Facial Rehabilitation Evaluation PDF

Facial Rehabilitation Evaluation and Treatment Strategies for the Patient with Facial Palsy Mara Wernick Robinson, PT, MS, NCS*, Jennifer Baiungo, PT, MS KEYWORDS  Facial rehabilitation  Physical therapy  Neuromuscular retraining  Synkinesis  Postsurgical facial reanimation K...

Facial Rehabilitation Evaluation and Treatment Strategies for the Patient with Facial Palsy Mara Wernick Robinson, PT, MS, NCS*, Jennifer Baiungo, PT, MS KEYWORDS  Facial rehabilitation  Physical therapy  Neuromuscular retraining  Synkinesis  Postsurgical facial reanimation KEY POINTS  Evaluation of the patient with facial palsy includes the Sunnybrook Facial Grading System, eFACE, FaCE (Facial Clinimetric Evaluation), and the Facial Disability Index.  Facial rehabilitation treatment strategies are used for adults and children with peripheral unilateral and bilateral facial palsy.  Neuromuscular retraining, synkinesis management, and chemodenervation are essential in the treatment of postparalysis synkinesis.  Rehabilitation optimizes facial function after surgical dynamic facial reanimation.  A multidisciplinary team approach in the management of patients with facial palsy is most effective. Video content accompanies this article at http://oto.theclinics.com/. INTRODUCTION Rehabilitation of the paralyzed face addresses both the physical and psychological aspects of facial disability. Individuals with facial palsy suffer from lack of facial expression, as well as a host of functional limitations, including oral incompetence, articulation difficulties, and visual impairments. Furthermore, when the ability to ex- press emotions is sacrificed, patients are classified as having a negative affect.1–3 Quality of life is frequently affected, and anxiety and depression may develop.1,4 Lack of treatment of the sequelae associated with incomplete or aberrant nerve regen- eration can lead to dysfunctional facial movements and devastating psychosocial Disclosure Statement: No disclosure. Facial Plastic and Reconstructive Surgery Department, Facial Nerve Center, Massachusetts Eye and Ear Infirmary, Facial Nerve Center, 9th Floor, 243 Charles Street, Boston, MA 02114, USA * Corresponding author. E-mail address: [email protected] Otolaryngol Clin N Am 51 (2018) 1151–1167 https://doi.org/10.1016/j.otc.2018.07.011 oto.theclinics.com 0030-6665/18/ª 2018 Elsevier Inc. All rights reserved. 1152 Robinson & Baiungo consequences. Restoring facial function to the highest degree results in improved self-esteem and quality of life.5–7 People who experience facial palsy, irrespective of cause, can benefit from facial rehabilitation intervention.5,6,8–12 Facial rehabilitation is also an essential component of postoperative management following dynamic facial reanimation.7 EVALUATION Initial evaluation of the patient with facial palsy includes review of the medical record, followed by history of the present illness, including timing of onset and degree of facial palsy, and associated symptoms (eg, hearing loss, dizziness). Measurement of impair- ments, functional limitations, and degree of disability is gathered through clinician- graded outcome measures, still photographs, video, and patient-reported outcome measures. The most widely used, and objective, clinician-graded outcome measurement among rehabilitation therapists is the Sunnybrook Facial Grading System (FGS). The FGS is a performance-based measure of facial impairment in 3 areas: resting symmetry compared with the unaffected side, symmetry of voluntary movement of 5 facial movements, and associated synkinesis.13 Reliability and validity,13,14 as well as intrarater repeatability,15 have been established. The measurement of synki- nesis, however, has been found to be less reliable.16 An example of the FGS score is shown in Fig. 1B. The eFACE is an electronic clinician-graded facial function scale that generates an overall disfigurement score and offers simple graphic output.17,18 Similar to the Sunnybrook FGS, the eFACE measures static position, dynamic move- ment, and synkinesis patterns. An example of the eFACE score is shown in Fig. 1C. Additional facial movement patterns that are not included in the Sunnybrook FGS and eFACE (eg, lower lip depression, lip approximation, lip rolling, and scowl) should also be examined. It is also useful to analyze facial expression during spontaneous conversation and note the amount of symmetry, movement, and synkinesis when a patient emotes. Gathering personal, professional, and recreational information from the patient while also analyzing spontaneous facial expression helps to formulate in- dividual patient goals. Finally, a set of still photographs and a video of facial expres- sion is a useful adjunct to objective data. Patient-reported outcome measures provide useful and, perhaps, the most impor- tant, data. The FaCE instrument is a disease-specific, self-reported 15-item question- naire that is widely used in patients with facial nerve disorders.19 Domains of the questionnaire relate to both impairment and disability categories, and are considered to be quality-of-life measurements for patients with facial palsy. The reliability and val- idity of the FaCE is strong19 and a positive correlation between an initial Sunnybrook FGS score and an initial FaCE score has been demonstrated.20 The Facial Disability Index (FDI) is another widely used self-reporting tool for the assessment of physical disability and psychosocial factors related to facial nerve injury. This 10-item question- naire has 2 5-item subscales: the physical function subscale, which assesses daily life activities such as tooth brushing, eating, and drinking; and the social wellbeing sub- scale, which includes items related to psychological and social aspects.1,21–24 The FDI has been shown to have reliability, as well as construct validity, of the physical function subscale with the clinician’s physical examination of facial movement.24 The Synkinesis Assessment Questionnaire (SAQ) is a simple patient-graded instru- ment designed to self-rate facial synkinesis associated with facial expression. The SAQ has been demonstrated to have high test-retest reliability, internal consistency, and construct validity.25  Facial Rehabilitation 1153 Fig. 1. (A) Facial expressions. (B) The Sunnybrook FGS score of the individual depicted in the photographic series. (C) The eFACE score of the individual depicted in the photo- graphic series. (Courtesy of Sunnybrook Health Sciences Centre, Toronto, Ontario, Can- ada; with permission.) 1154 Robinson & Baiungo Given the variability of facial palsy and individual personalities, it is imperative to gain the patient’s perspective on their limitations to develop an individualized treat- ment plan. Inquiring, “What bothers you the most?” is a very useful and direct question that can guide and prioritize treatment intervention. For example, some patients may highlight the inability to smile, or a slight smile asymmetry, whereas others are solely bothered by ocular discomfort or facial tightness. The remainder of the evaluation of the patient with facial palsy should include testing of sensation to light touch, range of motion of the temporomandibular joint, and screening of the remaining cranial nerves. The latter may prove useful if the referring diagnosis does not support clinical examination findings. Obtaining the patient’s past medical history, and screening the patient’s neurologic, vestibular, and musculoskeletal systems, is necessary for treatment planning. Finally, and most importantly, the therapist must gain an understanding of the patient’s goals and expectations of facial rehabilitation. Results of the evaluation guide the clinician into thinking globally about the state of the facial muscles. Identifying the specific facial neuromuscular impairments guides the clinician on appropriate treatment strategies. Understanding facial nerve patho- logic conditions and the potential for nerve recovery guides the clinician in formulating realistic goals. Generally speaking, patients can be further classified into the acute or subacute stages of facial nerve injury (ie, within 6 months of onset of facial nerve insult) or chronic facial palsy (ie, >6 months), with or without synkinesis (Fig. 2). TREATMENT Facial rehabilitation for all patients typically includes 5 main components: (1) patient education to explain the pathologic condition and set realistic goals; (2) soft tissue mobilization to address facial muscle tightness and edema; (3) functional retraining to improve oral competence; (4) facial expression retraining, including neuromuscular reeducation; and (5) synkinesis management (when appropriate). The emphasis of facial rehabilitation is on teaching the patient self-management strategies. Education in the anatomy of the facial nerve, the muscles it innervates, and the role of individual facial muscles during expressions is included. Treatment sessions are designed to identify areas of functional and communicative limitation, and patients are guided on independent soft tissue mobilization techniques and motor control exercises as part of their individualized home program. Patients are taught to identify, develop, and refine appropriate movement patterns and facial expressions through neuromuscular retraining (NMR), a process of facilitating the return of intended facial movement patterns and eliminating or lessening unwanted patterns of facial movement, or synkinesis, due to aberrant nerve regeneration. VanSwearingen and colleagues initially described 4 basic treatment categories as a guide for therapeutic intervention strategies.6,11,26,27 Initiation Patients who present with complete facial paralysis due to an acute facial nerve injury, or have a delayed recovery following facial nerve damage, begin treatment with initi- ation strategies because the main goal is to help patients initiate movement from the flaccid or weak muscles. Patients present with lack of muscle activation on the involved side, including incomplete eye closure, and lack synkinesis. Individuals with acute facial palsy typically have impaired articulation, oral incompetence, and inability to express emotions. Treatment of patients in the initiation category includes education about facial mus- cle anatomy; expectations for recovery; gentle eyelid stretching; soft tissue  Facial Rehabilitation 1155 Fig. 2. Facial rehabilitation algorithm for individuals with facial palsy. mobilization, initiation, or active-assistive movement exercises; and compensatory strategies for functional deficits. Patients in this category often present with lagophthalmos due to weakness of the orbicularis oculi musculature and unopposed action of the levator palpebrae superio- ris.28,29 The lack of active motion of the orbicularis oculi may cause formation of cross- linkages between the myosin and actin filaments in the levator muscle fibers. Patients are taught to stretch the superior eyelid for 30 seconds, to passively lengthen the 1156 Robinson & Baiungo levator palpebrae superioris, and effectively interrupt the cross-bridges. Immediately following the stretch, patients experience improved eye closure.28 An example of the eyelid stretch is shown in Fig. 3. Soft tissue mobilization techniques are provided to affected facial muscles to improve circulation and muscle health. Some patients complain of tightness and fatigue on the uninvolved side, related to absence of antag- onistic activity on the involved side, and can benefit from massage. Patients are taught exercises to initiate movement of facial expression with manual or passive movement. For example, to improve smile excursion, the patient places the finger at the corner of the mouth and gently assists the oral commissure superiorly to encourage zygomaticus contraction. Importantly, patients are instructed to avoid mass movements of the face and focus on balanced facial expressions. Though sym- metry and balance are stressed, education in compensatory strategies may be neces- sary for issues related to oral incompetence. Education regarding realistic recovery, expectations of rehabilitation, and importance of compliance with a home program is provided. As facial nerve regeneration occurs, the patient transitions to facilitation treatments; when regeneration is unlikely (eg, nerve transection), surgical reanimation is an option (see Fig. 2). Facilitation Patients with acute facial palsy who present with incomplete flaccid facial palsy without obvious synkinesis begin treatment with facilitation strategies because the main goal is to assist or facilitate motor return. Treatment in this category includes pa- tient education, eyelid stretching, soft tissue mobilization, and NMR. Soft tissue mobi- lization is included when muscle tightness or tenderness to palpation is present in facial musculature. Active-assistive techniques are used here because minimal contraction is observed. When more obvious movement occurs to form a moderate degree of contraction, neuromuscular reeducation exercises, including mime therapy (ie, emotional expression exercises), are taught.5,9,11 The importance of slow- controlled symmetric movements and avoidance of mass movement is rein- forced.5,6,11,27 Patients are taught to dampen the uninvolved facial muscles to minimize opposing forces, in an effort to gain movement on the involved side. For example, patients are taught to smile on the unaffected side only to the same degree as possible on the affected side. This permits production of a balanced smile without overpowering the affected side by the opposing force of the unaffected side. Because Fig. 3. Eyelid stretch.  Facial Rehabilitation 1157 the intrinsic muscle and joint receptors that would normally provide proprioceptive feedback are few or absent in the facial muscles, visual feedback, in the form of a mirror11 or the use of camera technology on hand-held and desktop devices, is used to guide movement. Surface electromyography (EMG) biofeedback can serve as an adjunct to the reeducation process, providing visual or audio feedback to the patient regarding recruitment of motor units during NMR, as well as decreasing mus- cle activity on the contralateral side for symmetry.27,30 Movement Control Patients who demonstrate active motion in some or all zones of the face but also pre- sent with synkinesis due to aberrant nerve regeneration, begin treatment using move- ment control strategies. Movement control treatment strategies are designed to teach the patient to activate specific facial expressions while also releasing or dampening the synkinesis contractions that are limiting intended movements. Patient education about the phenomenon of synkinesis and the patient’s specific synkinetic patterns are vital components of the treatment plan. NMR teaches pa- tients to mindfully relax or release the tension in the synkinetic musculature while simultaneously performing associated facial movements. For example, the patient is taught to form a small symmetric smile while also controlling periocular synkinesis (Fig. 4, Video 1). Controlling synkinesis can be described to the patient as releasing the tension as in slowly draining the air out of an inflated tire. Patients are taught to use the unaffected side as a template for what normal feels like. Conscious control of synkinesis is challenging for most patients and requires utmost concentration. Frequent practice of NMR exercises is required for neural plasticity to permit long- lasting new neural pathways because the ultimate goal is improved spontaneous Fig. 4. Smile expression photographs of an individual who presented with chronic left-sided facial palsy and synkinesis at initial evaluation (left), followed by facial rehabilitation and chemodenervation (right). 1158 Robinson & Baiungo facial expression with fewer intense involuntary synkinetic movement patterns. It is important that NMR exercise repetitions are of good quality to avoid reinforcement of the abnormal movement pattern. Recommendations for frequency and duration of the prescribed NMR routine is based on an individual’s presentation, motivational level, and specific goals. As conscious control of synkinesis improves, patients are taught to incorporate NMR concepts into daily facial activities.11 A patient who experiences periocular syn- kinesis while eating or drinking is instructed to attempt to control the synkinesis during this activity (Video 2). Although constant attention to automatic movements is unreal- istic, some degree of awareness is beneficial. With repetition, neural plasticity may allow for improved facial function over time. Similar to the process in the facilitation category, patients begin learning movement patterns with visual feedback via a mirror or camera, or with EMG biofeedback. As patients develop greater appreciation for synkinetic control with visual feedback, they are encouraged to move away from visual or EMG feedback and rely on kinesthetic awareness. The patient with acute facial palsy who began treatment with initiation or facilitation strategies may transition into needing movement control strategies if synkinesis evolves (see Fig. 2). Relaxation Patients with chronic facial paralysis who present with severe synkinesis begin treatment with relaxation strategies. Patients present with significant asymmetry related to muscle tightness, and moderate to severe synkinesis. Patients typically complain of facial ten- sion and discomfort on the affected side. Aggressive soft tissue mobilization techniques and synkinesis control through relaxation strategies are taught as a primary intervention. The use of an audio relaxation recording, using guided visual imagery to release facial tension, and using mindfulness to dampen synkinesis, is recommended. With time, pa- tients may learn to spontaneously use relaxation techniques to release facial tension. Af- ter muscle tension decreases, the patient can learn movement control strategies. Instructions for the frequency and intensity of massage and NMR exercises are pro- vided to the patient as an individualized home exercise program encouraging daily prac- tice. Written explanations with illustrations, or video instruction, influence the quality of performance, motivation, and confidence to perform the complex exercises. Subsequent therapy sessions focus on modifying and advancing the home program based on the de- gree of facial nerve recovery and the patient’s degree of motor learning. Reviewing pre- vious exercises and providing new strategies at each session enhances the patient’s interest and compliance. Clinician-reported and patient-reported outcomes should be administered every 6 to 8 weeks to gauge progress. The average patient with facial palsy is seen for a total of 6 to 12 months. Yearly reevaluations to ensure maintenance and re- view the home program are suggested. Given the long-standing nature of facial palsy and synkinesis, long-term commitment to home exercise programs is emphasized. SPECIAL CONSIDERATIONS Not all patients belong precisely in a treatment category. The experienced clinician should collaborate with the entire facial nerve team to maximize patient outcomes based on the diagnosis. Additionally, patients with bilateral facial palsy, pediatric cases, or patients with an unclear cause pose a challenge for the rehabilitation therapist. Bilateral Facial Paralysis Bilateral facial paralysis, a rare disorder with an incidence of less than 2% of all cases of facial palsy, can stem from various causes.31 The FGS and eFACE are not reliable  Facial Rehabilitation 1159 scales for this patient population due to lack of an uninvolved side of the face for grading comparison.14,32 Patients may present with acute onset of bilateral flaccid facial palsy, bilateral chronic facial palsy, or chronic facial palsy on 1 side with the contralateral facial palsy. These scenarios represent a unique management strategy in which elements of each of the different approaches are introduced into the care plan. Compensatory strategies for oral incompetence and impairments in articulation are priority treatments for patients with bilateral facial palsy. Bilateral ocular synkinesis poses a safety concern if there is significant loss of the visual field and is often managed successfully with chemodenervation. Pediatrics Facial palsy in the pediatric population is also a rare condition, with an incidence of 21.1 per 100,000 per year for children younger than the age of 15 years.33 There are many causes of facial palsy in children, including congenital or acquired (eg, inflam- matory, neoplastic, traumatic, or iatrogenic causes) facial palsy.33,34 Classification of a child’s facial nerve insult, as well as the basics of the treatment intervention, are similar to that of an adult. However, the strategies and delivery of treatment are altered to be more child-friendly, and to accommodate the specific interest and per- sonality of a child. For example, children are engaged by technology and, therefore, computerized games and applications are successful strategies. Stickers or face paint on the facial muscles can be used in place of surface electrodes to provide feedback about symmetric movements. Lollipops, bubbles, and whistles are used to teach oral motor control. Goals of very young children (and their parents) with facial paralysis typically include improving the ability to drink, eat, and speak clearly, whereas the goals of a teenager are more likely taking photographs for social media, and improving self-confidence in school, recreational activities, and social interactions. CHEMODENERVATION Chemodenervation, using botulinum toxin (eg, Botox), is commonly used to eliminate inappropriate movements caused by synkinesis.35–38 Numerous studies have shown its efficacy, including improvements in Sunnybrook FGS scores,39 as well as quality-of-life scores.39,40 Precise botulinum toxin injections decrease the strength of the synkinetic contraction. For example, injection into the superior and inferior oculi will diminish the involuntary eye closure often seen with smiling and puckering in these patients. The pattern and intensity of synkinesis varies among patients, therefore each chemodenervation plan is individualized. To balance facial expression, chemodener- vation is also beneficial in treating the contralateral, nonparalyzed side. For example, weakening the contralateral depressor labii inferioris is often used to address lower lip asymmetry during speech and smiling. The facial rehabilitation therapist plays an integral role in the development and modi- fication of chemodenervation therapy. It is imperative that individuals have a good un- derstanding of the phenomenon of synkinesis and its effect on facial motor control before initiating botulinum toxin injections. Patients seem to gain the most benefit from facial rehabilitation when chemodenervation is initiated after the patient has partic- ipated in facial rehabilitation and achieved some degree of conscious control over their synkinesis. Fig. 5 demonstrates the progress made by a patient with a 4-year history of Bell palsy after participating in facial rehabilitation for 3 months, followed by initial che- modenervation injections. Multiple sessions of skilled facial rehabilitation, including reevaluation with clinician-reported and patient-reported outcome measures, as well 1160 Robinson & Baiungo Fig. 5. Smile (top row) and pucker (bottom row) photographs of an individual who pre- sented with chronic left-side facial palsy and synkinesis, at initial evaluation (left column), followed by facial rehabilitation for 3 months (middle column), and followed by initial che- modenervation injections (right column). as photographs, enables the therapist and patient to assess the effects of chemodener- vation, and to provide feedback to modify injection sites and dosage if needed. REHABILITATION FOR POSTSURGICAL DYNAMIC FACIAL REANIMATION For patients with complete facial paralysis, for example, when the facial nerve has been sacrificed during tumor extirpation, or transected secondary to a temporal bone fracture, surgical intervention to restore nerve function may be the only option in hopes of restoration of facial expression. For patients with postparalytic facial palsy who have not regained adequate commissure excursion, facial reanimation surgery is also an option to restore a meaningful smile.41–43 The decision to advance from facial rehabilitation to dynamic surgical reanimation is made by the patient and the entire treatment team with the primary motivation being patient satisfaction. Facial rehabil- itation intervention is then indicated to maximize smile restoration, as well as to maxi- mize function following surgery. Several surgical procedures have been described for smile restoration.41,44–46 Com- mon surgical reanimation strategies include nerve transfer to the native facial muscula- ture controlling the smile using the ipsilateral nerve to masseter in isolation or in conjunction with other nerve transfers (eg, cross-facial nerve grafts or hypoglossal nerve  Facial Rehabilitation 1161 transfer), or functional free muscle transfer for smile reanimation using nerve to masseter and/or a cross-facial nerve graft from smile branches of the contralateral facial nerve. The ipsilateral nerve to masseter provides powerful neuronal input for smile reani- mation; however, patients must learn to bite down (ie, clench the jaw) to activate smile. This initially may feel unnatural, necessitating more intense rehabilitation than would otherwise be required when reanimated smile is driven by cross-facial nerve grafting. Though cross-facial nerve graft–driven smile provides spontaneity, axonal density through the graft is far less than that obtained from the nerve to masseter, resulting in higher failure rates.41,46 The appropriate surgical intervention is based on the loca- tion of nerve injury, the degree of facial paralysis, the length of time since onset, and individual patient factors such as age, prognosis, patient choice, and surgeon choice and experience.41,43 Each approach has advantages and disadvantages and should be individualized for each patient. For all patients undergoing surgical reanimation, facial rehabilitation includes 4 main components: (1) patient education to review facial anatomy and patient expectations, (2) soft tissue mobilization to manage postoperative edema and muscle tightness, (3) functional retraining to improve oral competence, and (4) smile retraining specific to the facial reanimation surgery performed. NERVE TO MASSETER–DRIVEN SMILE Following nerve to masseter transfer to native midfacial musculature, or to free mus- cle, a smile occurs when the patient bites down as a result of innervation by the trigem- inal motor branches. Muscle activity from biting down occurs approximately 2 to 5 months postoperatively, with an average gain in commissure excursion of 8 mm.47,48 Patients are referred for facial rehabilitation approximately 2 months post- operatively with the goal of educating the patient about movement expectations, soft tissue massage, and identification of any movement from biting down. The goal of soft tissue mobilization is to decrease postsurgical edema that commonly occurs following surgery. Four rehabilitation stages of motor learning for patients who have undergone nerve to masseter–driven smile reanimation surgery are described in the following sections. The 4 stages are designed to guide therapists and patients with a general framework of progression (Table 1). Stage 1. Biting Down to Engage the Masseter for Commissure Excursion The patient is instructed to gently bite down on a soft medium placed between the contralateral or unilateral molars. Commonly used mediums include a mouth guard, gauze pad, or chewy soft candy. The patient places the medium between their molars, looks at the affected commissure, and bites down. The goal of this stage is to simply teach the patient that biting down generates movement of the commissure. Next, the patient is taught to grade the amount of tension used to bite down to generate move- ment, using a visual analog scale from 0 to 10, in which 0 represents no biting and 10 represents maximal bite effort. Therapy involves teaching the patient to bite down with the least amount of effort required to achieve ideal excursion. Initially, patients must often bite down with maximal effort to drive smile, with less effort required over time. Patients are educated that they may experience fatigue in the masseter during practice. In addition to biting down, patients are taught to perform self-guided effleur- age massage to the midface. The patient is instructed on range-of-motion exercises to facilitate jaw opening to prevent temporomandibular joint dysfunction that may occur from forceful and repetitive biting. 1162 Robinson & Baiungo Table 1 Stages of facial rehabilitation following ipsilateral nerve to masseter–driven smile reanimation surgery Stage Key Points of Rehabilitation Time Frame 1. Commissure excursion: Massage the zygomaticus or gracilis Movement begins 2–5 mos bite down to engage Mirror feedback for commissure after surgery masseter for isolated excursion Practice 2–4 wks, commissure excursion Bite down on soft medium (eg, depending on the candy) strength of the Visual analog scale contraction 10–20 repetitions, 2–3/d 2. Voluntary posed smile: Massage the zygomaticus or gracilis Smile symmetry practice bite down to smile Mirror feedback to bite down and begins within 2 wks of symmetrically smile with goal of initial sign of movement  Symmetry Practice 4–12 wks  Normal timing between affected depending on and unaffected side motivation of the patient 10–20 repetitions, 2–3/d 3. Voluntary engaging Massage the zygomaticus or gracilis Practice 4–12 wks smile: bite down to Engage frequently in habits of depending on smile during smiling during routine points daily; motivation of the patient conversation for example, “good morning” followed by a biting smile 4. Spontaneous smile: Use of smile without biting may Depends on patient smile without biting eventually become automatic after understanding and intense practice motivation Stage 2. Biting Down to Smile Symmetrically: Voluntary Posed Smile After meaningful commissure excursion (ie, greater than approximately 4 mm of move- ment) is demonstrated, patients are instructed on integration of bite-effort with con- current smiling on the contralateral (ie, healthy) side. The patient is instructed to gently bite down, using mirror feedback, while simultaneously forming a small balanced smile. The goal of this stage is to teach the patient that biting down gener- ates a smile. As in stage 1, the patient is taught to grade the amount of tension used to bite down to generate movement, using a visual analog scale. The patient is taught to bite down with the least amount of effort to achieve smile symmetry. Patients are encouraged to envision a happy thought while gently biting down to trigger smile on the healthy side, typically with the lips together to achieve a natural appearing grin (closed-mouth smile). The goal is to form a voluntary posed smile that is balanced and symmetric. This biting smile is considered by patients to be an acceptable posed smile that can be generated in photographs. The patient then progresses to biting down using a thicker structure (eg, thicker gauze) that demands less biting effort. Stage 3. Biting Down to Smile During Conversation: Voluntary Engaging Smile The goal of this stage is to voluntarily form a biting smile while engaging in conversa- tion. This smile displays pleasure or demonstrates agreement during conversation. The patient should begin using the biting smile during conversation and to transition into using the biting smile consciously throughout daily interactions. For example, when meeting a friend, coworker, or a family member, the intent is to say a typical pleasant greeting followed by a biting smile. Over time, this type of biting smile should transition from a conscious and voluntary motor plan to an automatic gesture display- ing a smile. Video 3 demonstrates a cumulative 4-month process, of stages 1 through  Facial Rehabilitation 1163 3, of a patient who underwent free gracilis transfer driven by the masseteric branch of the trigeminal nerve. Stage 4. Smile Without Biting: Spontaneous Smile The ultimate goal of smile reanimation surgery is a spontaneous smile. The ability for patients who have undergone nerve to masseter reanimation procedures that require biting down to execute a smile to form a spontaneous smile is variable. The percent- age of patients who acquire a spontaneous smile following the masseteric nerve sur- gery has not been well characterized, in part due to the challenge of assessing spontaneous smile.49 How some patients achieve spontaneous smile following smile reanimation driven by motor branches of the trigeminal nerve is unclear. Coactivation of the masseter muscle with smile is known to occur naturally in some patients and may explain spontaneity seen postopereatively.50 Alternatively, cortical neuroplastic- ity might result in spontaneous bite-activated smile in the postoperative state.49,51 FACIAL REHABILITATION FOLLOWING FREE MUSCLE TRANSFER DRIVEN BY A CROSS-FACE NERVE GRAFT Cross-face nerve graft–driven smile reanimation results in spontaneous move- ment. Patients who have undergone 2-stage free gracilis transfer for smile reani- mation by cross-facial nerve grafting are expected to see muscle activity approximately 5 to 9 months following the second stage.52 Contraction of the free muscle is generated when the patient smiles either voluntarily or spontane- ously. Although spontaneous smiling seems straightforward, 2 to 4 rehabilitation sessions are indicated to teach the patient how to facilitate movement and symme- try. Patients are instructed to perform both maximal effort smiles (including expo- sure to funny videos or situations that facilitate smiling and laughter) followed by symmetric, perhaps even smaller excursion, smiles. The use of a mirror or camera for visual feedback helps the patient appreciate new movement. Surface EMG biofeedback may also be used. Soft tissue mobilization and functional retraining for oral competence is also indicated. Smile reanimation surgery has become a mainstay in the management of patients with facial palsy. Objective outcomes following free muscle transfer using the gracilis have demonstrated quantifiable improvements in resting symmetry and in the amount of oral commissure excursion.7,44,47,48 Although outcomes measures from facial rehabilitation following such surgery has yet to be reported in the literature, facial rehabilitation exercises are suggested by most surgeons. Quality-of-life mea- sures have demonstrated improved function following surgical intervention in a clinic where most patients receive facial rehabilitation following surgery.7,43,44 Fig. 6 shows preoperative and postoperative photographs of patients who reported excel- lent patient satisfaction following dynamic facial reanimation surgery and facial rehabilitation. PSYCHOLOGY OF FACIAL EXPRESSION The ability to activate facial muscles alone is inadequate to perform the complex inter- actions involved in facial expression. Facial expression, including functional actions such as communication and personal interactions, are both cortically and subcorti- cally driven. Cortically mediated expressions are voluntary, with an intended facial function, such as protruding the lips to drink from a cup. Subcortical actions are typi- cally driven by a reaction such as surprise or laughter. Although difficult to achieve, the skill of connecting the cortical and subcortical responses is the ultimate goal of facial 1164 Robinson & Baiungo Fig. 6. Smiles of individuals who participated in facial rehabilitation at presentation (top row) and after rehabilitation for dynamic reanimation surgery (bottom row). (A) Functional free muscle (gracilis) transfer using ipsilateral nerve to masseter nerve. (B) Functional free muscle (gracilis) driven by a cross-facial nerve graft from smile branches. (C) Ipsilateral nerve to masseter nerve to native facial muscles. (D) Bilateral free muscle (gracilis) driven by ipsi- lateral nerves to masseter nerves. rehabilitation. Because emotions elicit a set of stereotypical facial muscle contractions of an expression, the alternative may also be true. Facial muscle activity may elicit or reinforce emotions (facial feedback hypothesis); for example, the inability to smile and psychological distress.8,53 Little is actually known about the contribution of deficient facial feedback to the psychosocial problems of individuals with facial palsy; however, limited social interactions and depression are commonly reported. Therapists should guide treatment in specific facial expressions connected to emotions for optimal recovery.8,9,11,54 Additionally, individuals with facial palsy are taught to alter their verbal tone and body language to improve self-expression and nonverbal communication. Hairstyle modifications can help to minimize appearances of facial asymmetries, especially in the brow region. The use of accessories, such as eye glasses, earrings, necklaces, scarves, and make-up, may draw attention away from facial asymmetry. Patients are encouraged to participate in physical exercise to alleviate stress and improve health and overall wellbeing. When emotional distress interferes with rehabilitation, referral for psychological support is indicated. SUMMARY Although facial rehabilitation cannot restore perfect premorbid appearance and func- tion, appropriate intervention can make a substantial difference in facial muscle motor  Facial Rehabilitation 1165 control with the ultimate goal of improved physical function, enhanced appearance, and increased patient self-confidence. Patient education, including management of expectations, is crucial. Rehabilitation goals must be tailored to the individual on a functional, cosmetic, and emotional level. Realistic functional outcomes include improved ability to smile, eat, drink, speak clearly, and blink on the affected side. Addi- tionally, reduction of facial pain and tension in the affected musculature is achieved. At the interpersonal level, willingness to participate in social activities and improved self-confidence are realistic goals. Patients who possess the motivation necessary to commit to a consistent and thorough home program are most successful. SUPPLEMENTARY DATA Supplementary data related to this article can be found online at https://doi.org/10. 1016/j.otc.2018.07.011. REFERENCES 1. Coulson SE, O’dwyer NJ, Adams RD, et al. Expression of emotion and quality of life after facial nerve paralysis. Otol Neurotol 2004;25(6):1014–9. 2. Ishii LE, Godoy A, Encarnacion CO, et al. What faces reveal: impaired affect display in facial paralysis. Laryngoscope 2011;121(6):1138–43. 3. Bogart KR, Tickle-Degnen L, Ambady N. Communicating without the face: holis- tic perception of emotions of people with facial paralysis. Basic Appl Soc Psych 2014;36(4):309–20. 4. Fu L, Bundy C, Sadiq SA. Psychological distress in people with disfigurement from facial palsy. Eye 2011;25(10):1322–6. 5. 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