Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

Summary

The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

Abstract

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic facial paralysis (Bell’s palsy) is the most common diagnosis, patients can also present with a history of physical trauma, infectious disease, tumor, or iatrogenic facial paralysis. Early repair within one year of injury can be achieved by direct nerve repair, cross-face nerve grafting or regional nerve transfer. It is due to muscle atrophy that in long lasting facial paralysis complex reconstructive methods have to be applied. Instead of one single procedure, different surgical approaches have to be considered to alleviate the various components of the paralysis.

The reconstruction of a spontaneous dynamic smile with a symmetric resting tone is a crucial factor to overcome the functional deficits and the social handicap that are associated with facial paralysis. Although numerous surgical techniques have been described, a two-stage approach with an initial cross-facial nerve grafting followed by a free functional muscle transfer is most frequently applied. In selected patients however, a single-stage reconstruction using the motor nerve to the masseter as donor nerve is superior to a two-stage repair. The gracilis muscle is most commonly used for reconstruction, as it presents with a constant anatomy, a simple dissection and minimal donor site morbidity.

Here we demonstrate the pre-operative work-up, the post-operative management, and precisely describe the surgical procedure of single-stage microsurgical reconstruction of the smile by free functional gracilis muscle transfer in a step by step protocol. We further illustrate common pitfalls and provide useful tips which should enable the reader to truly comprehend the procedure. We further discuss indications and limitations of the technique and demonstrate representative results.

Introduction

The facial nerve is involved in ocular protection, articulation, oral continence and greatly affects the aesthetic appearance of the face. Impairment of this nerve is therefore associated with significant morbidity and social withdrawal. Despite significant advances in therapy, the multitude of problems associated with the paralyzed face can only be targeted with a broad spectrum of additional procedures. Common to all surgical techniques is the need for an exact anatomical knowledge.

Facial nerve anatomy

The facial nerve consists of a branchial motor component for voluntary motor control of the facial musculatur....

Protocol

NOTE: The Patient shown in the video has agreed on publication of the video material. Written consent was obtained. The protocol follows the guidelines of the human research ethics committee of the University of Freiburg. Though surgeons may have different preferences, the following protocol will focus on the authors’ preferred technique.

1. Pre-operative Workup

1. Accomplish a standardized pre-operative work-up that consists of a structured history and thorough examination for accurate treatment planning. Thereby, request the etiology of the disease and ask for functional limitations. It is of utmost importance to determine ....

Results

The use of the masseteric nerve for reinnervation of the muscle graft was assessed in 5 patients (Table 1). Among them, acoustic neuroma resection was the main cause for facial paralysis. 3 candidates preferred the single-stage procedure rather than the “gold standard” two-stage approach. In two patients, the procedure served as a rescue procedure after insufficient stimulation by the cross-facial nerve graft (CFNG).

Reinnervation of the gracilis flap after single-stage repair.......

Discussion

Even though different surgical techniques have been described to regain a dynamic smile in patients with long standing facial paralysis, the two-stage repair with initial cross facial nerve grafting and consecutive free gracilis muscle transfer is seen as the “criterion standard”.

Although a two-stage procedure, the technique allows for spontaneity of the smile which is seen as a crucial factor to overcome the social handicap associated with facial palsy¹³.In cases of bi.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Nylon Suture, 9-0	Serag Weissner	Z0039490	°
Polypropylene Suture	Ethicon	-	Multiple thread sizes
Suprarenin 1mg/ml	Sanofi	-	°
Cook-Swartz Doppler Probe	Cook Medical	G03014	°
DP-M350 Blood Flow Monitor	Cook Medical	-	°
Surgical Microscope OPMI Vario	Carl Zeiss	-	°
Microsurgical instruments lab set	S&T	767	°
Biemer vessel clip	Diener	64,562	°
Applying forceps	Diener	64,568	for Biemer vessel clip
Cefuroxim 1500mg	Fresenius	J01DC02	°
Braunoderm	Braun Melsungen	3881105	°
Octenisept	Schuelke & Mayr	5702764	°
ISIS Neuromonitoring System	Inomed	-	°
Tissucol	Baxter	1.33052E+12	Fibrin glue
Jackson-Pratt Wound Drainage	Medline	SU130-1060
Myacyne Ointment	Schur Pharma	-