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Cross-facial nerve grafts and microneurovascular free muscle transfer for long established facial palsy
British Journal of Pfostic Surgery (19&a), 33, zoz-215 Q 19%
The Trusteesof BritishAssociation of PlasticSurgeons
CROSS-FACIAL NERVE GRAFTS AND MICRONEUROVASCULAR FREE MUSCLE TRANSFER FOR LONG ESTABLISHED FACIAL PALSY By BERNARDMcC. O’BRIEN, B.&z., M.D., M.S., F.R.C.S., F.R.A.C.S., F.A.C.S., JOHN D. FRANKLIN, M.D. andWAYNE A. MORRISON,F.R.A.C.S. Plastic Surgery and Microsurgery Research Units, St Vincent’s Hospital, Melbourne, Australia
The correction of the deformities caused by unilateral facial paralysis, whatever its aetiology, is a complex problem. No single procedure has been described to alleviate the various components of the palsy. The aims of facial reconstruction are to restore an aesthetic appearance at rest, symmetry during voluntary motion and, if possible, a satisfactory appearance with the expression of emotion (Freeman, 1977). Improved speech and mastication are also desirable. Early repair (within I year of injury) of the facial nerve or replacement of a resected segment by nerve graft often achieves reasonable success. Nerve transpositions utilising the hypoglossal, accessory or phrenic nerves are less satisfactory due to the lower success rate achieved, the mass movement produced, and the secondary deformity created by sacrifice of the donor nerve. Smith (1971) investigated the possibility of using a cross-facial nerve graft. He tunnelled a sural nerve transplant through the upper lip from the normal to the paralysed side, connecting buccal plexus to buccal plexus. Three to 6 months after operation he noted some decrease in paralysis; especially in terms of facial symmetry. Anderl (1973, 1978) simultaneously developed a modified technique with multiple cross-facial nerve grafts in 2 stages. Initially, the nerve was grafted to the normal facial nerve fasciculi and 3 to 4 months later the nerve graft was anastomosed to the nonfunctioning fasciculi on the opposite side of the face. This cross-facial nerve graft appears to be the procedure of choice for facial palsy of less than I year duration, when no direct union or grafting of the ipsilateral nerve is possible. In long-standing facial palsy where muscle atrophy has occurred, other reconstructive methods must be considered. A number of muscle transfers have been described in which muscles such as the masseter and temporalis are utilised. These require re-education of the patient and often produce unpleasant mass movements. Thompson (1971) advocated placing thin autogenous free muscle grafts on normally innervated muscle thus limiting their application and usefulness. The merits of this procedure are doubtful (Miller, 1978). Harii et al. (1976) reported 2 cases in which the gracilis muscle was used in the treatment of facial palsy. The gracilis vascular pedicle was joined to the superficial temporal vessels and a deep temporal nerve was anastomosed to the motor nerve of the gracilis. Satisfactory movement was obtained in the lower face, but there was an exaggerated asymmetrical movement when the jaws were clenched. In one case a myomectomy was necessary. A long powerful segment of gracilis was used with the superior attachment at the temporal level, and this length was probably responsible for the excessive movement. Address for reprints: Mr B. McC. O’Brien, Director, Microsurgery Research Unit, St Vincent’s Hospital, Melbourne 3065, Australia 202
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O’Brien (1977) reported a small series of cases in which some degree of facial moveA cross-facial nerve graft was performed ment was achieved in a z-stage procedure. initially and was followed in a few months by microneurovascular extensor digitorum Better facial support was provided as well as improved speech and brevis transfer. elimination of dribbling, but the strength of the transplanted muscle was inconsistent. The muscle has only a small excursion, it is not consistently revascularised in its upper segment and the nerve repair may be wasteful of cross-facial motor fibres. In this paper, we review the procedures performed in a group of patients with long-standing facial nerve palsy. The results of the transfer of 2 different muscles, extensor digitorum brevis and gracilis, are discussed. A feasible method of total reconstruction of unilateral facial nerve palsy is presented, CLINICALMATERIALSANDMETHODS In the past 5; years (December rg73-June 1979), 20 patients have undergone treatment of unilateral facial nerve palsy with 2-stage cross-facial nerve grafting and transfer of a free muscle with microneurovascular union. The aetiology of the paralysis is varied (Table I). Duration of the facial palsies ranged from 15 months to 40 years with a mean of 15.x years. There were 14 complete, and 6 incomplete palsies. In the latter 6, the lower face was primarily affected. The sides affected were almost equally distributed with g left and II right (Tables II and III). The surgical programme has been accomplished in 2 stages in all but 5 patients. The first stage consists of taking a sural nerve for cross-facial grafting. The second stage, 4 to 12 months later, involves the transfer of a muscle utilising microneurovascular techniques, Muscle transfer is performed several months after percussion of the terminal TABLE I Aetiology of long-established Postoperative Mastoid Parotid Acoustic neuroma Bell’s palsy C$i;zanat Skull fracture Infections
facial palsy 8 4 2 2 4 4 2 2 20
Total
TABLE
II Unilateral facial palsy Extensor Patient DE H”o :F FJL WA
digitorum
Duration of palsy 10 15 14 4 40 24 7 g
years months years years years years years years
brevis group Side Left Left Left Fe$; Left Right Right
Degree Incomplete Complete Incomplete Complete Incomplete Complete Complete Complete
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TABLE III Unilateral facial palsy Gracilis group Patient &? !zz LE ER zk :g GW
Duration of palsy 11 years 17 years 13 years 15 years 38 years 13 years 24 years 12 years 3 years 16 years 24 years 7 years
Side Fe;; eght % Right Left Left Right Right Right Right
Degree Incomplete Complete Complete Complete Complete Incomplete Complete Incomplete Complete Complete Complete Complete
neuroma of the graft produces a mildly painful sensation at the site of nerve union on the opposite side of the face (termed reversed Tine1 sign). This is attributed to the sensory fibres in the peripheral facial nerve growing down the nerve graft, derived from the facial nerve itself or possibly from the fifth cranial nerve. STAGE
I
Cross-facial nerve graft. A length of sural nerve, approximately 25 cm is taken from the leg through a series of small transverse incisions. An incision is made 1.5 cm lateral to the nasolabial line. Using the operating microscope, peripheral branches of the normal facial nerve, which control the upper and lower lips, and the angle of the mouth and the nose are identified in a deep plane under the facial muscles. Fasciculi are
FIG. I. Lower cross-facial nerve graft.
Stage I.
FiG. 2. Combined upper and lower cross-facial nerve grafts.
Stage I.
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selected for suturing, after ascertaining, by electrical stimulation, that the remaining The fasciculi of the reversed sural nerve fasciculi provide sufhcient facial animation. graft are sutured to selected fasciculi of the normal facial nerve (Fig. I). The nerve is reversed so that regenerating axones are not wasted along unused branches. The graft is passed across the chin to the opposite pre-auricular area where it is fixed with a single silk suture to the dermis. The graft is tunnelled at this low level to avoid later damage by the muscle transfer. Three patients have undergone, in addition, cross-facial nerve grafts from the zygomatic distribution of the functioning facial nerve. The grafts pass above the eyebrows and are attached to the dermis of the pre-auricular area (Fig. 2) of the opposite face near the end of the lower cross-facial nerve graft. Recently, a modified meloplasty incision has been utilised in performing the crossfacial nerve grafts. This technique allows better exposure and easier identification of the peripheral branches of the facial nerve anterior to the parotid gland. A modified face lift may also be performed in older patients. Experience has shown that facial nerve branches can be taken more proximally as in this case without weakening of the normal face. STAGE2 Free muscle transfer. In the first 8 patients in this series, an extensor digitorum brevis muscle was used in an endeavour to reanimate the paralysed face. A free gracilis microneurovascular transfer has been performed in 12 patients. The techniques utilised for both extensor digitorum brevis and gracilis transfer are described. Four to 12 months following the nerve graft, the paralysed face is opened through a modified meloplasty incision. The end of the nerve graft is identified. Using the operating microscope, the neuromatous end is resected and a segment of nerve is sent for histological examination. The nerve graft bleeds freely. The facial artery and vein are identified in the cheek just superficial to the lower border of the body of the mandible
FIG. 3.
Exposure
of the termination of 2 cross-facial external facial vessels
nerve grafts. The have been identified.
superficial
temporal
vessels
and
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TABLE
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IV
Results with extensor digitorum brevis transfer Operative stages
DB
Age at muscle transfer 46 years
FH
48 years
I
No
Comment Static effect only. Anastomosed deeply onto the hypoglossal Muscle not revascularised
g
14 years 16 years 62 years
2 2 2
Yes Yes Yes
Mild movement Mild movement Excellent movement
ML
28 years
2
Lost to
No follow-up
7 years g years
2 I
Kow-up Slight
Mild movement Long (16 cm) deep peroneal . nerve ^ . . joined to opposite racial nerve. Muscle survived but failed to reinnervate
Patient
%
I
Functioning muscles No
. ..
and anterior to the edge of the masseter muscle. artery and vein may be used (Fig. 3).
Alternatively,
Subsequent procedures None Blepharoplasty, face lift Fascia lata sling: Fascia lata sling Face lift, muscle biopsy Tendons tightened Plication of viable EDB muscle nerve biopsy
the superficial temporal
Extensor digitorum brevis. This technique has been previously described (O’Brien, 1977). Under tourniquet control, the extensor digitorum brevis of the contralateral foot is used as a donor muscle so that, when transferred to the face, the neurovascular bundle is inferior to the transplanted muscle. The extensor digitorum brevis is inserted into the face attaching the aponeurosis of the muscle to the fascia overlying the zygomatic arch and parotid gland. The tendons are brought down into the upper and lower lips, across the midline and to the angle of the mouth. The dorsalis pedis artery and one of the venae commitantes are sutured to the facial artery and vein, with IO/O atraumatic nylon. Some redirection of the facial vessels is usually necessary to achieve correct alignment. The nerve supplying the muscle is then attached with IO/O atraumatic nylon, in epineural fashion, to the previously inserted nerve graft from the opposite side of the face. In the early cases, the nerve supplying the muscle was dissected intraneurally in the foot and joined to the nerve graft. This union exhibited some size asymmetry as there were only 2 or 3 small fasciculi in the nerve of the muscle, while there was a larger number of fasciculi in the sural nerve. Subsequently, the deep peroneal nerve was dissected in the leg and the sural nerve graft in the face was joined to the transplanted deep peroneal nerve, achieving better fascicular satisfaction after repair. The distal unsatisfied fasciculi were then dissected, thrust into the lower muscle bellies, and fixed with one IO/O nylon suture. This was accomplished in order that any nerve regeneration The in the fasciculi might, in time, reinnervate some of the muscle belly directly. tendons were inserted tightly into the muscle of the opposite side of the lips and to the angle of the mouth, so that these areas were in an over-corrected position. Gracilis. The gracilis muscle from the contralateral thigh is used. The muscle is isolated through an obtuse angled incision in themedial thigh (Fig. 4). The longitudinal axis of the incision follows the adductor longus muscle from its easily palpable origin in the groin to its insertion behind the medial condyle of the femur. At the junction of the upper quarter and lower three-quarters the incision angles obliquely upward and laterally to the femoral vessels at the inguinal ligament. This incision exposes the
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anterior border of the gracilis and the angle at the junction of the upper quarter and lower three-quarters overlies the neurovascular pedicle. The subcutaneous fat and fascia are separated from the anterior surface of the muscle inferiorly and the neurovascular pedicle is identified superiorly and dissected. The pedicle is traced laterally under the adductor longus to the femoral vessels. There are usually I artery and 2 venae commitantes, although the veins most often terminate as a common tributary at the femoral or profunda vein. The vessels are divided at, or near, their origin and measure 5 to 7 cm in length. Vascular connections with the adductor longus and brevis are coagulated with a bipolar coagulator. The nerve to the gracilis, the anterior branch of the obturator nerve, is identified and traced to the obturator foramen, where it is transected to provide maximum length. Prior to division of the muscle, 2 silk sutures, one on either side of the neurovascular hilum are placed 5 cm apart along the anterior edge as an indicator for comparable tension after transfer to the face. The muscle is transected distally, after ensuring an adequate length. The gracilis aponeurosis attached to the pubis is divided proximally. The vascular pedicle is divided at, or near, its origin and the wound is closed with suction drainage. The gracilis is inserted in the face, deep surface uppermost, so that the microneurovascular union is performed superficially, the nerve union is close to the muscle,
FIG. 1. femoral
Skin markings for exposure of gracilis in the contralateral thigh. The incision begins over the vessels at the inguinal ligament and intersects the adductor line one-quarter to one-third the distance down the medial thigh.
FIG. 5.
Gracilis
muscle divided into segments for attachment and forehead.
to the upper and lower lips, nose, eyelids
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and the pulsation of the artery is usually detectable through the skin. When only the lower two-thirds of the face is paralysed, the proximal aponeurosis of the gracilis is sutured to the zygomatic and parotid fascia. The direction of pull of the muscle is upward and backwards. When the entire face is paralysed and there are obvious eyelid problems, a longer gracilis muscle is necessary and the scalp is undermined above the ear. The gracilis aponeurosis is then sutured to the temporal fascia well above the arch. The muscle is widely spread to prevent an appearance of undue bulk. For correction of lower facial palsy, the distal end of the muscle is separated bluntly into 3 tails of equal size which are sutured under maximum tension (Fig. 5). Two tails are attached to the orbicularis oris of the upper and lower lip just beyond the midline and at the angle of the mouth. The third tail is sutured to the deep tissues at the alar base of the nose. The muscle tails are placed through subcutaneous tunnels sufficiently wide to prevent compression and bunching of the muscle. Maximum tension is placed on each segment of muscle when it is sutured in place so that the distance between the 2 indicator sutures on the muscle is at least 5 cm. In complete facial palsy the gracilis is again divided into 3 segments using blunt dissection under loupe magnification with preservation of vessels and nerves. The lower two-thirds are attached as previously described. The upper one-third is divided into 3 Two are sutured together and to deeper tissues with adequate additional segments. tension at the medial canthus of the upper and lower eyelids and the third tail is attached to the dermis of the forehead above the upper nerve graft and the outer third of the eyebrows (Fig. 6). The microvascular anastomoses between the facial and gracilis vessels are performed with IO/O nylon, and the muscle is gradually vascularised in all its segments. The superficial temporal vessels are preferred for the gracilis revascularisation when a The nerve to the muscle is anastomosed with complete facial palsy is being corrected. IO/O nylon, in epineural fashion, to the previously inserted nerve graft. The gracilis nerve usually divides into 2 branches before entering the muscle with the branches When 2 cross-facial nerve grafts are supplying the superior and inferior segments. used, the fasciculi supplying the superior half of the muscle are attached to the supra-
FIG. 6.
Diagrammatic
sketch depicting total reconstruction with nerve grafts and vascular anastomosis to the facial vessels.
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orbital nerve graft. The fasciculi supplying the lower half of the gracilis are joined to the lower cross-facial nerve graft (Fig. 7). The pulsation in The facial wound is closed with a rubber drain placed inferiorly. the gracilis artery may be monitored with a Doppler probe or by palpation. The patient is followed in the ensuing months by periodic examination, electromyographic study, and biopsy of the transplanted muscle when possible.
RESULTS
Extensor digitorum brevis. Eight patients with unilateral facial palsy have had extensor digitorum brevis muscle transfers. Only 4 achieved any reinnervation of their transplanted muscle. The first free muscle transplant (DB) to the face was performed
FIG. 7.
Gracilis
muscle with its neurovascular
FIG.
Electron
photomicrograph is evident.
8.
bundle. Note the long nerve dividing before entry into the muscle.
of nerve grafts, 20 months postoperatively. Myelination Stained with Uranyl nitrate and lead citrate.
of the fibres
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on 18th December 1973. The descendens hypoglossi nerve in the neck was used as the donor nerve. No innervation of the muscle was observed in an electromyogram, after I year. However, static support to the face has been obtained which has been worthwhile. In the second case (FH), the dorsalis pedis artery was discovered to be absent and the perforating branch of the peroneal artery was probably the main source of blood supply to the dorsum of the foot. Although the neurovascular supply to the muscle was isolated, it was not possible to revascularise the muscle upon release of the tourniquet. Adequate static support has been achieved with tendinous slings. Further cosmesis has been obtained with a blepharoplasty and face lift. The first z-stage operation involving a cross-facial nerve graft and a microvascular extensor digitorum brevis transfer (HO) was carried out on 11th July 1974 (cross-facial nerve graft) and on 28th November 1974 (muscle transfer). One patient (ML) has achieved no useful function. A boy (WA) aged 9 years underwent a single stage nerve muscle transfer. A long (IS cm) segment of anterior tibial nerve was joined to the opposite facial nerve just lateral to the nasolabial line. Despite gross evidence of viable muscle, no reinnervation of the muscle was evident at subsequent operation at 20 months. A nerve biopsy at that stage showed reasonable myelinisation but little muscle activity was achieved (Fig. 8).
TABLE
V
Results with gracilis transfer Age at muscle transfer
Operative stages
Months since muscle transfer
AH
42 years
2
29
PK
20 years
28
Yes
MS
13 years
28
Yes
PW
52 years
2
19
Yes
EN
17 years
2
I7
Yes
ER MN
68 years 43 years
2 2
I3
12
Yes Yes
vc
65 years
2
9
Yes
MB EG
71 years 49 years
2
:
Yes Yes
LH
48 years
3
53
TETE
GW
40 years
2
I$
TETE
Patient
Subsequent procedures
Comments
TETE
Nearly normal motor function. Cannot move forehead. Independent movement either side of face Good movement paralysed side. Muscle almost too strong. Independent movement of gracilis Muscle function but not enough pull. Still had drooling prominent lower lip but has congenital athetoid movements Gaining strength, beginning to move entire right side of face Muscle adherent to upper lip with eversion. Independent movement of gracilis Movement in cheek Muscle adherent to upper lip with eversion. Independent movement of gracilis Movement of gracilis. Independent movement of gracilis Movement of gracilis First total correction with one lower cross-facial nerve graft. Early movement of gracilis First total correction with two cross-facial nerve grafts Total correction with two cross facial nerve grafts = Too early to evaluate.
None
Unilateral face lift, suspension of gracilis, muscle biopsy P&cation of gracilis, suspension of lower lip with fascia lata sling? unilateral face lift, diversion of saliva. Muscle biopsy
Release of gracilis from right upper and lower lip. Muscle biopsy. Release of gracilis from right upper and lower lip. Muscle biopsy
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An excellent result was obtained in I patient (JC). The paralysed lower two-thirds of the face is well re-animated with good balance. The corner of the mouth is elevated well, and he is able to whistle. Three other patients (HO, JW and DJ) have obtained some motion in their transferred muscle, but to a more limited degree. The results of free gracilis transfers have been more encouraging Gracilis. {Table 5). Two procedures are too recent to evaluate but the other IO patients, all 6 months or more after completion of the muscle transfer, have shown active gracilis Five of 8 patients, 9 months or more since transfer, have demonstrated movement. movement in the gracilis, independent of the opposite face. Progressive improvement in muscle function occurs for at least 2 years. Young patients reinnervate their muscle and achieve function more rapidly. The first patient (AH) to undergo free gracilis muscle transfer had her cross-facial nerve graft on 27th May 1976, and her muscle transfer on 18th November 1976. She demonstrates excellent correction of her palsy, 2 years postoperatively. She exhibits essentially normal function in the paralysed face, except for an inability to wrinkle her forehead and close her eyelids. She has developed excellent independent motion in the reconstructed face. Electromyographs of the transplanted muscle have shown progressive improvement with sequential investigations (Fig. 9).
FIG. 9. A. AH-preoperatively. B. AH--?4 months postgracilis go;tt, m repose.. . C. AH-24 transfer postgracilis demonstrating symmetry with smiling.
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FIG. IO. A. PK-preoperatively. 3. PK-23 months postoperatively, smil.ng. C. IX-23 months postoperatively zlemonstrating independent movement If the previously paralysed face.
PR, who had a gracilis transfer on 9th December 1976,has also developed independent motion in the transplanted muscle (Fig. IO). Twenty-two months after the muscle transplant the unilateral. face lift, suspension of the gracilis, and biopsy of the transplanted muscle were performed. ~~sto~ogi~~~y the muscle appeared essentially normal. (Fig. II) Sequential electromyographs have shown progressive innervation of the gracilis. The last electramyograph performed, on 5th May 1979, showed that the latency response had decreased from 22 to 11.5 milliseconds, consistent with increased myelination and enlargement of the nerve graft (Fig. 12). Three other patients (MS, EN, MN) have had secondary procedures and all have exhibited a large amount of innervated muscle. One patient (MS) required suspension of the gracilis due to a loosening of the parotid and temporal fascial attachments with a decrease in the effective excursion of the muscle. Two required detachment of the gracihs from the upper and lower bps to produce better symmetryThree patients have had total microneurovascular corrective procedures to the paralysed face. In addition to the usual lower lip, angle of the mouth, upper lip and nasal attachments, muscle was placed in the upper and lower eyelids as well as in the lateral third of the eyebrow, EG had a single cross-facial nerve graft. Five months later she developed early movem~t of the gracilis. The contractions were palpable in the entire muscle, with the right eyebrow showing the first significant movement. A
CROSS-FACIAL
FIG. II.
Transplanted
NERVE
gracilis muscle biopsied at
22
GRAFTS
months postoperatively-patient
213
PK.
FIG. 12. EMG upper line-no action potential in transplanted muscle with stimulation in region of left facial nerve. Lower line, action potential generated in transplanted gracilis muscle left side of face I 1.5 millisecs. after stimulation of right facial nerve-patient PK.
minimal amount of bulk from the ~~splanted gracilis is demonstrated under the skin of the right side of her face (Fig. 13), LH and GW had union of the zygomatic crossfacial nerve graft to the upper motor innervation of the gracilis and the transbuccal crossfacial nerve to the lower gracilis nerve. DISCUSSION
The use of the extensor digitorum brevis in facial palsy reinnervation is of limited value. Ins~cient active muscle remains after atrophy of non-rei~ervat~d muscle. This occurs primarily for 2 reasons. Firstly, the deep peroneal nerve is both motor and sensory, and an inadequate number of fascicles reach motor end plates. Secondly, the amount of muscle that does reinnervate is inadequate to produce acceptable facial These patients are being reviewed for consideration of a gracilis transfer. re-animation. Gracilis transfers have resulted in much better re-animation. Most patients
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FIG. 13. A. EG-5 months after gracilis transfer -for total palsy; note no evidence of muscle bulk. B. EG-eyes open. C. EG-eyes closed tightly; note right lateral eyebrow is now elevated indicating activation of the muscle transfer to the frontalis region.
demonstrate contraction of the transplanted muscle 4 to 5 months postoperatively. At I year, especially in younger patients, a more marked contraction of the transplanted muscle is noted. A final result may not be seen for 2 years-possibly longer. An unexpected asset in these patients is the development of independent movement of the previously paralysed face as early as IO months postoperatively. Initially the muscle may appear too bulky, but this decreases gradually in size over the first 12 months. Occasionally, the muscle may become loose and exert inadequate It may also become adherent and exert contraction thus requiring resuspension. excessive tension on the lip, requiring peripheral release. The muscle is spread more diffusely in the patients with total palsy and the question of bulk does not arise. No effective method for re-animation of complete unilateral facial palsy has previously been reported. Near total correction of the paralysed face with a gracilis muscle transfer, utilising I or 2 cross-facial nerve grafts, has now been achieved. Re-animation of the lower two-thirds of the face can produce adequate appearance at rest, symmetry during voluntary motion, and a satisfactory appearance with the expression of emotion. Some patients have developed better control of speech and mastication. Independent movement of segments of the transplanted gracilis develops and this may be an additional advantage if they are innervated separately. In addition to movement, the gracilis provides suspension and may possibly lead to ne~o~sation of underlying facial muscles. In the majority of patients under review, the
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interval between nerve graft and muscle transfer has been about 6 months. A longer interval may further aid better and more rapid muscle reinnervation. A gracilis transfer procedure is useful in congenital palsy, acquired palsy of more than I year’s duration, and facial palsy in which cross-facial nerve grafts have failed, provided that evidence of nerve regeneration is established by biopsy and/or a positive percussion sign. SUMMARY
Cross-facial nerve grafts followed in 4 to 12 months by microneurovascular free gracilis ~~spl~tation can produce adequate reconst~ction in the lower two-thirds of a paralysed face. The mixed sensory and motor deep peroneal nerve and the small muscle bulk of the extensor digitorum brevis limit its usefulness in facial palsy. The gracilis has proved to be a much superior muscle. A feasible method for total reanimation of unilateral facial palsy is presented. REFERENCES ANI>ERL? H. (1973). Reconstruction of face through cross face nerve transplantation in facial paralysis. Chirurgia Plusrica, 2, 17. ANDERL, H. (1978). Nerve repair and cross-over grafting in facial nerve palsy, in “Symposium on the Neurological Aspects of Plastic Surgery”, edited by Fredericks, S. and Brody, G., St Louis: C. V. Mosby Co., p. 259. FREEMAN, B. S. (1977). “Facial Palsy, in Reconstructive Plastic Surgery”, edited by Converse J. M., Philadelp~a, London and Toronto: W. B. Saunders Co, chapter 36. HARII, K., OHMORI, R. and TORII, S. (1976). Free gracilis muscle transplantation, with microneurovascular anastomosis for the treatment of facial paralysis. Plastic and Reconstructive Surgery, 57, 133. MILLER, T. A. (1978). Are free muscle grafts a viable reconstructive method? Plastic and Reconstructive Surgery, 62, 597. O’BRIEN, B. McC. (1977). Microvascular free muscle transfer, in “Microvascular Reconstructive Surgery, edited by O’Brien, B. McC. Edinburgh, London and New York: Churchill Livingstone, chapter 15. SMITH, J. W. (197r). A new technique of facial animation. Transactions of the Vth International Congress in Plastic Surgery. Melbourne: Butterworths, p_ 83. THOMPSON, N. (1971). Treatment of facial paralysis by free skeletal muscle grafts. Transactions of the Vth International Congress in Plastic and Reconstructive Surgery. Melbourne: Butterworths, p. 66
3312-F
The Trusteesof BritishAssociation of PlasticSurgeons
CROSS-FACIAL NERVE GRAFTS AND MICRONEUROVASCULAR FREE MUSCLE TRANSFER FOR LONG ESTABLISHED FACIAL PALSY By BERNARDMcC. O’BRIEN, B.&z., M.D., M.S., F.R.C.S., F.R.A.C.S., F.A.C.S., JOHN D. FRANKLIN, M.D. andWAYNE A. MORRISON,F.R.A.C.S. Plastic Surgery and Microsurgery Research Units, St Vincent’s Hospital, Melbourne, Australia
The correction of the deformities caused by unilateral facial paralysis, whatever its aetiology, is a complex problem. No single procedure has been described to alleviate the various components of the palsy. The aims of facial reconstruction are to restore an aesthetic appearance at rest, symmetry during voluntary motion and, if possible, a satisfactory appearance with the expression of emotion (Freeman, 1977). Improved speech and mastication are also desirable. Early repair (within I year of injury) of the facial nerve or replacement of a resected segment by nerve graft often achieves reasonable success. Nerve transpositions utilising the hypoglossal, accessory or phrenic nerves are less satisfactory due to the lower success rate achieved, the mass movement produced, and the secondary deformity created by sacrifice of the donor nerve. Smith (1971) investigated the possibility of using a cross-facial nerve graft. He tunnelled a sural nerve transplant through the upper lip from the normal to the paralysed side, connecting buccal plexus to buccal plexus. Three to 6 months after operation he noted some decrease in paralysis; especially in terms of facial symmetry. Anderl (1973, 1978) simultaneously developed a modified technique with multiple cross-facial nerve grafts in 2 stages. Initially, the nerve was grafted to the normal facial nerve fasciculi and 3 to 4 months later the nerve graft was anastomosed to the nonfunctioning fasciculi on the opposite side of the face. This cross-facial nerve graft appears to be the procedure of choice for facial palsy of less than I year duration, when no direct union or grafting of the ipsilateral nerve is possible. In long-standing facial palsy where muscle atrophy has occurred, other reconstructive methods must be considered. A number of muscle transfers have been described in which muscles such as the masseter and temporalis are utilised. These require re-education of the patient and often produce unpleasant mass movements. Thompson (1971) advocated placing thin autogenous free muscle grafts on normally innervated muscle thus limiting their application and usefulness. The merits of this procedure are doubtful (Miller, 1978). Harii et al. (1976) reported 2 cases in which the gracilis muscle was used in the treatment of facial palsy. The gracilis vascular pedicle was joined to the superficial temporal vessels and a deep temporal nerve was anastomosed to the motor nerve of the gracilis. Satisfactory movement was obtained in the lower face, but there was an exaggerated asymmetrical movement when the jaws were clenched. In one case a myomectomy was necessary. A long powerful segment of gracilis was used with the superior attachment at the temporal level, and this length was probably responsible for the excessive movement. Address for reprints: Mr B. McC. O’Brien, Director, Microsurgery Research Unit, St Vincent’s Hospital, Melbourne 3065, Australia 202
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O’Brien (1977) reported a small series of cases in which some degree of facial moveA cross-facial nerve graft was performed ment was achieved in a z-stage procedure. initially and was followed in a few months by microneurovascular extensor digitorum Better facial support was provided as well as improved speech and brevis transfer. elimination of dribbling, but the strength of the transplanted muscle was inconsistent. The muscle has only a small excursion, it is not consistently revascularised in its upper segment and the nerve repair may be wasteful of cross-facial motor fibres. In this paper, we review the procedures performed in a group of patients with long-standing facial nerve palsy. The results of the transfer of 2 different muscles, extensor digitorum brevis and gracilis, are discussed. A feasible method of total reconstruction of unilateral facial nerve palsy is presented, CLINICALMATERIALSANDMETHODS In the past 5; years (December rg73-June 1979), 20 patients have undergone treatment of unilateral facial nerve palsy with 2-stage cross-facial nerve grafting and transfer of a free muscle with microneurovascular union. The aetiology of the paralysis is varied (Table I). Duration of the facial palsies ranged from 15 months to 40 years with a mean of 15.x years. There were 14 complete, and 6 incomplete palsies. In the latter 6, the lower face was primarily affected. The sides affected were almost equally distributed with g left and II right (Tables II and III). The surgical programme has been accomplished in 2 stages in all but 5 patients. The first stage consists of taking a sural nerve for cross-facial grafting. The second stage, 4 to 12 months later, involves the transfer of a muscle utilising microneurovascular techniques, Muscle transfer is performed several months after percussion of the terminal TABLE I Aetiology of long-established Postoperative Mastoid Parotid Acoustic neuroma Bell’s palsy C$i;zanat Skull fracture Infections
facial palsy 8 4 2 2 4 4 2 2 20
Total
TABLE
II Unilateral facial palsy Extensor Patient DE H”o :F FJL WA
digitorum
Duration of palsy 10 15 14 4 40 24 7 g
years months years years years years years years
brevis group Side Left Left Left Fe$; Left Right Right
Degree Incomplete Complete Incomplete Complete Incomplete Complete Complete Complete
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TABLE III Unilateral facial palsy Gracilis group Patient &? !zz LE ER zk :g GW
Duration of palsy 11 years 17 years 13 years 15 years 38 years 13 years 24 years 12 years 3 years 16 years 24 years 7 years
Side Fe;; eght % Right Left Left Right Right Right Right
Degree Incomplete Complete Complete Complete Complete Incomplete Complete Incomplete Complete Complete Complete Complete
neuroma of the graft produces a mildly painful sensation at the site of nerve union on the opposite side of the face (termed reversed Tine1 sign). This is attributed to the sensory fibres in the peripheral facial nerve growing down the nerve graft, derived from the facial nerve itself or possibly from the fifth cranial nerve. STAGE
I
Cross-facial nerve graft. A length of sural nerve, approximately 25 cm is taken from the leg through a series of small transverse incisions. An incision is made 1.5 cm lateral to the nasolabial line. Using the operating microscope, peripheral branches of the normal facial nerve, which control the upper and lower lips, and the angle of the mouth and the nose are identified in a deep plane under the facial muscles. Fasciculi are
FIG. I. Lower cross-facial nerve graft.
Stage I.
FiG. 2. Combined upper and lower cross-facial nerve grafts.
Stage I.
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selected for suturing, after ascertaining, by electrical stimulation, that the remaining The fasciculi of the reversed sural nerve fasciculi provide sufhcient facial animation. graft are sutured to selected fasciculi of the normal facial nerve (Fig. I). The nerve is reversed so that regenerating axones are not wasted along unused branches. The graft is passed across the chin to the opposite pre-auricular area where it is fixed with a single silk suture to the dermis. The graft is tunnelled at this low level to avoid later damage by the muscle transfer. Three patients have undergone, in addition, cross-facial nerve grafts from the zygomatic distribution of the functioning facial nerve. The grafts pass above the eyebrows and are attached to the dermis of the pre-auricular area (Fig. 2) of the opposite face near the end of the lower cross-facial nerve graft. Recently, a modified meloplasty incision has been utilised in performing the crossfacial nerve grafts. This technique allows better exposure and easier identification of the peripheral branches of the facial nerve anterior to the parotid gland. A modified face lift may also be performed in older patients. Experience has shown that facial nerve branches can be taken more proximally as in this case without weakening of the normal face. STAGE2 Free muscle transfer. In the first 8 patients in this series, an extensor digitorum brevis muscle was used in an endeavour to reanimate the paralysed face. A free gracilis microneurovascular transfer has been performed in 12 patients. The techniques utilised for both extensor digitorum brevis and gracilis transfer are described. Four to 12 months following the nerve graft, the paralysed face is opened through a modified meloplasty incision. The end of the nerve graft is identified. Using the operating microscope, the neuromatous end is resected and a segment of nerve is sent for histological examination. The nerve graft bleeds freely. The facial artery and vein are identified in the cheek just superficial to the lower border of the body of the mandible
FIG. 3.
Exposure
of the termination of 2 cross-facial external facial vessels
nerve grafts. The have been identified.
superficial
temporal
vessels
and
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IV
Results with extensor digitorum brevis transfer Operative stages
DB
Age at muscle transfer 46 years
FH
48 years
I
No
Comment Static effect only. Anastomosed deeply onto the hypoglossal Muscle not revascularised
g
14 years 16 years 62 years
2 2 2
Yes Yes Yes
Mild movement Mild movement Excellent movement
ML
28 years
2
Lost to
No follow-up
7 years g years
2 I
Kow-up Slight
Mild movement Long (16 cm) deep peroneal . nerve ^ . . joined to opposite racial nerve. Muscle survived but failed to reinnervate
Patient
%
I
Functioning muscles No
. ..
and anterior to the edge of the masseter muscle. artery and vein may be used (Fig. 3).
Alternatively,
Subsequent procedures None Blepharoplasty, face lift Fascia lata sling: Fascia lata sling Face lift, muscle biopsy Tendons tightened Plication of viable EDB muscle nerve biopsy
the superficial temporal
Extensor digitorum brevis. This technique has been previously described (O’Brien, 1977). Under tourniquet control, the extensor digitorum brevis of the contralateral foot is used as a donor muscle so that, when transferred to the face, the neurovascular bundle is inferior to the transplanted muscle. The extensor digitorum brevis is inserted into the face attaching the aponeurosis of the muscle to the fascia overlying the zygomatic arch and parotid gland. The tendons are brought down into the upper and lower lips, across the midline and to the angle of the mouth. The dorsalis pedis artery and one of the venae commitantes are sutured to the facial artery and vein, with IO/O atraumatic nylon. Some redirection of the facial vessels is usually necessary to achieve correct alignment. The nerve supplying the muscle is then attached with IO/O atraumatic nylon, in epineural fashion, to the previously inserted nerve graft from the opposite side of the face. In the early cases, the nerve supplying the muscle was dissected intraneurally in the foot and joined to the nerve graft. This union exhibited some size asymmetry as there were only 2 or 3 small fasciculi in the nerve of the muscle, while there was a larger number of fasciculi in the sural nerve. Subsequently, the deep peroneal nerve was dissected in the leg and the sural nerve graft in the face was joined to the transplanted deep peroneal nerve, achieving better fascicular satisfaction after repair. The distal unsatisfied fasciculi were then dissected, thrust into the lower muscle bellies, and fixed with one IO/O nylon suture. This was accomplished in order that any nerve regeneration The in the fasciculi might, in time, reinnervate some of the muscle belly directly. tendons were inserted tightly into the muscle of the opposite side of the lips and to the angle of the mouth, so that these areas were in an over-corrected position. Gracilis. The gracilis muscle from the contralateral thigh is used. The muscle is isolated through an obtuse angled incision in themedial thigh (Fig. 4). The longitudinal axis of the incision follows the adductor longus muscle from its easily palpable origin in the groin to its insertion behind the medial condyle of the femur. At the junction of the upper quarter and lower three-quarters the incision angles obliquely upward and laterally to the femoral vessels at the inguinal ligament. This incision exposes the
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anterior border of the gracilis and the angle at the junction of the upper quarter and lower three-quarters overlies the neurovascular pedicle. The subcutaneous fat and fascia are separated from the anterior surface of the muscle inferiorly and the neurovascular pedicle is identified superiorly and dissected. The pedicle is traced laterally under the adductor longus to the femoral vessels. There are usually I artery and 2 venae commitantes, although the veins most often terminate as a common tributary at the femoral or profunda vein. The vessels are divided at, or near, their origin and measure 5 to 7 cm in length. Vascular connections with the adductor longus and brevis are coagulated with a bipolar coagulator. The nerve to the gracilis, the anterior branch of the obturator nerve, is identified and traced to the obturator foramen, where it is transected to provide maximum length. Prior to division of the muscle, 2 silk sutures, one on either side of the neurovascular hilum are placed 5 cm apart along the anterior edge as an indicator for comparable tension after transfer to the face. The muscle is transected distally, after ensuring an adequate length. The gracilis aponeurosis attached to the pubis is divided proximally. The vascular pedicle is divided at, or near, its origin and the wound is closed with suction drainage. The gracilis is inserted in the face, deep surface uppermost, so that the microneurovascular union is performed superficially, the nerve union is close to the muscle,
FIG. 1. femoral
Skin markings for exposure of gracilis in the contralateral thigh. The incision begins over the vessels at the inguinal ligament and intersects the adductor line one-quarter to one-third the distance down the medial thigh.
FIG. 5.
Gracilis
muscle divided into segments for attachment and forehead.
to the upper and lower lips, nose, eyelids
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and the pulsation of the artery is usually detectable through the skin. When only the lower two-thirds of the face is paralysed, the proximal aponeurosis of the gracilis is sutured to the zygomatic and parotid fascia. The direction of pull of the muscle is upward and backwards. When the entire face is paralysed and there are obvious eyelid problems, a longer gracilis muscle is necessary and the scalp is undermined above the ear. The gracilis aponeurosis is then sutured to the temporal fascia well above the arch. The muscle is widely spread to prevent an appearance of undue bulk. For correction of lower facial palsy, the distal end of the muscle is separated bluntly into 3 tails of equal size which are sutured under maximum tension (Fig. 5). Two tails are attached to the orbicularis oris of the upper and lower lip just beyond the midline and at the angle of the mouth. The third tail is sutured to the deep tissues at the alar base of the nose. The muscle tails are placed through subcutaneous tunnels sufficiently wide to prevent compression and bunching of the muscle. Maximum tension is placed on each segment of muscle when it is sutured in place so that the distance between the 2 indicator sutures on the muscle is at least 5 cm. In complete facial palsy the gracilis is again divided into 3 segments using blunt dissection under loupe magnification with preservation of vessels and nerves. The lower two-thirds are attached as previously described. The upper one-third is divided into 3 Two are sutured together and to deeper tissues with adequate additional segments. tension at the medial canthus of the upper and lower eyelids and the third tail is attached to the dermis of the forehead above the upper nerve graft and the outer third of the eyebrows (Fig. 6). The microvascular anastomoses between the facial and gracilis vessels are performed with IO/O nylon, and the muscle is gradually vascularised in all its segments. The superficial temporal vessels are preferred for the gracilis revascularisation when a The nerve to the muscle is anastomosed with complete facial palsy is being corrected. IO/O nylon, in epineural fashion, to the previously inserted nerve graft. The gracilis nerve usually divides into 2 branches before entering the muscle with the branches When 2 cross-facial nerve grafts are supplying the superior and inferior segments. used, the fasciculi supplying the superior half of the muscle are attached to the supra-
FIG. 6.
Diagrammatic
sketch depicting total reconstruction with nerve grafts and vascular anastomosis to the facial vessels.
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orbital nerve graft. The fasciculi supplying the lower half of the gracilis are joined to the lower cross-facial nerve graft (Fig. 7). The pulsation in The facial wound is closed with a rubber drain placed inferiorly. the gracilis artery may be monitored with a Doppler probe or by palpation. The patient is followed in the ensuing months by periodic examination, electromyographic study, and biopsy of the transplanted muscle when possible.
RESULTS
Extensor digitorum brevis. Eight patients with unilateral facial palsy have had extensor digitorum brevis muscle transfers. Only 4 achieved any reinnervation of their transplanted muscle. The first free muscle transplant (DB) to the face was performed
FIG. 7.
Gracilis
muscle with its neurovascular
FIG.
Electron
photomicrograph is evident.
8.
bundle. Note the long nerve dividing before entry into the muscle.
of nerve grafts, 20 months postoperatively. Myelination Stained with Uranyl nitrate and lead citrate.
of the fibres
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on 18th December 1973. The descendens hypoglossi nerve in the neck was used as the donor nerve. No innervation of the muscle was observed in an electromyogram, after I year. However, static support to the face has been obtained which has been worthwhile. In the second case (FH), the dorsalis pedis artery was discovered to be absent and the perforating branch of the peroneal artery was probably the main source of blood supply to the dorsum of the foot. Although the neurovascular supply to the muscle was isolated, it was not possible to revascularise the muscle upon release of the tourniquet. Adequate static support has been achieved with tendinous slings. Further cosmesis has been obtained with a blepharoplasty and face lift. The first z-stage operation involving a cross-facial nerve graft and a microvascular extensor digitorum brevis transfer (HO) was carried out on 11th July 1974 (cross-facial nerve graft) and on 28th November 1974 (muscle transfer). One patient (ML) has achieved no useful function. A boy (WA) aged 9 years underwent a single stage nerve muscle transfer. A long (IS cm) segment of anterior tibial nerve was joined to the opposite facial nerve just lateral to the nasolabial line. Despite gross evidence of viable muscle, no reinnervation of the muscle was evident at subsequent operation at 20 months. A nerve biopsy at that stage showed reasonable myelinisation but little muscle activity was achieved (Fig. 8).
TABLE
V
Results with gracilis transfer Age at muscle transfer
Operative stages
Months since muscle transfer
AH
42 years
2
29
PK
20 years
28
Yes
MS
13 years
28
Yes
PW
52 years
2
19
Yes
EN
17 years
2
I7
Yes
ER MN
68 years 43 years
2 2
I3
12
Yes Yes
vc
65 years
2
9
Yes
MB EG
71 years 49 years
2
:
Yes Yes
LH
48 years
3
53
TETE
GW
40 years
2
I$
TETE
Patient
Subsequent procedures
Comments
TETE
Nearly normal motor function. Cannot move forehead. Independent movement either side of face Good movement paralysed side. Muscle almost too strong. Independent movement of gracilis Muscle function but not enough pull. Still had drooling prominent lower lip but has congenital athetoid movements Gaining strength, beginning to move entire right side of face Muscle adherent to upper lip with eversion. Independent movement of gracilis Movement in cheek Muscle adherent to upper lip with eversion. Independent movement of gracilis Movement of gracilis. Independent movement of gracilis Movement of gracilis First total correction with one lower cross-facial nerve graft. Early movement of gracilis First total correction with two cross-facial nerve grafts Total correction with two cross facial nerve grafts = Too early to evaluate.
None
Unilateral face lift, suspension of gracilis, muscle biopsy P&cation of gracilis, suspension of lower lip with fascia lata sling? unilateral face lift, diversion of saliva. Muscle biopsy
Release of gracilis from right upper and lower lip. Muscle biopsy. Release of gracilis from right upper and lower lip. Muscle biopsy
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An excellent result was obtained in I patient (JC). The paralysed lower two-thirds of the face is well re-animated with good balance. The corner of the mouth is elevated well, and he is able to whistle. Three other patients (HO, JW and DJ) have obtained some motion in their transferred muscle, but to a more limited degree. The results of free gracilis transfers have been more encouraging Gracilis. {Table 5). Two procedures are too recent to evaluate but the other IO patients, all 6 months or more after completion of the muscle transfer, have shown active gracilis Five of 8 patients, 9 months or more since transfer, have demonstrated movement. movement in the gracilis, independent of the opposite face. Progressive improvement in muscle function occurs for at least 2 years. Young patients reinnervate their muscle and achieve function more rapidly. The first patient (AH) to undergo free gracilis muscle transfer had her cross-facial nerve graft on 27th May 1976, and her muscle transfer on 18th November 1976. She demonstrates excellent correction of her palsy, 2 years postoperatively. She exhibits essentially normal function in the paralysed face, except for an inability to wrinkle her forehead and close her eyelids. She has developed excellent independent motion in the reconstructed face. Electromyographs of the transplanted muscle have shown progressive improvement with sequential investigations (Fig. 9).
FIG. 9. A. AH-preoperatively. B. AH--?4 months postgracilis go;tt, m repose.. . C. AH-24 transfer postgracilis demonstrating symmetry with smiling.
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FIG. IO. A. PK-preoperatively. 3. PK-23 months postoperatively, smil.ng. C. IX-23 months postoperatively zlemonstrating independent movement If the previously paralysed face.
PR, who had a gracilis transfer on 9th December 1976,has also developed independent motion in the transplanted muscle (Fig. IO). Twenty-two months after the muscle transplant the unilateral. face lift, suspension of the gracilis, and biopsy of the transplanted muscle were performed. ~~sto~ogi~~~y the muscle appeared essentially normal. (Fig. II) Sequential electromyographs have shown progressive innervation of the gracilis. The last electramyograph performed, on 5th May 1979, showed that the latency response had decreased from 22 to 11.5 milliseconds, consistent with increased myelination and enlargement of the nerve graft (Fig. 12). Three other patients (MS, EN, MN) have had secondary procedures and all have exhibited a large amount of innervated muscle. One patient (MS) required suspension of the gracilis due to a loosening of the parotid and temporal fascial attachments with a decrease in the effective excursion of the muscle. Two required detachment of the gracihs from the upper and lower bps to produce better symmetryThree patients have had total microneurovascular corrective procedures to the paralysed face. In addition to the usual lower lip, angle of the mouth, upper lip and nasal attachments, muscle was placed in the upper and lower eyelids as well as in the lateral third of the eyebrow, EG had a single cross-facial nerve graft. Five months later she developed early movem~t of the gracilis. The contractions were palpable in the entire muscle, with the right eyebrow showing the first significant movement. A
CROSS-FACIAL
FIG. II.
Transplanted
NERVE
gracilis muscle biopsied at
22
GRAFTS
months postoperatively-patient
213
PK.
FIG. 12. EMG upper line-no action potential in transplanted muscle with stimulation in region of left facial nerve. Lower line, action potential generated in transplanted gracilis muscle left side of face I 1.5 millisecs. after stimulation of right facial nerve-patient PK.
minimal amount of bulk from the ~~splanted gracilis is demonstrated under the skin of the right side of her face (Fig. 13), LH and GW had union of the zygomatic crossfacial nerve graft to the upper motor innervation of the gracilis and the transbuccal crossfacial nerve to the lower gracilis nerve. DISCUSSION
The use of the extensor digitorum brevis in facial palsy reinnervation is of limited value. Ins~cient active muscle remains after atrophy of non-rei~ervat~d muscle. This occurs primarily for 2 reasons. Firstly, the deep peroneal nerve is both motor and sensory, and an inadequate number of fascicles reach motor end plates. Secondly, the amount of muscle that does reinnervate is inadequate to produce acceptable facial These patients are being reviewed for consideration of a gracilis transfer. re-animation. Gracilis transfers have resulted in much better re-animation. Most patients
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FIG. 13. A. EG-5 months after gracilis transfer -for total palsy; note no evidence of muscle bulk. B. EG-eyes open. C. EG-eyes closed tightly; note right lateral eyebrow is now elevated indicating activation of the muscle transfer to the frontalis region.
demonstrate contraction of the transplanted muscle 4 to 5 months postoperatively. At I year, especially in younger patients, a more marked contraction of the transplanted muscle is noted. A final result may not be seen for 2 years-possibly longer. An unexpected asset in these patients is the development of independent movement of the previously paralysed face as early as IO months postoperatively. Initially the muscle may appear too bulky, but this decreases gradually in size over the first 12 months. Occasionally, the muscle may become loose and exert inadequate It may also become adherent and exert contraction thus requiring resuspension. excessive tension on the lip, requiring peripheral release. The muscle is spread more diffusely in the patients with total palsy and the question of bulk does not arise. No effective method for re-animation of complete unilateral facial palsy has previously been reported. Near total correction of the paralysed face with a gracilis muscle transfer, utilising I or 2 cross-facial nerve grafts, has now been achieved. Re-animation of the lower two-thirds of the face can produce adequate appearance at rest, symmetry during voluntary motion, and a satisfactory appearance with the expression of emotion. Some patients have developed better control of speech and mastication. Independent movement of segments of the transplanted gracilis develops and this may be an additional advantage if they are innervated separately. In addition to movement, the gracilis provides suspension and may possibly lead to ne~o~sation of underlying facial muscles. In the majority of patients under review, the
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interval between nerve graft and muscle transfer has been about 6 months. A longer interval may further aid better and more rapid muscle reinnervation. A gracilis transfer procedure is useful in congenital palsy, acquired palsy of more than I year’s duration, and facial palsy in which cross-facial nerve grafts have failed, provided that evidence of nerve regeneration is established by biopsy and/or a positive percussion sign. SUMMARY
Cross-facial nerve grafts followed in 4 to 12 months by microneurovascular free gracilis ~~spl~tation can produce adequate reconst~ction in the lower two-thirds of a paralysed face. The mixed sensory and motor deep peroneal nerve and the small muscle bulk of the extensor digitorum brevis limit its usefulness in facial palsy. The gracilis has proved to be a much superior muscle. A feasible method for total reanimation of unilateral facial palsy is presented. REFERENCES ANI>ERL? H. (1973). Reconstruction of face through cross face nerve transplantation in facial paralysis. Chirurgia Plusrica, 2, 17. ANDERL, H. (1978). Nerve repair and cross-over grafting in facial nerve palsy, in “Symposium on the Neurological Aspects of Plastic Surgery”, edited by Fredericks, S. and Brody, G., St Louis: C. V. Mosby Co., p. 259. FREEMAN, B. S. (1977). “Facial Palsy, in Reconstructive Plastic Surgery”, edited by Converse J. M., Philadelp~a, London and Toronto: W. B. Saunders Co, chapter 36. HARII, K., OHMORI, R. and TORII, S. (1976). Free gracilis muscle transplantation, with microneurovascular anastomosis for the treatment of facial paralysis. Plastic and Reconstructive Surgery, 57, 133. MILLER, T. A. (1978). Are free muscle grafts a viable reconstructive method? Plastic and Reconstructive Surgery, 62, 597. O’BRIEN, B. McC. (1977). Microvascular free muscle transfer, in “Microvascular Reconstructive Surgery, edited by O’Brien, B. McC. Edinburgh, London and New York: Churchill Livingstone, chapter 15. SMITH, J. W. (197r). A new technique of facial animation. Transactions of the Vth International Congress in Plastic Surgery. Melbourne: Butterworths, p_ 83. THOMPSON, N. (1971). Treatment of facial paralysis by free skeletal muscle grafts. Transactions of the Vth International Congress in Plastic and Reconstructive Surgery. Melbourne: Butterworths, p. 66
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