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Facial Reanimation With Gracilis Muscle Transplantation And Obturator Nerve Coaptation To The Motor Nerve Of Masseter Muscle As A Salvage Procedure In An Unreliable Cross‐face Nerve Graft

R. Horta, P. Silva, Álvaro Silva, Isabel Bartosh, Rita Filipe, Mário Mendanha, T. Burnay, Joana Costa, J. Amarante, M. Rebelo
Published 2011 · Medicine

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Surgical treatment of unilateral long-standing facial paralysis requires transposition of new musculature to restore function and a microneurovascular free-muscle flap is the procedure of choice. The gracilis muscle has been used with success but one of the critical factors of this procedure is the selection of a motor nerve to innervate the transplanted muscle. To achieve synchronous and spontaneous activity, the contralateral facial nerve is used by means of a cross-facial nerve graft when available. In 1995, Zuker et al. successfully used the nerve of the masseter muscle, branch of the trigeminal nerve in the treatment of Moebius syndrome (bilateral palsy), and the results suggested that this technique could be an option for treating unilateral facial paralysis as well. A comparison of commissure excursion following gracilis muscle free flap with a cross-face nerve graft versus the motor nerve to the masseter muscle was performed by Bae et al., showed that the extent of movement was greater using the masseteric muscle. Clinical analysis of different techniques, also found that one-stage unilateral facial reanimation with gracilis muscle innervated by the motor nerve to the masseter, produced more predictable and consistent results and the extent of movement is greater. However, the cross-face nerve graft provides a more spontaneous movement which is crucial in producing a normal appearing smile, but there is usually less movement and it is not suitable for the older patient (reinervation is difficult). Manktelow et al., speculated that there may be a larger role for the masseter motor nerve in innervation of patients with unilateral paralysis. The majority of patients develop the ability to smile spontaneously and without jaw movement. We report a case of a 32 years old man with established facial paralysis as sequelae of surgery for an acoustic neuroma (vestibulocochlear nerve tumor). (Fig. 1) We had chosen a cross-face sural nerve graft as we believed that the two-stage method provide better symmetry at rest and a spontaneous smile. During the first-stage a sural nerve graft (segment of 12 cm length) was harvested, coaptated to a buccal nerve of the facial nerve and transposed subcutaneously above the upper lip onto the contralateral hemiface. After 12 months, a second stage surgical procedure was planned for gracilis muscle transplantation. During the surgery, we found that the length of the sural nerve did not allow it to reach the contralateral facial side at the exact point for neurotherapy to the anterior branch of the obturator nerve and it was surrounded by fibrosis. After a rectangular portion of the gracilis muscle (7 3 6 cm) was settled into the cheek pocket, the obturator nerve was therefore coapted to the motor nerve of the masseter muscle, and microvascular anastomoses were done to the facial vessels. The postoperative course was uneventful. *Correspondence to:Ricardo Horta Oliveira, Avenida Menéres, no 234, bloco 2, 48 Frente Esquerdo 4450-189, Matosinhos SulPorto, Portugal. E-mail: rickhardinho@hotmail.com Received 12 July 2010; Accepted 9 September 2010
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