Facial reanimation with masseter nerve–innervated free gracilis muscle transfer in established facial palsy patients

ABSTRACT BACKGROUND: Neurofibromatosis type 2 (NF2) is a tumor suppressor syndrome defined by bilateral vestibular schwannomas. Facial paralysis, from either tumor growth or surgical intervention, is a devastating complication of this disorder and can contribute to disfigurement and corneal keratopathy. Historically, physicians have not attempted to treat facial paralysis in these patients. OBJECTIVE: To review our clinical experience with free gracilis muscle transfer for the purpose of facial reanimation in patients with NF2. METHODS: Five patients with NF2 and complete unilateral facial paralysis were referred to the facial nerve center at our institution. Charts and operative reports were reviewed; treatment details and functional outcomes are reported. RESULTS: Patients were treated between 2006 and 2009. Three patients were men and 2 were women. The age of presentation of debilitating facial paralysis ranged from 12 to 50 years. All patients were treated with a single-stage free gracilis muscle transfer for smile reanimation. Each obturator nerve of the gracilis was coapted to the masseteric branch of the trigeminal nerve. Measurement of oral commissure excursions at rest and with smile preoperatively and postoperatively revealed an improved and nearly symmetric smile in all cases. CONCLUSION: Management of facial paralysis is oftentimes overlooked when defining a care plan for NF2 patients who typically have multiple brain and spine tumors. The paralyzed smile may be treated successfully with single-stage free gracilis muscle transfer in the motivated patient.

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Facial Reanimation with Gracilis Muscle Transfer Neurotized to Cross-Facial Nerve Graft versus Masseteric Nerve

Plastic & Reconstructive Surgery ◽

10.1097/prs.0b013e31828bd4da ◽

2013 ◽

Vol 131 (6) ◽

pp. 1241-1252 ◽

Cited By ~ 48

Author(s):

Bernardo Hontanilla ◽

Diego Marre ◽

Álvaro Cabello

Keyword(s):

Facial Nerve ◽

Nerve Graft ◽

Gracilis Muscle ◽

Muscle Transfer ◽

Facial Reanimation ◽

Masseteric Nerve

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Salvage Procedures After Failed Facial Reanimation Surgery Using the Masseteric Nerve as the Motor Nerve for Free Functional Gracilis Muscle Transfer

JAMA Facial Plastic Surgery ◽

10.1001/jamafacial.2014.163 ◽

2014 ◽

Vol 16 (5) ◽

pp. 359-363 ◽

Cited By ~ 7

Author(s):

Steffen U. Eisenhardt ◽

Nils A. Eisenhardt ◽

Jan R. Thiele ◽

G. Björn Stark ◽

Holger Bannasch

Keyword(s):

Motor Nerve ◽

Gracilis Muscle ◽

Muscle Transfer ◽

Facial Reanimation ◽

Masseteric Nerve

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Faculty Opinions recommendation of Facial reanimation with gracilis muscle transfer neurotized to cross-facial nerve graft versus masseteric nerve: a comparative study using the FACIAL CLIMA evaluating system.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718142708.793485299 ◽

2013 ◽

Author(s):

Kofi Boahene

Keyword(s):

Comparative Study ◽

Facial Nerve ◽

Nerve Graft ◽

Gracilis Muscle ◽

Muscle Transfer ◽

Facial Reanimation ◽

Masseteric Nerve

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Hypoglossal-Facial Side-to-End Neurorrhaphy With Concomitant Masseteric-Zygomatic Nerve Branch Coaptation and Muscle Transfer for Facial Reanimation: Technique and Case Report

Operative Neurosurgery ◽

10.1093/ons/opaa128 ◽

2020 ◽

Vol 19 (3) ◽

pp. E230-E235

Author(s):

Nobutaka Yoshioka

Keyword(s):

Facial Nerve ◽

Facial Paralysis ◽

Mass Movement ◽

Nerve Transfer ◽

Nerve Graft ◽

Gracilis Muscle ◽

Muscle Transfer ◽

Nerve Branch ◽

Facial Reanimation ◽

Healthy Side

Abstract BACKGROUND Hypoglossal-facial direct side-to-end neurorrhaphy has become widely used for facial reanimation in patients with irreversible facial nerve damage. Although this procedure achieves good restoration of facial function, it has disadvantages such as mass movement and lack of spontaneity. OBJECTIVE To present a new facial reanimation technique using hypoglossal-facial direct side-to-end neurorrhaphy with concomitant masseteric-zygomatic nerve branch coaptation and secondary muscle transfer to reduce mass movement and achieve a spontaneous smile in patients with facial paralysis. METHODS This article describes a novel facial reanimation technique that employs hypoglossal and masseteric nerve transfer combined with secondary vascularized functional gracilis muscle transfer. RESULTS Details of the technique are reported in a patient with complete facial paralysis after brain surgery. The hypoglossal nerve was partially served and connected to the mastoid segment of the facial nerve by side-to-end anastomosis to restore facial symmetry. A nerve supplying the masseter muscle was coapted with a zygomatic branch by end-to-end anastomosis to restore voluntary movement of the oral commissure, as well as to assist with eye closure. A cross face sural nerve graft was connected to zygomatic branches on the healthy side. In the second stage, a vascularized functional gracilis muscle graft was transplanted using the cross face nerve graft as the donor nerve to restore a natural smile. CONCLUSION Hypoglossal-facial neurorrhaphy with concomitant masseteric-zygomatic nerve branch coaptation and muscle transfer is an alternative facial reanimation technique that reduces mass movement and achieves a natural smile.

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Comparison of Lengthening Temporalis Myoplasty and Free-Gracilis Muscle Transfer for Facial Reanimation in Children

Journal of Craniofacial Surgery ◽

10.1097/scs.0000000000005885 ◽

2020 ◽

Vol 31 (1) ◽

pp. 85-90 ◽

Cited By ~ 2

Author(s):

Phuong D. Nguyen ◽

Kristin S. Faschan ◽

Daniel M. Mazzaferro ◽

Tami Konieczny ◽

Oksana A. Jackson ◽

...

Keyword(s):

Gracilis Muscle ◽

Muscle Transfer ◽

Facial Reanimation

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Outcome Analysis Following Microvascular Free Gracilis Muscle Transfer for Multi-Vector Facial Reanimation

Tropical Health and Medical Research ◽

10.35916/thmr.v3i1.32 ◽

2021 ◽

Vol 3 (1) ◽

pp. 44-52

Author(s):

Muhammad Izzuddin Hamzan ◽

Mior Faiq Abu Tahrin ◽

Wan Azman Wan Sulaiman

Keyword(s):

Facial Nerve ◽

Operating Time ◽

Gracilis Muscle ◽

Outcome Analysis ◽

Muscle Transfer ◽

Facial Symmetry ◽

Institutional Review ◽

Facial Reanimation ◽

The Mean

The purpose of this research to address objective excursion and symmetry results from a series of free gracilis muscle transfer (FGMT) cases and examine the predictive intraoperative number of vectors anchored during flap inset on outcomes. A retrospective analysis performs by data retrieved from the HUSM Plastic & Reconstructive Surgery OR Registry from January 2005 to June 2019. All patients who reported facial nerve palsy were recorded and re-evaluated. All characteristics in interest were epidemiologically tabulated and analyzed in detail. Subsequently, outcome assessment was performed to look for facial symmetry and smile excursion compared to the healthy side of the face—this study exempted by the Institutional Review Board of the Hospital of University of Sciences Malaysia. Out of 12 patients diagnosed with facial palsy, four patients underwent static facial reanimation. Eight patients underwent a dynamic facial reanimation, with 4 of them completed two stages of cross-facial nerve grafting (CFNG) and free gracilis muscle transfer (FGMT). One of the FGMTs patients had missed a follow-up. The mean age was 20 (range 11 to 30), one patient was male, and two were female. The mean duration for follow-up was 69 months. The mean duration of operating time was 8.67 hours. All operations without complication, and there was no microvascular re-exploration. Smile excursion and angle excursion at smile improved following FGMT. Association between the number of vectors anchored during flap inset to the outcome were identified. Dynamic facial reanimation using FGMT still the gold standard of treatment, which provides an excellent quantifiable improvement in oral commissure excursion and facial symmetry with smiling. The use of multivector gracilis flap was suggestive to associate with the good outcome on excursion and symmetrical of the smile.

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Dynamic Facial Reanimation in an Overweight Patient and with Significant Comorbidities: An Objective Analysis of Labbè Technique

The Surgery Journal ◽

10.1055/s-0041-1736668 ◽

2021 ◽

Vol 07 (04) ◽

pp. e342-e346

Author(s):

Ricardo Horta ◽

Francisca Frias ◽

Diogo Barreiro ◽

Ana Gerós ◽

Paulo Aguiar

Keyword(s):

Facial Palsy ◽

Movement Control ◽

Standard Technique ◽

Horizontal Displacement ◽

Functional Results ◽

Preoperative Period ◽

Muscle Transfer ◽

Cardiovascular Comorbidities ◽

Facial Reanimation ◽

Almost All

AbstractGracilis free muscle transfer is considered the gold standard technique for facial reanimation in cases of facial palsy. However, it is limited by its long operative and recovery times, the need for a second surgical site, and its outcomes that can sometimes show midfacial bulk and oral commissure malposition. Facial reanimation with lengthening temporalis myoplasty (LTM)—Labbé technique— carries the advantage of having a shorter surgical time, a faster recovery, and being a less invasive surgery. Almost all patients included in studies of LTM were evaluated by subjective methods, and very little quantifiable data was available. A 64-year-old woman presented with long-standing incomplete right facial palsy secondary to acoustic neuroma surgery. Since she was overweight (body mass index [BMI]: 43.9) and had several cardiovascular comorbidities (hypertension, dyslipidemia), she was not a good candidate for gracilis free muscle transfer. She was submitted to facial reanimation with LTM. Fourteen months after surgery, she presented excellent facial symmetry, both at rest and in contraction, while smiling. She was evaluated with the Facegram-3D, a technology that we have developed for dynamic evaluation of facial muscle contraction. The analysis showed symmetry at rest and contraction, according to Terzis and Noah. Regarding vertical and horizontal displacement, the postoperative movement was synchronized and with less fluctuations when compared with the preoperative period. Notably, the anatomical pair's trajectories were smoother. Similar velocity profiles were found between anatomical pairs, with less abrupt changes in velocity values, further supporting improved movement control. Comparing the symmetry index, which takes a theoretical maximum of 1.0 for perfect 3D symmetry, its value was 0.56 for the commissures and 0.5 for the midpoints in the preoperative period, having improved to 0.91 and 0.82, respectively, 3 months postoperatively. Good aesthetic and functional results were achieved using the Labbè technique. LTM is a good option in cases of long-standing facial paralysis, if the patient desires a single-stage procedure with almost immediate dynamic function. Moreover, this technique assumes extreme importance in facial reanimation of patients of advanced age, overweight, or those who have several comorbidities.

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