Reanimation Reconstruction Microsurgery Free flap muscleflap gracilis sural nerve crossface cross face end to side end to end neurorrhaphy nerve surgery nervesurgery reanimation of paralyzed face restoring facial function dynamic movements symmetry static symmetry restoration asymmetry smile laugh chew droop corner dropped corner breathing problem dry eyes swollen eyes unable to close eye closure

Cantopexy

Cantopexy provides support to the lower eyelid. This procedure tightens a loose or sagging lower eyelid, improves the shape or position of the lower eyelid, or reattaches a displaced lateral canthal tendon.

Crossface Nerve

A crossface nerve graft can be performed if paralysis affects only one side of the face. Typically the sural nerve in the lower leg is used as a nerve graft. This nerve is an expendable sensory nerve, which is harvested via two small incisions. Specific facial nerve branches from the healthy side provide healthy nerve fibers to innervate the paralyzed side. The nerve graft it is coapted on one end to the facial nerve of the healthy side and on the other to the facial nerve of the paralyzed side. The crossface nerve graft guides the regenerating nerve fibers as they migrate from the healthy facial nerve, across the nerve graft into the facial muscles of the paralyzed side. The nerve graft serves like an extension cord, carrying more power to the paralyzed nerve. After about 6 to 12 months, the regeneration across the nerve graft is complete. Nerve signals will flow from the healthy facial nerve across the nerve graft into the paralyzed facial muscles, producing spontaneous and emotionally mediated movements.

Muscle Transplantation

Muscle transplantation is a microsurgical technique which transplants a muscle from another body region to the face for restoring the smile. Microneurovascular muscle transplantation (free muscle flap) is indicated in individuals with absent facial muscles, as in Moebius Syndrome and Craniofacial Microsomia, or with facial muscles that have undergone irreversible atrophy, or in patients where the facial muscles are removed during tumor excision or damaged by trauma. A segment of the gracilis muscle from the inner thigh is transferred with its blood vessels and its nerve, to the face and connected to blood vessels and a nerve within the face. The new muscle position in the face allows a smile movement upon contraction. Using the gracilis muscle from the thigh does not impair leg function, as other muscles perform its same task.

Nerve Transfer

Nerve transfer (neurotization) is a nerve reconstruction technique to direct a healthy nerve to innervate (neurotize) a damaged nerve and its muscle. If the facial nerve is impaired or unavailable but its distal nerve branches and facial muscles are viable, a nerve branch of the chewing muscles (masseter muscle) or of the shoulder elevation muscle (trapezius muscle) can be redirected to the facial branches (buccal, zygomatic or marginal mandibular) of the facial nerve. Over time, axons from the healthy nerve will grow into the impaired facial nerve branches and its muscles, which will allow facial movements.

Reanimation of the Paralyzed Face

Reanimation of the paralyzed face is a microsurgical technique to reestablish voluntary facial movements (dynamic reconstruction), for example, a symmetrical smile or eye closure in patients with long-lasting facial palsy, where the facial muscle are not present. Reanimation of the face is performed in one or two surgical stages, depending on the nerve that will be used. For one-stage reconstruction, the masseteric or the accessory nerve, and for two-stage reconstruction, crossface nerve grafts (sural nerve) will be used. In a one-stage operation, the nerve will be coapted to the gracilis nerve transplantation. In a two-stage reconstruction, a crossface operation (add link CROSS FACE) will be performed, and then after 7 to 12 months’ nerve regeneration time, the gracilis muscle transplantation will accomplish the reanimation of the face. For bilateral reconstructions, a gracilis muscle can be transplanted to each side of the face in two separate surgeries, with a minimum interval of 3 months.

Synkinesia and Spasm

Synkinesia and Spasm are abnormal involuntary movements of the face of various patterns. If the facial nerve is damaged (as from trauma, infection, inflammation, tumors, or surgery) it will self-repair and facilitate the growth of nerve fibers to regenerate toward their original muscle-segments. However, scar tissue or less ideal growth conditions may divert regenerating nerve fibers to the wrong targets (i.e., different muscle segments or groups, or the lacrimal gland), which result in incomplete recovery from facial nerve with synkinetic muscle contractions. Symptoms of misdirection of regenerating nerve fibers are commonly related to eye closure, oral function, facial mass movements, muscle spasm, or hyperlacrimation (excessive tear flow). Synkinesis and spasm affect each individual differently. Some cases are mild and do not require treatment, as the symptoms gradually improve; others will benefit from selective reduction of muscle activity. Treatments such as surgeryand botulinum toxin aim to reduce synkinetic and spastic activities in the face.

Tarsorrhaphy

Tarsorrhaphy is a surgical procedure in which the lower and upper eyelids are partially sewn together at the outer corner of the eye, to narrow the eyelid opening. It may be done to protect the cornea in cases of corneal exposure, as a treatment for Graves' ophthalmopathy or Möbius syndrome, or after corneal graft surgery.

Temporalis Transfer

Temporalis Transfer is a technique to restore dynamic eye closure in patients with severe lagothalmus and unable to close their eyes. A segment of the temporalis chewing muscles is rerouted and attached to the inner corner of the eye. Clenching ones teeth together activates the redirected muscle segment to close the eyes. The temporalis muscle is often chosen because its direction of pull can produce a natural eye closure. This technique is reserved for individuals where upper eyelid gold weight implantation does not achieve a full eye closure.

Moebius Syndrome

Möbius syndrome is a bilateral facial nerve paralysis, sometimes with limb abnormalities—clubbed feet, missing fingers or toes, chest-wall abnormalities (Poland Syndrome), crossed eyes (strabismus), and difficulty in breathing and/or in swallowing. This syndrome generates psychological disability due to lack of facial animation and the inability to show happiness, sadness, or anger. A detailed neurologic evaluation and electrophysiological examination is obligatory. The surgical therapy is to reanimate the paralyzed face with bilateral free gracilis muscle transplantations coaptated to the masseter or spinal accessory nerves to achieve smile movements in the face. This therapy is carried out in two separate surgeries, with an interval of not fewer than 3 months.