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

Single stage dynamic reanimation of the smile in irreversible facial paralysis by free functional muscle transfer represents an alternative to the gold standard two stage repair. We here provide a detailed description to safely perform the technique, including elevation of the flap and facial preparation, Revascularization of the transferred muscle, nerve repair and definite insertion of the ulus Fla. The reconstruction of a spontaneous smile together with a sufficient symmetry at rest is a primary goal of reconstruction in facial paralysis patients.

This goal is usually achieved by two stage procedure of a cross face nerve graft, followed by a free functional muscle crustless transfer. However, this procedure has several limitations that we overcome with a single stage procedure of innovating the cressler muscle by the esoteric nerve, which we present. Here in this video Files, We here demonstrate a case of a 49-year-old female who presented with a complete picture of left peripheral facial paralysis.

Following resection of an acoustic neuroma. The patient was most afflicted by facial asymmetry, particularly when smiling at rest. The patient showed a trago MEUs distance of 11 centimeters on the right and 11.5 centimeters on the left.

Upon smiling trago MEUs distance scaled down to nine centimeters on the right and elongated to 12 centimeters on the left. Operation is performed on A general anesthesia. The patient is placed.

Toine prevent pressure points by using protective padding. The procedure is best performed in a two team approach. Here surgical steps are as described, one after another turn the patient's head to the healthy side and adjust the height of the operating table as desired to alleviate subsequent preparation steps through the application of Hair clips.

Shaving is dispensable. Mark the Facial incision line that virtually corresponds to the facelift incision. Begin with a submandibular extension and cause upward stop at the scalp at the upper pole of the ear.

Carefully plug fatty goes into the auditory canal. This prevents blood to flow in and coagulate before incision is made. Subcutaneous application of supra rein diluted in normal saline solution prevents excessive bleeding during dissection.

Vasoconstriction is visible shortly Thereafter. Dissection begins at The level of the SMA at the anterior border of the mosquito muscle. The dissection is continued sma.

In order to identify the facial artery and vein, Locate the temporal vessels that pass superficially over the posterior root of the matic process of the temporal bone, thereby covered by a thin fascia. Identify the facial vessels anterior to the border of the mosquito. The facial vein runs generally parallel to the anterior border of the mosquito muscle and upward towards the nose.

The facial artery causes anteriorly parallel to the body of the mandible and then curves upwards heading towards the oral commissure where it divides. In the course of the operation, the dissected facial vein and artery will be cut at the AAL ends. Continue dissection anteriorly just above the vessels to the commissure and upper lip.

A long exposure is necessary to allow for relocating the vessels towards the mosquito muscle for an easy microvascular anastomosis to the pedicle of the ulus muscle. Start positioning of the sutures for secure anchorage of the muscle at the or commissure. Use double armed polypropylene Sutures.

The Second suture is placed in the lower lip so that with traction it'll elevate the lower lip. This suture will serve as an unlocked pullout suture to relieve the traction from the flap within the first days after surgery. The third and fourth sutures are placed in the upper lip along the cause of the facial artery Indicated.

Here is the nasal level crease corresponding to the contralateral side and the desire vector of the muscle. Carefully check the placement of the four sutures by equally pulling all sutures. The presence of a harmonic, natural looking nasal level rease together with the absence of aversion or inversion of the skin indicates an acceptable result.

Once satisfied with the position of the suture cover, the temporal pullout suture for technical facilitation. The remaining sutures are locked carefully and needles are left in place. Identify the esoteric motor nerve that will innovate the transplant Here.

The application of a nerve stimulator is extremely helpful. Simultaneous with the facial dissection is the harvesting of the ulus. The grassly muscle is just medial and inferior to the adductor longus muscle.

In the upper part. Start with an upper medial thigh skin incision of about 10 centimeters in length at the anterior border of the ulus. Once the ulus is encountered, great care is taken to dissect the neurovascular pedicle without damage.

To locate the neurovascular pedicle, define a distance of approximately eight to 10 centimeters from the origin of the muscle to distally as this is the region of the hilum. Alternatively, identify the cutaneous perforator of the muscle that also originates from the hilum. Dissect the neurovascular pedicle between the adductor longus and the ulus muscle.

Hold the muscle bulks aside and trace the pedicle laterally under the adductor longus Muscle. Identify the motor nerve to the GREs, which is an anterior branch of the ator nerve. A nerve stimulator may thereby be applied.

Vascular connections to the adductor longus and brevis are coagulated or ligated and divided. Dissect the pedicle proximal to the branches to the adductor longus that is shown here, and apply a vascular loop to the very proximal end of the vascular pedicle. Define a segment to be harvested.

Indicated in blue is the level of the hilum where the pedicle enters the muscle. The distance from the oral commissure to the tragus plus two centimeters will give you the lengths of the muscle transplant. Dissect the muscle circumferentially for a distance of at least two centimeters in excess of the lengths Required.Indicated.

Here Are the adductor longus muscle, the ulus muscle, the vascular pedicle, And the mo nerve to the ulus. In Order to reduce the muscle bulk harvest about 30%of the circumference of the muscle. Usually an anterior and posterior muscle segment can be separated and not included with the pedicle.

The application of the nerve stimulation can thereby confirm the integrity of the separated segment. Isolate The muscle segment at its proximal and distal pole using the bipolar cautery. Divide the motor nerve to the GREs as Proximal as possible.

Afterwards, carefully divide the vessel's edge or near the origin using micro ligation clips and remove the muscle segment for ex vivo preparation of the muscle flap. Place the gressly segment on a separate operating table and thoroughly rinse the artery. In order to prevent intravascular thrombus formation.

Check the motor nerve for Integrity by application of the nerve stimulator, strong contraction of the muscle should be apparent.Indicated. Here are the motor nerve to the ulus muscle and the vascular pedicle that consists of two veins and a central artery. The distal end of the muscle will be inserted into the nasal level crease to prevent rupture, place non-resorbable mattress sutures, or alternatively a continuous suture along the distal end.

These sutures will provide stability of the Anchor sutures, suture the anchor Sutures that have been placed in the mouth through the muscle in an interlocking fashion so that they overlap the distally placed continuous suture of the muscle. The Very distal suture will not be fixed to the flap suture guided. The flap is cautiously inserted into the facial cavity.

Remove the needles afterwards and tie the sutures tightly in order to prevent secondary release. The Operating microscope is moved in and the clamped ends of the facial artery and vein are brought in an attic fat position for revascularization, adjust the pedicle of the GREs muscle. Usually the larger of the two veins is anes Tomos to the facial vein Under the operating microscope, Use diluted Heparin solution to flush the lumen of the vessels.

This will give you an idea of the quality of the intima. Start vascular repair with the artery and carefully bring the vessel ends together. Stress-free adjustment is indispensable to prevent thrombus formation.

Use interrupted nylon sutures to adjust the front side of the artery first and then turn the vessel lens 180 degrees to complete the anastomosis on the rear side. Make sure to not penetrate the front and backside with one suture by repeated inspection of the vessel lumen. Continue with the venous anastomosis that can be more demanding.

Venous vessel walls are much thinner and unlike the artery tend to collapse shortly after rinsing. Use interrupted nylon sutures for the venous anastomosis. Again, adjust the front side first and then turn the vessel lens 180 degrees to complete the anastomosis on the rear Side.

Upon release of the clamps, excellent blood flow should be seen throughout the entire extent of the transferred muscle. The application Of an implantable doppler probe for monitoring of the flap is recommended. Place the Doppler probe, which is attached to the silicone cuff against the draining vein.

Remove excessive material of the cuff. Carefully secure The cuff with nylon sutures. Connect the doppler probe to the control box to Check for correct placement of the probe.

Attention is then turned to the nerve repair. Adjust the length of the motor nerve to the G ulus to the minimum that is required. For tension-free coaptation.

Use high power magnification for coaptation with interrupted nylon sutures. In ep neural fashion. Consecutive application of fibrin glue will give additional stability to the palpation side.

Following the neuromuscular repairs, the muscle origin is secure to the temporal fascia and preor clear fascia. With mattress sutures. It is critical to provide sufficient tension with the muscle flap to produce a lateral movement of the oral commissure.

Divert the pullout suture At the temporal end of the wound and tie it with sufficient tension over a bolster in order to keep the tension of the muscle. For the first posta operative week, insert a drain to prevent postoperative hematoma formation that might constrain flap perfusion, requisition the cheek flap and close the wound with staple sutures in the hair bearing areas and a continuous nylon suture. Fix the doppler cord and apply antibiotic ointment to the wound.

A head bandage may then be applied Four months after surgery. The patient presented with an excellent symmetry address and deliberate smiling. Also, definition of the nasal level crease was satisfactory indicated.

Here is the comparison with the preoperative presentation. The patient showed a completely spontaneous smile postoperatively. The dynamic Reanimation of the smile in the facial paralysis patient is one of the most challenging areas of facial plastic surgery.

In patients of high age and with a lot of comorbidities, we usually prefer single stage procedures that deliver a reliable outcome such as the procedure presented herein. One major advantage over the two stage procedure with a cross face nerve graft is that the esoteric nerve provides a higher excellent load that will deliver a stronger oral commission excursion than the cross face nerve graft. One limitation though that needs to be discussed with the patient is that not in all patients, a spontaneous smile can be achieved approximately in two thirds of the patient.

A spontaneous smile can be achieved, whereas in one third of the patient, only a voluntary smile can be achieved. SS limitation needs to be discussed with the patient, and future research is needed to be able to predict the outcome more reliably and be able to pick the patients that will achieve a spontaneous smile. Particularly For this procedure.