Double innervation in free-flap surgery for long-standing facial paralysis

Department of Maxillo-Facial Surgery, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy.
Journal of Plastic Reconstructive & Aesthetic Surgery (Impact Factor: 1.47). 06/2012; 65(10):1343-9. DOI: 10.1016/j.bjps.2012.04.030
Source: PubMed

ABSTRACT One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patient's ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch.
Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve.
All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noah's five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes.
In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

1 Follower
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To date, nerve stumps have been dissected at the proximal side of the donor muscle for reinnervation of the muscle in free neurovascular muscle transfer. Herein, we examined the use of the distal thoracodorsal nerve, dissected from the muscle belly at the distal side of the latissimus dorsi muscle, for the reinnervation of muscle. The rat right latissimus dorsi muscle was employed as the model for our study. Twenty Wistar rats were used in this study. A rectangular muscle segment was dissected with the distal stump of dominant thoracodorsal nerve. After rotation of muscle, the distal nerve stump was sutured to a severed proximal recipient thoracodorsal nerve (n = 5). The degree of reinnervation through the distal nerve stump was compared with control groups that received proximal-to-proximal nerve sutures (n = 5), nerves that were not severed (n = 5), and severed nerves that were not sutured (n = 5) using electrophysiological, histological, and muscular volume assessments. Reinnervation of the distal nerve stump was confirmed by the contraction of the muscle following electrical stimulation and electromyography. Crossing of axons into motor endplates was confirmed by histology. Results of these assays were similar to that of the proximal nerve suture group. The volume of muscle in the distal nerve suture group was not significant different from that of the proximal nerve suture group (P = 0.63). It was demonstrated that the distal stump of the thoracodorsal nerve can be used to innervate segmented latissimus dorsi muscle. This novel procedure for the reinnervation of transplanted muscle deserves further investigations. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.
    Microsurgery 10/2013; 33(7). DOI:10.1002/micr.22164 · 2.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: IMPORTANCE Free muscle transfer innervated by a cross-facial nerve graft represents the criterion standard for smile reconstruction in facial paralysis. If primary reconstruction fails, a second muscle transfer is usually needed. Herein, we investigated the possibility of avoiding a second free muscle transfer by in situ coaptation of the gracilis muscle to the masseteric nerve. OBSERVATIONS We report a series of 3 failed free muscle transfers for facial reanimation among 21 free flap transfers performed for facial reanimation between March 2008 and August 2013. To salvage the muscle, we performed coaptation of the neural pedicle from the cross-facial nerve graft to the masseteric nerve. This method allows for leaving the fixation sutures of the muscle at the oral commissure in place. All patients showed muscle contraction after 3 months and a smile with open mouth after 6 months. No significant difference in the range of commissure excursion was observed between the healthy and operated sides. CONCLUSIONS AND RELEVANCE Recoaptation of the neural pedicle from the cross-facial nerve graft to the masseteric nerve, leaving the muscle transplant in place, is a suitable salvage procedure after unsuccessful reconstruction with a cross-facial nerve graft, avoiding a second free muscle transfer.
    07/2014; 16(5). DOI:10.1001/jamafacial.2014.163
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction The facial paralysis is a non-rare condition that has very disabling functional, morphological and psychological repercussions. The current gold standard in facial reanimation is revascularized re-innervated muscle transfers. Materials and methods In this paper, we report the results of a new method using the gracilis flap with a double innervation on the masseter motor nerve and the controlateral facial nerve via a sural graft in a single stage intervention, on a series of six patients. Results No failure was observed. The average delay of a voluntary contraction was 3.8 months, and 7.2 months for a spontaneous one. Three of the six patients had “excellent” results according to the Terzis and Noah classification, two were classified as “good” and one “average”. Discussion A choice is to be made between a method advocating a natural and spontaneous dynamicity (controlateral facial nerve stimulus) and a method focusing on the quality and quantity of contractions (ipsilateral trijeminal stimulus). In this new technique, we combine the two methods: a free gracilis transfer with a dual innervation on the healthy controlateral facial nerve via a sural graft, on one hand, and a second anastomosis on the ipsilateral masseter nerve, on the other hand. Conclusion This new proposed method seems to be, according to our results, a reliable technique rallying voluntary contraction and emotional smile.
    Annales de Chirurgie Plastique Esthétique 04/2013; 58(2):89–95. DOI:10.1016/j.anplas.2012.12.001 · 0.59 Impact Factor