The management of longstanding facial paralysis presents a unique surgical challenge. It has been established that during the first several years after facial nerve sacrifice or injury, techniques that reestablish neural input to the native facial musculature yield the most satisfactory clinical results.1 In the case of primary or cable graft repair of the facial nerve, the restoration of neural input from the facial motor nucleus directly to existing facial musculature offers the only chance for return of natural, emotive expression. In cases in which the proximal facial nerve is not available for grafting, reinnervation techniques with alternative proximal neural sources provide direct innervation of facial muscles. This type of repair may yield satisfactory resting tone and function during voluntary smiling, but lacks spontaneous emotive function.

Perhaps the most challenging clinical situation is one in which reinnervation of the facial muscles themselves is not possible. This occurs when the distal facial nerve stump is either absent or severely fibrotic or when the facial musculature is atrophic beyond contractile capability. Efforts to restore facial symmetry and tone then involve static and dynamic tissue transfer techniques. These methods routinely provide less satisfactory functional and aesthetic results, and controversy surrounds which procedures are best employed in different clinical situations. There are numerous static and dynamic approaches to facial reanimation, and various techniques have proved to be well matched to particularclinical situations.

Background

Whereas the entity of facial paralysis was described and linked to damage of the facial nerve almost two centuries ago, efforts to perform corrective procedures evolved very slowly. Until 30 years ago, the problem was thought of by most as a permanent deformity. However, increasing interest in correction of the problem was generated during the 1960s. Electrophysiologic techniques for measurement of neural function, classification schemes for the measurement of recovery, and surgical techniques for correction were developed.

In this contemporary era, the first-line approach to reanimation of the atrophic paralyzed face has been to perform a regional muscle transfer to provide dynamic facial movement.^{2, 3}Both masseter and temporalis muscles have been used; currently, the temporalis muscle is favored. The middle third of the muscle is brought down to the oral commissure, and the donor site defect filled with an ipsilateral temporoparietal fascia flap(TPFF).⁴ An accompanying eye procedure, such as gold weight implantation, is usually executed for eyelid closure.

Drawbacks to the temporalis muscle transfer include a persistent soft tissue defect in the donor site despite partial fill-in with the TPFF and the fact that the resulting oral commisure movement is not physiologic. Physical therapy helps train individuals to elicit a smile by biting down; however, emotive expression is never restored.

Techniques for the transfer of free muscle grafts for dynamic facial reanimation have also been developed over the past two decades.⁵ Gracilis, pectoralis minor, latissimus dorsi, and serratus anterior muscle slips have all been used. Microneurovascular transfer is carried out in conjunction with a cross-facial jump graft for innervation. Results from these free muscle transfers vary substantially. Drawbacks include nasolabial distortion, excessive cheek fullness, and flap failure. For these reasons, they tend to be reserved for congenital facial palsy patients(i.e., Mobius syndrome).

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