The Facial Nerve Center at the University of Nebraska Medical Center is a multidisciplinary effort to provide comprehensive care in the evaluation and treatment of facial nerve disorders. The center brings together a team of specialists including plastic and reconstructive surgery, neuro-otology, neurosurgery, skull base surgery, radiology, physical therapy and facial nerve diagnostics.
Facial expression is an integral component of human expression and communication. Consequently, patients afflicted with facial paralysis suffer a severe functional and cosmetic deformity that profoundly affects their perception of themselves and their social interactions. The reconstructive goals in the patient with facial paralysis include symmetry at rest, voluntary movement and emotional involuntary movement without synkinesis. Because of the emotionally charged aspects of facial paralysis as well as the complex and varied management options, the treatment of these patients although individualized is best accomplished via a team approach. The management team consists of the plastic and reconstructive surgeon, otolaryngologist (neurootologist), ophthalmologist, neurosurgeon, physical therapist, psychologist/psychiatrist and ancillary support.
The facial nerve controls multiple fine muscles for facial reanimation. Reconstruction of the chronic facial paralysis patient does not try to recreate all the fine interplay of these muscle for facial reanimation, but rather focuses on recreation of the smile and eye closure.
Our preferred approach for dynamic reanimation of the smile is cross facial nerve grafting followed by microvascular muscle transfer. Free muscle transfer when properly conceived and executed fulfills all the goals for reanimation of the smile: symmetry at rest, volitional and reflexive emotional movement . Typically the procedure is staged with cross facial nerve grafting using sural nerve performed first. The microvascular free muscle transfer is then typically performed 9 to 12 months later.
Cross Facial Nerve Grafting
The branches of the facial nerve on the nonparalyzed side are approached through a face-lift type incision. One or two large branches of the zygomatic portion are selected. These branches can be safely divided without causing significant weakness of the nonparalyzed side. The sural nerve graft is reversed so that the sprouting axons are ot lost through the side branches. The graft is tunneled subcutaneously across the upper lip or under the chin and the distal end tacked with a silk suture near the tragus for ease of later identification. Tunneling the graft under the chin instead of across the upper lip avoids potential injury to the nerve graft with dissection of the paralyzed side and insetting of the muscle flap. The timing for muscle transfer is determined by percussion along the nerve graft. When the Tinel sign reaches the area of the tragus on the paralyzed side free muscle transfer is performed.
Free Muscle Transfer
The ideal muscle should have minimal donor site morbidity, an adequate neurovascular pedicle and be segmentally innervated. Although a variety of muscles have been used, the most commonly used muscles are the gracilis, serratus anterior and pectoralis minor. It is important that when the muscle is harvested, the resting length is measured. When the muscle is inset the resting length must be restored to achieve maximal contraction. The facial vessels are the favored recipient vessels followed by the superficial temporal vessels. The exact angle of orientation of the muscle inset is determined preoperatively by calculating the direction of the vector of the nonparalyzed side smile using the MSRA
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