Technique For Facial Reanimation Research Articles

Facial nerve reconstruction for flaccid facial paralysis: a systematic review and meta-analysis.

To determine the functional outcome after facial nerve reconstruction surgery in patients with flaccid facial paralysis. A systematic review and meta-analysis was performed on studies reporting outcomes after direct facial nerve suture (DFS), facial nerve interpositional graft suture (FIGS), hypoglossal-facial nerve suture (HFS), masseteric-facial nerve suture (MFS), and cross-face nerve suture (CFS). These studies were identified from PubMed/MEDLINE, Embase, and Web of Science databases. Two independent reviewers performed two-stage screening and data extraction. A favorable result was defined as a final House-Brackmann grade I-III and is presented as a ratio of all patients in percentage. Pooled proportions were calculated using random-effects models. From 4,932 screened records, 54 studies with 1,358 patients were included. A favorable result was achieved after DFS in 42.67% of the patients [confidence interval (CI): 26.05%-61.12%], after FIGS in 66.43% (CI: 55.99%-75.47%), after HFS in 63.89% (95% CI: 54.83%-72.05%), after MFS in 63.11% (CI: 38.53%-82.37%), and after CFS in 46.67% (CI: 24.09%-70.70%). There was no statistically significant difference between the techniques (Q = 6.56, degrees of freedom = 4, p = 0.1611). The established facial nerve reconstruction techniques including the single nerve cross-transfer techniques produce satisfactory results in most of the patients with permanent flaccid facial paralysis. An international consensus on standardized outcome measures would improve the comparability of facial reanimation techniques.

Post Facelift Facial Paralysis: A 20-Year Experience.

Facial nerve (FN) injury during a facelift is a relatively rare but potentially devastating complication. Despite extensive literature discussing facial nerve anatomy and danger zones, few studies describe detailed management, FN exploration intraoperative findings, and outcome following post-facelift facial paralysis (PFFP). We review a 20-year experience in managing iatrogenic PFFP. PFFP patients were retrospectively identified between 2002-2022. Demographic data, operative details from the facelift procedure, post-facelift facial function, medical and surgical management, intraoperative findings, and long-term outcome were analyzed. 25 patients who experienced PFFP were referred for evaluation over the past 20 years. Eight patients required FN exploration, of which 6 underwent nerve repair; all recovered to some degree, with 50% achieving essentially normal facial function. 14 patients underwent non-surgical management including physical therapy, chemodenervation and filler therapy. Of these non-surgical patients who were not lost to follow up, 50% achieved normal facial function and 42% achieved near-normal facial function. The single patient who had no spontaneous improvement presented outside the re-innervation window and was not an operative candidate. PFFP outcome depends on injury type and location, accurate assessment and appropriate treatment; however, overall prognosis is quite favorable. FN exploration is warranted when nerve transection is suspected. Observation is suitable for patients demonstrating early signs of recovery. Patients presenting beyond a reasonable re-innervation window will be offered other facial reanimation techniques. When FN exploration is required, outcomes may be superior in a facial nerve center setting. Adjunctive interventions for symmetry improvement while awaiting recovery are available.

Tri-Vector Gracilis Microneurovascular Free Tissue Transfer with Periocular Component to Achieve a Duchenne Smile in Patients with Facial Paralysis.

Importance: Traditional techniques of facial reanimation using gracilis free tissue transfer do not address the lower eyelid or provide contraction at the site of orbicularis oculi, which is necessary to create a natural appearing Duchenne smile. In this report, we describe a novel technique to achieve this element of a true mimetic smile using a tri-vector gracilis muscle flap. Objective: To describe a novel gracilis free flap technique for facial reanimation to provide contraction of the inferior and lateral orbicularis oculi and achieve a Duchenne smile. Design, Setting, and Participants: This was a surgical pearls-description of a novel surgical technique at Academic Tertiary Medical Center. Three patients underwent the operation.

Multiple Model Evaluation of the Masseteric-to-Facial Nerve Transfer for Reanimation of the Paralyzed Face and Quick Prognostic Prediction.

Facial paralysis is negatively associated with functional, aesthetic, and psychosocial consequences. The masseteric-to-facial nerve transfer (MFNT) has many advantages in facial reanimation. The aim is to evaluate the effectiveness of our MFNT technique and define the potential factors predictive of outcome. The authors conducted a retrospective review of 20 consecutive patients who underwent MFNT using the temporofacial trunk of facial nerve. Videotapes and images were documented and evaluated according to Facial Nerve Grading Scale 2.0 (FNGS2.0) and Sunnybrook Facial Grading System (FGS). The quality-of-life was obtained using the Facial Clinimetric Evaluation (FaCE) Scale. Moreover, Facial Asymmetry Index (FAI), quantitative measurement of the width of palpebral fissure, deviation of the philtrum, and angles or excursions of the oral commissure were applied to explore the effect of the transfer metrically. Multivariable logistic regression models and Cox regression were prepared to predict the effect of MFNT by preoperative clinical features. The patients showed favorable outcomes graded by FNGS2.0, and experienced significantly improved scores in static and dynamic symmetry with slightly elevated scores in synkinesis evaluated by the Sunnybrook FGS. The score of FaCE Scale increased in all domains after reanimation. The quantitative indices indicated the symmetry restoration of the middle and lower face after MFNT. Regression analysis revealed that younger patients with severe facial paralysis are preferable to receive MFNT early for faster and better recovery, especially for traumatic causes. The findings demonstrate that MFNT is an effective technique for facial reanimation, and case screening based on clinical characteristics could be useful for surgical recommendation.

Supercharging the Smile: A Novel Dual Nerve Transfer for Facial Reanimation.

Background:Facial paralysis has profound effects on the functional and psychosocial well-being of patients. Various surgical facial reanimation techniques have been described to address this devastating condition. While traditional surgical approaches have proved successful in restoring either facial tone or facial movement, newer combination nerve transfer techniques are addressing the limitations of the traditional single nerve transfer approaches.Methods:This study aimed to describe a promising new surgical approach to facial reanimation utilizing a dual nerve transfer to maximize both resting and active symmetry while minimizing postoperative synkinesis. Here, we use the masseteric nerve to selectively innervate the midface in combination with a hypoglossal facial nerve graft to reanimate the remaining facial regions.Results:To date, we have performed this operation on four patients, all of whom tolerated the procedure well. Our patients are showing significant improvements in both resting facial tone and facial movement with no signs of synkinesis at 9 months postoperative.Conclusions:We believe this dual nerve transfer to be superior in restoring the combination of tone, symmetry, and movement to the paralyzed face when compared with traditional single nerve transfer approaches.

English

Facial nerve palsy is the disease of cranial nerve. From the total number of cases, 60 to 75 % of Bell's palsy cases are idiopathic form of facial palsy. Facial nerve palsy results in weakness of facial muscles, atrophy, asymmetry of face and also disturbs the quality of life. Bell’s palsy occurs in every class of population affecting people of all the age groups but the most common age group affected is 15 - 50 years with equal sex prediliction accounting 11 - 40 cases per 100,000. If facial palsy is not treated properly then it may result in variety of complications like motor synkinesis, dysarthria, contractures of facial muscles, and crocodile tear. Currently facial paralysis treatment consists of combination of pharmacological therapy, facial neuromuscular re-entrainment physiotherapy or surgical intervention by static and dynamic facial reanimation techniques. Physiotherapy treatment is effective for treating facial paralysis with minimal complications and can be individualized. Bell's palsy is the idiopathic form of facial nerve palsy which accounts for 60 to 75 % of cases and male to female ratio is 1:3.1 The aetiology of facial paralysis is not yet thoroughly understood. Cases of varicella-zoster, mononucleosis, herpes simplex virus, mumps and measles have demonstrated good serology in several reports for their association but still stands unclear. 2 Peripheral facial nerve palsy may be idiopathic (primary cause) or Bell’s palsy (secondary). Causes of the secondary unilateral facial nerve palsy are diabetes, stroke, Hansen's disease, herpes simplex infection, birth injury, trauma, tumour, Guillain-Barre syndrome, and immune system disorders. Causes of the bilateral facial nerve palsy are leukemia, brainstem encephalitis, leprosy, and meningitis. The most prominent current theories of facial nerve paralysis pathophysiology include the reactivation of herpes simplex virus infection (HSV type 1). Current facial paralysis treatment consists of a combination of pharmacological therapy, facial neuromuscular re-entrainment physiotherapy or surgical intervention by dynamic and static facial reanimation techniques.7 This is a diagnosed case of right facial nerve palsy which was treated under physiotherapy department with proper rehabilitation protocol.

The sternohyoid muscle flap for new dynamic facial reanimation technique: Anatomical study and clinical results

Long-term facial nerve palsy has a highly negative impact on patients' quality of life. In 2016, Alam reported one case of facial reanimation with the sternohyoid muscle after publishing a preclinical study in 2013. Despite the potentially ideal characteristics of this muscle for reanimation of facial palsy, this technique is still not widely used. The objective of our description of cases was to present the clinical results obtained with the surgical procedure and the study on cadavers to confirm the anatomical findings. This work describes the anatomical study of the vascular and nervous pedicle of the sternohyoid muscle compared with clinical results from a series of patients with long-term facial paralysis who underwent facial reanimation between June 2016 and September 2019, through the insertion of the sternohyoid muscle into the masseteric nerve. The anatomical study was conducted in eight human hemi-necks. In five cases (62%), the vascular pedicle was provided by the superior thyroid artery, and the entrance of the ansa cervicalis to the muscle was constant 1.8 cm from the distal insertion. This series included ten patients who underwent the surgery technique of facial reanimation using the sternohyoid muscle, with a 90% (n = 9) of reinnervation; 100% (n = 10) of flaps were viable, and none of the patients showed complications in the donor area. The sternohyoid muscle showed itself as a reliable muscle as a free flap in facial reanimation, and alternative to the gracilis flap. The surgical technique was safe, without any complications, with excellent excursion, recovery, and aesthetic results.

Using the Post-Descendens Hypoglossal Nerve in Hypoglossal-Facial Anastomosis: An Anatomic and Histologic Feasibility Study.

Hypoglossal-facial anastomosis (HFA) is a popular facial reanimation technique. Mobilizing the intratemporal segment of the facial nerve and using the post-descendens hypoglossal nerve (ie, the segment distal to the take-off of descendens hypoglossi) have been proposed to improve results. However, no anatomic study has verified the feasibility of this technique. To assess the anatomic feasibility of HFA and the structural compatibility between the 2 nerves when the intratemporal facial and post-descendens hypoglossal nerves are used. The facial and hypoglossal nerves were exposed bilaterally in 10 sides of 5 cadaveric heads. The feasibility of a side-to-end (ie, partial end-to-end) HFA with partial sectioning of the post-descendens hypoglossal nerve and the mobilized intratemporal facial nerve was assessed. The axonal count and cross-sectional area of the facial and hypoglossal nerves at the point of anastomosis were assessed. The HFA was feasible in all specimens with a mean (standard deviation) 9.3 (5.5) mm of extra length on the facial nerve. The axonal counts and cross-sectional areas of the hypoglossal and facial nerves matched well. Considering the reduction in the facial nerve cross-sectional area after paralysis, the post-descendens hypoglossal nerve can provide adequate axonal count and area to accommodate the facial nerve stump. Using the post-descendens hypoglossal nerve for side-to-end anastomosis with the mobilized intratemporal facial nerve is anatomically feasible and provides adequate axonal count for facial reanimation. When compared with use of the pre-descendens hypoglossal nerve, this technique preserves C1 fibers and has a potential to reduce glottic complications.

Suprazygomatic Aponeurotic McLaughlin Myoplasty for Facial Reanimation.

Suprazygomatic aponeurotic McLaughlin (SAM) myoplasty technique for facial reanimation is based on the classical McLauglin's lengthening temporalis myoplasty with a series of new modifications. A comprehensive review of previously described other orthodromic temporalis myoplasty techniques is also included to give a succinct comparison. Twelve adult patients of facial palsy underwent SAM myoplasty for a period of 4 years. Three had congenital facial palsy, 4 patients had facial palsy secondary to acoustic neuromas, 3 were posttraumatic, and 2 patients had Bell's palsy. Range of modiolus excursion achieved as measured at 3 months postoperatively on reanimation in our patients was 5 mm to 20 mm with an average of 12.6 mm. With SAM myoplasty technique, we were able to achieve excellent result in 4 patients and good results in 8 patients as evaluated with May and Druker scoring system. Suprazygomatic aponeurotic McLaughlin myoplasty for facial reanimation demonstrates a successful modification of the classical McLaughlin lengthening temporalis myoplasty, making it more customizable, simple, and predictable by taking the level of transection to the temporalis aponeurosis without the need for zygomatic osteotomy. A new classification of orthodromic temporalis myoplasty based on level of transections is also proposed for the first time. Good to excellent outcomes coupled with high patient satisfaction and low morbidity should make this technique popular among the facial reanimation surgeons.

Intraoral temporalis transposition for facial reanimation: A novel technique in facial nerve palsy

BackgroundFacial palsy patients require reconstructive surgery because they suffer from an expressionless and deformed appearance especially during smiling. To gain a natural smile, various dynamic procedures rather than static procedures are performed. Through cadaveric studies with clinical implications on temporalis muscle and intraoral transposition, we were able to come up with a more effective and less invasive procedure than the conventional temporalis muscle transposition or lengthening temporalis myoplasty. The aim of this study is to describe our novel surgical technique for facial reanimation and evaluate its efficacy. MethodTwo intraoral incisions were made. Through the posterior incision, the tendinous portion of the temporalis was separated from the coronoid process and anterior border of the ramus. Through the anterior incision, submucosa tunneling was performed to fixate the temporalis tendon onto the new perioral site. Results14 patients with facial palsy underwent intraoral temporalis transposition and their mouth corner excursion was measured for objective assessment after surgery. At resting state, mouth and cheek drooping was improved. At smiling, the excursion of the unaffected side was 10–17 mm. For the reconstructed side, 8 cases were considered excellent (exceeding 75% of normal side), 5 cases were considered good (exceeding 50%), and 1 case fair (exceeding 25%). ConclusionThis temporalis transposition through the intraoral approach is a novel technique for facial reanimation reconstruction. It is s less invasive, immediately effective method with rapid recovery and minimal donor site morbidity without visible scar. Level of evidenceIV.

Use of Objective Metrics in Dynamic Facial Reanimation: A Systematic Review.

Facial nerve deficits cause significant functional and social consequences for those affected. Existing techniques for dynamic restoration of facial nerve function are imperfect and result in a wide variety of outcomes. Currently, there is no standard objective instrument for facial movement as it relates to restorative techniques. To determine what objective instruments of midface movement are used in outcome measurements for patients treated with dynamic methods for facial paralysis. Database searches from January 1970 to June 2017 were performed in PubMed, Embase, Cochrane Library, Web of Science, and Scopus. Only English-language articles on studies performed in humans were considered. The search terms used were ("Surgical Flaps"[Mesh] OR "Nerve Transfer"[Mesh] OR "nerve graft" OR "nerve grafts") AND (face [mh] OR facial paralysis [mh]) AND (innervation [sh]) OR ("Face"[Mesh] OR facial paralysis [mh]) AND (reanimation [tiab]). Two independent reviewers evaluated the titles and abstracts of all articles and included those that reported objective outcomes of a surgical technique in at least 2 patients. The presence or absence of an objective instrument for evaluating outcomes of midface reanimation. Additional outcome measures were reproducibility of the test, reporting of symmetry, measurement of multiple variables, and test validity. Of 241 articles describing dynamic facial reanimation techniques, 49 (20.3%) reported objective outcome measures for 1898 patients. Of those articles reporting objective measures, there were 29 different instruments, only 3 of which reported all outcome measures. Although instruments are available to objectively measure facial movement after reanimation techniques, most studies do not report objective outcomes. Of objective facial reanimation instruments, few are reproducible and able to measure symmetry and multiple data points. To accurately compare objective outcomes in facial reanimation, a reproducible, objective, and universally applied instrument is needed.

Mixed facial reanimation technique to treat paralysis in medium-term cases

Recent facial paralyses, in which fibrillations of the mimetic muscles are still detectable by electromyography (EMG), allow facial reanimation based on giving new neural stimuli to musculature. However, if more time has elapsed, mimetic muscles can undergo irreversible atrophy, and providing a new neural stimulus is simply not effective. In these cases function is provided by transferring free flaps into the face or transposing masticatory muscles to reinstitute major movements, such as eyelid closure and smiling.In a small number of cases, patients affected by paralysis are referred late — more than 18 months after onset. In these cases, reinnervating the musculature carries a high risk of failure because some or all of the mimetic muscles may atrophy irreversibly while axonal ingrowth is taking place. A mixed reanimation technique to address this involves a neurorrhaphy between the masseteric nerve and a facial nerve branch for the orbicularis oculi, to ensure a stronger innervation to that muscle, associated with the transposition of the temporalis muscle to the nasiolabial sulcus. This gives good symmetry in the rest of the midface, while smiling movement is achievable, but not guaranteed. This one-time facial reanimation is particularly indicated for those who refuse major free-flap surgery or when that may be risky, as in previously operated and irradiated fields. More extensive procedures based on utilizing a free flap to recover smiling, while adding a cross-face nerve graft to restore blinking, may be proposed for motivated patients.Between 2010 and 2015, five patients affected by complete unilateral facial palsy underwent this technique in the Maxillofacial Surgery Department, San Paolo Hospital (Milan, Italy).Symmetry of the middle-third of the face at rest and recovery of smiling was quite good. Complete voluntary eyelid closure was obtained in all cases.Combining temporalis flap rotation and a masseteric-to-orbicularis-oculi-facial-nerve branch neurorrhaphy seems to be a valid solution for those medium-term referred patients.

Abstract: 15.20 Revisited Fascia Lata In Facial Palsy

INTRODUCTION: Fascia lata suspension for static surgical treatment of the nasolabial region in long-standing facial paralysis is well established. The objective of this study was to evaluate, from a retrospective viewpoint, the functional and cosmetic effectiveness of static suspension in facial paralysis by introducing a new way to insert the fascial graft in patients with different indications, such as: onset of paralysis, age, general conditions, etiopathogenesis, expectations, and combination with reanimation procedures. We considered the stability, in time, of the results of this ancillary procedure present in every facial reconstructive surgeonÕs armamentarium, and we thought it should be re-evaluated and utilized either alone or in combination with techniques that reanimate the paralyzed face. MATERIALS AND METHODS: In our series, 55 patients with facial paralysis underwent static suspension with fascia lata, advanced in the same fashion as the temporalis muscle in Labbé’s myoplasty, between February 2009 and November 2015. The surgical technique is reported together with preoperative and postoperative records (photographs and videos reviewed for feasibility of the technique), symmetry, aesthetic results. Complications, need for further minor revisions, patients degree of satisfaction and role in improvement of the facial reanimation techniques were also considered. RESULTS: In all the patients the procedure was uneventful and none developed surgery-related complications, including donor-site problems. During follow-up, all the patients achieved improved symmetry at rest and showed satisfaction. The cosmetic outcome was satisfactory, too. Eight patients needed small revision in local anaesthesia. CONCLUSIONS: The results show immediate, aesthetic, stable in time improvement, thus confirming this method as a simple technique for static restoration in patients who have lost any functional reconstructive possibility. The method also works in patients who underwent facial reanimation requiring slight aesthetic improvement. The application of the modified technique has led to a new appraisal and re-evaluation of an almost obsolete method.

A technique for facial reanimation: The partial temporalis muscle-tendon transfer with a fascia lata sling

This report describes the results of a surgical procedure for facial reanimation. This single-stage technique involves the orthodromic transfer of only a superficial segment of the temporalis tendon. This is extended with fascia lata to achieve elevation of the oral commissure along the desired vector in the paralysed hemi-face. A retrospective case note review was performed. Patients' photographs were objectively evaluated with Facial Assessment by Computer Evaluation (FACE) software. Thirty-nine patients underwent the procedure from 2001 to 2011. Median age at the operation was 57.0 years (interquartile range (IQR) 38.2-66.3 years), and median duration of follow-up was 0.9 years (IQR 0.5-1.8 years). All patients achieved early improvements in appearance and function after surgery. Three patients underwent further, minor procedures for aesthetic and functional adjustments around the oral commissure. Complications occurred in three patients: two minor facial haematomas and one thigh wound infection. The surgery did not disturb natural temporalis muscle function. FACE analysis demonstrated that no significant movement of the oral commissure occurred during attempted smiling in the paralysed hemi-face before surgery. However, symmetry was achieved when the healthy and paralysed hemi-faces were compared post-operatively, both in repose and during controlled smiling. This modified, single-stage technique for facial reanimation improves commissure mobilisation and has been objectively shown to restore symmetry of the commissure to the reanimated hemi-face.

Lower facial reanimation techniques following cancer resection and free flap reconstruction.

Evaluate outcomes of the standard static sling and orthodromic temporalis tendon transfer reanimation for facial nerve paralysis. Retrospective case series at a tertiary care hospital of head and neck cancer patients with facial nerve palsy secondary to malignancy or resection. From 2004 to 2014, patients undergoing resection of malignancy that involved facial nerve palsy requiring facial reanimation were identified. All procedures were performed by the senior author (e.l.r.). Demographics, methods, revision rates, combination with other procedures, and complications were evaluated. A total of 77 patients underwent 92 procedures, with two patients requiring more than one revision, for a total of 20 revisions. Average time to revision was 9 months. Age, sex, race, side of repair, paralysis prior to procedure, sling type or method, timing of procedure, and radiation therapy were not significantly different between those requiring revision and those who did not. There was no difference in complications between patients who received radiation and those who did not (P = .5), nor between static versus orthodromic temporalis muscle transfer (P = .5). Complication rate was low at 5.4%. Sling procedures can be successfully performed in patients with facial nerve palsy secondary to cancer resection with radiation therapy, with a low revision rate and few complications. 4 Laryngoscope, 126:1990-1994, 2016.

Facial Reanimation Technique for Facial Nerve Paralysis following Cancer Resection

Objectives: Analyze outcomes after static sling suspension and orthodromic temporalis tendon transfer reanimation for facial nerve paralysis after definitive cancer resection with flap reconstruction. Methods: Prospectively collected case series in which patient data were collected prospectively from 2004 to 2013 for patients undergoing reconstruction and facial reanimation after resection of malignancy which involved facial nerve sacrifice. Thirty patients were selected for 2 cohorts: static sling suspension (n = 18) and orthodromic temporalis tendon transfer (n = 12). Revision rates, length of stay, complications, time to follow-up, and postoperative symmetry were compared between the 2 groups. Results: Of the 30 patients, 18 underwent static suspension and 12 underwent temporalis tendon transfer. In the static sling group, 6 patients (33%) were advised to undergo revision compared with 2 in the temporalis tendon group (17%; P = .31). Only 4 patients underwent revision, 3 from the static group and 1 from the temporalis transfer group. Suture size, average number of sutures used to suspend the face, timing of procedure, radiation history, and flap reconstruction played no significant role between patients requiring revision surgery and those that did not. Of the patients requiring revision in the static sling group, 33% had undergone preoperative radiotherapy compared with 0% in the temporalis tendon transfer group ( P = .35). The remaining patients either underwent adjuvant therapy or were observed. Conclusions: There was no significant difference between the reconstruction methods. Static sling was performed more commonly at time of flap reconstruction.

Facial Functioning following Split XI‐VII Anastomosis

Objective: 1) Assess facial function in patients who underwent a split XII-VII nerve anastomosis for facial reanimation. 2) Review our series of 4 patients. 3) Present a facial recovery grading system for patients who undergo a combination of static and mimetic procedures for facial reanimation. Method: Patients were included with facial paralysis who were treated with XII-VII anastomosis at our institution between March of 2008 and December of 2011. Each patient’s facial function was evaluated using a new facial recovery grading scale that takes into account any method of static or mimetic facial reanimation techniques. Results: All 4 patients had complete facial paralysis prior to performing a split XII-VII anastomosis. All of the patients demonstrated gains in facial functioning without compromising their oral competence. This proposed facial recovery grading scale provides a means by which clinicians can follow gains in facial function in patients who lack an anatomically intact facial nerve. Conclusion: The split XII-VII nerve graft is a dynamic procedure that can assist in reanimating patients with facial nerve paralysis in whom the proximal facial nerve is not available. Patients in this group experienced minimal morbidity, maintained their oral competence, and demonstrated significant improvement in eye closure and midface animation.

Double innervation in free-flap surgery for long-standing facial paralysis

One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patient's ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch. Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve. All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noah's five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes. In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

Facial reanimation after nerve sacrifice in the treatment of head and neck cancer

This article reviews literature on the facial reanimation technique, from direct facial nerve repair and grafting to neuromuscular-free transplantation. The discussion will focus on the indications of the different approaches based on timing of the facial palsy and on patient's features. Facial nerve coaptation technique with masseteric nerve, babysitter procedures, and neuromuscular transplantation represent today the gold standard for facial reanimation after facial nerve sacrifice. Surgeon's experience and patient selection have to be considered as other important factors for surgical approach selection. Facial animation represents a difficult challenge for the reconstructive surgeon. A large number of surgical techniques and modifications have been published, and the appropriate approach must be selected based on the kind of facial palsy, its timing, and the patient's age, prognosis, and general condition. A complete grasp of all the approaches that allows for a target surgery represents today an essential assumption for the facial reanimation.

Facial animation in patients with Moebius and Moebius-like syndromes

Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterised predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. Facial paralysis causes inability to smile and 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. Other relevant clinical findings are incomplete eye closure and convergent strabismus. The authors report on 48 patients with Moebius and Moebius-like syndromes seen from 2003 to September 2007 (23 males and 25 females, mean age 13.9 years). In 20 cases a reinnervated gracilis transplant was performed to re-animate the impaired sides of the face. In this series, all free-muscle transplantations survived the transfer, and no flap was lost. In 19 patients complete reinnervation of the muscle was observed with an excellent or good facial symmetry at rest in all patients and whilst smiling in 87% of cases. In conclusion, according to the literature, the gracilis muscle free transfer can be considered a safe and reliable technique for facial reanimation with good aesthetic and functional results.