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Abstract

Sir:FigureThe timing of facial reanimation surgery in congenital facial palsy syndrome has been recommended in the child at approximately 5 years of age for psychosocial rehabilitation.1 However, the dental occlusion and facial proportion actually are not yet mature, and the effects of muscle transfer on a developing facial skeleton are difficult to predict. There is a lack of long-term follow-up for those children with Möbius syndrome who underwent reanimation surgery reported in the literature. The series of Möbius and Möbius-like syndrome patients in the article by Bianchi et al.2 had rather minor severity. The absence of muscle activity in the upper lip causes excessive forward growth of the maxilla, whereas downward growth is arrested. For cases in which dental problems are corrected in the Möbius patient, we strongly recommend that orthognathic surgery precede microsurgery, especially in the patient lacking normal masticatory muscle function and with possible developmentally abnormal facial proportions. For poor dental occlusion and a longer middle and lower face, orthognathic surgery is worthwhile before “smile” reconstruction. The bony work, mainly addressed during orthognathic surgery, should be scheduled in late adolescence. Surgically, the entire maxilla can be moved forward up to 10 mm with good stability and as far as 10 to 15 mm with excellent stability. The procedure is technically exacting but not otherwise problematic.3 Orthognathic surgery should be performed first to obtain a class I dental relationship and to optimize static facial aesthetics and substantially reduce drooling, oral incompetence, and speech difficulties.4 Microsurgical functional muscle transfers may be delayed until bone maturation and reshaping by orthognathic surgery. Facial animation and nonhollowed cheeks are later achieved in a second-stage procedure. The severity of cranial nerve involvement in Möbius syndrome is variable. The classic technique of hypoglossal nerve transfer in facial nerve reconstruction with the resultant hemiglossal paralysis may lead to significant morbidity, including speech, mastication, and swallowing difficulties. These problems may be further compounded if the patient has bilateral or multiple lower cranial nerve palsies (e.g., Möbius syndrome). A weaker facial response and longer recovery time have been observed even incising the hypoglossal nerve distal to the descendens hypoglossi branch to avoid compromising adequate tongue motor innervation.5 The masseter motor branch of the fifth cranial nerve is another tempting source, because free muscle transfer can be connected directly without the need for nerve grafting. The masseter muscle has to be stripped during orthognathic surgery, and that may add to the degree of difficulty in nerve end identification later. For these reasons—risk of aspiration, speech and swallowing difficulties, and the need for bilateral motor nerves—we selected the spinal accessory nerve instead of other motor branches in contemplating functioning muscle nerve repair for patients with Möbius syndrome. By far the most often selected nerve source in the series review was the spinal accessory nerve, which is the least involved nerve reported in the literature.6 Because there are various cranial nerves involved in Möbius syndrome, no single standard procedure for dynamic restoration should be overemphasized. Sophia Chia-Ning Chang, M.D., Ph.D. Department of Plastic Surgery, China Medical University Hospital, and, School of Medicine, China Medical University, Taichung, Taiwan David Chwei-Chin Chuang, M.D. Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan DISCLOSURE Neither of the authors has any commercial associations or financial disclosures.