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Use of the masseter motor nerve in facial animation with free muscle transfer
Abstract
Facial paralysis is either congenital or acquired, and of varying severity, which leads to an asymmetrical or absent facial expression. It is an important disability both from the aesthetic and functional points of view. Between 2003 and 2008, at the Department of Maxillofacial Surgery, University of Parma, Italy, 21 patients with facial paralysis had their faces reanimated with a gracilis transplant reinnervated by the masseter motor nerve. All free-muscle transplants survived the transfer, and no flap was lost. Facial symmetry at rest and while smiling was excellent or good in most cases, and we found an appreciable improvement in both speech and oral competence. We consider that the masseter motor nerve is a powerful and reliable donor nerve, which allows us to obtain movement of the commissure and upper lip similar to those of the normal site for degree and direction. There may be a role for the masseter motor nerve in innervation of patients with facial paralysis.
... Eighteen studies met eligibility criteria [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] (summarized in Table 1), which were published between 2008 and 2022, and 7 (38.9%) originated from Europe, 7 (38.9%) ...
Background: Facial palsy patients face significant challenges. Gracilis free flap transfer is a key procedure in facial reanimation. Objective: This study aims to analyze oral commissure excursion improvement after gracilis free flap transfer and the differences regarding donor nerve: cross-facial nerve graft (CFNG), hypoglossal or spinal accessory nerves, motor nerve to masseteric (MNTM), and most recently, double anastomosis using both the MNTM and CFNG. Methods: A systematic review and meta-analysis were conducted of studies reporting oral commissure excursion improvement after free gracilis muscle transfer. Pooled proportions were calculated using a random-effects model. Results: Eighteen studies, 453 patients, and 488 free gracilis flaps were included. The mean change in perioperative oral commissure excursion was 7.0 mm, for CFNG 7.2 mm, for MNTM 7.7, and for double anastomoses 5.5 mm. Conclusions: There is a significant improvement in oral commissure excursion after gracilis muscle-free flap. Unfortunately, we could not make definitive conclusions regarding the optimal choice of donor nerve.
... The masseteric nerve is a motor branch of the trigeminal nerve often used as a donor nerve in the treatment of facial paralysis 1 . Several anatomical studies have been reported about the detection of anatomical markers that can assist in the identification of the nerve [3][4][5] . ...
The masseteric nerve is often used as a donor nerve in the treatment of facial paralysis. Even if several anatomical studies described landmarks for its identification, their main disadvantages are the anatomical variability and the changes due to surgery.
Sixteen dissections were performed on cadaveric specimens. The masseteric muscle (MM), the zygomatic arch (ZA), the masseteric nerve (MN) and the zygomatic branch of the facial nerve (ZB) were identified and their relationships were measured.
The relationships between MN and ZB resulted to be constant, with MN intersecting ZB at a depth of 0,78 cm in the muscle, 1,6 cm below ZA and 0,8 cm from the posterior border of MM.
The measures obtained demonstrated as the main zygomatic branch of the facial nerve can be a suitable landmark for the identification of the masseteric nerve, with no variations due to the surgical procedure or patient characteristics.
... The program included bite motion exercises as well as mental tasks associated with the bite. It is likely that during this period of recovery, the rehabilitation exercises encourage and activate connections between the facial nerve and trigeminal nerve centers [21]. The age of the patient at operation did not influence the result from an aesthetic or functional point of view. ...
... Among candidates, the MN is important and so is the anterior branch of the obturator nerve (ON) that innervates the transferred gracilis muscle. Moreover, for many surgeons, this is the ideal muscle to use for dynamic restoration of FP (Zuker et al., 2000;Woollard et al., 2010;Fattah et al., 2011;Bianchi et al., 2012;Fattah et al., 2012). ...
The masseteric nerve (MN) and the anterior branch of the obturator nerve (ON) that innervate the transferred gracilis muscle have proved highly efficient for reanimating paralyzed facial muscles when muscle transfer is required. Previous researchers have published the total axonal load for myelinated fibers in both nerves. However, the real motor axonal load has not been established. We performed the study on 20 MN and 13 ON. The segments of the MN and the ON were embedded in paraffin, sectioned at 10 μm, and stained following a standard immunohistochemical procedure using anti‐choline acetyltransferase to visualize the motor fibers. The MN has a higher axonal load than the ON. There were statistically significant differences between the axonal load of the proximal segment of the MN and the ON. These findings confirm that end‐to‐end anastomoses between the MN and the ON should preferably use the proximal segment. However, MN neurotomy should ideally be performed between the proximal and distal segments, preserving innervation to the deep fascicles. Our results show that the MN is ideal as a donor motor nerve for reinnervating transplanted muscle for dynamic reanimation of the paralyzed face. The neurotomy should ideally be performed between the first and second collateral branches of the MN. Clin. Anat. 32:612–617, 2019. © 2019 Wiley Periodicals, Inc.
... The masseteric nerve provides powerful and synergistic reinnervation capability. 1,4,9 The nerve location is closed to facial nerve and the transplanted muscle used for smile reanimation. It is expendable since there are other muscles that compensate for the denervation of the masseteric nerve. ...
Background:
The use of the masseteric nerve has been escalated as a donor nerve for facial reanimation in facial palsy patient (Wang et al., 2014; Manktelow et al., 2006; Klebuc, 2011; Bianchi et al., 2012; Zuker et al., 2000; Bae et al., 2006; Terzis, Konofaos, 2013; Terzis, Olivares, 2009; Bianchi et al., 2014). Previous studies had been done in Euro-Caucasian cadavers (Kaya et al., 2014). However, difference in anatomical details does exist between Asian and Euro-Caucasian population (Tzou et al., 2005; Farkas et al., 2005). In this study, we have conducted a detailed anatomical study of masseteric nerve in adult Thai cadavers which might elaborate better details of masseteric nerve anatomy in Asian population.
Methods:
Twenty eight hemifaces from 14 adult Thai non-formaldehyde preserved soft cadavers were used in this study. The anatomical pathway of the masseteric nerve was defined relating to four surgical landmarks which are auricular tragus, zygomatic arch, posterior border of the temporomandibular joint, and alar base.
Results:
The suitable starting area for the masseteric nerve dissection is 3.7 ± 0.4 cm anterior to the auricular tragus at the level of 0.8 ± 0.2 cm inferior to the zygomatic arch. The nerve was found 1.1 ± 0.2 cm deep to the superficial surface of the masseteric fascia and 1.7 ± 0.2 cm anterior to the posterior border of the temporomandibular joint. The point where the nerve giving off its first branch as it courses distally is 7.3 ± 0.7 cm from the ipsilateral alar base. The mean diameter of this nerve is 1.59 ± 0.42 mm.
Conclusion:
The anatomy of the masseteric nerve during its course in the muscle is consistent. In our study, the details of its anatomy is slightly different from the previous works which were performed in the Euro-Caucasian cadavers.
... Other surgical teams, such as those of Manktelow 7 and Bianchi, 8 have used a combination of gracilis muscle and anastomosis to the masseteric nerve. These two authors studied 27 and 21 patients, respectively. ...
Congenital facial paralysis (FP) is present from birth. It can produce major esthetic and functional disorders. It can be from two different etiologies: developmental and acquired. There is no curative treatment for congenital FP and the aim for the plastic surgeon is to restore a smile as symmetrical and as dynamic as possible. For this, two opposite techniques can be used: muscular free flaps and locoregional flaps whose lengthening temporalis myoplasty.
We report our series of 34 congenital FP patients who were operated by lengthening temporalis myoplasty (LTM). We divided the patients into three categories: acquired FP (11 cases), isolated developmental FP (13 cases), and syndromic developmental FP (10 cases). The evaluation of the smile is based on the quality of the commissural course compared to the healthy side and the spontaneity of it.
In the acquired FP group, 100% obtained a spontaneous smile with a postoperative delay of 9.5 months, 12 of the 13 cases of isolated developmental FP (92.7%) after 7.3 months postoperatively, and finally, in the 10 cases of syndromic FP, nine (90%) had a spontaneous smile after 9.7 months.
Muscular free flaps continue to be the gold standard for the reanimation of smile on the FP. To our knowledge, no articles comparing smile restoration using free flap and smile restoration using LTM exist. A comparison of the success rates from different studies shows that both these techniques yield good results and can be used for smile restoration in FP. This technique is faster and easier than a free flap and has a same result, which is why we consider this technique as a reference on smile reanimation in FP.
Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.
... Nosotros, que a día de hoy no disponemos de dichos recursos, proponemos un método fácil, sencillo, reproducible, económico y rápido, que nos ha permitido objetivar de manera clara nuestros resultados de movimiento mediante el VR. Si bien no se puede establecer una comparativa clara, vemos concordancia con la series previas como Gousheh y Arasteh 8 quienes reportan un movimiento de la comisura labial de 1,5-2 cm en el 76% de sus pacientes, Manktelow et al. 17 entre 1,3 cm ± 4,7 mm, Bianchi et al. 12,18 aproximadamente 16 mm, Frey et al. 11 un rango de 14 ± 9 mm, Schliephake et al. 10 encuentran que el colgajo alcanza el 65% del movimiento del lado no parético y Hadlock et al. 13 quienes informan de un movimiento entre 8,8 ± 5 mm en una serie de población pediátrica. Así mismo vemos una clara similitud en el inicio de movimiento muscular de nuestra serie con la de otros autores, situándose globalmente entre los 4 y 6 meses 8,10---13,17 . ...
Introduction and objectives Micro-neurovascular free muscle flap transfer is currently the procedure of choice for long-standing facial paralysis. We present a case series of patients treated with gracilis muscle free flap with motor innervation by the masseteric nerve. We discuss the surgical technique and quantify the movement granted by the muscle, the improvement in quality of life and aesthetic results.
Materials and methods
We report ten patients with unilateral facial paralysis who underwent free gracilis muscle flap, between the years 2010 and 2012 in two tertiary hospitals.
Results
It is not reported any failure of the microsuture with survival of all flaps. The muscle movement was quantified by vectors at rest and contraction with an average of 1.7 cm that initiated around the fourth month after surgery. Patients also reported a significant improvement in symmetry at rest as well as oral and ocular competition.
Conclusion
As currently presented in literature, microvascular free flaps are the technique of choice for facial reanimation. In our experience, we believe that gracilis muscle flap innervated by the masseteric nerve is a reliable and secure technique that provides adequate functional and aesthetic results.
... Nosotros, que a día de hoy no disponemos de dichos recursos, proponemos un método fácil, sencillo, reproducible, económico y rápido, que nos ha permitido objetivar de manera clara nuestros resultados de movimiento mediante el VR. Si bien no se puede establecer una comparativa clara, vemos concordancia con la series previas como Gousheh y Arasteh 8 quienes reportan un movimiento de la comisura labial de 1,5-2 cm en el 76% de sus pacientes, Manktelow et al. 17 entre 1,3 cm ± 4,7 mm, Bianchi et al. 12,18 aproximadamente 16 mm, Frey et al. 11 un rango de 14 ± 9 mm, Schliephake et al. 10 encuentran que el colgajo alcanza el 65% del movimiento del lado no parético y Hadlock et al. 13 quienes informan de un movimiento entre 8,8 ± 5 mm en una serie de población pediátrica. Así mismo vemos una clara similitud en el inicio de movimiento muscular de nuestra serie con la de otros autores, situándose globalmente entre los 4 y 6 meses 8,10---13,17 . ...
Introduction and objectives Micro-neurovascular free muscle flap transfer is currently the procedure of choice for long-standing facial paralysis. We present a case series of patients treated with gracilis muscle free flap with motor innervation by the masseteric nerve. We discuss the surgical technique and quantify the movement granted by the muscle, the improvement in quality of life and aesthetic results.
We report ten patients with unilateral facial paralysis who underwent free gracilis muscle flap, between the years 2010 and 2012 in two tertiary hospitals.
It is not reported any failure of the microsuture with survival of all flaps. The muscle movement was quantified by vectors at rest and contraction with an average of 1.7cm that initiated around the fourth month after surgery. Patients also reported a significant improvement in symmetry at rest as well as oral and ocular competition.
As currently presented in literature, microvascular free flaps are the technique of choice for facial reanimation. In our experience, we believe that gracilis muscle flap innervated by the masseteric nerve is a reliable and secure technique that provides adequate functional and aesthetic results.
Background:
Surgical treatment of long-term facial palsy has been reported using various techniques, including functioning muscle-free flaps. The free gracilis muscle flap is the most common because of its many advantages. Our study presents a modified way of shaping the gracilis muscle for transfer to the face to improve the restoration of natural smiles.
Methods:
This retrospective study assessed 5 patients who received the classical technique and 43 patients who received modified, U-shaped, free gracilis muscle flap for smile reanimation from 2013 to 2018. The surgery is single-staged. Preoperative and postoperative photos were taken. Functional outcomes were evaluated using the Terzis and Noah score and the Chuang smile excursion score.
Results:
The mean patient age at the time of operation was 31 years. The length of gracilis muscle harvested was 12-13 cm. Of the 43 patients who received U-shaped design-free gracilis muscle, results were excellent for 15 (34.9%), good for 20 (46.5%), and fair for 8 (18.6%) followed the Terzis and Noah score. The Chuang smile excursion score was 2 for 16.3%, 3 for 46.5%, and 4 for 37.2% of 43 patients. Of the 5 patients who underwent classical technique, there are no excellent results based on the Terzis and Noah score. The Chuang smile excursion score was only 1 and 2.
Conclusions:
The U-shaped modification to the gracilis muscle-free flap is a simple and effective technique to help restore a symmetrical and natural smile in patients with facial palsy.
Background: Although a dual-innervation technique has emerged in single-stage functional latissimus dorsi (LD) muscle transfer for smile reanimation, its benefits over conventional techniques have not been elucidated. Objective: To compare outcomes of dual-innervation technique with those of single-innervation. Methods: Patients with facial palsy treated with single-stage functional LD muscle transfer were identified, and categorized into two groups: single and dual innervation. Outcomes were assessed using clinical examination based on the Terzis grading system and using automated software (Emotrics). Results: Fifty-nine patients (mean age 37.6 years; male/female 30/29) were analyzed, including 40 in single (35.1 years, 23/17) and 19 in dual-innervation group (43.0 years, 7/12), with a median follow-up of 34 months (range, 9-165) (single: 41.5, 12-165, dual: 23.0, 9-41). Tumor-related paralysis was the most common etiology in both groups (overall: 45.8%, single: 40.0%, dual: 57.9%). The dual group had a significantly higher rate of cases with Terzis grade IV or V postoperatively. In the Emotrics-based evaluation, the dual group exhibited significantly enhanced improvements in smile excursion in the dynamic state compared with the single. The degree of improvement in the resting state did not differ between groups. Conclusion: The dual-innervation technique might provide promising results in achieving enhanced smile excursion.
Background
The choice of neurotization source for gracilis neuromuscular transplant is a key point in the treatment of unilateral long-standing paralysis. To combine the advantages of different donor nerves and overcome their disadvantages, mixed neurotization sources have been described with encouraging results. The authors present a preliminary report of a novel technique, the “supercharged” cross-graft, a two-step technique consisting of a double powered cross nerve graft provided by a zygomatic branch of the healthy facial nerve and the masseter nerve of the healthy side.
Patients and methods
From January 2015 to December 2019 eight patients, aged between 19 and 61 years old (mean age at surgery 33.62) suffering unilateral established paralysis (congenital or acquired, >24 months) underwent gracilis reinnervation with the supercharged cross grafting technique. Subjects underwent a two-step surgical rehabilitation: in the first operation sural nerve was harvested and used as cross-graft cooptated by healthy side facial nerve branch and masseteric nerve. During second procedure gracilis neuromuscular transplant was performed reinnervarting the muscle with the cross-graft. Patients were evaluated using Emotrics software, which allowed for automated facial measurements on post-operative pictures taken at the last follow-up. The results of the different poses were compared to assess the contribution to smile excursion by the masseter and facial nerve, together and separately. Finally, we analyzed spontaneous smile to assess whether masseteric contribution is used in daily life.
Results
No major or minor complications occurred. Follow-up time ranged from 12 to 41 months, with a mean of 22.75 months. A good commissure excursion (mean 33.84 mm) was obtained during smile with no teeth clenching (without masseter activation), as well as during teeth clenching without smiling (activation of gracilis only – mean 32.55). When smiling and biting simultaneously the excursion was greater than the single two components (mean 35.91). In spontaneous smile, commissure excursion was higher (mean 34.23) than that provided by only the facial nerve (smile only) in most patients.
Conclusions
This novel technique of mixed neurotization for gracilis transplant shows consistent results with powerful contraction and good smile coordination. It also allows us to extend the indications for mixed neurotization techniques.
Purpose: Oral competence refers to the maintenance of lip closure with sufficient strength to prevent anterior spillage of saliva, food and fluid, and to clearly articulate labial sounds. Despite facial nerve paralysis having an impact on eating, drinking and communicating, little research has been done in this area.
Method: Studies examining oral competence associated with a diagnosis of facial nerve paralysis were considered using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement checklists and evaluated for their risk of bias using the RevMan Risk of Bias Tool.
Result: 44 articles were examined. There was an over-representation of case-series and cohort studies. All studies carried a high risk of bias due to lack of (a) validated outcome measures, (b) comparison group and (c) blinding or randomised assessors and participants. Studies primarily examined facial nerve intervention for the purpose of restoring smiling or facial aesthetics rather than oral competence.
Conclusion: Whilst oral competence is often compromised after a facial nerve paralysis, it is inconsistently measured, managed and described. Further studies are required to examine the (a) incidence, (b) severity and (c) impact on quality of life relating to oral incompetence using validated measures at consistent time intervals.
Background:
Lengthening temporalis myoplasty (LTM) and cross-face nerve graft with free gracilis muscle transfer (CFNG-FGMT) are the 2 most common procedures used to restore dynamic facial animation and improve facial symmetry. There has not been direct comparison or consensus. Here, the authors compare our experience with respect to muscle activity, symmetry, and excursion.
Methods:
A retrospective review was performed of patients with facial palsy who had CFNG-FGMT or LTM from 2008 to 2016 at a single institution. Postoperative surface EMG was recorded at maximum open smile. Normal and paralyzed sides of the face were analyzed with Facial Assessment by Computer Evaluation software. Commissure excursion and symmetry was assessed.
Results:
Six patients with LTM and 10 with CFNG-FGMT met inclusion criteria. Muscle activity was 1st identified in LTM patients after 3 months (47.42 mV, P < 0.001) and CFNG-FGMT patients after 3 months (28.30 mV, P < 0.001) compared to immediate postoperative period. Relative to preoperative excursion, there was significant increase of 3.33 mm in commissure excursion seen at the 0 to 3 month period for LTM patients (P = 0.04). Commisure excursion for CFNG-FGMT was seen later, in the 3- to 6-month postoperative period (4.01, P = 0.024). During smile, CFNG-FGMT patients had better symmetry than unilateral LTM patients. In bilateral LTM patients, there was no significant change in symmetry.
Conclusion:
Dynamic facial animation improved in both surgical groups. The LTM demonstrates a faster rate of muscle recruitment compared to CFNG-FGMT. After 3 months, both LTM and CFNG-FGMT groups had comparable excursions. A decision-making algorithm is presented.
Facial nerve paralysis is a relatively common condition of the seventh cranial nerve affecting the population, causing esthetic, functional and psychological problems. With the advancement of technology many surgical techniques have been developed for treating patients with facial palsy. This article reviews about the surgical techniques in the management of patients with facial palsy for smile reconstruction. Also, it discusses about the etiology and clinical features of facial palsy, anatomy of smile, goals of reanimation, choosing the appropriate surgical option based on patient's condition and its outcomes.
Aim:
In patient with facial paralysis, facial appearance and muscular ability are impaired, and the psychological integrity is affected. Botulinum toxin A may be used to improve facial symmetry in patients suffering with facial palsy reducing the progressive contralateral hyperkinesis and facial asymmetry after primary surgery for facial paralysis.
Material of study:
Six patients, whom have been suffering unilateral facial palsy with an House-Brackmann score grade from III to VI, were included in this study for a residual facial asymmetry and contralateral hyperkinesis after previous facial reanimation. They were treated with 50 units of botulinum toxin type A injected in muscles of the unaffected side of face to improve muscular ability and facial symmetry.
Results:
This study demonstrated reduction in contralateral hyperkinesis and facial asymmetry that lasted approximately 120 days. All patients reported satisfactory results with the treatment.
Comments:
Botulinum toxin type A injections improved facial asymmetry and muscular function in all patients.
Discussion and comments:
Botulinum toxin type A injections may be an indispensable technique as a nonsurgical treatment or as a complementary measure in postsurgical treatments and should be certainly considered for temporary or permanent asymmetries in patients who suffer from facial palsy.
Conclusions:
Contralateral botulinum toxin type A injection was useful in reducing muscular hyperkinesis in patients with residual facial asymmetry after primary surgery for facial palsy, improving aesthetic and functional facial recovery with not widely common adverse events.
Key words:
Botulinum toxin type A, Contralateral muscular hyperkinesis, Facial palsy.
Background Multiple studies have detailed promising smile restoration following gracilis free muscle transfer for facial reanimation but information detailing the potential complications is lacking. The aim of this study is to systematically review the literature to evaluate the reported complication rate associated with this procedure. We also aim to determine the most common occurring complications. Methods The PubMed, Embase, and Web of Science databases were queried with multiple search strategies for published articles between January 1950 and February 2013 that detailed gracilis free muscle transfer for facial reanimation. Title, abstract, and full text review was performed. Complications were defined as any reported, identifiable adverse outcome that required an alteration in treatment for correction. Results The literature search yielded 62 studies of gracilis free muscle transfer for facial reanimation. Overall, 36 articles (58%) reported whether or not a complication had occurred. The overall complication rate based on pooled proportions was 9.6% and the most commonly occurring complications were postoperative hematoma (3.6%) and infection (3.5%). Conclusions Our data suggests that complications after gracilis free muscle transfer for facial reanimation may be underreported and this complex procedure may in fact be associated with significant adverse outcomes as high as 9.6%.
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Facial palsy is a relatively common condition, from which most cases recover spontaneously. However, each year, there are 127,000 new cases of irreversible facial paralysis. This condition causes aesthetic, functional and psychologically devastating effects in the patients who suffer it. Various reconstructive techniques have been described, but there is no consensus regarding their indication. While these techniques provide results that are not perfect, many of them give a very good aesthetic and functional result, promoting the psychological, social and labour reintegration of these patients. The aim of this article is to describe the indications for which each technique is used, their results and the ideal time when each one should be applied.
Copyright © 2014 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.
Purpose of review:
To review the growing literature on the use of the masseteric nerve in facial reanimation, from direct neurotization, to 'baby-sitter' techniques, to its use in powering neuromuscular free tissue transfer. We focus on the indications for the different uses based on the timing of the facial paralysis and other patient factors.
Recent findings:
The use of the masseteric nerve in facial reanimation is gaining widespread acceptance for use in an expanding number of clinical scenarios. Surgeon's experience and preference as well as patient selection are very important factors in choosing the appropriate surgical use of this nerve.
Summary:
Facial reanimation surgery is a difficult challenge for any reconstructive surgeon. The use of the masseteric nerve branch to reanimate the face is gaining popularity. Its versatility, anatomical location, relative ease of dissection, low morbidity, and high potential for motor neural input make it an excellent option for many different reanimating techniques. The appropriate nerve use should be based on the type of facial paralysis, its timing, and patient factors such as age, prognosis, and desires. Understanding the benefits and potential drawbacks of utilizing this nerve represents an essential piece of knowledge for the facial reanimation surgeon.
The masseteric nerve has many advantages including low morbidity, its proximity to the facial nerve, the strong motor impulse, its reliability, and the fast reinnervation that is achievable in most patients. Reinnervation of a neuromuscular transplant is the main indication for its use, but it has been used for the treatment of recent facial palsies with satisfactory results. We have retrospectively evaluated 60 patients who had facial animation procedures using the masseteric nerve during the last 10 years. The patients included those with recent, and established or congenital, unilateral and bilateral palsies. The masseteric nerve was used for coaptation of the facial nerve either alone or in association with crossfacial nerve grafting, or for the reinnervation of gracilis neuromuscular transplants. Reinnervation was successful in all cases, the mean (range) time being 4 (2-5) months for facial nerve coaptation and 4 (3-7) months for neuromuscular transplants. Cosmesis was evaluated (moderate, n=10, good, n=30, and excellent, n=20) as was functional outcome (no case of impairment of masticatory function, all patients able to smile, and achievement of a smile independent from biting). The masseteric nerve has many uses, including in both recent, and established or congenital, cases. In some conditions it is the first line of treatment. The combination of combined techniques gives excellent results in unilateral palsies and should therefore be considered a valid option.
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.
Background:
The use of facial cross-grafting in acquired recent unilateral facial palsy provides spontaneity and emotional activation. Masseteric nerve for facial animation has mainly been described for reinnervation of neuromuscular transplants, babysitter procedures, or direct facial nerve cooptation. The simultaneous use in a single procedure of cross-facial nerve grafting and masseteric cooptation has not been described.
Methods:
Eight patients underwent facial animation using single stage cross-facial nerve grafting and masseteric nerve cooptation. The mean duration of facial palsy was 10.2 months (range, 1-23 months).
Results:
Voluntary contraction in response to masseteric nerve activation was observed after 2 to 4 months. All patients underwent postoperative rehabilitation and spontaneous contraction was achieved in 7 to 13 months postoperatively. Cosmetic outcomes were evaluated as moderate in 1 patient, good in 5 patients, and excellent in the remaining 2 patients.
Conclusion:
This new technique could provide good results with fast, reliable, and powerful reinnervation, spontaneity, and low morbidity.
The patient with facial paralysis presents a daunting challenge to the reconstructive surgeon. A thorough evaluation is key in directing the surgeon to the appropriate treatment methods. Aggressive and immediate exploration with primary repair of the facial nerve continues to be the standard of care for traumatic transection of the facial nerve. Secondary repair using dynamic techniques is preferred over static procedures, because the outcomes have proved to be superior. However, patients should be counseled that facial movement and symmetry are difficult to mimic and none of the procedures described is able to restore all of the complex vectors and overall balance of facial movement and expression.
Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. The symptoms depend on which branch of the nerve has been damaged and the severity of the injury. The purpose of this paper is to review currently available treatments for dynamic reanimation of a damaged facial nerve, and the goals are a symmetrical and coordinated smile. Careful selection of patients and use of the appropriate surgical technique can have excellent results. © 2013 The British Association of Oral and Maxillofacial Surgeons.
The plyzed face represents a significant challenge to the reconstructive surgeon. The ultimate goal of reconstruction should be restoration of symmetry in movement as well as in repose. Immediate nerve grafting and early hypoglassal transfer provide the best methods of reinnervating existing facial muscles and maintaining tone for further reconstruction. New techniques of cross-facial nerve grafting combined with microneurovascular muscle transfer make symmetric movement a possibility even in cases in which plysis has been present for some time.
: Mobius syndrome is classically characterized by bilateral facial nerve and abducens nerve paralysis in combination with limb defects. In the past 110 years, physicians diagnosed children as having the syndrome on the basis of heterogeneity of symptoms and used the term "Mobius syndrome" or "Mobius-like syndrome" for patients with multiple cranial nerve involvement. The cause and the exact pathogenesis of the syndrome still elude understanding. Genetic work-ups, radiological findings, and data from autopsies differ in their approaches and their findings of the basic causes of Mobius syndrome. In the international literature, about 301 case reports are found scattered through the past century. The appearance of the facial deformity is easy to recognize, because the Mobius patient is impaired in his or her ability to communicate nonverbally. Despite ophthalmologic problems, it is the search for a smile that brings these patients to the reconstructive surgeon. Over the past 100 years, surgical efforts attempted to improve the mask-like appearance by static and dynamic procedures, usually local muscle transpositions. Today, combinations of microsurgical procedures and aesthetic techniques are being used to restore some movement to the expressionless face of these patients by nerve and muscle transplantation. This article discusses the heterogeneity of Mobius syndrome, advocates a new classification system, presents the clinical findings of 42 patients who were seen and examined in consultation, and discusses the surgical management of 20 patients who underwent dynamic restorative microsurgery. Exemplary cases illustrating the preoperative work-up regimen and possible outcomes are reported. (Plast. Reconstr. Surg. 111: 40, 2003.) (C)2003American Society of Plastic Surgeons
Facial paralysis is a congenital or acquired disorder of varying severity leading to an asymmetric or absent facial expression. It represents an important debilitation from both esthetic and functional points of view. In this article we report our experience with patients treated with gracilis muscle transplantation innervated by the motor nerve to the masseter muscle. We discuss the surgical technique and the functional and esthetic results and evaluate the effectiveness of this donor nerve in providing adequate innervation to the muscle transfer for lower facial reanimation.
Fifteen patients with unilateral facial paralysis were seen and surgically treated at the Department of Maxillofacial Surgery, University of Parma, Parma, Italy, between 2003 and 2007. In this study we report on 8 cases treated with gracilis muscle transfer reinnervated by the motor nerve to the masseter muscle.
In this series all free-muscle transplantations survived transfer, and no flap was lost. Facial symmetry at rest and while smiling was excellent or good in all patients, and we observed a significant improvement in speech and oral competence. With practice, the majority of patients developed the ability to smile spontaneously and without jaw movement.
We consider the masseter motor nerve a powerful and reliable donor nerve, allowing us to obtain a commissure and upper lip movement similar to those of the normal site for amount and direction. This is why we think that there may be a larger role for the masseter motor nerve for innervation of patients with unilateral facial paralysis who would otherwise have been considered candidates for cross-facial nerve graft innervation of the muscle transfer.
Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterized predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. The paralysis of the VI and VII cranial nerves leads to a lack of function in the muscles they supply. Facial paralysis often causes bilabial incompetence with speech difficulties, oral incompetence, problems with eating and drinking, including pocketing of food in the cheek and dribbling, as well as severe drooling.
In this study, we report on pediatric patients with Moebius and Moebius-like syndromes seen and treated surgically from 2003 to September 2007 at the Operative Unit of Maxillofacial Surgery, Head and Neck Department, University of Parma, Italy.
Twelve patients underwent microsurgical reconstruction for restoration of facial movement. The contralateral facial nerve was used as a motor donor nerve in 4 procedures, the motor nerve to the masseter muscle was used in 8 patients, and the gracilis muscle was used in all operations, with a total of 17 free-muscle transplantations. All free-muscle transplantations survived transfer, and no flap was lost. We observed a significant improvement in drooling, drinking, speech, and facial animation with a high degree of patient satisfaction.
The gracilis muscle free transfer is a surgical procedure well tolerated by the young patients and well accepted by their families. We consider it a safe and reliable technique for facial reanimation with good aesthetical and functional results in children with Moebius and Moebius-like syndromes.
The cross-facial nerve grafting/free-muscle transfer strategy for smile restoration is superior to static reconstruction or regional muscle transposition. The purpose of this study was to evaluate the long-term outcomes of this technique in adult patients.
Eighty-one adult patients received a free-muscle transfer for midface reanimation in the authors' center. Of this group, the authors identified 24 cases with follow-up of 5 years or longer. Smile symmetry and function were evaluated at three points: preoperatively, early postoperatively, and at long-term follow-up. To better evaluate the effect of time, patients were divided into groups according to the length of follow-up: group A, 5 to 6 years; group B, 7 to 10 years; group C, 11 to 15 years; and group D, more than 15 years. Four independent observers rated each patient's smile using a five-category scale ranging from poor to excellent. Panelists were asked to comment on whether the patient's smile weakened over time.
All patients obtained higher scores at 2 years from free-muscle transfer in comparison with their preoperative rates (p < 0.0001). Late outcomes demonstrated that muscle regeneration continues beyond the initial 2 years, with a further increase of the scores and motor units on electromyography at the late follow-up (p < 0.0001, p = 0.0313). No significance was found when comparing both variables among the four groups, indicating that time does not have a differential effect on muscle function. In 80 percent of the evaluations, the four observers agreed on maintained smile symmetry over time.
Cross-facial nerve grafting/free-muscle transfer is an effective technique for smile restoration in late facial paralysis. These data indicate maintenance of effective muscle function and progressive improvement with time.
Evaluation of long-term outcomes of free-muscle transfer for smile restoration is overdue. Arguments for and against free-muscle transplantation in children are considered, and the debate on the influence of the growing skeleton on muscle function is revisited. This study evaluated the fate of free-muscle transfer over long follow-up periods in pediatric patients.
Thirty-two children with follow-up of 5 years or longer who received a free-muscle transfer for smile restoration were reviewed. To better analyze the effect of time, patients were classified into groups based on the length of follow-up: group A, 5 to 6 years; group B, 7 to 10 years; group C, 11 to 15 years; and group D, more than 15 years. Patients were videotaped at three stages: preoperatively, 2 years after free-muscle transfer, and at the last follow-up visit. Four independent observers graded patients' videotapes using a five-category scale ranging from poor to excellent. Panelists were asked to comment on any noticeable craniofacial disharmony with growth.
All patients exhibited improved function and symmetry at 2 years after free-muscle transfer (averaged scores, p < 0.0001). A positive effect of time was seen in the long-term evaluation; observers' scores (p < 0.0001) and motor units on electromyography (p = 0.001) showed further improvement. No significance was found when comparing measured outcomes among the four follow-up groups, indicating that despite the growing skeleton, muscle function was maintained over time.
These clinical data support the use of free-muscle transfer for smile restoration in children. The transplanted muscle appears to grow harmoniously with the craniofacial skeleton, and muscle function and aesthetic outcomes improved over time.
The challenge of reconstruction in the paralyzed face is to provide symmetry both at rest and in active expression. Although functional considerations must take precedence, the patient with unilateral facial palsy faces social stigmata that are exceptionally difficult. The best reconstructions in late paralyses fall far short of natural facial expression. Conley, one of the pioneers in facial nerve rehabilitation, reflected the frustration of dealing with limited techniques: It has been assumed by many surgeons that involuntary emotional communication is through the facial nerve, but this has never been substantiated. Indeed, emotional expression may be beyond our concept of a mere physical tract. It certainly has never been totally restored by any surgical technique that attempts to rehabilitate the face. When injury to the facial nerve is established, early nerve grafting on the ipsilateral side is the best treatment. In acoustic neuroma and other intracranial operations, the only real opportunity for grafting or repair is at the time of the procedure. If the nature of the injury is uncertain, a period of 12 months is allowed to elapse before consideration of intervention, which should be started if there is no return of function at that point. Electromyography may be of assistance in assessing minimal early return; if any early return is noted, further waiting is indicated. If there is no return at 1 year, cranial nerve XII to VII crossover will preserve facial muscle tone and permit a more measured decision-making approach. Patients with multiple cranial nerves involved may be candidates for a partial hypoglossal transfer using a nerve graft, to attempt to preserve swallowing. In selected cases, cross-facial nerve grafting to the preserved facial muscles will give excellent results and obviate the need for local or distant muscle transfers. When treating established paralysis of long duration, cross-facial nerve grafting with microneurovascular muscle transfer is the best option for symmetrical movement of the face. Temporalis and masseter muscle transfers should be reserved for the patient with intercurrent medical disease or the patient who refuses additional operations or operative sites. Static slings and other related procedures should be considered adjunctive but not primary treatment in the vast majority of cases. Although there are limitations in each of the procedures described, close cooperation between the otolaryngologist, the neurosurgeon, and the plastic surgeon can provide many patients with satisfactory rehabilitation from facial paralysis.
Facial paralysis in children is a complex condition. It may involve functional issues and always involves esthetic issues. Significant psychosocial problems may arise and family support systems are often necessary. In this brief article the etiology of facial paralysis in children is discussed and the common types described. The philosophical approach to the child and his or her family is emphasized. The timing of surgical intervention is addressed as well as a brief outline of the surgical techniques of cross-face nerve grafting and muscle transplantation. Although these latter procedures have added enormously to our capabilities to deal with this condition, further progress will be necessary through research and clinical ingenuity if we are to restore these children to normality.
This paper reports our experience in facial reanimation using free innervated muscle transfer in 69 patients with long-term facial palsy. The majority of patients were treated in two stages with cross-facial nerve graft as the first stage and microvascular muscle transfer at the second stage. The gracilis muscle was used in 62 patients. A system of grading results has been utilized in the long-term evaluation. The overall final result was excellent or good in 51 percent of 47 patients who were available for follow-up. Although the results are not completely satisfactory, they justify the use of this approach to a difficult clinical problem. The results are improving as technical modifications to the procedure have evolved. The gracilis muscle is a reliable free transfer with internal anatomy conductive to use for reanimation of the paralyzed face. This type of transfer, in our experience, has proved superior to nonmicrosurgical methods for treatment of complete and severe incomplete facial palsy. The seventh cranial nerve is used in the innervation of the transferred muscle, the ipsilateral being preferable if available. The authors believe that use of the same cranial nerve is superior to methods that involve other cranial nerves, where spontaneity is often not achieved.
Free-muscle transplantation is the treatment of choice for long-standing facial paralysis. It enables the reconstructive surgeon to restore facial movement and some emotional animation. Despite all technical innovations and 20 years of experience with free-muscle transplantation, the aesthetic and functional outcomes of the surgery are still unpredictable. The present report reviews 100 free-muscle transplantations to the face by a single surgeon and analyzes various preoperative, intraoperative, and postoperative factors in relation to the functional recovery of the muscle transplants. These factors were demographic variables such as age, gender, and etiology as well as intraoperative variables such as choice of muscles, number of nerve coaptations, and ischemia time of the muscle. Additionally, four independent raters not involved in the care of these patients rated standardized preoperative and postoperative videos and judged the functional and aesthetic outcomes. From 1981 to 1993, 93 patients with facial paralysis underwent free-muscle transplantation. A total of 100 muscles were transplanted, since 7 patients received two muscle transplants. There were 33 male and 60 female patients ranging in age from 3 to 57 years, with an average of 22.2 +/- 14.9 years. The gracilis muscle was used in 63 cases of free-muscle transplantation, while the pectoralis minor was used in 34 cases. In 2 patients a segment of the rectus abdominis was transferred, and in 1 patient a small segment of the latissimus dorsi was transferred. In 89 patients the onset of muscle function was reported. The range was from 6 to 48 weeks postoperatively. The average was 21.6 +/- 9.14 weeks after muscle transplantation. The correlations showed a trend to earlier onset of function and higher aesthetic rating in young female patients. The intraoperative ischemia of the free muscle did not correlate with the onset of muscle function. Using a five-step scale of judgments, a higher postoperative rating was seen in 94 percent of the patients, and 80 percent of all patients achieved a moderate or better result.
The purpose of this study was to evaluate the success of functional free muscle transfer in patients with chronic facial paralysis using a recently developed quantitative method known as the maximum static response assay of facial motion. A retrospective review of a single surgeon series of six patients with longstanding facial paralysis was performed. The maximum static response assay was performed on all patients preoperatively and serially during the postoperative period. Twenty-seven patients (54 sides) with normal facial function were also evaluated and served as controls. The contralateral normal side in those patients with unilateral facial paralysis (n = 4) also served as a control. Movement of the modiolus during smile was recorded in the x axis and y axis. To determine net smile movement, the vector of movement was calculated by means of the Pythagorean theorem. Vectors were then defined mathematically by calculating direction and magnitude. The average direction of the vector during smile for the normal control population was 58.3 degrees (range 32.5 to 83.1 degrees) from the horizontal through the modioli, and the average magnitude was 10.6 mm (range 4.2 to 20.1 mm). The average preoperative direction for the reanimated sides was 176.8 degrees with a range of 83.3 to 225 degrees. Patients with bilateral paralysis (n = 2) were excluded for calculation of the vectors on the normal contralateral side. The average preoperative direction for the normal contralateral side in patients with facial paralysis was 58.3 degrees with a range of 48.2 to 68.4 degrees. Postoperatively, the average direction of the vector during smile for the reanimated sides improved to a value of 77.6 degrees with a range of 45.7 to 113.8 degrees. The average change in direction of the preoperative reanimated side compared with the postoperative reanimated side was significant (p = 0.01). Postoperatively, the average direction of the vector for the contralateral normal sides was 43 degrees with a range of 11 to 57.2 degrees. The change in direction for the contralateral normal side was not significant (p = 0.18). The average magnitude of the reanimated side improved from a non-anatomic 2.8 mm preoperatively (range 0.8 to 6.8 mm) to an anatomic 4.9 mm postoperatively (p = 0.02). The contralateral normal side magnitude decreased from 9.4 mm (range 7.3 to 11.6 mm) preoperatively to 5.7 mm (range 3.8 to 7.7 mm) postoperatively (p = 0.006). More specifically, the absolute change in movement on the reanimated side during smile for the x axis and y axis was 2.3 mm (p = 0.05) and 4.0 mm (p = 0.002), respectively. This corresponded to an absolute change in the magnitude of the vector of 4.6 mm in an anatomic direction. On the contralateral side the absolute change in magnitude during smile from preoperative to postoperative for the x axis and y axis decreased by 1.5 mm (p = 0.13) and 5.3 mm (p = 0.05), respectively. This reflected an absolute change in the magnitude of the vector of 5.5 mm. Functional free muscle transfer in patients with chronic facial paralysis resulted in anatomic recovery of motion in the majority of patients in this series. The maximum static response assay can be used to objectively assess the results of facial reanimation.
Microneurovascular free muscle transfer is fast becoming a standardized procedure in the treatment of established or long-standing facial paralysis. However, there is no general agreement as to whether muscle transfer should be employed for children who still are growing. A patient's natural growth may influence or disturb reproduction of a smile, or a child may not be able to collaborate with postoperative rehabilitation sufficiently well to obtain a satisfactory result. One may hesitate to employ the procedure for children aged under 10 out of fear of its technical difficulties. To investigate the influence of age, the results experienced by 23 patients under the age of 15 who underwent free muscle transfer combined with cross-face nerve grafting were compared with those of adult patients. The treatment employed was a two-stage operation consisting of cross-face nerve grafting and subsequent free muscle transfer.
Möbius syndrome is a complex congenital anomaly involving multiple cranial nerves, including the abducens (VI) and facial (II) nerves, and often associated with limb anomalies. Muscle transplantation has been used to address the lack of facial animation, lack of lower lip support, and speech difficulties these patients experience. The purpose of this study was to investigate the results of bilateral, segmental gracilis muscle transplantation to the face using the facial vessels for revascularization and the motor nerve to the masseter for reinnervation. The outcome of the two-stage procedure was assessed in 10 consecutive children with Möbius syndrome by direct interview, speech assessment, and oral commissure movement. Preoperative data were collected from direct questioning, viewing of preoperative videotapes, notes from prior medical evaluations, and rehabilitation medicine and speech pathology assessments. All of the patients developed reinnervation and muscle movement. The children who described self-esteem to be an issue preoperatively reported a significant posttransplant improvement. The muscle transplants produced a smile with an average commissure excursion of 1.37 cm. The frequency and severity of drooling and drinking difficulties decreased postoperatively in the seven symptomatic children. Speech difficulties improved in all children. Specifically, of the six children with bilabial incompetence, three received complete correction and three had significant improvement. Despite the length and complexity of these procedures, complications were minimal. Muscle transplantation had positive effects in all problematic areas, with a high degree of patient satisfaction and improvement in drooling, drinking, speech, and facial animation. The surgical technique is described in detail and the advantages over regional muscle transfers are outlined. Segmental gracilis muscle transplantation innervated by the motor nerve to the masseter is an effective method of treating patients with Möbius syndrome.
Functional magnetic resonance imaging (fMRI) can serve to localize activity in the cerebral cortex. The present study was performed to develop a quantitative means of describing the cortical location activated during voluntary smiling in multiple subjects and to determine whether this location is specific to smiling when compared with other motor tasks. Five human subjects were instructed to smile or to tap the fingers of both hands. Both tasks were performed in a blocked-trial paradigm that consisted of alternating 15-second blocks of a repetitive motor task and 15 seconds of rest. Smiling was also performed as an event-related paradigm in which the subject smiled briefly once every 15 seconds for 20 repetitions that were combined to produce an average response to a single smile. A series of 300 images was acquired using an echo-planar imaging sequence (24-cm field of view; 5-mm slice thickness; repetition time/echo time, 1000/27.2 msec). Each subject's three-dimensional brain images were transformed to Talairach coordinates by stretching or compressing the brain images to fit the standard brain as defined in the Talairach atlas. This allowed data from five subjects to be combined for a numeric description. Functional activation maps acquired by use of the event-related paradigm contained significantly fewer motion artifacts than maps acquired with the blocked-trial paradigm, allowing better visualization of functionally active areas. Three-dimensional Talairach coordinates to describe the locations of peak cortical activity after smiling and finger tapping were established. These coordinates were consistent among subjects. During smiling, statistically significant activation was seen in the motor cortex, primarily along the precentral sulcus; this was inferior and anterior to the region that was associated with finger tapping. This study demonstrates that motion artifacts associated with traditional blocked-trial fMRI protocols can be overcome by employing an event-related paradigm to obtain an average response from a single smile. With the implementation of new imaging paradigms with fMRI, an area of the cerebral cortex has been identified that is specifically activated during voluntary smiling, and remains consistent among subjects. Quantification of fMRI data represents a powerful tool by which to study the cortical response to motor activity and to monitor possible alteration in this activity after injury or surgery. When combined with biofeedback therapy, this technique may help to improve the outcome of facial reanimation procedures in the future.
Möbius syndrome is classically characterized by bilateral facial nerve and abducens nerve paralysis in combination with limb defects. In the past 110 years, physicians diagnosed children as having the syndrome on the basis of heterogeneity of symptoms and used the term "Möbius syndrome" or "Möbius-like syndrome" for patients with multiple cranial nerve involvement. The cause and the exact pathogenesis of the syndrome still elude understanding. Genetic work-ups, radiological findings, and data from autopsies differ in their approaches and their findings of the basic causes of Möbius syndrome. In the international literature, about 301 case reports are found scattered through the past century. The appearance of the facial deformity is easy to recognize, because the Möbius patient is impaired in his or her ability to communicate nonverbally. Despite ophthalmologic problems, it is the search for a smile that brings these patients to the reconstructive surgeon. Over the past 100 years, surgical efforts attempted to improve the mask-like appearance by static and dynamic procedures, usually local muscle transpositions. Today, combinations of microsurgical procedures and aesthetic techniques are being used to restore some movement to the expressionless face of these patients by nerve and muscle transplantation. This article discusses the heterogeneity of Möbius syndrome, advocates a new classification system, presents the clinical findings of 42 patients who were seen and examined in consultation, and discusses the surgical management of 20 patients who underwent dynamic restorative microsurgery. Exemplary cases illustrating the preoperative work-up regimen and possible outcomes are reported.
A review of the literature on clinical manifestations of facial paralysis shows a lack of well-integrated, cohesive methods of classification. The aim of the classification system presented here is to provide a clinically relevant, generalized scheme for categorization, focusing on clinical presentation and general etiology. This article will also describe some of the more common conditions that have shaped the organization of the classification charts. A review of the literature on clinical manifestations of facial paralysis shows a lack of well-integrated, cohesive methods of classification. Although there are several specific systems designed to classify discrete areas of facial palsy, 1,2 there are few means by which to clearly combine the information. The aim of the system presented here is to provide a clinically relevant, generalized scheme for categorization, focusing on clinical presentation and general etiology. Furthermore, this classification system attempts to clarify some of the terminology used in this field because our research revealed a great deal of inconsistency and contradiction. This article will also describe some of the more common conditions that have shaped the organization of the classification charts. While much of the reviewed literature had a pediatric basis, the information compiled into the present system may also be applied to adolescents and adults.
The child with Möbius syndrome presenting for facial reanimation presents a difficult challenge. When bilateral paralysis and paresis preclude use of the contralateral facial nerve, the authors' preferred donor nerve for reinnervation of free muscle transfer is a branch of the trigeminal nerve, the ipsilateral nerve to the masseter.
The authors have used a branch of the trigeminal nerve as a donor for three children with Möbius syndrome.
Of three children with Möbius syndrome, two are now able to smile independently of jaw closure. One child is now 2.6 years past bilateral free gracilis transfers completed at age 13.2 years. The second child is 8.2 years past free gracilis transfer to the left side of the face performed at age 7.6 years. The third child is 5.6 years past bilateral facial reanimation with free latissimus and free gracilis flaps completed at age 13.4 years. This child is not able to smile independently of jaw closure. The two who are able to smile independently of jaw closure demonstrated maximum excursion of the lateral commissure on the affected sides when asked to smile without biting; however, they demonstrated minimal excursion of the lateral commissure on the affected sides when asked to bite without trying to smile.
These findings indicate that smiling independently of jaw closure is attainable with reanimation to the masseteric branch, refuting previous speculations. Early age at operation and absence of complete bilateral paralysis in these two children may have contributed to cortical adaptation to smiling.
The microneurovascular transfer of a free muscle transplant is the procedure of choice for facial animation in a child with facial paralysis. One of the critical factors of this procedure is the selection of a motor nerve to innervate the transplanted muscle.
From 1989 to 1999, 166 free segmental gracilis muscle transfers were performed in 121 children for facial animation. The cross-face nerve graft was used in 70 procedures (cross-face nerve graft group) to innervate the muscle by branches of the seventh nerve for the normal side. The ipsilateral masseteric nerve was used in 94 procedures (50 patients, masseter group) and the ipsilateral accessory nerve was used in two procedures (one patient). To compare the operative procedures between the first two groups, all charts were reviewed. The extent of oral commissure movement was determined by measurements taken from the tragion to the oral commissure, both at rest and with full smile. In the cross-face nerve graft group (n = 20), the extents were measured on both the normal side and the reconstructed side; in the masseter group (n = 16), they were measured on the left and right sides.
No significant difference was found between the two groups (p < 0.05) for the mean age at the time of muscle transplantation, for the total operation time for muscle transplantation, and for the length of the muscle used or for the fraction of circumference of the segment of gracilis muscle used. Although the operative variables were similar between two groups, the muscle excursion differed. Excursion in the cross-face nerve graft group was less than that on the right (p = 0.0006) or left (p = 0.0000) in the masseter group. It was also less than on the normal side (p = 0.0000) of the cross-face nerve graft group. Also, there was no significant difference between the left and right sides within the masseter group (p < 0.05). Furthermore, the extent of oral commissure movement in the masseter group was similar to that of the normal side in the cross-face nerve graft group (p = 0.35, p = 0.61).
These results indicate that segmental gracilis muscle transplantation using the motor nerve to the masseter nerve for facial animation in children is a very reproducible operation and provides a commissure excursion in the range of normal.
This study assesses the ability of the masseter motor nerve-innervated microneurovascular muscle transfer to produce an effective smile in adult patients with bilateral and unilateral facial paralysis.
The operation consists of a one-stage microneurovascular transfer of a portion of the gracilis muscle that is innervated with the masseter motor nerve. The muscle is inserted into the cheek and attached to the mouth to produce a smile. The outcomes assessed were the amount of movement of the transferred muscle; the aesthetic quality of the smile; the control, use, and spontaneity of the smile; and the functional effects on eating, drinking, and speech. The study included 27 patients aged 16 to 61 years who received 45 muscle transfers.
All 45 muscle transfers developed movement. The commissure movement averaged 13.0 +/- 4.7 mm at an angle of 47 +/- 15 degrees above the horizontal, and the mid upper lip movement averaged 8.3 +/- 3.0 mm at 42 +/- 17 degrees. Age did not affect the amount of movement. Patients older than 50 years had the same amount of movement as patients younger than 26 years (p = 0.605). Ninety-six percent of patients were satisfied with their smile.
A spontaneous smile, the ability to smile without thinking about it, occurred routinely in 59 percent and occasionally in 29 percent of patients. Eighty-five percent of patients learned to smile without biting. Age did not affect the degree of spontaneity of smiling or the patient's ability to smile without biting.
Facial paralysis is a relatively common disorder from which most people recover without complications. However, some are left with significant functional impairment and disfigurement, the treatment of which has challenged physicians for centuries. Within the spectrum of surgical procedures to reanimate the face is cross-facial nerve grafting. This article chronicles the history of cross-facial nerve grafting, including its past and present use, and describes various factors associated with its use. A brief discussion of aetiology and morbidity of facial paralysis and some fundamental surgical options will be presented. A complete review of these topics is beyond the scope of this manuscript.
Evaluation of the severity of facial paralysis deformity and the effectiveness of reconstructive surgery requires a measurement tool that is practical and simple enough for daily use. It should be able to objectively measure facial asymmetry at rest and the amount of facial movement during expression. The authors present and assess a simple measurement technique that is readily usable in the clinic. Designed to evaluate smile reconstruction, the technique can be used to evaluate other parts of the paralyzed face, such as the eye, nose, and forehead.
A standardized handheld ruler measuring technique is described for the assessment of the position and the movement of five points marked on the lips. The measured points are used to characterize the position of the mouth at rest and the movement that occurs with smiling. The technique uses two transparent rulers that are held in the examiner's hand. Using this technique, two experienced examiners separately measured the rest position of 21 unilateral facial paralysis patients twice, creating 84 sets of measurements. Accuracy was assessed by simultaneously measuring the movement of the commissure and mid upper lip during smiling on 10 normal persons using both handheld ruler and a proven technique, the facial reanimation measurement system.
The average intraclass correlation coefficients for interrater and intrarater reliability exceed 0.89. The mean difference between the handheld ruler and facial reanimation measurement system measurements was 1.7 mm.
The handheld ruler technique is simple, reliable, and accurate, providing useful measurements for the evaluation of facial paralysis reconstructions.