PEDIATRIC/CRANIOFACIAL The Outcomes of Dynamic Procedures for Blink Restoration in Pediatric Facial Paralysis Julia K. Terzis, M.D., Ph.D. Dimitrios Karypidis, M.D. Norfolk, Va. Background: Surgical planning aims to restore coordinated eyelid function. Although achieving voluntary eye closure is one of the primary goals, it cannot guarantee return of involuntary blink. Restoration of the afferent pathway of the reflex is a prerequisite, but successful coordination of the reflex components and restoration of their time-related function are also required. Methods: A retrospective review of 49 patients who underwent dynamic procedures for blink restoration was performed. The patients were divided into two groups. Group A (n = 42) included patients who underwent nerve transfers: cross-facial nerve grafting and subsequent microcoaptations, mini- hypoglossal nerve transfers, and direct orbicularis oculi neurotization. Group B (n = 14) included patients who underwent eye sphincter substi- tution techniques: pedicled frontalis, free platysma, mini-temporalis, and a slip of free pectoralis minor transfers. Seven of the patients included in the groups underwent both nerve and muscle transfer procedures. Objective blink ratios were measured according to an established protocol by the senior author (J.K.T.). Results: Thirty patients were girls and 19 were boys. The age of the patients ranged from 1 to 17 years, with a mean  SD age of 7.5  3.2 years. Denervation time ranged from 76 months to 15.25 years. Blink improvement was noted in all of the patients. Blink scores and ratios were consistently better in group A than in group B. Conclusion: Dynamic procedures provide the functional potential on which subsequent static procedures can be performed to aid blink return, taking into account the future needs of the still growing patient. (Plast. Reconstr. Surg. 125: 629, 2010.) I n patients with facial paralysis, except for re- storing adequate voluntary eye closure in cases of impaired eyelid function, one of the chal- lenges has been restoration of the blink reflex. The protective role of the blink reflex has been described, and sequelae including corneal abra- sions, exposure keratopathy, epiphora, and even loss of vision can be avoided by achieving adequate blink return. 1 Surgical planning in pediatric patients in- cludes particular concerns distinct from the gen- eral population. The requirements for the physi- cally and psychologically developing child differ from those of an adult with already developed body image and psychological integrity. This study presents a retrospective review of the pediatric patients who underwent dynamic procedures aim- ing at the restoration of the blink reflex per- formed by the senior author (J.K.T.) as a part of multistage facial reanimation procedures. From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Microsurgery Program, Eastern Virginia Medical School. Received for publication March 26, 2009; accepted August 10, 2009. Copyright ©2010 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181c91f69 Disclosure: The authors have no financial interest to declare in relation to the content of this article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text; simply type the URL address into any Web browser to access this content. Click- able links to the material are provided in the HTML text of this article on the Journal‘s Web site (www.PRSJournal.com). www.PRSJournal.com 629