Extratemporal Facial Paralysis

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RECONSTRUCTIVE SURGERY

Extratemporal Facial Paralysis Julia K. Terzis, MD, PhD, and Katerina Anesti, MD, MRCS

Purpose: This report summarizes our experience in the management of extratemporal facial paralysis with a variety of reconstructive techniques and explores those parameters which are considered to be useful in achieving better outcomes. Methods: In all, 56 patients with extratemporal facial paralysis were studied. All the patients had a mean follow-up of 5 years (SD: 3.5). Video evaluation was performed by 3 independent assessors at the required follow-up intervals. Results: The final median score for the partial facial paralysis group was significantly higher (4.175) compared with the complete facial paralysis (3.3), P ⫽ 0.007. In this series, the only other factor that appeared to influence the final outcome was the denervation time and not the age group, type of facial nerve injury, or method of repair. Conclusion: The concept of dynamic panfacial reconstruction with an individual and tailored to patient’s needs approach is demonstrated in all and particularly in bilateral cases. Key Words: extratemporal facial paralysis, facial palsy post head and neck tumors, facial palsy post vascular anomalies, facial palsy following iatrogenic lesions, facial paralysis following trauma, Bell palsy (Ann Plast Surg 2012;XX: 000 – 000)

E

xtratemporal facial palsy represents a common clinical problem, as the facial nerve is the most liable of all the cranial nerves to damage, partially because of its long anatomic course and its rather superficial location after its exit from the skull. Injury to the extratemporal facial nerve can occur as a sequela of road traffic accidents, gunshot wounds, as a result of direct invasion or compression from tumor growth, secondary to infectious diseases, or because of damage during surgical manipulations.1 The management of these injuries is dependent on a thorough understanding of facial nerve anatomy, nerve physiology, and microsurgical techniques.2 The goals of facial nerve reconstruction are to restore facial symmetry and voluntary control of the facial musculature, allow involuntary expression, and restore an adequate blink and eye protection. Several studies have assessed outcomes following extratemporal facial paralysis treatment and have demonstrated improvement in function and aesthetics.3–9 Correlation of demographic variables such as age, etiology, denervation time, type of repair with outcome has been inconclusive.3–9 The purpose of this report is to analyze the management of extratemporal facial paralysis, selectively with a variety of reconstructive techniques. The ultimate goal is to present our experience, highlight the etiology of this lesion, and explore the impact of the

Received August 25, 2011, and accepted for publication, after revision, August 29, 2011. From the Microsurgery Program, Division of Plastic and Reconstructive Surgery, Department of Surgery, Eastern Virginia Medical School, Norfolk, VA. This study has been approved by the Institutional Review Board at EVMS. Conflicts of interest and sources of funding: None declared. Reprints: Julia K. Terzis, MD, PhD, 700 Olney Ave, EVMS—LH—2055, Norfolk, VA 23501. E-mail: [email protected]. Copyright © 2012 by Lippincott Williams & Wilkins ISSN: 0148-7043/12/0000-0001 DOI: 10.1097/SAP.0b013e3182352221

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various factors that have influenced the outcomes, including age of the patients, denervation time, type of facial nerve lesion, and reconstructive strategy.

MATERIALS AND METHODS Population Dynamics The study received approval from the institutional review board of Eastern Virginia Medical School and followed its guidelines. Since 1979, facial nerve reconstruction and reanimation procedures were performed in 56 patients with extratemporal facial paralysis. In this study, 22 patients with established Bell idiopathic palsy were selected as a comparison group. Once facial paralysis is established in Bell palsy, the facial reanimation approach that is followed is the same as it would be in extratemporal paralysis.10 This concept gave us the opportunity to directly compare the outcomes of intratemporal with extratemporal facial paralysis, in 2 different groups with similar otherwise characteristics. The different causes of extratemporal facial nerve injury that we come across in our center included the following.

Tumors of Head and Neck Facial paralysis of neoplastic origin is uncommon, being estimated to represent etiology in approximately 5% of all cases.11 Neoplastic involvement may be by primary VII nerve tumor (ie, nerve schwannomas) or by secondary extrinsic neoplasm. Adequate clearance with preservation of the facial nerve is the prime objective, unless it is directly involved by malignancy.12 The management strategies of facial reanimation after tumor excision are determined by the tumor type (benign or malignant), the requirement of postoperative radiation, as well as the patient’s age and motivation. Tumor cure is always the first concern, overriding that of facial paralysis reconstruction. Exemplary case is presented in Figure 1.

Iatrogenic Injuries Facial nerve paralysis is a well-recognized complication of many cosmetic, orthognathic,13 and maxillofacial procedures in the head and neck. Although the incidence for most elective procedures is below 5%, it is so devastating that often can lead to litigation.14 Possible causes include electrocoagulation, intraneural injection of local anesthetic, ligatures or plication sutures, crushing by forceps, traction or transection, hematoma within the nerve sheath, and infection.15 However, injury to the facial nerve in rhytidectomy is reported in ⬍1% of the cases, and a spontaneous return of function in ⬎80% of these injuries has resulted within 6 months16 (Fig. 2).

Gunshot Wounds Gunshot wounds tend to cause more severe damage compared with other injuries because of the penetrating nature of the injury and the thermal tissue destruction. Optimal management of these wounds requires a systematic approach to recognize immediately life-threatening injuries while minimizing secondary damage and delayed complications. www.annalsplasticsurgery.com | 1

Terzis and Anesti

FIGURE 1. Example of facial palsy secondary to excision of branchial cyst. A 7-year-old girl presented in our office with left partial facial paralysis after extirpation of a left branchial cyst. The facial paralysis was evident postoperatively, and immediate exploration and repair of the injured facial nerve were attempted unsuccessfully. Appearance and smile at her first office visit, 19 months after the onset of her facial palsy (A). At the first stage, she had cross facial nerve grafts and 9 months later, secondary microcoaptations took place to selected branches of the left facial nerve. Her smile was augmented with a mini-temporalis transfer to the left commissure, and she also had a left eyebrow lift. Appearance and smile at her last office visit, 8 years later (B). The Panel graded her preoperative smile as 2 (fair) and 4 (good) at her final visit (patient 9, Table 7). In facial nerve injuries, although the reconstruction planning should start at the time of initial surgery, any extensive or complex reconstruction can be performed later17 (Fig. 3).

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FIGURE 2. Example of iatrogenic facial paralysis secondary to facelift. A 55-years-old woman presented with right partial facial paralysis secondary to an iatrogenic injury during a facelift procedure. Subsequently, she had several procedures elsewhere and presented to our center nearly 3 years later. Appearance and smile at her first office visit (A). During the first stage, a minitemporalis muscle was transferred to her right commissure and upper lip for smile augmentation, and an eye spring was placed on her right upper eyelid, whereas a mini-tendon graft was used to suspend her right lower eyelid. Three months later, she had adjustment of the eye spring and loosening of the lower eyelid tendon graft. Her right eye tearing was managed with an elliptical conjunctiva excision that achieved better opposition of the lower punctum against the globe. Appearance and smile at her last office visit (B). The Panel graded her pre-operative appearance as 4 (good) and 5 (excellent) at her final visit (patient 18, Table 5).

Bell Palsy Vascular Anomalies The biologic classification of hemangiomas and vascular malformations by Mulliken and Glowacki18 has not only simplified the terminology, but has also clarified their clinical behavior and treatment options. In general, the effective management of all vascular lesions in the head and neck requires a team approach, to understand their biologic behavior, complete the necessary diagnostic studies, and understand the benefits and limitations of interventional radiologic and surgical procedures.19 The synthesis of this knowledge can help determine the best treatment, and minimize complications, such as facial nerve injury (Fig. 4).

Motor Vehicle Accidents Motor vehicle collision has been the most common mechanism of craniomaxillofacial trauma for all age groups.20 Seat belts and airbags, in combination with legislations on road safety and restrictions on alcohol consumption, have significantly reduced the incidence of severe injuries.21 In cases with complex craniomaxillofacial defects, establishing an early surgical plan and proceeding with a staged reconstruction that addresses all defects is the most successful approach. The principles of preservation and restoration of skeletal buttresses are essential in achieving facial harmony.22 Provision of adequate bone support and soft-tissue envelope, followed by facial nerve reconstruction, can aid in regaining optimal function and cosmesis (Fig. 5). 2 | www.annalsplasticsurgery.com

Although the initial description by Sir Charles Bell in 1800 was related to facial paralysis caused by trauma, Bell palsy is the term commonly used to describe an acute peripheral palsy of unknown etiology. However, with the evolution of new diagnostic techniques, the terms Bell palsy and idiopathic facial paralysis are no longer considered synonymous.23 A herpes simplex-mediated viral inflammatory/immune mechanism has become widely accepted as the likely cause in most cases. Alternative postulated mechanisms of Bell palsy include ischemia of the facial nerve and genetic predisposition in some cases.24 Histopathology findings are consistent with an inflammatory and possible infectious cause25 that can potentially affect any level of the facial nerve, but the intratemporal portion appears to be the most vulnerable site.26 The charts of all patients were retrospectively reviewed to obtain demographic information. There were 66 adults (84.61%) with a mean age of 40 years (range: 18 –76), and 12 children (15.38%) with a mean age of 10 years (range: 1–16). Of these, 54 were females (69.23%) and 24 were males (30.76%). The right facial nerve was involved in 42 patients (53.84%), whereas the left in 31 patients (39.74%), and 5 patients (6.41%) presented with bilateral facial palsy. The main types of paralysis were iatrogenic (n ⫽ 21, 26.92%), motor vehicle accidents (n ⫽ 11, 14.10%), following head and neck tumor surgery (n ⫽ 11, 14.10%), vascular anomalies (n ⫽ 8, 10.25%), gunshot injuries (n ⫽ 5, © 2012 Lippincott Williams & Wilkins

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Extratemporal Facial Paralysis

FIGURE 3. Example of facial paralysis secondary to a gunshot injury to the right face. A 44-year-old woman with complete right facial paralysis as a result of a gunshot wound to her right face. She was shot at close range during an attempted burglary of her home. She was initially managed elsewhere with emergency tracheostomy; extensive debridement of all her wounds; and stabilization of maxillary, orbital, and mandibular Le Fort I and III fractures. Intraoperative appearance immediately after the gunshot injury (A). She subsequently required multiple procedures, including a free suprascapular flap to her right face. She presented to our center 8 years after the injury. Appearance and smile at her first office visit (B). In the first stage, she underwent exploration of the right facial nerve with a transmastoid approach. A left free gracilis muscle was transferred to her right cheek. The obturator nerve was coapted in an end-to-side manner on the facial nerve trunk at the site of an epineurial and perineurial window. Subsequently, she underwent multiple revisional surgeries, including a minitendon graft for suspension of her right lower eyelid, right facelift, and bilateral neck lifts and scar revisions. Appearance and smile at her last office visit, 6.5 years later (C). The Panel graded her preoperatively as 1.75 (fair) and 5 (excellent) at her final visit (patient 3, Table 3).

6.41%), and Bell palsy (n ⫽ 22, 28.20%). In 61 cases, the paralysis was partial (78.20%) and in 17 cases, it was complete (21.79%). Demographic characteristics are demonstrated in Tables 1 and 2, and analytic details of each group of facial paralysis patients are depicted in Tables 3 to 8. All the reconstructive operations were performed by the senior author. Surgical techniques of nerve grafting, free muscle transplantation, and rehabilitation procedures were performed as previously described.27 Three independent reviewers, not involved in the care of these patients, rated standardized videos pre- and postoperatively and at the final office visit, using the Terzis Functional and Aesthetic Grading System28 (Table 9). A minimum follow-up period of 6 months was selected for patients who underwent neurolysis, 12 months for direct facial nerve repair, 18 months for ipsilateral facial nerve grafting procedures, and at least 2 years after cross facial nerve grafts and/or after the muscle transfer. The surgical strategies used for reanimation of the upper, middle, and lower face are presented in Tables 10 and 11 and are illustrated in detail later in the text.

The Upper Face In all, 28 patients in this series (35.9%) required no intervention for eye support. Six cases of long-standing paralysis (7.7%) had a silent orbicularis oculi muscle (OOM) on needle electromyography (EMG). OOM substitution consisted of pedicled frontalis transposition in 1 case and pedicled temporalis in 2 cases, whereas 1 patient received a free-extensor digitorum brevis transfer, the upper slip of a free pectoralis minor was used in 1 case, and a split gracilis was used in another. In 20 patients (25.6%) with fibrillations in the OOM on EMG, and still viable but denervated muscle fibers in the eye sphincter, © 2012 Lippincott Williams & Wilkins

FIGURE 4. Example of facial paralysis secondary to extirpation of a vascular tumor. An 8-month-old child presented to our office with complete right facial paralysis, 6 months following extirpation of a hemangioma in the parotid area. Appearance while crying at her first office visit (A). She underwent exploration of the right facial nerve and required unroofing of the right mastoid, in order to identify a healthy proximal nerve stump, as the facial nerve was significantly scarred and fibrosed at the level of the stylomastoid foramen. Subsequently, the distal extratemporal branches of the right facial nerve were identified. There was a 3-cm gap between the proximal facial nerve stump and its distal branches. The defects were bridged with 5 interposition sural nerve grafts. Three years later, she required a second stage of reconstruction, for augmentation of the right eye blinking and smile. Two cross facial nerve grafts were employed, the upper graft neurotized the right upper and lower eye sphincter, whereas the lower graft was coapted to the zygomatic branches. Nine years later, due to changes with growth, chemodenervation of the left nasolabial fold took place with Botox injections. The right chin dimpling was also managed successfully with the same approach. Appearance and smile at her last office visit, 12 years later (B). The Panel graded her preoperatively as 2 (fair) and postoperatively as 5 (excellent) (patient 11, Table 5). www.annalsplasticsurgery.com | 3

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Terzis and Anesti

TABLE 2. Demographic Characteristics of Our Study Population Demographic Characteristics Side Right Left Bilateral

Gender 42 Female 31 Male 5

Age

Denervation Time

Grade

54 1–16 12 ⬍12 mo 18 Complete 24 16–40 41 12–24 mo 11 Partial ⬎40 25 ⬎24 mo 49

17 61

The Midface

FIGURE 5. Example of left facial paralysis secondary to a motor vehicle accident. A 23-year-old man presented to our center 5 months after severe trauma to his left face, from a motor vehicle accident. He was initially treated elsewhere with internal fixation of compound panfacial Le Fort III fractures and extensive soft-tissue debridements, and subsequently required multiple procedures for treatment of osteomyelitis and oronasal fistula. Appearance and smile at his first office visit to our center (A). He underwent exploration of the left facial nerve with unroofing of the mastoid, neurolysis of the cervicofacial division, and reconstruction of the frontozygomatic division with 5 interposition sural nerve grafts, 5 cm each. Three years later, a small segment of the left gracilis split in 2 slips was transferred to his left upper and lower eyelids, in order to substitute his left atrophic eye sphincter. The obturator nerve was coapted to a previously banked nerve graft from the superior aspect of the left facial nerve proximal stump. A pedicled vascularized superficial temporal fascia flap was transferred for improvement of the contour of his left zygoma and midface. At the same stage, he underwent further revisional surgery by the maxillofacial team that included release of left mandibular ankylosis, and calvarial bone graft to the left orbital floor. Appearance and smile at his last office visit, 3.5 years later (B). The panel graded his appearance as 1 (poor) preoperatively and 3 (moderate) at his last office visit (patient 5, Table 4). TABLE 1. Causes of Extratemporal Facial Paralysis 5 11 21 8 11 22 78

MVA indicates motor vehicle accidents.

direct neurotization (n ⫽ 6, 7.7%) or VII–VII transfer (CFNG secondary microcoaptations) (n ⫽ 14, 17.9%) was used to strengthen the eye sphincter. Of these 28 cases, 12 (15.4%) gained satisfactory results without further surgery. 4 | www.annalsplasticsurgery.com

The Lower Face In all, 45 patients (57.7%) did not require any intervention to the depressor mechanism. On the other hand, 15 patients (19.2%) had their function substituted by an ipsilateral pedicled platysma (n ⫽ 11) or anterior digastric (n ⫽ 4). In 18 patients (23%), with electrical activity on EMG but inadequate lower-lip excursion, function was augmented by means of direct neurotization (3), VII–VII transfer (5), and minihypoglossal transfer (10).

Statistical Analysis Analysis was performed with PC software (GraphPad Instat, La Jolla, CA). Unpaired t test and 1-way analysis of variance test were computed for comparison of 2 or more groups managed with different techniques. Mann-Whitney and Kruskal-Wallis nonparametric tests were used if normality test failed. Level of significance was chosen as P ⬍ 0.05.

RESULTS

Causes of Facial Paralysis Gunshot wounds MVA Iatrogenic (total) Vascular anomalies Head and neck tumors Bell palsy Total

The main strategy for smile restoration (65.4%) consisted of CFNG or nerve-grafting to an ipsilateral motor on the first stage, followed by a free muscle transfer in the second stage. Twelve patients with satisfactory results following CFNG and babysitter procedure respectively were complemented with a minitemporalis transposition to the oral commissure. Fifteen patients required revisional surgery for smile augmentation following the free muscle transfer with minitemporalis transposition. In 9 cases (11.5%), facial reanimation consisted of 2-stage VII–VII transfer.

The children had a mean follow-up of 7 years (SD: 5), which ranged from 3 to 14 years, whereas the adults had a mean follow-up of 4.6 years (SD: 4.2), which ranged from 1 to 21 years. At least 1 stage of revisions (median: 2, range: 1– 4) was required in 34 adults (51.5%) and 10 children (83.3%). A majority of patients who required ⬎1 additional stage were in the iatrogenic injuries (47.6%) and the Bell palsy (36.6%) groups, whereas 15 of them had previous attempts of reconstruction elsewhere. Video evaluation was performed in 66 patients whose assessments had available at the required follow-up intervals. The outcome scores improved in all patients, as demonstrated in Tables 12 and 13. Similar results were confirmed with the evaluation of the electromyographic studies. Bell palsy patients achieved equally good results as the rest of the population. For each type of reconstruction, a percentage gain score has been calculated comparing the preoperative and the final follow-up © 2012 Lippincott Williams & Wilkins

© 2012 Lippincott Williams & Wilkins

44

52

3

4

Mean (SD)

35.6 (11.8)

24

19

2

5

29

Age (y)

1

Case

M

M

F

M

F

Gender

Bil

L

R

L

L

Side

Partial

Complete

Complete

Complete

Complete

Grade

Gunshot injury during Vietnam war

L zygoma

High velocity missile

Bullet transected nerve at stylomastoid foramen Shot at close range during attempted burglary at home

Alleged assault, gunshot wounds Head ⫹ abdomen

Mechanism of Injury

93.8 (145.7)

346

2

92

2

27

Dnt (mo)

TABLE 3. Demographic Variables of Patients With Gunshot Wounds

L condyle, zygomatic arch, mandibular ramus Secondary mandibular ankylosis and malunion Bone and soft tissue injuries to lower face

Partial (R) V injury (IFO, inferior alveolar)

Gunshot wounds R face, R forearm, L thigh, chest

(Total 25 procedures) Karapandzic repair Staged scar excisions ⫹ revisions ⫹ several muscle ⫹ bone grafts

Evacuation of intracerebral hematoma Debridement of L temporal lobe Primary wound exploration ⫹ debridement Tracheostomy, wound debridement, MaxOrbital-Mandibular stabilization (40 operations in total) ORIF R zygoma, orbital floor, Le Fort I Suprascapular free flap to face Multiple revisions L neck wound exploration ⫹ application Dental arch bars

L cornea scarring

R hemiparesis, expressive aphasia (L) V, X, XII nerves

Splenectomy

Previous Surgery

Loss of hearing

Associated Injuries

49.4 (64.4)

150

6

78

0

13

Follow-Up (mo)

4.25

2.25

1.75

1.25

Preoperative Score

5

4

5

3

Postoperative Score

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28

19

40

33

31

5

6

7

8

9

Mean 29.8 (6.7) (SD)

36

34

4

11

25

3

34

29

2

10

19

Female

Female

Female

Female

Female

Male

Male

Female

Female

Female

Male

R

R

Roof of car hit his L cheek

Mechanism of Injury

Riding motorcycle w/o helmet ⫹ hit car

Partial

Partial

Partial

Partial

Partial

Front seat passenger, car lost control and hit an obstacle

While driving a truck, she struck the porch of a house head on

Car lost control, pt was thrown out and hit guardrail

Head on collision with a pick up truck

Head on collision with snow plow

Trunk slipped on icy road

Complete Unrestrained front seat passenger, jeep overturned, Pt hit head to the gravel road, no LOC

Partial

2 car head on collision pt thrown out through windshield Complete Thrown out of a jeep, propelled through the windshield

Partial

Partial

Grade

Bil Partial

R

L

R

L

R

R

L

L

Age (y) Gender Side

1

Case

30.4 (42.2)

17

16

147

19

14

25

2

4

66

16

9

Dnt (mo)

59

Primary ORIF mandible ⫹ repair facial lacerations

37 (19.4)

65

50

32

46

21

39

45

38

3

10

3.5

4

4

2.5

1

11

4.5

4.5

2.5

5

5

5

3

3

3

5

5

3

Follow-Up Preoperative Postoperative (mo) Score Score

Repair of extensive soft tissue injuries⫹ ORIF facial

Penetrating wound L cheek closed primarily

Primary debridement ⫹ repair of all wounds

Previous Surgery

Stab C spine, tracheostomy ORIF LeFort III, Repair facial lacerations Maxillectomy of osteomyelitic bone ⫹ closure oral fistula Avulsion R side of face, facial Tracheostomy, ORIF facial Repair Facial N with GAN graft L cheek laceration Primary debridement ⫹ repair of all wounds Liver laceration, R wrist, R scapula, R 2–3–4 ribs, R foot Multiple facial lacerations, Tracheostomy, repair facial facial , nose lacerations, reduction facial, multiple scar revisions, fat Decreased sensation at V inj, chin implant distribution R supracondylar, zygomatic, ORIF zygoma, Iliac BG defect nasal bridge Correction of bil enopthalmos⫹ telecanthus, R lacrimal duct ⫹ R upper eyelid ptosis Forehead laceration R TMJ arthrogram (limited mouth opening): displaced Nasoorbital defect TMJ meniscus with Multiple facial fractures: R perforation maxillary, R orbital, frontoethmoidal sinus Bil mandibular condyles, nasal Tracheostomy, ORIF R bones, R mandible, R zygoma⫹ orbital floor, orbital floor, R zyg arch, R exploration R facial N maxilla Extensive soft tissue injury ORIF mandible, correction lip defect Hemifacial atrophy Multiple revisions

Multiple facial lacerations ⫹ fractures, Le Fort III R forearm laceration, humerus Hemifacial atrophy Multiple facial lacerations ⫹ comminuted R mandible, linear R temporal bone Panfacial open Le Fort III extensive facial lacerations: Laceration L nasolacrimal apparatus

Avulsion of parotid duct Parotid gland laceration Transection of facial muscles Head injury, L cheek laceration

Associated Injuries

TABLE 4. Demographic Variables of Patients With Motor Vehicle Accidents (MVA)

Terzis and Anesti Annals of Plastic Surgery • Volume XX, Number XX, XXX 2012

© 2012 Lippincott Williams & Wilkins

© 2012 Lippincott Williams & Wilkins

35 1 34

10 11 12

30

62 54

8 9

15

54

7

45

18 40

5 6

14

16

4

31

44 22 66

1 2 3

13

Age (y)

Case

F

M

F

F F F

F F

M

F M

F

F F F

Gender

R

R

R

L R R

L Bil

L

R R

L

R L L

Side

Partial

Partial

Partial

Partial Complete Partial

Partial Partial

Complete

Partial Partial

Partial

Partial Partial Partial

Grade

Submandibular cyst

I and D (R) cheek infection

Hemangioma

Parotidectomy Parotid hemangioma Hemangioma

Parotidectomy Parotidectomy

Pleomorphic adenoma parotid

Mandibular osteotomies Dental procedure

Mandibular osteotomies

TMJ exploration TMJ surgery Le Fort I osteotomy

Cause

6

10

376

62 6 405

432 358

303

20 78

20

5 0.3 54

Dnt (mo)

TABLE 5. Demographic Variables of Patients With Iatrogenic Injuries

Frey syndrome

(R) VIII nerve ⫹ taste loss

L infraorbital nerve neuroma Malocclusion (she will also require chin augmentation)

Associated Injuries

TFL sling to R commissure Oral encircling band R lower eyelid metal spring R commissure with Dacron sling Fascia graft to R commissure Release R commissure

R facial N decompression 6 procedures for rec. tumors: GAN graft, SM flap ⫹ abd fascia, GW L rhytidectomy ⫹ NSLFold resection CFNG ⫻ 2 Multiple stage revisions Lat canthoplasty TFL graft R commissure Z plasty R medial canthus Bil facelift

R oral antral fistula

Previous Surgery

20

3

70

23 148 36

32 59

40

262 94

44

10 25 61

Follow-Up (mo)

3

2

2 2.5

2.75 3.75

1

3.5 1.5

4

0.5 4.25 4

Preoperative Score

2 (Continued)

4

5 3

3 5

3

5 3

5

3 4.5 4

Postoperative Score

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Annals of Plastic Surgery • Volume XX, Number XX, XXX 2012

49.8 (59.3)

2.5 Facial Nerve reconstructed primarily with NG from cervical plexus

30

4

5 4.5 4 3.5 Facelift

6 31 12 5

3 2 34 Pec major ⫹SM flap reconstruction Resection Ac neuroma ⫹ XII-VII Temporalis sling ⫻2 to R commissure Platysma sling

Preoperative Score

median scores. Results are presented in Tables 14 to 17, with the associated P values. Age, type of facial nerve injury, and method of repair did not affect the final outcome. Patients with complete facial paralysis had a higher percentage gain comparing with patients with partial facial paralysis (Table 14). However, the overall final median score was significantly better in the partial paralysis group (P: 0.0007). The other factor that appeared to affect the final outcome was the denervation time (Table 15). The group of ⬍12 months denervation achieved better percent gain compared with the 12 to 24 months group and the patients who had ⬎24 months denervation time (P: 0.0493).

Complications In only 1 adult case, there was a free flap loss because of vein graft thrombosis. Salvage attempts failed, and he subsequently required debridement of the free flap and reconstruction with a free gracilis flap 1 year later. The final outcome was satisfactory. In this series, 15 of the 23 patients with Bell palsy (65%) presented with signs of facial synkinesis preoperatively. The symptoms improved clinically in 10 of these, whereas 5 had some minor degree of residual synkinesis in the last office visit. The only other group of patients (n ⫽ 4) that demonstrated some minor synkinesis were patients with long-standing facial paralysis and more proximal lesions, but they all improved following reconstructive procedures.

DISCUSSION

197.5 (223.1)

18 Postfacelift Hematoma I and D

Mean (SD)

43.4 (19)

F 72 21

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Type of Repair Malik et al in 20057 compared the outcomes of following 3 surgical techniques used in the rehabilitation of the paralyzed face: end-to-end anastomosis, cable graft interposition, and hypoglossalfacial transposition, in 66 patients. End-to-end coaptation had the best facial function, followed by cable nerve graft interposition and then hypoglossal-facial transposition. Overall, increasing age was associated with a poorer outcome. Terzis and Noah in 199727 also reported that younger patients achieved earlier functional recovery. In our study, age group, type of facial nerve injury, and method of repair did not affect the final outcome. Children achieved a better percentage gain compared with adults, but the outcome difference between the groups was not significant (P: 0.5918). One possible explanation can be the small number of patients in the different types of extratemporal facial paralysis group.

Denervation Time

L

Partial

3 23 0.5 4 Facelift Facelift Postfacelift full ⫹ SMAS Facelift Partial Partial Partial Partial 67 55 50 55 17 18 19 20

F F F F

L R R R

Excision of SCC (R) cheek 61

F

R

Partial

61

Although it is difficult to compare outcomes of the different techniques used because of the small sample sizes, some important points should be highlighted.

16

Gender Age (y) Case

TABLE 5. (Continued)

Side

Grade

Cause

Dnt (mo)

Associated Injuries

Previous Surgery

Follow-Up (mo)

Postoperative Score

Terzis and Anesti

After a retrospective review of 72 facial palsy patients (54% of extratemporal etiology), Bascom et al in 20004 concluded that denervation time, type of injury, and method of repair did not affect the outcome. Only patients with neoplastic etiology tended to have poorer results. Pillsbury and Fisch9 reported on 19 patients with extratemporal facial palsy who were managed with nerve grafting and who had worse results following radiation treatment. The age and denervation time did not affect the final outcome. In our series, the group of ⬍12 months denervation achieved a better percent gain compared with the 12 to 24 months group and the patients who had ⬎24 months denervation time (P: 0.0493). © 2012 Lippincott Williams & Wilkins

© 2012 Lippincott Williams & Wilkins

16 31

10

14

6

1

3 4

5

6

7

8

18 (12.9)

29

2

Mean (SD)

37

Age (y)

1

Case

M

F

M

M

M F

F

F

Gender

R

L

R

R

R R

R

R

Side

Complete

Partial

complete

complete

Partial Partial

Partial

Partial

Grade

Infected cystic hygroma R neck/mastoid area

Giant lymphangioma

Cystic hygroma

Cystic hygroma

Hemangioma Lymphangioma

Hemangioma

Parotid hemangioma

Cause

156.6 (113)

12

64

167

113

199 351

268

79

Dnt (mo)

Bil XII palsy

Partial (R) XII

Associated Injuries

Resection tumor with SM/Omohyoid Re-exploration R neck

Lymphangioma reexcision at age 4 and 5 Lat tarsorrhaphy ⫹ fascia sling to mouth R mastoid exploration, R buccal nerve transfer R rectus abd free to R face, further exc Temporalis sling, Tarsorrhaphy Masseter transfer Gold weight GAN graft 5 cm CFNG Expl R Facial N L thoracostomy, gastrostomy Laser ⫹ debulk lymphangioma L cheek/ neck Expl L Facial nerve I and D

R blepharoplasty ⫹ facelift R sup parotidectomy ⫹ resection of hemangioma Hemangioma resection when 1 y old ⫹ radiation implant

Previous Surgery

TABLE 6. Demographic Variables of Patients With Facial Palsy Following Resection of Vascular Lesions

65.4 (48.5)

32

50

65

169

68 93

18

28

Follow-Up (mo)

2.5

4

3

2.5

3.5 3

2

2.5

Preoperative Score

4.5

3.5

4

4

5 4

5

4

Postoperative Score

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34

53 51

53

38

35

7 26 56

3

4 5

6

7

8

9 10 11

36.5 (116.7)

11 38

1 2

Mean (SD)

Age (y)

Case

F M M

M

F

F

F F

M

F F

Gender

L R L

L

R

R

R L

R

L L

Side

Partial Complete Complete

Partial

Complete

Complete

Partial Partial

Partial

Partial Partial

Grade

Superficial parotidectomy Superficial parotidectomy Abscess submandibular gland Brachial cyst Ewing sarcoma SCC maxilla

Parotid tumor Parotidectomy

Mixed parotid tumor

Parotid hemangioma Parotid Angioendothelioma

Cause

116.4 (158.7)

19 31 11

25

1

2

31 362

220

129 449

Dnt (mo)

Maxilla bone ⫹ softtissue deficit

Sensory deficit at upper inframandibular area

Frey syndrome

Associated Injuries

Hemimaxillectomy

Bil upper/lower blepharoplasties myectomy R frontalis ⫹ procerus TFL sling, bil facelift, scar revisions

Eye spring Subperiosteal cheek lift, TFL sling Multiple procedures for recurrence Radical parotidectomy Ant masseter transfer

Previous Surgery

TABLE 7. Demographic Variables of Patients With Facial Paralysis Following Resection of Head and Neck Tumors

66.5 (57.9)

99 4 39

35

58

31

75 42

64

60 224

Follow-Up (mo)

2

4.5

2

1

3 4.5

1

2 1

Preoperative Score

4

5

4

4

4 5

4

3.5 3

Postoperative Score

Terzis and Anesti Annals of Plastic Surgery • Volume XX, Number XX, XXX 2012

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© 2012 Lippincott Williams & Wilkins

8 43

31 41

28 55

47

24 34

49 16 22 38

30 29 37

42 43

44 46

47 48

49

51 52

53 54 55 68

71 72 50

35.3 (15.2)

16 23 55

38 39 40

Mean (SD)

75 39 36

Age (y)

34 35 36

Case

F M F

M F M F

F F

M

F F

M F

M F

F F M

F F F

Gender

R L R

R L R L

R L

R

L R

R L

R L

L R Bil

L R R

Side

Partial Complete Partial

Partial Partial Partial Partial

Partial Partial

Complete

Partial Partial

Partial Partial

Partial Partial

Partial Partial Partial

Partial Partial Partial

Grade

127.2 (112.5)

21 130 87

65 162 131 3

269 99

85

29 436

346 123

38 207

78 257 49

11 91 82

Dnt (mo)

TABLE 8. Demographic Variables of Patients With Bell Palsy

Synkinesis, other cranial nerves involved (R) XI, XII, X Synkinesis Crocodile tears Synkinesis

Synkinesis

Synkinesis

Synkinesis Synkinesis

Synkinesis Synkinesis

Synkinesis Synkinesis

Synkinesis Synkinesis Cranial nerves involved: (L) V, XII, XI Synkinesis

Associated Clinical Findings

Fascia sling R commissure, R brow lift, cartilage graft tip of nose Revision fascia sling R temporal scar

Bil upper blepharoplasty Scar revisions

TFL sling to R commissure, Bil upper/lower blepharoplasty Decompression Facial Canal CFNGx3 Medial tarsorrhaphy

L temporal mastoidectomy muscle sling L face facelift x2, Revisions

Decompression facial canal, temporalis L lip, R depressor myectomy, R Frontal neurectomy, risorius myectomy

Canthoplasty/ tighten lower eyelid ⫹ tarsorrhaphy

Bil lower lid blepharoplasty

Previous Surgery

65.8 (39.6)

104 83 80

107 64 100 99

45 147

61

17 39

28 25

153 31

47 42 80

19 30 46

Follow-Up (mo)

3 0.5 2.25

0.5

3 1.5

4 2

0.5

2.5

2.75

3.5 3.5

0.5 1 3

3 4.5 4.5

Preoperative Score

3 4 5

3.25

5 5

5 4.5

2

3.5

4.5

5 5

2 3 5

4 3.5 5

Postoperative Score

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Synkinesis Facial synkinesis is an extremely distressing sequela of facial paralysis, and its prevention and treatment are less than adequate. Yamada et al29 investigated the incidence of facial synkinesis after compression injury in an animal experimental model. They documented that only the intratemporal lesions resulted in synkinesis and reorganization of the facial nucleus, in contrast with the extratemporal lesions.

TABLE 9. Terzis Grading System of Facial Paralysis and Reconstruction Group

Grade

Result

I II

1 2

Poor Fair

III

3

Moderate

IV V

4 5

Good Excellent

Description Deformity, no contraction No symmetry, bulk, minimal contraction Moderate symmetry and contraction, mass movement Symmetry, near full contraction Symmetrical smile with teeth showing, full contraction

Yamamoto et al in 198830 investigated the occurrence of sequelae in Bell palsy. The authors found synkinesis in 93.3% of the patients with some kind of sequelae in Bell palsy. Moran and Neely in 199631 postulated that synkinetic patterns appear predictable and nonrandom. Of the 3 pathogenesis hypotheses—aberrant fiber regeneration, ephaptic transmission between adjacent axons, and nuclear hyperexcitability—the first has had the most general acceptance.32–34 In experimental studies,3 synkinesis was more prevalent in autologous nerve grafting than in tubulization experiments. The regenerating nerve model with tubulization created a more controlled environment and reduced the neural arborisation with collateral axons. Better understanding of these patterns will lead to more effective therapeutic interventions. In our series, the introduction of new functional motor fibers, from the contralateral normal facial nerve with cross facial nerve grafts, that were subsequently used for direct neurotization and/or free muscle transfer resulted in a more coordinated and spontaneous animation, with almost complete resolution of the synkinesis.

Type of Injury Another area that presents a challenge in the application of facial reanimation procedures are the patients with extensive cran-

TABLE 10. Patient Distribution by Number of Stages/Procedures Patients (%) 2 (2.5%) 6 (7.7%) 13 (16.7%) 7 (9%) 5 (6.4%) 32 (41%) 12 (15.4%) 1 (1.3%)

Stage 1

Stage 2

Add. Stages

Direct coaptation Microneurolysis Nerve graft to VII trunk or branches Mini XII to main VII transfer CFNG CFNG/IPNG Ips. M. donor CFNG CFNG

Secondary microcoaptations Free muscle for smile ⫹/or eye Regional transfer for eye and smile Lost in follow-up

Revisions/ancillary Revisions/ancillary Revisions/ancillary

TABLE 11. Details of Reconstructive, Ancillary, and Aesthetic Procedures to the Upper, Middle, and Lower Face, of the 57 Patients Who Underwent Multistage Reanimation Reconstructive Options Target: the upper face Pedicled frontalis Pedicled temporalis Free split gracilis Free split pectoralis Free ext brevis Direct neurotization or Selective VII–VII transfer Target: the middle face CFNG ⫹ free gracilis CFNG⫹ free pec minor CFNG ⫹ babysitter ⫹ minitemporalis VII–VII transfer Target: the lower face Digastric transfer Platysma transfer Direct neurotization or selective VII–VII transfer XII—cervicofacial branch

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Ancillary Procedures

Aesthetic Revisions

1 2 1 1 1 6 14

Eye spring Minitendon Wedge excision Webbing correction

8 14 9 4

27 4 12 9

Mini-Temporalis Platysma for extra pull Vascular STFF for contour Vascular STFF for muscle gliding

15 2 5 5

4 11 8 10

Blepharoplasty Brow lift

Dermal fat graft to chin Chin implant Defat neck

7 18

7 3 8

© 2012 Lippincott Williams & Wilkins

Annals of Plastic Surgery • Volume XX, Number XX, XXX 2012

Extratemporal Facial Paralysis

TABLE 12. Gain Percent (Pre- vs. Postsurgery Median Scores) in Different Facial Paralysis Groups Facial Paralysis Treatment Group

Preoperative Score (Median)

Final Score (Median)

% Gain Score

2.813 3.528 2.625 1.8125 3.125 2.163

3.875 4.5 4.25 3.563 4.282 3.738

21.26% 18.33% 32.5% 35% 23.12% 31.5%

Gunshot wounds MVA Head and neck tumors Vascular anomalies Iatrogenic injuries Bell palsy Difference between groups

P 0.3429 (NS) 0.1866 (NS) 0.058* 0.0063* 0068* 0.0002* 0.5918 (NS)

NS: nonsignificant result, P ⬎ 0.05. *Statistically significant result P ⬍ 0.05.

TABLE 13. Gain Percent (Pre- vs. Postsurgery Median Scores) With Different Procedures to the Upper, Middle, and Lower Face

Target: the upper face Pedicled temporalis transposition Free extensor dig. brevis transfer Direct neurotization or VII-VII transfer Target: the middle face Free gracilis transfer Free pectoralis minor Minitemporalis transposition Platysma transposition to oral sphincter for excess pull Target: the lower face Pedicled digastric transposition Pedicled platysma transposition Direct neurotization or VII-VII transfer XII—cervicofacial branch transfer

Group Size

% Gain Score Pre/Postsurgery

Confidence Interval

P

n⫽2 n⫽1 n ⫽ 20

20 20 26.9

9.53–44.38

P ⬎ 0.05 (NS) P ⬎ 0.05 (NS) P: 0.0043*

n ⫽ 27 n⫽4 n ⫽ 12 n⫽2

43.2 56 27.1 35

29.2–57.2 36.4–75.4 0.4–53.9

P ⬍ 0.001* P ⬍ 0.001* P: 0.047* P ⬎ 0.05 (NS)

n⫽4 n ⫽ 11 n⫽8 n ⫽ 10

42.5 16.7 14.4 13.9

52.88–79.72

P: 0.0286* P ⬎ 0.05 (NS) P ⬎ 0.05 (NS) P ⬎ 0.05 (NS)

NS: non significant result, P ⬎ 0.05. *Statistically significant result P ⬍ 0.05. CI indicates confidence interval.

TABLE 14. Gain Percent (Pre- vs. Postsurgery Median Scores) in Children Versus Adult Facial Paralysis Groups Facial Paralysis Treatment Group

Preoperative Score (Median)

Final Score (Median)

% Gain Score

Children Adults Difference between groups

2 2.819

3.875 4.032

37.5% 24.26%

P P: 0.0002* P ⬍ 0.0001* P: 0.5918 (NS)

NS: non significant result, P ⬎ 0.05. *Statistically significant result P ⬍ 0.05.

iomaxillofacial defects and long-standing facial paralysis, following trauma or tumor extirpation. Neurovascular muscle transfer is usually applied to achieve facial reanimation and to restore the soft-tissue defect. Selection of recipient nerves and vessels can be quite challenging because of previous trauma, surgery, or adjuvant treatment.35 When the ipsilateral facial nerve stump is available, it is the first choice motor © 2012 Lippincott Williams & Wilkins

source for innervating the transferred muscle; otherwise, a 2-stage method combining free muscle transfer with cross-facial nerve grafting is performed. An alternative nerve source for interposition nerve grafting can be the thoracodorsal nerve when the latissimus dorsi flap is used to reconstruct the cervical defect following ablative surgery,36 or the intercostal nerve with the rectus abdominis free flap.37 This techwww.annalsplasticsurgery.com | 13

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TABLE 15. Gain Percent (Pre- vs. Postsurgery Median Scores) in Complete and Partial Facial Paralysis Facial Paralysis Treatment Group

Preoperative Score (Median)

Final Score (Median)

% Gain Score

Complete Partial Difference between groups

1.386 2.883

3.3 4.175

38.28% 25.84%

P P: 0.0014* P ⬍ 0.0002* P: 0.007*

NS: non significant result, P ⬎ 0.05. *Statistically significant result P ⬍ 0.05.

TABLE 16. Gain Percent (Pre- vs. Postsurgery Median Scores) Among Groups With Different Denervation Time (⬍12 mo, 12–24 mo, ⬎24 mo) Facial Paralysis Treatment Group

Preoperative Score (Median)

Final Score (Median)

% Gain Score

DNT ⬍12 mo DNT 12–24 mo DNT ⬎24 mo Difference between groups

2.357 4.031 2.566

3.875 4.750 3.933

30.36% 14.376% 27.34%

P P: 0.0125* P: 0.0499* P: 0.0001* P: 0.0493*

NS: non significant result, P ⬎ 0.05. *Statistically significant result P ⬍ 0.05. DNT indicates denervation time.

TABLE 17. Gain Percent (Pre- vs. Postsurgery Median Scores) Between Groups With Different Facial Nerve Repair (Nerve Graft vs. Neurolysis) Facial Paralysis Treatment Group Facial nerve graft Facial nerve neurolysis

% Gain Score

Confidence Interval

P

40.4% 5%

6.6–74.2 ⫺3 to 13

P ⬍ 0.05* NS

NS: non significant result, P ⬎ 0.05. *Statistically significant result P ⬍ 0.05.

nique was used in 1 patient with a maxillectomy defect following excision of squamous cell carcinoma in our series.

Revisional Surgery Several investigators have discussed the need for secondary surgery in dynamic reanimation.38 – 43 Our Center stresses panfacial dynamic reconstruction with the goal of physiological animation of all 3 regions of the face (eye, smile, and depressor). We have observed, as others have, that irrespective of the reconstructive mode employed, secondary revisions are often needed.44,45 The reason being not merely how skillful the surgeon or how severe the pathology, but also the response to regenerative procedures. In addition, the impact of aging and growth has to be taken into consideration.

Excess Contraction of the Free Muscle In 2004, Takushima et al35 presented the results of neurovascular free muscle transfer in 45 patients with facial paralysis, resulting from ablative surgery in the parotid region. In 2 patients, acquired muscle contraction was excessive, resulting in unnatural animation of the smile. In both cases, recipient nerves were ipsilateral facial nerve stumps that had been dissected by opening the facial nerve canal in the mastoid process. 14 | www.annalsplasticsurgery.com

In 1995, Chuang et al46 presented 4 cases in which transferred muscle reinnervated with using the ipsilateral facial nerve displayed excessive contraction over time. They suggested that excessive reinnervation of the muscle was largely responsible for the contracture, and they advocated that the use of interposition nerve graft or a cross facial nerve graft had a better outcome. However, 3 cases in our series developed excessive contraction of the free gracilis muscle following the standard approach of CFNG Free Muscle Revisions. Two of them were managed with transfer of contralateral pedicled platysma transfer and 1 with selected myotomies of the free muscle, all resulted in long-term satisfactory outcome.

Bell Palsy The natural history of Bell palsy without treatment was described by Pietersen.47 Overall, 85% showed signs of recovery within 3 weeks. Patients with incomplete lesions had 94% return to normal function, whereas only 60% of those with complete lesions returned to normal function. Our findings confirm that the multistaged facial reanimation approach in established Bell palsy can achieve as good results as in any other extratemporal facial paralysis patients.

CONCLUSION The critical assessment of facial paralysis and associated craniomaxillofacial defects is essential for an adequate approach to reconstruction. Patients with extratemporal facial paralysis should be offered an individualized approach and “tailor made treatment strategies” based on the etiology of the lesion and functional sequelae. The different aspects of facial paralysis sequelae are interrelated and have to be treated almost simultaneously because the treatment modalities reinforce each other. Because of the complexity of these © 2012 Lippincott Williams & Wilkins

Annals of Plastic Surgery • Volume XX, Number XX, XXX 2012

multistage reanimation procedures, multiple revisions and refinements are usually required. The beneficial role of physiotherapy, with motor re-education and biofeedback should not be overlooked.48 The extensive experience of our unit has contributed in the development of reliable and effective strategies to restore form and function.

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22. Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an approach to the management of Le Fort fractures. Plast Reconstr Surg. 1980;66:54 – 61. 23. May M. Peripheral facial paralysis: diagnosis, prognosis and treatment. J Natl Med Assoc. 1972;64:424 – 426. 24. Devriese PP. Compression and ischaemia of the facial nerve. Acta Otolaryngol. 1974;77:108. 25. Liston SL, Kleid MS. Histopathology of Bell’s palsy. Laryngoscope. 1989; 99:23. 26. Balkany T, Fradis M, Jafek B, et al. Intrinsic vasculature of the labyrinthine segment of the facial nerve—implications for site of lesion in Bell’s palsy. Otolaryngol Head Neck Surg. 1991;104:20 –23. 27. Terzis JK, Noah EM. Analysis of 100 cases of free-muscle transplantation for facial paralysis. Plast Reconstr Surg. 1997;99:1905–1921. 28. Terzis JK, Olivares FS. Long-term outcomes of free-muscle transfer for smile restoration in children. Plast Reconstr Surg. 2009;123:543–555. 29. Yamada H, Hato N, Murakami S, et al. Facial synkinesis after experimental compression of the facial nerve comparing intratemporal and extratemporal lesions. Laryngoscope. 2010;120:1022–1027. 30. Yamamoto E, Nishimura H, Hirono Y. Occurrence of sequelae in Bell’s palsy. Acta Otolaryngol. 1988;446(suppl):93–96. 31. Moran CJ, Neely GJ. Patterns of facial nerve synkinesis. Laryngoscope. 1996;106:1491–1496. 32. Baker RS, Stava MW, Nelson KR, et al. Aberrant reinnervation of facial musculature in a subhuman primate: a correlative analysis of eyelid kinematics, muscle synkinesis, and motoneuron localization. Neurology. 1994;44: 2165–2173. 33. Husseman J, Mehta RP. Management of synkinesis. Facial Plast Surg. 2008;24:242–249. 34. Hadlock T, Kowaleski J, Lo D, et al. Rodent facial nerve recovery after selected lesions and repair techniques. Plast Reconstr Surg. 2010;125:99–109. 35. Takushima A, Harii K, Asato H, et al. Neurovascular free-muscle transfer for the treatment of established facial paralysis following ablative surgery in the Parotid Region. Plast Reconstr Surg. 2004;113:1563–1571. 36. White MW, McKenna MJ, Deschler DG, et al. Use of the thoracodorsal nerve for facial nerve grafting in the setting of pedicled latissimus dorsi reconstruction. Otolaryngol Head Neck Surg. 2006;135:962–964. 37. Sajjadian A, Song AY, Khorsandi CA, et al. One stage reanimation of the paralyzed face using the rectus abdominis neurovascular free flap. Plast Reconstr Surg. 2006;117:1553–1559. 38. Frey M, Giovanoli P. The three-stage concept to optimize the results of microsurgical reanimation of the paralyzed face. Clin Plast Surg. 2002;29: 461– 482. 39. Freeman BS. Correcting facial paralysis. Plast Reconstr Surg. 1981;68:262–263. 40. Kumar PA, Hassan KM. Cross-face nerve graft with free-muscle transfer for reanimation of the paralyzed face: a comparative study of the single-stage and two-stage procedures. Plast Reconstr Surg. 2002;109:451– 462. 41. Ferreira MC, Marques de Faria JC. Result of microvascular gracilis transplantation for facial paralysis: personal series. Clin Plast Surg. 2002;29:515–522. 42. Takushima A, Harii K, Asato H, et al. Revisional operations improve results of neurovascular free muscle transfer for treatment of facial paralysis. Plast Reconstr Surg. 2005;116:371–380. 43. Ferreira MC. Aesthetic considerations in facial reanimation. Clin Plast Surg. 2002;29:523–532. 44. Terzis JK, Olivares FS. Secondary surgery in adult facial paralysis reanimation. Plast Reconstr Surg. 2009;124:1916 –1931. 45. Terzis JK, Olivares FS. Secondary surgery in paediatric facial paralysis reanimation. J Plast Reconstr Aesthet Surg. 2010;63:1794 –1806. 46. Chuang DC, Devaraj VS, Wei FC. Irreversible muscle contracture after functioning free muscle transplantation using the ipsilateral facial nerve for reinnervation. Br J Plast Surg. 1995;48:1–7. 47. Pietersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol. 2002;549:4 –30. 48. Diels JH. Facial paralysis: is there a role for a therapist? Facial Plast Surg. 2000;16:361–364.

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