1. Copyright restrictions may apply JAMA Facial Plastic Surgery Journal Club Slides: Objective Assessment of Smile Outcomes Bhama PK, Weinberg JS, Lindsay RW, Hohman MH, Cheney ML, Hadlock TA. Objective outcomes analysis following microvascular gracilis transfer for facial reanimation: a review of 10 years’ experience. JAMA Facial Plast Surg. Published online January 30, 2014. doi:10.1001/jamafacial.2013.2463.

2. Copyright restrictions may apply Introduction Gracilis free tissue transfer (GFTT) is the gold standard for dynamic reanimation of the oral commissure. Objective assessment of smile outcome after microvascular free gracilis transfer is challenging, and quantification of smile outcomes in the literature is inconsistent. Lack of objective outcomes measurements makes it challenging to predict outcomes based on patient characteristics and intraoperative events.

3. Copyright restrictions may apply Purpose The purpose of this study was to quantify smile outcomes in patients following GFTT and find relationships between intraoperative parameters and outcomes.

4. Copyright restrictions may apply Relevance to Clinical Practice The advancement of facial reanimation treatment is dependent on the ability of facial plastic surgeons to reliably quantify results so that comparisons between current treatments and novel procedures can be made. If associations between perioperative parameters and ultimate outcomes can be determined, clinicians can more accurately educate and prepare patients for the results of their interventions.

5. Copyright restrictions may apply Description of Evidence All patients who underwent GFTT at the Massachusetts Eye and Ear Infirmary from March 2003 to March 2013 were included in the study. Patients with flap failure and patients who were still in the process of recovery were excluded.

6. Copyright restrictions may apply Description of Evidence Face-GRAM software used to make facial measurements. 1, Horizontal interpupillary line; 2, vertical line bisecting and perpendicular to horizontal interpupillary line; A, intersection of line 2 and vermilliocutaneous border of lower lip; B, oral commisure; 3, line with distance spanning points A and B; and a, angle between line 2 and line 3.

7. Copyright restrictions may apply Description of Evidence Gracilis muscle following inset.

8. Copyright restrictions may apply Description of Evidence Preoperative and postoperative gracilis recipients. Left column represents trigeminally innervated flaps; right column represents flaps innervated by contralateral facial nerve.

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12. Copyright restrictions may apply Controversies and Consensus Our data only reflect 2-dimensional measurements of facial movement and do not account for the Z plane, which is an important metric. The average postoperative excursion in our study was 8 mm, which is similar to smile excursion in the normal population. Excursion in trigeminally innervated flaps is greater than in flaps innervated by the contralateral facial nerve.

13. Copyright restrictions may apply Comment Larger, prospective studies are indicated to better define associations between intraoperative gracilis muscle parameters and outcomes. It is important to investigate quality-of-life changes following GFTT to determine whether associations between quality of life and objective measurements exist.

14. Copyright restrictions may apply Conclusions GFTT is a reliable procedure for dynamic reanimation of the paralyzed oral commissure and results in measureable improvements in smile excursion and oral commissure symmetry.

15. Copyright restrictions may apply Contact Information If you have questions, please contact the corresponding author: –Prabhat K. Bhama, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Harvard Medical School/Massachusetts Eye and Ear Infirmary, Harvard School of Public Health, 243 Charles St, Boston, MA 02114 (pbhama@gmail.com). Funding/Support This research was supported by grant R01NS071067 from the National Institutes of Health. Conflict of Interest Disclosures None reported.