What is the role of muscle transfer in the treatment of congenital facial paralysis?

Updated: Jan 07, 2019
  • Author: Alan D Bruns, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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This procedure is indicated when distal nerves or neuromuscular junctions are absent or when significant atrophy is present. Children often have good facial tone at rest, and the risk of the surgery must be weighed carefully against the potential benefit of muscle transfer.

The usual donor muscles for transposition flaps include the masseter and temporalis muscles. Ideal results are good symmetry at rest and some voluntary motion; however, no emotional movement is expected. The temporalis muscle can be split and used to suspend the upper and the lower face.

Mini-temporalis transposition in association with facial nerve microsurgery may be a valuable alternative to free muscle transfer in selected cases. All patients demonstrated an increase in the observers' scores after mini-temporalis transfer in comparison with the scores granted preoperatively or after neural microsurgery. Highly motivated patients committed to postoperative motor reeducation exhibited the best results. [46] Often, a combination of temporalis and masseter muscle transfers is used to rehabilitate the upper and lower face. The trigeminal nerve innervates these muscles; thus, voluntary movement can be achieved with rehabilitation training.

Facial reanimation with free neuromuscular flaps is becoming an accepted standard treatment in patients with complete unilateral facial paralysis. This has been accomplished with a 2-stage technique with the gracilis muscle; recently, a single-stage reanimation technique with the latissimus dorsi may decrease recovery time for patients.

The 2-stage technique involves placing a cross-facial nerve graft in the first stage, followed by microneurovascular muscle transfer 10-12 months later. In these cases, the sural nerve is widely used as the nerve graft, and the gracilis is the preferred donor muscle. A short nerve graft may allow the second stage to be completed in 3.5-5 months. [47] In a study by Terzis and Olivares of pediatric patients, function and symmetry improvement was observed in all patients 2 years after free-muscle transfer, with functional and aesthetic gains increasing over time. Evidence indicated that the transplanted muscles grew in harmony with the craniofacial skeleton. [48]

A single-stage facial reanimation has been used to reduce recovery time. This involves one nerve anastomosis instead of 2, with a latissimus dorsi flap and long thoracodorsal nerve anastomosed to the facial nerve on the contralateral side. [49]

A study by Veyssière et al indicated that lengthening temporalis myoplasty is an effective treatment for congenital facial paralysis. The study, which included 34 patients, found that all of the patients with acquired congenital facial paralysis (11 cases) achieved a spontaneous smile by 9.5 months postoperatively, while 92.3% of those with isolated developmental congenital facial paralysis (12 out of 13 patients) achieved a spontaneous smile by 7.3 months postoperatively, and 90% of patients with syndromic congenital facial paralysis (9 out of 10 cases) obtained a spontaneous smile by 9.7 months postoperatively. [50]

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