CHAPTER 38Facial Reanimation SurgeryTessa A. Hadlock, Mack L. Cheney, and Michael J. McKennaFacial nerve disorders encompass a broad spectrum of dys- other than the native facial nerve. They are indicated in twofunction, ranging from subtle dynamic facial asymmetry to situations. The ﬁrst is when the proximal facial nerve stumpcomplete, dense paralysis. Facial nerve regeneration follow- is not available but the distal facial nerve and facial muscu-ing injury can vary greatly and may result in hypofunction lature are present and functional. This occurs following(persistent weakness or poor excursion of facial muscles), skull base tumor resections involving sacriﬁce of the nervehyperfunction (hypertonicity, spasm), or aberrant regenera- at or very close to the brainstem, where neurorrhaphy is nottion (synkinesis). The impact of a facial nerve disorder can technically achievable. The second situation occurs follow-be dramatic. Disabilities encountered include corneal expo- ing skull base surgery, intracranial injury, or traumatic facialsure of the affected eye, oral incompetence and articulation paralysis, when the nerve is thought to be anatomically in-difﬁculties from orbicularis oris weakness, and functional tact but there is no discernable return of function after a sat-nasal obstruction from dilator nares paralysis. None of these isfactory waiting period of 12 months. Lack of functionalis perhaps as signiﬁcant as the social isolation these patients recovery, electrophysiologic demonstration of lack of rein-often succumb to based on their perceived disﬁgurement and nervation potentials, and the presence of ﬁbrillation poten-inability to convey emotion through facial expression. Be- tials at 12 months indicate persistent complete denervation.cause of the profound effect of this disorder on patient qual- This suggests insufﬁcient regenerative potential from theity of life, a great deal of effort has been focused toward re- proximal facial nerve stump and therefore mandates alterna-habilitation of the paralyzed face. tive proximal axonal input to the distal facial nerve and fa- When facial nerve discontinuity is encountered, the ﬁrst cial musculature.approach is to attempt to reestablish direct neural continuitybetween the facial motor nucleus and the distal facial nerve Hypoglossal–Facial Transfer (XII-VII Crossover)through either primary repair or autografting techniques.When this is not possible, other methods of reestablishing The nerve most often utilized to reinnervate the distal facialfacial balance and movement may be considered. Facial re- nerve is the hypoglossal nerve. Its proximity to the extratem-animation procedures refer to interventions that restore poral facial nerve, its dense population of myelinated motorfacial symmetry, resting tone, voluntary movement, or a axons, the relative acceptability of the resultant hemitonguecombination of these. Several broad categories of facial re- weakness, and the highly predictable and reliable resultanimation techniques exist, each appropriate to a speciﬁc set make it a logical choice (1–4). In the classic XII-VII trans-of clinical, anatomic, or outcome-related circumstances. fer, the entire hypoglossal nerve is transected and reﬂectedThese include reinnervation techniques, muscle transfers, upward for direct neurorrhaphy to the facial nerve stumpand static procedures. The aim of this chapter is to describe (Fig. 38.1A). Several modiﬁcations have been describedeach of these approaches, including appropriate clinical sce- (Fig. 38.1B–D), including the “split” XII-VII transfer (5), innarios, technical aspects of the surgery, and adjunctive man- which approximately 30% of the width of the hypoglossalagement strategies to optimize postoperative appearance and nerve is divided from the main trunk of the nerve for severalfunction. centimeters and secured to the lower division of the facial nerve (Fig. 38.1B). Another modiﬁcation, designed to re- duce tongue morbidity by avoiding the splicing away of aREINNERVATION TECHNIQUES signiﬁcant length of the partial hypoglossal trunk, is the XII-Reinnervation techniques, also termed nerve substitution VII jump graft. This involves an end-to-side neurorrhaphytechniques, are procedures that provide neural input to the between the hypoglossal nerve and a donor cable graft (usu-distal facial nerve and facial musculature via motor nerves ally the great auricular nerve), which in turn is sewn to the 457
458 / CHAPTER 38distal facial trunk (6) (Fig. 38.1C). This modiﬁcation is panomastoid suture line. The hypoglossal nerve is then lo-based upon improved appreciation of the microanatomy of cated in its ascending portion, deep to the posterior belly ofthe hypoglossal nerve, which demonstrates interwoven fas- the digastric, along the medial surface of the internal jugularcicular architecture; separating a 30% segment away from vein. The nerve is followed anteriorly and freed of fascial at-the main trunk for several centimeters divides a signiﬁcantly tachments beyond the takeoff of the descendens hypoglossi.greater number of axons than if the ﬁbers were oriented in The hypoglossal nerve is then sharply transected and re-parallel (6). ﬂected superiorly to meet the facial nerve. The facial nerve In some circumstances where the facial nerve is able to be is transected at the stylomastoid foramen, and the entire dis-mobilized from the second genu within the temporal bone tal trunk is reﬂected inferiorly and secured to the hypoglos-and reﬂected inferiorly, removal of the mastoid tip allows sal nerve with 5 to 7 10-0 nylon epineurial microsutures.for direct coaptation of the facial nerve to the hypoglossal A modiﬁcation designed to decrease mass movement ofwithout the need for an interposition graft (7) (Fig. 38.1D). the face involves sectioning the entire facial nerve but per-Elimination of the cable graft provides a theoretical regener- forming a neurorrhaphy only to the inferior division of theative advantage by reducing from two neurorrhaphies to facial nerve, or ligating the upper division distal to the pesone. (Fig. 38.1), and employing separate techniques for manage- ment of the upper face. The split XII-VII transfer provides many fewer axons and is therefore best utilized only for theSurgical Technique lower segment of the face.The classic XII-VII procedure is performed via a modiﬁed In the jump graft or direct XII-VII end-to-side procedure,Blair parotidectomy incision. The main trunk of the facial once the exposure has been obtained the great auricularnerve and the pes anserinus are identiﬁed using standard fa- nerve graft is harvested or the proximal facial nerve is mobi-cial nerve landmarks, such as the tragal pointer and the tym- lized from the temporal bone, sectioned at the second genu, Hypoglossal Nerve Reflected Superiorly A B 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.
FACIAL REANIMATION SURGERY / 459 C D FIG. 38.1, cont’d. Hypoglossal facial nerve transfer. Hypoglossal nerve is shown in green, facial nerve in 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 out of the mastoid bone to meet the hypoglossal nerve in the neck.and transposed into the neck by removal of the mastoid tip. The two most signiﬁcant drawbacks of the procedure areThe facial nerve can be further mobilized by dissecting it the mass facial movement experienced by many patients andaway from the parotid tissue beyond its bifurcation. The the variable tongue dysfunction, which has been categorizedend-to-side neurorrhaphy is executed by removing a seg- as severe in up to 25% of patients. Articulation and mastica-ment of hypoglossal epineurium, then cutting a 30% open- tion difﬁculties are commonly cited. The modiﬁcationsing into the hypoglossal nerve and allowing the defect to mentioned earlier are aimed at one or the other of these twoopen up. The recipient nerve is then laid into the defect, fac- problems. In addition, botulinum toxin administration in theing the proximal cut surface, and secured with microsutures. region of the eye and physical therapy have proven useful adjuncts for patients with clinically signiﬁcant mass move- ment.Results, Drawbacks, and Contraindications The procedure is contraindicated in patients who areWith a XII-VII transfer, good resting facial tone is achieved likely to develop other cranial neuropathies (e.g., neuroﬁ-in more than 90% of patients. When successful, the transfer bromatosis type II) or who have ipsilateral tenth nerveallows deliberate facial movement with intentional manipu- deﬁcits, as the combined X-XII deﬁcit can lead to profoundlation of the tongue. Recovery generally occurs over 6 to 24 swallowing dysfunction.months and in some cases has been reported to continue upto 5 years. Results are variable, with time from denervation VII-VII CROSS FACIAL GRAFTINGto transfer playing a key role in outcome. There is generalconsensus that reinnervation must occur within 2 years fol- Another potential source of axons for facial reinnervation islowing injury, otherwise neuromuscular ﬁbrosis and atrophy the contralateral healthy facial nerve (8). The two distinctprogress to a point where meaningful tone and movement advantages of its use are that it is the only donor source withare not achievable (6). the potential for mimetic function (the involuntary blink and
460 / CHAPTER 38emotive smile) and that it is signiﬁcantly arborized distally, dicates the presence of regenerating axons. Once regenera-so several branches may be sacriﬁced for use in cross facial tion has occurred across the face, a second stage is per-grafting, usually without adversely affecting the healthy formed where the sural nerve graft is sewn to one or severalside. The disadvantages include many fewer motor axons branches of the affected facial nerve. Alternatively, the ipsi-than the hypoglossal, with unpredictable results; the need lateral neurorrhaphy can be performed in the same operativefor a lengthy sural nerve jump graft; and the potential for fa- setting.cial weakness on the donor side (9). Most surgeons feel themotor power provided by the hypoglossal nerve is distinctly Results, Drawbacks, and Contraindicationssuperior, and the use of the contralateral facial nerve strictlyfor reinnervation of native facial musculature has largely The major disadvantage with cross facial nerve grafting isbeen replaced by cross face nerve grafting in conjunction that results are inconsistent. Some authors report excellentwith free muscle transfer. recovery, whereas many others ﬁnd it entirely unsatisfac- tory. It appears that it is most useful in association with other reanimation modalities, to address a single territory withinSurgical Technique the face rather than to reinnervate the entire contralateral fa-The VII-VII cross facial graft technique has a great deal of cial nerve. Recent studies employing the cross facial graftsurgical variability with regard to exposure of the donor and for isolated marginal mandibular paralysis demonstrate itsrecipient nerves, the length and positioning of jump grafts, utility (13).and the timing of second stage neurorrhaphy. There are in-sufﬁcient data to allow speciﬁc approaches to emerge as su- OTHER REINNERVATION TECHNIQUESperior to others (10–12). It is ordinarily a staged procedure,where in the ﬁrst stage a sural nerve graft is harvested from Several other cranial nerves have been employed for rein-the leg, tunneled subcutaneously from the ipsilateral preau- nervation of the distal facial nerve stump. The spinal acces-ricular region across the face, and sewn to the fresh cut sory nerve (14), glossopharyngeal nerve, and trigeminaledges of one or several buccal branches of the functioning nerve have all been described as potential donors, thoughfacial nerve (Fig. 38.2), via a nasolabial fold or a preauricu- none has gained great popularity. The donor morbidity andlar incision. The growth of axons into the graft is followed difﬁculty with surgical exposure far exceed that found withclinically by tapping on the graft (Tinel’s sign); tingling in- XII-VII and cross facial grafting. Experimentation with uti- Facial Nerve Sural Nerve Graft FIG. 38.2 Placement of a cross face nerve graft. Note that several midface branches are sacriﬁced and routed into the graft.
FACIAL REANIMATION SURGERY / 461lizing isolated branches, such as the sternocleidomastoid and sometimes extending postauricularly as with a rhytidec-branch of the spinal accessory nerve (15,16), would de- tomy. Flaps are then raised both anteriorly and posteriorly increase donor morbidity, potentially increasing the utility of the subdermal plane, just under the hair follicles. Care isthis technique. taken to preserve the superﬁcial temporal artery and veins, so that the temporoparietal fascial ﬂap can be utilized to obliterate the donor site defect. The temporoparietal fascialMUSCLE TRANSPOSITION TECHNIQUES ﬂap is then reﬂected from the true temporalis muscular fas-When the distal facial nerve or facial musculature has under- cia, working superiorly to inferiorly, leaving the tem-gone degeneration to a point of signiﬁcant atrophy or ﬁbro- poroparietal fascial ﬂap pedicled on its vessels. A ﬂap issis, even the delivery of viable motor axons will not provide then raised in the subdermal plane from the zygomatic archadequate excursion to create appreciable facial expression. to the oral commissure. The skin ﬂap extends medially allOccasionally, resection of extensive disease involves re- the way to the lateral border of the orbicularis oris muscle tomoval of facial musculature for adequate tumor extirpation. achieve adequate coaptation to the transferred muscle. AIn these situations, the transfer of functional innervated 1.5-cm wide strip of temporalis muscle with its underlyingmusculature into the face offers the only possibility of pericranium is then elevated from the calvarium. The seg-meaningful facial movement. A segment of innervated mus- ment is chosen so that reﬂection over the zygomatic archcle can be transposed into the appropriate segment of the will pull the commissure in a vector appropriate to the pa-face from the temporalis, masseter, digastric, or other re- tient’s smile pattern (20). A double staple line of gastroin-gional muscles or transferred from a distant site (gracilis, testinal anastomosis staples is placed along the superiorpectoralis minor, serratus anterior, latissimus dorsi) and muscle edge, to provide a ﬁrm purchase for the insetting su-reinnervated locally. tures (Fig. 38.3A). Once this is accomplished, the muscle is Effective rehabilitation requires training and physical reﬂected into the midface and secured with vicryl sutures totherapy to achieve optimal function. The literature does sup- the orbicularis oris, with good muscle-to-muscle contact toport the concept of neural plasticity whereby, after a certain promote potential neurotization of the orbicularis ﬁbers. Thetraining period, patients with trigeminally driven muscle commissure is deliberately overcorrected, so that with relax-transfers into the face are able to achieve movement without ation, appropriate position is achieved (Fig. 38.3B). Theinitiating a clenching of teeth. Whether this is a central nerv- temporoparietal fascial ﬂap is then placed into the tempo-ous system phenomenon or a peripheral phenomenon is not ralis strip defect (Fig. 38.3C), and the incision is closed overknown (17). a 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-Temporalis Muscle Transposition factory muscle function and is instituted within weeks afterWhen intact, the temporalis muscle is the ﬁrst choice for re- the transfer to develop appropriate control and excursion ofanimation of the smile in the chronically paralyzed face. It is the transferred muscle.also useful as an interim therapy, when the regenerative po-tential of the facial nerve is in question (e.g., following skull Other Regional Muscle Transfersbase surgery), during the waiting period for regeneration(18), as it does not interfere with any potential facial nerve The masseter muscle transfer, popularized by Rubin (20)regeneration. Further, it may be utilized to manage the upper and by Baker and Conley (21), can also provide excursion atface in conjunction with a XII-VII transfer to the lower divi- the oral commissure. The entire muscle is ordinarily freedsion of the nerve. It serves as a static support to the oral from its mandibular attachments and secured to the lateralcommissure and provides trigeminally controlled dynamic aspect of the orbicularis oris, much the same way as the tem-movement. poralis muscle. However, given its more lateral vector pull Before proceeding, it is imperative to establish that the and the contour defect it creates at the commissure, it re-muscle and its nerve and vascular supply are intact, as many mains a far second choice to the temporalis muscle transpo-neurotologic procedures damage these structures, and sev- sition. Modiﬁcations which address this and simplify theeral congenital facial palsy syndromes are associated with procedure have been reported in a few patients (22), thoughother cranial nerve abnormalities that may affect temporalis no substantial improvement has been clearly established.muscle function. Severe atrophy of the musculature, such as The digastric muscle transfer is useful in isolated mar-in an edentulous patient, would also be a contraindication to ginal mandibular nerve injuries, but compromises oral com-this approach. petence in the total facial paralysis patient. In the appropri- ately selected patient with isolated marginal mandibular nerve injury, the procedure can be effective at restoring de-Surgical Technique (19) pressor function to the lower lip. It involves sectioning theThe procedure is performed through an incision from the su- digastric muscle at the junction of the posterior belly and itsperior temporal line down to the attachment of the lobule, tendon, then freeing the anterior belly and tendon from sur-
462 / CHAPTER 38 Transposed Temporalis Muscle Orbicularis Oris Muscle A B Bone Surface Temporoparietal Fascia Temporalis MuscleFIG. 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. C
FACIAL REANIMATION SURGERY / 463rounding structures and securing it to the orbicularis oris this approach is preferred. First, if the proximal facial nervealong the ipsilateral inferior border (Fig. 38.4). Mylohyoid stump is available but the facial musculature has been re-nerve innervation to the anterior belly can be maintained sected, a free muscle graft can be transferred and driven by(23) or the muscle can be driven by a cross face nerve graft the ipsilateral proximal facial nerve. This has the potential ofas shown (13). providing involuntary, mimetic movement in the face. Pa- Other local muscle ﬂaps have been suggested—for exam- tients with long-standing facial paralysis in whom the tem-ple, the innervated platysma musculocutaneous ﬂap (24)— poralis transposition is not an option may achieve superiorbut insufﬁcient numbers of treated patients leave their ulti- results from free muscle transfer powered by either the ipsi-mate utility in question. lateral trigeminal nerve or a cross facial nerve graft rather than through an alternative regional muscle transfer. Congenital facial palsy patients are also good candidatesFree Muscle Transfer for the procedure because they lack adequate muscles of fa-With the advent of microvascular free tissue transfer, the op- cial expression or facial nerve trunks for neurorrhaphy andportunity to bring functional muscle from a distant site into may have other cranial neuropathies (25). The procedure isthe face became possible. In a number of clinical scenarios, most commonly performed as a two-stage procedure for Anterior Belly of Digastric Muscle Cross Face Nerve Graft FIG. 38.4 Transfer of the anterior belly of the digastric. The tendon is divided and ﬁlleted into separate slips and secured to the orbicularis oris. Note that native innervation can be maintained or replaced by a cross face nerve graft.
464 / CHAPTER 38unilateral paralysis and a single-stage procedure for bilateral the muscle, 8 to 10 cm distal to the pubic tubercle, and fol-paralysis (i.e., Moebius syndrome). This is because for uni- lowed proximally for a length of 6 cm. The obturator nervelateral paralysis, the muscle is powered by a cross facial is then identiﬁed 2 to 3 cm proximal to the vascular pediclegraft from a buccal branch of the healthy facial nerve, re- and similarly traced. The muscle is marked at 1-cm incre-quiring a 9- to 12-month waiting period for axonal extension ments so that when it is surgically removed and contracted,through the cable graft before muscle transplantation. For the resting length can be estimated. The pedicle, nerve, andbilateral paralysis, the muscle is driven by the ipsilateral muscle belly are then divided, using the gastrointestinaltrigeminal or hypoglossal nerve, which eliminates the need anastomosis stapler for the muscle division, and removedfor a regeneration phase and second operative procedure. from the surgical bed (29). The gracilis muscle was the ﬁrst muscle utilized in suc- A preauricular incision is then made and extended to justcessful facial reanimation (26), and remains the most popu- below the mandible to identify the facial vessels for mi-lar choice for this purpose. Modiﬁcations involving use of crovascular anastomosis. An anterior ﬂap is raised, exposingsubsegments of the muscle and alternative neural sources for the zygomatic arch and malar eminence, extending mediallythe graft have been described (27, 28). The muscle implanta- to expose the orbicularis oris. The stump of the cross facetion procedure is described next. nerve graft is identiﬁed for the neurorrhaphy, in the case of a cross face nerve graft, and the masseteric nerve is identiﬁed immediately under the zygomatic arch if it is a one-stageSurgical Technique procedure. Some surgeons place a temporary static slingPreoperatively, the vector of the smile on the healthy side (if from the zygomatic arch to the corner of the mouth so thatpresent) is noted so that it can be emulated on the affected the newly transferred muscle will not bear the weight of theside. The procedure is begun by harvest of the gracilis mus- face for the initial postoperative period (30). The graciliscle from the medial aspect of the thigh. An incision is made muscle is then secured to the modiolus, stretched to its rest-1.5 cm posterior and parallel to a line connecting the pubic ing tension length as determined by the incremental mark-tubercle to the medial condyle of the tibia. The soft tissues ings, trimmed to the appropriate length, and secured to theare divided until the belly of the gracilis muscle is identiﬁed. zygomatic arch or temporalis fascia to create the appropriateThe vascular pedicle is located entering the deep surface of vector pull (Fig. 38.5). The microvascular anastomoses and Nerve Graft Gracilis Muscle Facial Artery and Vein FIG. 38.5 Inset of the gracilis muscle. Note the staple lines at either end of the transferred muscle.
FACIAL REANIMATION SURGERY / 465the neurorrhaphy are performed, and the incisions are closed STATIC FACIAL REANIMATION PROCEDURESover suction drainage. Chewing is avoided for the ﬁrst 5 Some facial paralysis patients are best rehabilitated throughpostoperative days. static techniques. These include patients who are poor candi- Alternative free muscle grafts for facial reanimation have dates for prolonged general anesthesia for medical reasons, pa-been described, including the pectoralis minor, latissimus tients with a poor prognosis in whom reanimation over a longdorsi, serratus anterior, and abductor hallucis (31–36). The time is not appropriate, and dynamic reanimation failures.current thrust is to achieve a one-stage reconstruction pow- Patients with partial recovery following Bell’s palsy,ered by the contralateral facial nerve (37). This requires a Ramsay Hunt syndrome, or other conditions leading to aber-muscle whose nerve supply can be harvested to a length of rant regeneration are also suitable candidates for static rean-15 cm, eliminating the need for a separate cross facial graft. imation procedures. Often there is adequate facial move-Several pioneers of the initial gracilis transfer now prefer ment, and the unsightly facial asymmetry is attributable toone-stage reconstruction with the latissimus dorsi and its hypertonicity, contracture, synkinesis, and subtle cervicallong neural pedicle (30,37). Subjective and objective com- and brow positioning abnormalities. These can be addressedparisons of free muscle transfer versus temporalis transfer via an asymmetric rhytidectomy with unilateral or asymmet-demonstrate superior excursion in the former but overall ric superﬁcial muscular aponeurotic system with possiblepoorer aesthetic results based on increased bulk and overly- intraoperative intentional sacriﬁce of selected branches oning skin tethering (38). These methods are in a period of the pathologic side to relax an area of hypertonicity. Unilat-rapid evolution, and time will reveal which free muscle eral brow lift often complements the procedure.transfers yield most optimal long-term facial reanimation re- Static procedures can be directed at speciﬁc functionalsults. and cosmetic issues (19,39) (Figs. 38.6–38.9). For example, nasal obstruction due to nasal valve collapse from dilator nares paralysis can be addressed with standard nasal valve FIG. 38.6 Static technique for facial reanimation. A patient with long-standing left facial paralysis is depicted. Note the brow ptosis, midfacial asymmetry, external nasal valve collapse, and commissure malposition.
466 / CHAPTER 38repair (Fig. 38.7). If oral incompetence is a signiﬁcant com- suture technique, a modiﬁcation of the Keller facelift (41),plaint, lateral lower lip resection (Fig. 38.8) or selective has proven effective as well. Management options for themyomectomy may be of beneﬁt; fascia lata slings have been eye are discussed in detail in a subsequent chapter, thoughdescribed to improve cosmesis and competence in this area unilateral brow lifting is commonly utilized (Fig. 38.9). Sta-(40). Creation of a nasolabial fold via a two-stitch prolene tic procedures are also used in conjunction with dynamic re- Temporalis Fascia Alar Batten Graft Fascia Lata Graft Alar Base FIG. 38.7 External nasal valve repair via fascia lata sling from alar base to zygoma. Surgical Pin in Calvarium Permanent SutureFIG. 38.8 Lower lip wedge resection assists with lower lip FIG. 38.9 Brow lifting is performed by the placement of acompetence. surgical pin in the calvarium and securing of a permanent su- ture to the pin.
FACIAL REANIMATION SURGERY / 467animation techniques as touch-ups or to reﬁne a satisfactory 15. Poe DS, Scher N, Panje WR. Facial reanimation by XI-VII anastomo- sis without shoulder paralysis. Laryngoscope 1989;99:1040–1047.result even further. 16. Griebie MS, Huff JS. Selective role of partial XI-VII anastomosis in fa- cial reanimation. Laryngoscope 1998;108:1664–1668. 17. Rubin LR, Rubin JP, Simpson RL, et al. Search for the neurocranialSUMMARY pathways to the ﬁfth nerve nucleus in the reanimation of the paralyzed face. Plast Reconstr Surg 1999;103:1725–1728.Facial paralysis is a disﬁguring and debilitating condition 18. Cheney ML, McKenna MJ, Megerian CA, et al. Early temporalis mus-whose management is determined by a large set of clinical cle transposition for the management of facial paralysis. Laryngoscope 1995;105:993–1000.variables. A systematic approach to the problem is presented 19. Cheney ML, Megerian CA, McKenna MJ. Rehabilitation of the para-here, employing reinnervation techniques as a ﬁrst line and lyzed face. In: Cheney ML, ed. Facial surgery: plastic and reconstruc-muscle transfer for dynamic reanimation as a second line tive. Baltimore: Williams & Wilkins, 1997:655–694. 20. Rubin L. Reanimation of the paralyzed face. St. Louis: CV Mosby,when feasible, reserving static rehabilitation procedures for 1977.otherwise poor surgical candidates and those with modest or 21. Baker DC, Conley J. Regional muscle transposition for rehabilitationspeciﬁc deﬁcits. of the paralyzed face. Clin Plast Surg 1979;6:317–331. 22. Maegawa J, Saijo M, Murasawa S. Muscle bow traction method for dy- Efforts are ongoing to improve or preserve neural func- namic facial reanimation. Ann Plast Surg 1999;43:354–358.tion, to evoke better native facial nerve regeneration with 23. Aszmann OC, Ebmer JM, Dellon AL. 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