Reconstruction After Critical Window of Muscle Denervation

For people with long-standing facial paralysis (greater than 12-24 months), providing a nerve supply to the native muscles of the face is no longer possible. In these circumstances, static reconstructions or reconstructions involving muscles from other regions of the body may be performed.

Static Reconstructions

Static reconstructions act as an internal sling for the face. They provide support, but not movement. Static support slings may be constructed from other regions of the body, such as fascia from the thigh, forearm, or temple, or from surgical products. Static techniques are sometimes used in combination with dynamic techniques of reconstruction, such as regional muscle transfers.

Dynamic Reconstructions

There are many techniques for dynamic reconstruction of facial paralysis. Some examples of dynamic reconstructions are provided.

Regional Muscle Transfers

Functioning muscles on the paralyzed side of the face can sometimes be moved at one end of the muscle to provide facial movement. These transferred muscles, such as the temporalis muscle or masseter muscle, are innervated by the trigeminal nerve (cranial nerve V) and are involved in chewing.

Free Functional Muscle Transfers

Advances in microsurgical techniques have made free functional muscle transfers reliable and more elegant. In the absence of usable facial expression muscles, a small piece of muscle can be transplanted from other areas of the body (we prefer the inner thigh) to the face. The gracilis muscle is an expendable muscle from the inner thigh that is an ideal candidate for transfer to the face. Use of this muscle produces little or no leg weakness as there are four remaining muscles that perform the same function. The segment of muscle is moved with its blood vessels (so that it is alive) and its nerve (so that it may move). The blood vessels and nerve are then connected to blood vessels and a nerve within the face. The muscle is precisely positioned so that when it contracts, it creates a smiling movement in the corner of the mouth and upper lip and balances pull from the movement on the opposite side of the mouth. This procedure is technically very demanding, and it requires the use of microsurgery to connect vessels with sutures (stitches) several times thinner than human hairs. This reconstruction may be performed in one or two surgical stages, depending on the nerve supply that will be used. We most commonly use this technique in combination with a cross-facial nerve graft (two stages) or a masseteric nerve transfer (one stage). For both of these nerve sources, the donor nerve (either the graft or the masseteric nerve) are connected to the nerve to the gracilis muscle (the obturator nerve). The nerve fibers then slowly grow into the transferred gracilis muscle to allow it to contract over time, usually in 4-9 months. For bilateral reconstructions, a gracilis muscle can be transplanted to each side of the face. We prefer to do this in two separate surgeries, usually at a minimum of 3 months apart.

To schedule an appointment with Dr. Snyder-Warwick, please call 314-362-7388 or 1-800-454-KIDS.