10.5\ Facial Reanimation

10.5.1  Discussion

Facial reanimation can be performed for treating the effects of chronic facial nerve paralysis. This can be accomplished with techniques, such as functioning free muscle transfer or temporalis muscle transposition and suspension combined with suborbicularis oculi fat (SOOF) lift. Overall, these techniques successfully restore smiles and provide improvement in mouth function in most patients.

Functioning free gracilis microneurovascular muscle transfer is a form of dynamic facial ­reanimation that can help restore facial tone and

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c

movement. The free muscle flap is buried in the subcutaneous tissues of the face extending from the temporal fossa to the oral commissure region. CT and MRI can demonstrate the intact muscle fibers in the healthy grafts (Fig. 10.35). In addition, Doppler ultrasound is useful for evaluating the patency of the feeding artery and draining vein. Transfer of compound flaps containing muscle and other tissue, such as the skin, can be performed for cases of complex facial paralysis that involve skin or soft tissue deficits after tumor excision. Alternatively, tensor fascia lata and AlloDerm grafts can be used and also appear as soft tissue bands on imaging, but these do not offer dynamic facial animation (Figs. 10.36 and 10.37).

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d

Fig. 10.35  Free gracilis muscle transfer. The patient had right facial paralysis after right cerebellopontine angle schwannoma resection. Axial (a) and coronal (b) CT images

demonstrate the grafted muscle (arrows) within the right face subcutaneous tissues. Doppler ultrasound images of the graft artery (c) and vein (d) display normal waveforms

Temporoparietal fascia and temporalis muscle transposition and suspension procedures consist of detaching and repositioning the flap approximately 180° inferiorly toward the oral commissure and/or nasolabial folds via a tunnel through subcutaneous tissues (Figs. 10.38 and 10.39). The tissues superficial to the plane of dissection can be translated superomedially and sutured to the fascia of the temporalis muscle. If necessary, the

procedure can be augmented using Silastic prostheses to fill the defect. Alternatively, the muscle can be extended using polytetrafluoroethylene.

The suborbicularis oculi fat (SOOF) lift involves superior mobilization of midface ­structures, which are fastened to the orbital rim using a variety of approaches (Fig. 10.40). Often, the intraorbital fat pads are also released and sutured to the SOOF.

Fig. 10.39  Temporalis muscle transposition and suborbicularis oculi fat (SOOF) lift. The patient had left facial paralysis status post parotidectomy and facial nerve resection for adenoid cystic carcinoma. Serial axial T2-weighted

MR images from superior to inferior (a–c) and a sagittal T2-weighted FLAIR image (d) show the left temporalis (arrows) turned inferomedially toward the mouth. The suborbicularis oculi fat pad has also been raised