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Case Report/Case Series |

Salvage Procedures After Failed Facial Reanimation Surgery Using the Masseteric Nerve as the Motor Nerve for Free Functional Gracilis Muscle Transfer

Steffen U. Eisenhardt, MD1; Nils A. Eisenhardt, MD2; Jan R. Thiele, MD1; G. Björn Stark, MD1; Holger Bannasch, MD1
[+] Author Affiliations
1Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
2Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany
JAMA Facial Plast Surg. 2014;16(5):359-363. doi:10.1001/jamafacial.2014.163.
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Importance  Free muscle transfer innervated by a cross-facial nerve graft represents the criterion standard for smile reconstruction in facial paralysis. If primary reconstruction fails, a second muscle transfer is usually needed. Herein, we investigated the possibility of avoiding a second free muscle transfer by in situ coaptation of the gracilis muscle to the masseteric nerve.

Observations  We report a series of 3 failed free muscle transfers for facial reanimation among 21 free flap transfers performed for facial reanimation between March 2008 and August 2013. To salvage the muscle, we performed coaptation of the neural pedicle from the cross-facial nerve graft to the masseteric nerve. This method allows for leaving the fixation sutures of the muscle at the oral commissure in place. All patients showed muscle contraction after 3 months and a smile with open mouth after 6 months. No significant difference in the range of commissure excursion was observed between the healthy and operated sides.

Conclusions and Relevance  Recoaptation of the neural pedicle from the cross-facial nerve graft to the masseteric nerve, leaving the muscle transplant in place, is a suitable salvage procedure after unsuccessful reconstruction with a cross-facial nerve graft, avoiding a second free muscle transfer.

Level of Evidence  4.

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Figures

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Figure 1.
Revision Surgery Overview

A, The gracilis muscle is sutured to the orbicularis oris muscle and the temporal fascia and lies over the masseteric fascia. The neural pedicle lies under the muscle belly and is coapted to the cross-facial nerve graft short graft (interrupted line) at the level of the upper lip on the paralyzed side. B, Shown is the intraoperative exposure on reexploration at 6 months.

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Figure 2.
Intraoperative Views of Patient 3 in the Table

A, The motor nerve to the gracilis muscle lies under the gracilis muscle and can be released from surrounding scar tissue after elevation of the muscle. B, Shown are the elevated muscle flap and the released neural pedicle (yellow loop). C, The cross-facial nerve graft coaptation is dissected, and the gracilis nerve pedicle is pulled back to the masseteric fascia.

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Figure 3.
Intraoperative Views of Patient 3 in the Table

A, The neural pedicle of the gracilis muscle is coapted to the masseteric nerve. Note the immediate vicinity of the relevant anatomic structures. B, This view is after elevation of the gracilis flap and exposure and dissection of the masseteric fascia and identification of the masseteric nerve (red loop). C, Note the perfect size match of the nerves.

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Figure 4.
Preoperative and Postoperative Views of Patient 1 in the Table

Coaptation of the gracilis muscle to the masseteric nerve was successfully used as a salvage procedure at 6 months after the gracilis muscle transfer. A symmetrical voluntary smile was achieved.

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Figure 5.
Analysis of the Distance Between the Tragus and the Commissure When Smiling Before and After Surgery

Values are given as percentages of the resting distance between the tragus and the commissure. After surgery, the distance was significantly reduced on the paralyzed side, and no significant difference compared with the healthy nonoperated side was noted, indicating a symmetrical range of excursion. NS indicates nonsignificant.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Multimedia

Video 1.

Patient 1 in the Table After Acoustic Neuroma Resection

Patient with complete facial paralysis after acoustic neuroma resection following unsuccessful cross-facial nerve graft creation and gracilis muscle transfer.

Video 2.

Patient 1 in the Table After a Salvage Procedure

Patient with complete facial paralysis after a salvage procedure and coaptation of the motor branch to the gracilis muscle to the masseteric nerve.

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