Downloaded from http://journals.lww.com/plasreconsurg by 50t/VQDJQJx2FJ0LXaRsWUGENDbhLEoKWprAf7+j8gkGlAtH9zkuTHIGDHcEauaNgzP1b2YyfyJvjf06Wv68prhLp6TRNaFvBmZKrdP0ZkORjOCGe45AZDDQO2jk6M8J on 04/29/2019 Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. www.PRSJournal.com 1483 C omponents of a natural smile include sym- metric superolateral excursion of the oral commissure, appropriate orientation of the Disclosure: Drs. Massry and Azizzadeh receive roy- alties from Elsevier and Springer. Dr. Azizzadeh was a co-investigator for the Checkpoint head and neck nerve stimulator/locator product validation study (2004). The other authors have no financial inter- ests or conflicts of interest to disclose. No funding was received for this article. Copyright © 2019 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000005590 Babak Azizzadeh, M.D. Leslie E. Irvine, M.D. Jaqueline Diels, O.T. William H. Slattery, M.D. Guy G. Massry, M.D. Babak Larian, M.D. Kiersten L. Riedler, M.D. Grace Lee Peng, M.D. Los Angeles, Beverly Hills, and Santa Barbara, Calif.; and Madison, Wis. Background: To address functional and smile dysfunction associated with post–facial paralysis synkinesis, the senior author (B.A.) has offered “modified selective neurectomy” of the lower division of the facial nerve as a long-term solution. This article examines technical considerations and outcomes of this procedure. Methods: A retrospective review was conducted of patients who underwent modified selective neurectomy of buccal and cervical branches of the facial nerve performed by a single surgeon over a 4½-year period. House-Brackmann facial grading scores, electronic clinician-graded facial function scale, and ona- botulinumtoxinA (botulinum toxin type A) dosages were examined before and after the procedure. Results: Sixty-three patients underwent modified selective neurectomy between June 20, 2013, and August 12, 2017. There were no serious complications. The revision rate was 17 percent. Temporary oral incompetence was reported in seven patients (11 percent) postoperatively. A statistically significant improve- ment was achieved in electronic clinician-graded facial function scale analy- sis of nasolabial fold depth at rest, oral commissure movement with smile, nasolabial fold orientation with smile, nasolabial depth with smile, depressor labii inferioris lower lip movement, midfacial synkinesis, mentalis synkinesis, platysmal synkinesis, static score, dynamic score, synkinesis score, periocular score, lower face and neck score, and midface and smile score. There was a significant decrease in botulinum toxin type A dosage and House-Brackmann score after surgery. Conclusion: Modified selective neurectomy of the buccal and cervical divisions of the facial nerve is an effective long-term treatment for smile dysfunction in patients with post–facial paralysis synkinesis. (Plast. Reconstr. Surg. 143: 1483, 2019.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. From the Department of Head and Neck Surgery, David Gef- fen School of Medicine at the University of California, Los Angeles; the Center for Advanced Facial Plastic Surgery; the Santa Barbara Plastic Surgery Center; the Facial Nerve Clin- ic, University of Wisconsin Hospitals and Clinics; the Depart- ment of Neurotology, House Clinic; the Department of Oto- laryngology, University of Southern California, and Beverly Hills Ophthalmic Plastic and Reconstructive Surgery; Divi- sion of Oculoplastic Surgery, Department of Ophthalmology, and Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California. Received for publication January 10, 2018; accepted Sep- tember 27, 2018. Modified Selective Neurectomy for the Treatment of Post–Facial Paralysis Synkinesis Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www. PRSJournal.com). RECONSTRUCTIVE