Annual Report

General Editor: Daniel Buchbinder

Authors: Damir Matic, John Yoo

Facial nerve - Irreversible paralysis, midface and mouth

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Glossary

General considerations

Static procedures may provide symmetry at rest and the illusion of facial tone, but will not offer movement. These procedures do not provide symmetry during function.

Dynamic procedures in addition to providing symmetry at rest may also enable movement that is voluntary, symmetric, and spontaneous.

Static suspension with tendons
Main indication Skill Equipment
When dynamic reconstruction is not possible Some specialized surgical experience Simple surgical and imaging resources

Further indications

  • Patients with poor prognosis or significant comorbidities
  • Augmentation of reinnervation procedures, in order to improve facial symmetry at rest, especially during the period of facial nerve recovery.

Advantages

  • Simple and quick
  • Reliable
  • Immediate results

Disadvantages

  • Not dynamic
  • Relapse over time
  • May require donor site
Masseter muscle transposition
Main indication Skill Equipment
When the situation is not appropriate for a free vascularized muscle transfer Some specialized surgical experience Basic equipment only

Contraindications

  • Neurovascular compromise of the masseter muscle
  • Previous injury to the muscle

Advantages

  • Dynamic
  • Simple dissection and elevation
  • Early movement with no reinnervation period
  • Strong muscle contraction with correct vector
  • Patient can learn to bite and smile with practice
  • Improves symmetry, oral competence, and speech

Disadvantages

  • Not spontaneous
  • Commissure excursion may be less than a free muscle flap
  • Cheek contour deformity
Temporalis muscle (antidromic) mini-sling
Main indication Skill Equipment
Reconstruction of the upper portion of the nasolabial fold Some specialized surgical experience Basic equipment only

Further indication

  • Only used in combination with other dynamic techniques to reconstruct nasolabial fold

Contraindications

  • Neurovascular compromise of the temporalis muscle
  • Previous injury to the muscle

Advantages

  • Dynamic
  • Simple dissection and elevation
  • Immediate movement
  • Correct vector of muscle pull
  • Patient can learn to bite and smile with practice
  • Improves cosmesis
  • Minimizes temporal hollowing because only a small strip of muscle is transposed

Disadvantage

  • Not spontaneous
Temporalis muscle transposition
Main indication Skill Equipment
When the situation is not appropriate for a free vascularized muscle transfer Some specialized surgical experience Basic equipment only

Contraindications

  • Neurovascular compromise of the temporalis muscle
  • Previous injury to the muscle

Advantages

  • Dynamic
  • Simple dissection and elevation
  • Early movement with no reinnervation period
  • Strong muscle contraction with correct vector
  • Patient can learn to bite and smile with practice
  • Improves symmetry, oral competence, and speech

Disadvantages

  • Not spontaneous
  • Commissure excursion may be less than a free muscle flap
  • May have temporal hollowing
Innervated free muscle transfer (Gracilis)
Main indication Skill Equipment
Preferred option for dynamic, voluntary movement Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Further indications

  • Secondary reconstruction for irreversible paralysis
  • Primary reconstruction option in selected patients with ablative defects of facial muscles or distal facial nerve

Contraindications

  • When the situation is not appropriate for a free vascularized muscle transfer
  • No nerve available to power the gracilis

Advantages

  • Facial symmetry
  • Voluntary movement
  • Natural appearing smile
  • Potential for spontaneous movement (cortical adaptation)
  • Muscle fiber length, anatomy, and pull allows adequate excursion
  • Predictable muscle anatomy
  • Minimal donor site morbidity compared to other free muscle flaps
  • Improves oral competence and speech

Disadvantages

  • Complex and long surgery
  • Long learning curve
  • Separate donor site
  • Delay in muscle function until reinnervation occurs
  • Requires physiotherapy and practice to smile naturally
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources