6 years and developed
left PPFPS, pattern II. He received extensive myectomy and neurectomy and reconstruction
by CFNG-innervated gracilis, a 2-stage procedure. B, Results at 2 years after showed more
natural smile.
Fig. 4. A, A double opposing lip mucosa ap is designed: one inner-based and another outer-
based. The muscles of the both upper and lower lips should be sutured together before both
mucosal aps are adhesive. B, The healed lip adhesion.

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PRS Global Open • 2015
10
Table 6. Pattern III Patients
Patients Myectomy Neurectomy
Facial Reanimation
(Neurotizer-inner-
vated Muscle) Blepharoplasty
Lip
Revision
Rigotomy
+ Fat
Injection
Other
Procedures
Smile Score
(0–4) Preoperative
→ Postoperative)
Cortical
Adapta-
tion Stage
(I–V)
Synkinesis
Grading (I–III)
Preoperative→
Postoperative
Satisfactory
Score (1–5)
1* (Fig. 5) Ch, Pl Z, B, C CFNG-gracilis Yes TFL for NLF 0→4Yes III→I 5
2 Ch Z, B, C CFNG-gracilis Ye s Yes Yes Gold weight 1→4Yes III→I4
3 Ch, Pl Z, B, C CFNG-gracilis Yes Yes Yes Neurectomy of
contralateral
side frontal
branch
1→4Yes III→I4
4 Ch, Pl Z, B, C CFNG-gracilis 1→3Yes III→I4
5 Ch, Pl, Co Z, B, C CFNG-gracilis Yes Ye s Yes TFL suspension
for deep NLF 1→4Yes III→I4
6 Ch, Pl, Co Z, B, C CFNG-gracilis TFL suspension
for deep NLF 1→4Yes III→I3
7 Ch, Pl Z, B, C CFNG-gracilis Yes Yes TFL suspension
for deep NLF 1→4Yes III→I4
8*
(Fig. 6) Ch, Z, B, C CFNG-gracilis Yes Yes Yes (lip adhesion) 0→4Yes III→I5
9 Ch, Pl Z, B, C CFNG-gracilis 0→3Yes III→I4
10 Ch, Pl Z, B, C CFNG-gracilis Yes Yes Yes (lip adhesion) 0→3Yes III→I3
11 Ch, Pl Z, B, C CFNG-gracilis TFL suspension
for deep NLF 1→3Yes III→I3
12 Ch, Pl Z, B, C CFNG-gracilis 1→3Yes III→I3
13 Ch, Pl Z, B, C CFNG-gracilis Yes 1→4Ye s III→I4
14 Ch, Pl Z, B, C XI-gracilis Yes Yes Yes (lip adhesion) 1→4Yes III→I2
15 Ch, Pl Z, B, C CFNG-gracilis 1→3Yes III→I3
16 Ch, Pl Z, B, C XI-gracilis Wear glass 1→3Yes III→I4
17 Ch, Pl Z, B, C XI-gracilis Yes Yes Yes (lip adhesion) 1→4Yes III→I3
18 Ch, Pl Z, B, C XI-gracilis Yes 1→4Ye s III→I4
19 Ch, Pl Z, B, C XI-gracilis 1→4Yes III→I4
20 Ch Pl Z, B, C XI-gracilis Yes 1→4Yes III→I4
21 Ch Pl Z, B, C CFNG-gracilis Ye s Yes 1→4Ye s III→I5
22 Ch Pl Z, B, C XI-gracilis 1→3Yes III→I4
23 Ch Pl Z, B, C CFNG-gracilis 1→1Yes III→I3
24 Ch Pl Z, B, C CFNG-gracilis Yes Yes Ye s 1→4Yes III→I4
25 Ch Pl Z, B, C XI-gracilis 1→4Yes III→I5
26 Ch Pl Z, B, C XI-gracilis 1→3Yes III→I4
27 Ch Pl Z, B, C CFNG-gracilis Ye s 2→4Yes III→I4
28 Ch Pl Z, B, C XI-gracilis 1→4Yes III→I4
29*
(Fig. 7) Ch Pl Z, B, C masseter-gracilis
(CFNG-gracilis
failed)
Yes Yes 1→4Yes III→I4
30 Ch Pl Z, B, C CFNG-gracilis Yes Yes 1→4Yes III→I5
31 Ch Pl Z, B, C CFNG-gracilis Yes Yes 1→4Yes III→I4
32 Ch Pl Z, B, C XI-gracilis 1→4Yes III→I4
33 Ch Pl Z, B, C CFNG-gracilis Yes Yes 1→4Yes III→I4
34 Ch Pl Z, B, C XI-gracilis 1→4Yes III→I4
B, buccal branch; C, cervical branch; Ch, cheek muscles; Co, corrugator muscle; NLF, nasolabial fold; Pl, platysma muscle; TFL, tensor fascia lata; Z, zygomatic branch.
* Patient shown in figures or supplemental videos.

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Chuang et al. • Postparalysis Facial Synkinesis
11
Fig. 5. A, An 18-year-old man (patient 1, Table6) had Bell’s palsy for 14 years and developed
right PPFPS, pattern III. He received extensive myectomy and neurectomy and reconstruc-
tion by CFNG-innervated gracilis, a 2-stage procedure. B, Results at 2 years after showed
excellence.
Fig. 6. A, A 5-year-old boy (patient 8, Table6), who suered a dog bite to the face and re-
ceived facial nerve repair, developed right PPFPS for 1 year, pattern III. He received extensive
myectomy and neurectomy and reconstruction by CFNG-innervated gracilis in a 2-stage pro-
cedure. B, Results at 9 years after showed excellence. He had lip adhesion for 1 year when
developed contracture.

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12
Pattern IV (n = 5)
In pattern IV, all 5 patients underwent CFNG-
innervated gracilis, a classic 2-stage procedure for
reconstruction. Four patients had good results, but 2
developed upper lip contracture, requiring lip revi-
sion. The cortical adaptation stage was ≥stage III in
all, and the smile score improved from average 0.65
preoperatively to 3.0 postoperatively.
DISCUSSION
Aberrant reinnervation, for motor it is synkinesis,
may occur after nerve injury and repair, such as cases
of obstetric brachial plexus palsy.31,32 Deformities at
shoulder and elbow after recovery are seen quite of-
ten. The major treatment is surgical intervention31,32
not BTX-A and/or rehabilitation.
The philosophy of surgical treatment of PPFS is
similar to the treatment of scars. PPFS is a healing
process of facial nerve injury, similar to scar, a heal-
ing process of wound. Scars have many different clin-
ical presentations. Not all scars can be treated simply
by injection, massage, and pressure. Some scars,
hypertrophic scars and keloids, should be treated
aggressively, such as radical excision and resurface
by free tissue transfer. Similarly, not all PPFS can be
treated effectively and permanently by BTX-A and/
Fig. 7. A, A 25-year-old solider (patient 29, Table6) had right facial palsy for 1 year due to
a falling accident and developed right PPFS, pattern III. She had failed CFNG-innervated
gracilis (left gracilis) 1 year ago due to infection and muscle necrosis. After 11 months, she
had masseter-innervated second gracilis (right gracilis) for facial reanimation. B, Good facial
smile score with mild synkinesis was achieved. She needs rigotomy and fat grafts for uneven
surface of the reconstructed face later for rened surgery.
Table 7. Improvement of Synkinesis Grading and Smile Score after Aggressive Surgical Procedures
Pattern II (14 Patients) Pattern III (34 Patients) Improvement
Synkinesis grading (I–III) Before operation Before operation Synkinesis grading ≤ 1
III, 7 patients II, 0 patients Pattern II, 14/14 (P < 0.001)
II, 7 patients III, 34 patients Pattern III, 34/34 (P <
0.001)
After operation After operation
I, 14 patients I, 34 patients
Smile score (0–4) Before operation Before operation Smile score ≥ 2
Score 2, 6 patients Score 0, 4 patients Pattern II, 14/14 (P < 0.001)
Score 3, 5 patients Score 1, 29 patients Pattern III, 33/34
(P < 0.001)
Score 4, 3 patients Score 2, 1 patients
After operation After operation
Score 4, 14 patients Score 1, 1 patient
Score 3, 9 patients
Score 4, 24 patients

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Chuang et al. • Postparalysis Facial Synkinesis
13
or rehabilitation. The goal of PPFS treatment is not
only to decrease synkinesis but also to achieve a natu-
ral and symmetric smile permanently.
Rehabilitation therapy is attempting to inhibit
the trigger movement or change the intended vol-
untary movements to decrease synkinesis.9–12 It has
involved exercises (eg, mirror exercises, electromy-
ography feedback training), learning (neuromuscu-
lar reeducation), relaxation training, mime therapy,
electric stimulation, and BTX-A injection. However,
there has been little support showing it could signifi-
cantly and permanently reduce synkinesis.
BTX-A injection has been a well-established ben-
efit in the control of facial hyperkinesis in the lit-
eratures,13–16 mostly due to lack of effective surgical
treatment. The authors have been taught that BTX-
A can treat the whole PPFS for years (1990–2000)
and used it for treatment in the beginning. Quick
effects have been noted, but with many variations in
the procedure, including injection sites, injection
dosage, timing of injection, frequency of injection,
result evaluation, and follow-up period. In addi-
tion, the major disadvantages of BTX-A were many
injection sites (on the paralyzed and healthy face),
repeated injections, anaphylaxis, blepharoptosis,
diplopia, and accelerating the paralysis. The effect of
BTX-A will also be decreasing following the repeated
injections. Those will usually exhaust patients. Most
patients will lose their patience and finally disappear
from clinic after a short follow-up period (usually
less than 2 years), but they were not cured yet.
In PPFS, except pattern IV, 2 phenomena have
been seen: less synkinesis will tend to be more sym-
metric in smile; more muscle paralysis is associated
with less synkinesis. Our philosophy to treat PPFS is to
remove the trigger and synkinetic muscles as much as
possible to decrease the synkinesis and to remove the
innervated nerves to avoid its recurrence. The effect
is permanent. Our treatment protocol is based on pat-
terns of PPFS and patient’s desire. BT-A injection, re-
habilitation, and other additional aesthetic surgeries
were only our adjuvant therapy to improve the result.
VanSwearingen and Brach9 described the impor-
tance of treatment-based classification system for
facial synkinesis. As PPFS has many presentations
and patient expectations are usually high, pattern
classification is necessary, which can be used for
explanation and strategy of treatment. Narrow eye,
dominant nasolabial fold, dominant lower lip pulled
down, and dominant neck bands are all important
signs for judging degree of synkinesis. Tooth expo-
sure when smiling is a good sign for judging quality
of facial palsy. Most patients with PPFS are more con-
cerned with facial asymmetry than synkinesis. But to
the physician, correction of synkinesis should always
be done before treatment of asymmetry. This is es-
pecially true in pattern II and III patients with PPFS.
Treatment for pattern I patients will be much
closer to aesthetic surgery. BT-A injection, rehabilita-
tion, and distraction procedures (hair style changes
and eye glasses wearing), and minor facial contour-
ing surgeries can be helpful. However, those conser-
vative treatments cannot cure synkinesis. The best
treatment for pattern II and pattern III patients is
to treat synkinesis first and then aesthetics. Exten-
sive removal of the involved muscles and nerves,
followed by FFMT for facial reanimation, is our treat-
ment of choice. All patients with PPFS who received
such aggressive procedures should be aware that ad-
ditional minor procedures such as blepharoplasty
and fat grafts might be required later to enhance the
results. The advantage of such extensive procedures
is to avoid insufficient treatment and recurrence.
Performing aggressive surgical procedures to treat
pattern II and III patients with PPFS is a challenging
task. For a safe practice and to avoid potential law suit,
some prerequisites are essentially necessary:
1. The surgeon should have experiences in facial
palsy reconstruction and skills in aesthetic judg-
ment and management.
2. Extensive preoperative explanation to both the
patient and patient’s family is required, includ-
ing mechanism, 4 patterns of PPFS and their
treatment options, and conservative vs surgical
intervention. The patient should recognize that
the disfiguring involved is due to synkinesis ef-
fects. Surgical risks, postoperative rehabilitation,
potential sequelae, and further surgical proce-
dures should be explained for decision making.
Showing photographs or videos of results from
previously treated patients are also helpful. The
patient and parents should take the messages
home and think about them. The final decision
will be made by the patient not by a driven sur-
geon. The patient should be given enough time
for consideration of such invasive surgery.
3. The patient should have close follow-up postop-
eratively.
4. Indication and contraindication: patient selec-
tion is also crucial. The age of the patient should
not be too young (before 14 years old) or too
old (after 60). Patients with low education level
and high expectation for results or hesitation in
decision making should not be considered for
radical procedures.
Until now, for more than 25 years, the authors
have never met 1 case with law suit, even though 1
fair result (patient 23, pattern III) and 1 failed first
gracilis (patient 29, pattern III) were encountered.
The patients did not need repeated BTX-A injection

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PRS Global Open • 2015
14
or require a profound rehabilitation program dur-
ing the follow-up period.
CONCLUSIONS
Treatment of PPFS remains a challenging prob-
lem. Aggressive surgical procedures for pattern II
and III patients including myectomy, neurectomy,
and functioning muscle transplantation showed
more promising results than minor procedures. The
4 patterns of classification and treatment strategies
mentioned above are still constantly followed.
David Chwei-Chin Chuang, MD
Department of Plastic Surgery
Chang Gung Memorial Hospital
199 Tun-Hwa North Road
Taipei, Taiwan 105
E-mail: micro.cgmh@gmail.com
PATIENT CONSENT
Patients or their parents or guardians provided written
consent for the use of the patients’ image
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