Facial Reanimation Surgery

457

CHAPTER 38

Facial Reanimation Surgery

Tessa A. Hadlock, Mack L. Cheney, and Michael J. McKenna

Facial nerve disorders encompass a broad spectrum of dys-function, ranging from subtle dynamic facial asymmetry tocomplete, dense paralysis. Facial nerve regeneration follow-ing injury can vary greatly and may result in hypofunction(persistent weakness or poor excursion of facial muscles),hyperfunction (hypertonicity, spasm), or aberrant regenera-tion (synkinesis). The impact of a facial nerve disorder canbe dramatic. Disabilities encountered include corneal expo-sure of the affected eye, oral incompetence and articulationdifficulties from orbicularis oris weakness, and functionalnasal obstruction from dilator nares paralysis. None of theseis perhaps as significant as the social isolation these patientsoften succumb to based on their perceived disfigurement andinability to convey emotion through facial expression. Be-cause of the profound effect of this disorder on patient qual-ity of life, a great deal of effort has been focused toward re-habilitation of the paralyzed face.

When facial nerve discontinuity is encountered, the firstapproach is to attempt to reestablish direct neural continuitybetween the facial motor nucleus and the distal facial nervethrough either primary repair or autografting techniques.When this is not possible, other methods of reestablishingfacial balance and movement may be considered. Facial re-animation procedures refer to interventions that restore facial symmetry, resting tone, voluntary movement, or acombination of these. Several broad categories of facial re-animation techniques exist, each appropriate to a specific setof clinical, anatomic, or outcome-related circumstances.These include reinnervation techniques, muscle transfers,and static procedures. The aim of this chapter is to describeeach of these approaches, including appropriate clinical sce-narios, technical aspects of the surgery, and adjunctive man-agement strategies to optimize postoperative appearance andfunction.

REINNERVATION TECHNIQUES

Reinnervation techniques, also termed nerve substitutiontechniques, are procedures that provide neural input to thedistal facial nerve and facial musculature via motor nerves

other than the native facial nerve. They are indicated in twosituations. The first is when the proximal facial nerve stumpis not available but the distal facial nerve and facial muscu-lature are present and functional. This occurs followingskull base tumor resections involving sacrifice of the nerveat or very close to the brainstem, where neurorrhaphy is nottechnically achievable. The second situation occurs follow-ing skull base surgery, intracranial injury, or traumatic facialparalysis, when the nerve is thought to be anatomically in-tact but there is no discernable return of function after a sat-isfactory waiting period of 12 months. Lack of functional recovery, electrophysiologic demonstration of lack of rein-nervation potentials, and the presence of fibrillation poten-tials at 12 months indicate persistent complete denervation.This suggests insufficient regenerative potential from theproximal facial nerve stump and therefore mandates alterna-tive proximal axonal input to the distal facial nerve and fa-cial musculature.

Hypoglossal–Facial Transfer (XII-VII Crossover)

The nerve most often utilized to reinnervate the distal facialnerve is the hypoglossal nerve. Its proximity to the extratem-poral facial nerve, its dense population of myelinated motoraxons, the relative acceptability of the resultant hemitongueweakness, and the highly predictable and reliable resultmake it a logical choice (1–4). In the classic XII-VII trans-fer, the entire hypoglossal nerve is transected and reflectedupward for direct neurorrhaphy to the facial nerve stump(Fig. 38.1A). Several modifications have been described(Fig. 38.1B–D), including the “split” XII-VII transfer (5), inwhich approximately 30% of the width of the hypoglossalnerve is divided from the main trunk of the nerve for severalcentimeters and secured to the lower division of the facialnerve (Fig. 38.1B). Another modification, designed to re-duce tongue morbidity by avoiding the splicing away of asignificant length of the partial hypoglossal trunk, is the XII-VII jump graft. This involves an end-to-side neurorrhaphybetween the hypoglossal nerve and a donor cable graft (usu-ally the great auricular nerve), which in turn is sewn to the

distal facial trunk (6) (Fig. 38.1C). This modification isbased upon improved appreciation of the microanatomy ofthe hypoglossal nerve, which demonstrates interwoven fas-cicular architecture; separating a 30% segment away fromthe main trunk for several centimeters divides a significantlygreater number of axons than if the fibers were oriented inparallel (6).

In some circumstances where the facial nerve is able to bemobilized from the second genu within the temporal boneand reflected inferiorly, removal of the mastoid tip allowsfor direct coaptation of the facial nerve to the hypoglossalwithout the need for an interposition graft (7) (Fig. 38.1D).Elimination of the cable graft provides a theoretical regener-ative advantage by reducing from two neurorrhaphies toone.

Surgical Technique

The classic XII-VII procedure is performed via a modifiedBlair parotidectomy incision. The main trunk of the facialnerve and the pes anserinus are identified using standard fa-cial nerve landmarks, such as the tragal pointer and the tym-

panomastoid suture line. The hypoglossal nerve is then lo-cated in its ascending portion, deep to the posterior belly ofthe digastric, along the medial surface of the internal jugularvein. The nerve is followed anteriorly and freed of fascial at-tachments beyond the takeoff of the descendens hypoglossi.The hypoglossal nerve is then sharply transected and re-flected superiorly to meet the facial nerve. The facial nerveis transected at the stylomastoid foramen, and the entire dis-tal trunk is reflected inferiorly and secured to the hypoglos-sal nerve with 5 to 7 10-0 nylon epineurial microsutures.

A modification designed to decrease mass movement ofthe face involves sectioning the entire facial nerve but per-forming a neurorrhaphy only to the inferior division of thefacial nerve, or ligating the upper division distal to the pes(Fig. 38.1), and employing separate techniques for manage-ment of the upper face. The split XII-VII transfer providesmany fewer axons and is therefore best utilized only for thelower segment of the face.

In the jump graft or direct XII-VII end-to-side procedure,once the exposure has been obtained the great auricularnerve graft is harvested or the proximal facial nerve is mobi-lized from the temporal bone, sectioned at the second genu,

458 / CHAPTER 38

Hypoglossal NerveReflected Superiorly

FIG. 38.1 Hypoglossal facial nerve transfer. Hypoglossal nerve is shown in green, facial nerve in or-ange. A: Classic procedure, with entire hypoglossal nerve transected. B: Modification with 40% seg-ment of nerve secured to lower division.

A B

and transposed into the neck by removal of the mastoid tip.The facial nerve can be further mobilized by dissecting itaway from the parotid tissue beyond its bifurcation. Theend-to-side neurorrhaphy is executed by removing a seg-ment of hypoglossal epineurium, then cutting a 30% open-ing into the hypoglossal nerve and allowing the defect toopen up. The recipient nerve is then laid into the defect, fac-ing the proximal cut surface, and secured with microsutures.

Results, Drawbacks, and Contraindications

With a XII-VII transfer, good resting facial tone is achievedin more than 90% of patients. When successful, the transferallows deliberate facial movement with intentional manipu-lation of the tongue. Recovery generally occurs over 6 to 24months and in some cases has been reported to continue upto 5 years. Results are variable, with time from denervationto transfer playing a key role in outcome. There is generalconsensus that reinnervation must occur within 2 years fol-lowing injury, otherwise neuromuscular fibrosis and atrophyprogress to a point where meaningful tone and movementare not achievable (6).

The two most significant drawbacks of the procedure arethe mass facial movement experienced by many patients andthe variable tongue dysfunction, which has been categorizedas severe in up to 25% of patients. Articulation and mastica-tion difficulties are commonly cited. The modificationsmentioned earlier are aimed at one or the other of these twoproblems. In addition, botulinum toxin administration in theregion of the eye and physical therapy have proven usefuladjuncts for patients with clinically significant mass move-ment.

The procedure is contraindicated in patients who arelikely to develop other cranial neuropathies (e.g., neurofi-bromatosis type II) or who have ipsilateral tenth nervedeficits, as the combined X-XII deficit can lead to profoundswallowing dysfunction.

VII-VII CROSS FACIAL GRAFTING

Another potential source of axons for facial reinnervation isthe contralateral healthy facial nerve (8). The two distinctadvantages of its use are that it is the only donor source withthe potential for mimetic function (the involuntary blink and

FACIAL REANIMATION SURGERY / 459

FIG. 38.1, cont’d. Hypoglossal facial nerve transfer. Hypoglossal nerve is shown in green, facial nervein orange. C: Jump graft (purple) modification. Insert shows how graft is positioned to capture axons ex-tending from the proximal aspect of the opened hypoglossal nerve. D: Reflection of the facial nerve outof the mastoid bone to meet the hypoglossal nerve in the neck.

C D

emotive smile) and that it is significantly arborized distally,so several branches may be sacrificed for use in cross facialgrafting, usually without adversely affecting the healthyside. The disadvantages include many fewer motor axonsthan the hypoglossal, with unpredictable results; the needfor a lengthy sural nerve jump graft; and the potential for fa-cial weakness on the donor side (9). Most surgeons feel themotor power provided by the hypoglossal nerve is distinctlysuperior, and the use of the contralateral facial nerve strictlyfor reinnervation of native facial musculature has largelybeen replaced by cross face nerve grafting in conjunctionwith free muscle transfer.

Surgical Technique

The VII-VII cross facial graft technique has a great deal ofsurgical variability with regard to exposure of the donor andrecipient nerves, the length and positioning of jump grafts,and the timing of second stage neurorrhaphy. There are in-sufficient data to allow specific approaches to emerge as su-perior to others (10–12). It is ordinarily a staged procedure,where in the first stage a sural nerve graft is harvested fromthe leg, tunneled subcutaneously from the ipsilateral preau-ricular region across the face, and sewn to the fresh cutedges of one or several buccal branches of the functioningfacial nerve (Fig. 38.2), via a nasolabial fold or a preauricu-lar incision. The growth of axons into the graft is followedclinically by tapping on the graft (Tinel’s sign); tingling in-

dicates the presence of regenerating axons. Once regenera-tion has occurred across the face, a second stage is per-formed where the sural nerve graft is sewn to one or severalbranches of the affected facial nerve. Alternatively, the ipsi-lateral neurorrhaphy can be performed in the same operativesetting.

Results, Drawbacks, and Contraindications

The major disadvantage with cross facial nerve grafting isthat results are inconsistent. Some authors report excellentrecovery, whereas many others find it entirely unsatisfac-tory. It appears that it is most useful in association with otherreanimation modalities, to address a single territory withinthe face rather than to reinnervate the entire contralateral fa-cial nerve. Recent studies employing the cross facial graftfor isolated marginal mandibular paralysis demonstrate itsutility (13).

OTHER REINNERVATION TECHNIQUES

Several other cranial nerves have been employed for rein-nervation of the distal facial nerve stump. The spinal acces-sory nerve (14), glossopharyngeal nerve, and trigeminalnerve have all been described as potential donors, thoughnone has gained great popularity. The donor morbidity anddifficulty with surgical exposure far exceed that found withXII-VII and cross facial grafting. Experimentation with uti-

460 / CHAPTER 38

Facial Nerve

Sural NerveGraft

FIG. 38.2 Placement of a cross face nerve graft. Note that several midface branches are sacrificed androuted into the graft.

lizing isolated branches, such as the sternocleidomastoidbranch of the spinal accessory nerve (15,16), would de-crease donor morbidity, potentially increasing the utility ofthis technique.

MUSCLE TRANSPOSITION TECHNIQUES

When the distal facial nerve or facial musculature has under-gone degeneration to a point of significant atrophy or fibro-sis, even the delivery of viable motor axons will not provideadequate excursion to create appreciable facial expression.Occasionally, resection of extensive disease involves re-moval of facial musculature for adequate tumor extirpation.In these situations, the transfer of functional innervatedmusculature into the face offers the only possibility ofmeaningful facial movement. A segment of innervated mus-cle can be transposed into the appropriate segment of theface from the temporalis, masseter, digastric, or other re-gional muscles or transferred from a distant site (gracilis,pectoralis minor, serratus anterior, latissimus dorsi) andreinnervated locally.

Effective rehabilitation requires training and physicaltherapy to achieve optimal function. The literature does sup-port the concept of neural plasticity whereby, after a certaintraining period, patients with trigeminally driven muscletransfers into the face are able to achieve movement withoutinitiating a clenching of teeth. Whether this is a central nerv-ous system phenomenon or a peripheral phenomenon is notknown (17).

Temporalis Muscle Transposition

When intact, the temporalis muscle is the first choice for re-animation of the smile in the chronically paralyzed face. It isalso useful as an interim therapy, when the regenerative po-tential of the facial nerve is in question (e.g., following skullbase surgery), during the waiting period for regeneration(18), as it does not interfere with any potential facial nerveregeneration. Further, it may be utilized to manage the upperface in conjunction with a XII-VII transfer to the lower divi-sion of the nerve. It serves as a static support to the oralcommissure and provides trigeminally controlled dynamicmovement.

Before proceeding, it is imperative to establish that themuscle and its nerve and vascular supply are intact, as manyneurotologic procedures damage these structures, and sev-eral congenital facial palsy syndromes are associated withother cranial nerve abnormalities that may affect temporalismuscle function. Severe atrophy of the musculature, such asin an edentulous patient, would also be a contraindication tothis approach.

Surgical Technique (19)

The procedure is performed through an incision from the su-perior temporal line down to the attachment of the lobule,

and sometimes extending postauricularly as with a rhytidec-tomy. Flaps are then raised both anteriorly and posteriorly inthe subdermal plane, just under the hair follicles. Care istaken to preserve the superficial temporal artery and veins,so that the temporoparietal fascial flap can be utilized toobliterate the donor site defect. The temporoparietal fascialflap is then reflected from the true temporalis muscular fas-cia, working superiorly to inferiorly, leaving the tem-poroparietal fascial flap pedicled on its vessels. A flap isthen raised in the subdermal plane from the zygomatic archto the oral commissure. The skin flap extends medially allthe way to the lateral border of the orbicularis oris muscle toachieve adequate coaptation to the transferred muscle. A1.5-cm wide strip of temporalis muscle with its underlyingpericranium is then elevated from the calvarium. The seg-ment is chosen so that reflection over the zygomatic archwill pull the commissure in a vector appropriate to the pa-tient’s smile pattern (20). A double staple line of gastroin-testinal anastomosis staples is placed along the superiormuscle edge, to provide a firm purchase for the insetting su-tures (Fig. 38.3A). Once this is accomplished, the muscle isreflected into the midface and secured with vicryl sutures tothe orbicularis oris, with good muscle-to-muscle contact topromote potential neurotization of the orbicularis fibers. Thecommissure is deliberately overcorrected, so that with relax-ation, appropriate position is achieved (Fig. 38.3B). Thetemporoparietal fascial flap is then placed into the tempo-ralis strip defect (Fig. 38.3C), and the incision is closed overa drain. A mastoid-type dressing is placed for the first post-operative night. The incision is closed with 5-0 nylon inter-rupted sutures. Physical therapy is vital to achieving satis-factory muscle function and is instituted within weeks afterthe transfer to develop appropriate control and excursion ofthe transferred muscle.

Other Regional Muscle Transfers

The masseter muscle transfer, popularized by Rubin (20)and by Baker and Conley (21), can also provide excursion atthe oral commissure. The entire muscle is ordinarily freedfrom its mandibular attachments and secured to the lateralaspect of the orbicularis oris, much the same way as the tem-poralis muscle. However, given its more lateral vector pulland the contour defect it creates at the commissure, it re-mains a far second choice to the temporalis muscle transpo-sition. Modifications which address this and simplify theprocedure have been reported in a few patients (22), thoughno substantial improvement has been clearly established.

The digastric muscle transfer is useful in isolated mar-ginal mandibular nerve injuries, but compromises oral com-petence in the total facial paralysis patient. In the appropri-ately selected patient with isolated marginal mandibularnerve injury, the procedure can be effective at restoring de-pressor function to the lower lip. It involves sectioning thedigastric muscle at the junction of the posterior belly and itstendon, then freeing the anterior belly and tendon from sur-


462 / CHAPTER 38

TransposedTemporalis

Muscle

OrbicularisOris Muscle

BoneSurface

TemporoparietalFascia

TemporalisMuscle

FIG. 38.3 Temporalis muscle transposition.A: Securing the transposed muscle to the orbic-ularis oris. Note the double staple line and mat-tress sutures from temporalis muscle to modio-lus. B: Note the overcorrection of the commissureso that the first molar is visible. C: After muscleinset, the temporoparietal fascial flap is placedinto the donor site defect.

A B

C

rounding structures and securing it to the orbicularis orisalong the ipsilateral inferior border (Fig. 38.4). Mylohyoidnerve innervation to the anterior belly can be maintained(23) or the muscle can be driven by a cross face nerve graftas shown (13).

Other local muscle flaps have been suggested—for exam-ple, the innervated platysma musculocutaneous flap (24)—but insufficient numbers of treated patients leave their ulti-mate utility in question.

Free Muscle Transfer

With the advent of microvascular free tissue transfer, the op-portunity to bring functional muscle from a distant site intothe face became possible. In a number of clinical scenarios,

this approach is preferred. First, if the proximal facial nervestump is available but the facial musculature has been re-sected, a free muscle graft can be transferred and driven bythe ipsilateral proximal facial nerve. This has the potential ofproviding involuntary, mimetic movement in the face. Pa-tients with long-standing facial paralysis in whom the tem-poralis transposition is not an option may achieve superiorresults from free muscle transfer powered by either the ipsi-lateral trigeminal nerve or a cross facial nerve graft ratherthan through an alternative regional muscle transfer.

Congenital facial palsy patients are also good candidatesfor the procedure because they lack adequate muscles of fa-cial expression or facial nerve trunks for neurorrhaphy andmay have other cranial neuropathies (25). The procedure ismost commonly performed as a two-stage procedure for


Anterior Bellyof Digastric

Muscle

Cross FaceNerve Graft

FIG. 38.4 Transfer of the anterior belly of the digastric. The tendon is divided and filleted into separateslips and secured to the orbicularis oris. Note that native innervation can be maintained or replaced bya cross face nerve graft.

unilateral paralysis and a single-stage procedure for bilateralparalysis (i.e., Moebius syndrome). This is because for uni-lateral paralysis, the muscle is powered by a cross facialgraft from a buccal branch of the healthy facial nerve, re-quiring a 9- to 12-month waiting period for axonal extensionthrough the cable graft before muscle transplantation. Forbilateral paralysis, the muscle is driven by the ipsilateraltrigeminal or hypoglossal nerve, which eliminates the needfor a regeneration phase and second operative procedure.

The gracilis muscle was the first muscle utilized in suc-cessful facial reanimation (26), and remains the most popu-lar choice for this purpose. Modifications involving use ofsubsegments of the muscle and alternative neural sources forthe graft have been described (27, 28). The muscle implanta-tion procedure is described next.

Surgical Technique

Preoperatively, the vector of the smile on the healthy side (ifpresent) is noted so that it can be emulated on the affectedside. The procedure is begun by harvest of the gracilis mus-cle from the medial aspect of the thigh. An incision is made1.5 cm posterior and parallel to a line connecting the pubictubercle to the medial condyle of the tibia. The soft tissuesare divided until the belly of the gracilis muscle is identified.The vascular pedicle is located entering the deep surface of

the muscle, 8 to 10 cm distal to the pubic tubercle, and fol-lowed proximally for a length of 6 cm. The obturator nerveis then identified 2 to 3 cm proximal to the vascular pedicleand similarly traced. The muscle is marked at 1-cm incre-ments so that when it is surgically removed and contracted,the resting length can be estimated. The pedicle, nerve, andmuscle belly are then divided, using the gastrointestinalanastomosis stapler for the muscle division, and removedfrom the surgical bed (29).

A preauricular incision is then made and extended to justbelow the mandible to identify the facial vessels for mi-crovascular anastomosis. An anterior flap is raised, exposingthe zygomatic arch and malar eminence, extending mediallyto expose the orbicularis oris. The stump of the cross facenerve graft is identified for the neurorrhaphy, in the case of across face nerve graft, and the masseteric nerve is identifiedimmediately under the zygomatic arch if it is a one-stageprocedure. Some surgeons place a temporary static slingfrom the zygomatic arch to the corner of the mouth so thatthe newly transferred muscle will not bear the weight of theface for the initial postoperative period (30). The gracilismuscle is then secured to the modiolus, stretched to its rest-ing tension length as determined by the incremental mark-ings, trimmed to the appropriate length, and secured to thezygomatic arch or temporalis fascia to create the appropriatevector pull (Fig. 38.5). The microvascular anastomoses and

464 / CHAPTER 38

Gracilis Muscle

Facial Arteryand Vein

NerveGraft

FIG. 38.5 Inset of the gracilis muscle. Note the staple lines at either end of the transferred muscle.

the neurorrhaphy are performed, and the incisions are closedover suction drainage. Chewing is avoided for the first 5postoperative days.

Alternative free muscle grafts for facial reanimation havebeen described, including the pectoralis minor, latissimusdorsi, serratus anterior, and abductor hallucis (31–36). Thecurrent thrust is to achieve a one-stage reconstruction pow-ered by the contralateral facial nerve (37). This requires amuscle whose nerve supply can be harvested to a length of15 cm, eliminating the need for a separate cross facial graft.Several pioneers of the initial gracilis transfer now preferone-stage reconstruction with the latissimus dorsi and itslong neural pedicle (30,37). Subjective and objective com-parisons of free muscle transfer versus temporalis transferdemonstrate superior excursion in the former but overallpoorer aesthetic results based on increased bulk and overly-ing skin tethering (38). These methods are in a period ofrapid evolution, and time will reveal which free muscletransfers yield most optimal long-term facial reanimation re-sults.


FIG. 38.6 Static technique for facial reanimation. A patient withlong-standing left facial paralysis is depicted. Note the browptosis, midfacial asymmetry, external nasal valve collapse, andcommissure malposition.

STATIC FACIAL REANIMATION PROCEDURES

Some facial paralysis patients are best rehabilitated throughstatic techniques. These include patients who are poor candi-dates for prolonged general anesthesia for medical reasons, pa-tients with a poor prognosis in whom reanimation over a longtime is not appropriate, and dynamic reanimation failures.

Patients with partial recovery following Bell’s palsy,Ramsay Hunt syndrome, or other conditions leading to aber-rant regeneration are also suitable candidates for static rean-imation procedures. Often there is adequate facial move-ment, and the unsightly facial asymmetry is attributable tohypertonicity, contracture, synkinesis, and subtle cervicaland brow positioning abnormalities. These can be addressedvia an asymmetric rhytidectomy with unilateral or asymmet-ric superficial muscular aponeurotic system with possibleintraoperative intentional sacrifice of selected branches onthe pathologic side to relax an area of hypertonicity. Unilat-eral brow lift often complements the procedure.

Static procedures can be directed at specific functionaland cosmetic issues (19,39) (Figs. 38.6–38.9). For example,nasal obstruction due to nasal valve collapse from dilatornares paralysis can be addressed with standard nasal valve

repair (Fig. 38.7). If oral incompetence is a significant com-plaint, lateral lower lip resection (Fig. 38.8) or selectivemyomectomy may be of benefit; fascia lata slings have beendescribed to improve cosmesis and competence in this area(40). Creation of a nasolabial fold via a two-stitch prolene

suture technique, a modification of the Keller facelift (41),has proven effective as well. Management options for theeye are discussed in detail in a subsequent chapter, thoughunilateral brow lifting is commonly utilized (Fig. 38.9). Sta-tic procedures are also used in conjunction with dynamic re-

466 / CHAPTER 38

TemporalisFascia

Fascia LataGraft

Alar Base

Alar BattenGraft

FIG. 38.7 External nasal valve repair via fascia lata sling from alar base to zygoma.

FIG. 38.8 Lower lip wedge resection assists with lower lipcompetence.

Surgical Pinin Calvarium

PermanentSuture

FIG. 38.9 Brow lifting is performed by the placement of asurgical pin in the calvarium and securing of a permanent su-ture to the pin.

animation techniques as touch-ups or to refine a satisfactoryresult even further.

SUMMARY

Facial paralysis is a disfiguring and debilitating conditionwhose management is determined by a large set of clinicalvariables. A systematic approach to the problem is presentedhere, employing reinnervation techniques as a first line andmuscle transfer for dynamic reanimation as a second linewhen feasible, reserving static rehabilitation procedures forotherwise poor surgical candidates and those with modest orspecific deficits.

Efforts are ongoing to improve or preserve neural func-tion, to evoke better native facial nerve regeneration withnerve grafting techniques, and to optimize static and dy-namic transfer for facial expression. The quantification offacial muscle function is another ongoing area of study, sothat distinct, measurable changes in function can berecorded following different interventions. Observer-basedscales, computer-based image analysis programs, and pa-tient-based outcome surveys will serve as valuable tools inthe future to clarify the expected benefit from each of the de-scribed interventions.

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Facial Reanimation Surgery