These procedures involve suspending structures in the face into static symmetry using the contralateral side. They provide no dynamic return of function. Suspension from the eyelids, nares, oral commissure and lower lip continues to be described. Suspension procedures can be performed alone or in in conjunction with muscle transfers.
This technique is utilized when there has been longstanding paralysis and the muscles of facial expression have atrophied and fibrosed. In addition, local muscle transposition should be considered if additional mimetic function in a specific site is needed. The masseter and temporalis muscles would be the two most commonly used for transfer. Transposition of the platysma and sternoclidomastoid muscles have also been described; however they have poor excursion when compared to muscles of mastication.
The temporalis may be transposed by transecting its origin on the skull along with a rim of epicranium that will serve as an anchor for sutures. The muscle could be split longitudinally creating several slips. These might be transposed to the lower and upper eyelids, the ala, the mesolabial fold, and the lower and upper lips.
Overcorrection should be performed by sewing the slips under tension. The depression left from elimination of the temporalis could be repaired utilizing a silastic block. The temporalis can also be detached from its insertion to the condyle and sewn to the oral commissure or nasolabial fold.
The masseter is transferred partially or entirely, and it is medial end is split letting it sandwich the oral commissure . The superior portion is sutured to the dermis from the mesolabial fold and also to the underlying orbicularis oris, and the inferior portion is sutured to the lower lip.
The benefit of using a microneurovascular free muscle transplant is that it may be transferred with its nerve supply, which can be attached to the contralateral facial nerve utilizing a cross-facial nerve graft. This will enhance voluntary charge of the transferred muscle. Free flap transfer is suited primarily for patients who are paralyzed in the buccal distribution because of loss of the facial muscles after tumor resection.
It's also right for individuals with intracranial or congenital reasons for facial paralysis. A number of donor muscles have been described. A few of these, such as the biceps femoris muscle, can be harvested having a long neural pedicle that can be directly anastomosed towards the contralateral facial nerve eliminating the need for a cross-facial nerve graft.
The gracilis is the muscle most often used. This muscle could be split longitudinally and trimmed down to the right size. It features a predictable neurovascular pedicle. Harvest of this muscle is described in detail elsewhere in this text. The process is performed in two steps. In the first step, a cross-face nerve graft is performed.
Once the Tinel's sign indicates that the axons have become the length of the sural nerve graft, the second stage is performed. Muscle is harvested and trimmed down to its anterior one-third. It is sewn into place in a way that tries to recreate the zygomaticus major. The foundation is sewn to the zygoma and also the insertion to the oral commissure. Roughly one-third of patients will require a revision after free muscle transfer. These include reinsertion of a detached muscle, tightening of the muscle, debulking from the cheek, or even the addition of a suspension procedure.
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