Cross-Face Nerve Grafting Followed by Free Muscle Transplantation in Young Patients with Long-Standing Facial Paralysis

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Abstract
For reanimation of the cheek in 8 young patients with long-standing facial palsy a method with cross-face nerve grafting followed by free muscle transplantation has been used. The sural nerve was used as nerve graft and placed in a subcutaneous tunnel across the face. In the normal cheek 3–4 fascicles of the nerve were anastomosed to facial nerve branches innervating muscles elevating the angle of the mouth. Four to 13 months later the extensor digitorum brevis muscle to the second toe or the palmaris longus was transplanted to the paralysed cheek. It was attached between the zygomatic arch and the angle of the mouth. The end of the nerve was sutured to the muscle after taking a biopsy. The follow-up period has been 7–30 months. At 7 months 6 patients had positive EMG, either on voluntary movement or on stimulation of the contralateral facial nerve. Three of them had also a slight movement in the cheek. Two patients are as yet only 7 months postoperative. In the remaining two cases, No. 2 and 4, there were no signs of reinnervation. At 18 months 4 out of 6 patients had a synchronous natural contraction in the cheek giving increased balance to the mouth. These patients had a positive EMG. In patients No. 2 and 4 there was neither innervation nor improvement. At 30 months there was additional improvement in two cases but as previously in patients No. 2 and 4 there was neither improvement nor signs of innervation of the muscle on the EMG. The other 4 patients have not reached this postoperative stage. To summarize, synchronous, voluntary movement of the paralysed cheek was obtained in 6 out of 8 treated patients.