Article
A modification in the innervation pattern of the free muscle flap used in the reanimation of the irreparably paralyzed face and its efficacy
Eine Modifikation der Innervation des freien Muskellappens in der Reanimation der irreparablen N. facialis Lähmung und ihre Effektivität
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Authors
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K.G. Krishnan
- Klinik für Neurochirurgei, Universitätsklinikum Carl Gustav Carus, Dresden
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G. Schackert
- Klinik für Neurochirurgei, Universitätsklinikum Carl Gustav Carus, Dresden
| Published: | May 30, 2008 |
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Outline
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Objective: The surgical treatment in facial nerve lesions is based on various factors, viz., origin and level of lesion, age and compliance of patients, and latency from lesion to treatment. The choice of a method of treatment makes a differentiated approach necessary. The methods are: (a) microsurgical nerve suture with or without nerve transplant; (b) transfer of functionally intact motor nerves in the vicinity (e.g., XII, XI); (c) static reconstruction using autologous and non-autologous tissues; (d) macrosurgical dynamic reanimation using local and regional muscle transfers and (e) microsurgical dynamic reanimation using free vascularized and innervated muscle flaps as a two-stage procedure. We have described an effective one-stage procedure of the latter. In this report we present our experience with each of these methods and focus on the results of one stage dynamic microsurgical reanimation using free vascularized and innervated gracilis flap which we have evolved. The motor nerve donor in our modification are two fascicles of the ipsilateral masseteric nerve. Among a total of 26 patients (treated using all the above mentioned techniques) 14 patients underwent surgery according to our modified technique. All patients had a grade 6 unilateral palsy.
Methods: Evaluation criteria: House and Brackman grading system and self evaluating facial grading system.
Results: In contrast to the two-staged technique and cross-face technique, our modification showed clinical innervation of the gracilis flap within the first three months of follow-up in 13/14 patients. HB-Scale of 1 was achieved in 2/14, 2 in 7/14, 3 in 3/14 and 4 in 2/14 patients at a mean follow-up of 18 months (range 8-36 months). In the two patients with HB scale 3, innervation of the gracilis flap did not take place and the effect achieved was only static. At the latest follow-up 10/14 patients indicated a value of A in their self evaluation charts and the remaining 4 patients marked B. Complications: Failed innervation of flap in two cases; Synkinesis was present during the first six months, thereafter it disappeared in all cases.
Conclusions: Success in facial nerve reanimation depends on the appropriate combination of the method and technique of surgical treatement. Innervation of the free muscle flap through the masseteric nerve is quicker and synkinesis is a relative phenomenon.
