Craniofacial Muscles

15 Facial Nerve Innervation and Facial Palsies
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functional transfer of a segment of platysma with a cross-facial nerve graft
(CFNG) to restore the blink re fl ex, though the numbers are still small (Terzis and
Karypidis 2010 ) .
15.9.3 The Midface and Mouth
As with the forehead and the eye the reconstruction of the function of the midface
can also be approached through static and dynamic procedures. A loss of symmetry
and animation around the mouth is particularly noticeable and causes considerable
concern to patients with a facial paralysis. Young patients with facial palsy retain
good symmetry at rest due to the natural elasticity of the soft tissues. The aim of
reconstruction here is to restore the movement of the midface. These dynamic procedures
will provide additional static support as the new muscle is in effect also a
sling. In older patients with paralysis, the natural aging process gives a ptotic droop
to the cheeks and corner of the mouth, even in repose. These patients are bothered
by this static asymmetry and the appearance of instability in the face with contraction
of the non-paralyzed side. It causes drooling, dif fi culties with eye closure, and
affects their ability to mix comfortably in public situations. They tend to seek symmetry
at rest and a stable platform with which to use the expression of contralateral
mobile face, more than a broad smile. As a result of this, coupled with the reduced
capacity for nerve regeneration with increasing age, we have decided on an arti fi cial
cutoff of 55 years for dynamic transfers in our patients.
A static sling of autologous (palmaris longus, tensor fascia lata) or synthetic
(Goretex) material can address symmetry at rest and improve both the esthetic
appearance and functional aspects such as drooling. In our unit, we divide the medial
aspect into three slips that are fi rmly anchored to the ipsilateral philtral column and
commissure and the midline of the lower lip. In addition, resuspension of the suborbicularis
oculi fat pad (SOOF lift) can correct static ptosis of the midface (Horlock
et al. 2002 ) .
Early attempts at dynamic reanimation were based on a pedicled translation of
the temporalis muscle. Gilles in 1934 detached its posterior attachment and turned
it down over the zygomatic arch to insert into the corner of the mouth (Gillies 1934 ) .
There have been modi fi cations since then. MacLaughlin detached the temporalis
from the coronoid process and extended it to the corner of the mouth using fascial
grafts rather than folding it over the zygoma (McLaughlin 1952 ) . Labbé avoided the
need for the fascial grafts by partially detaching the origin of the temporalis allowing
the muscle to rotate and “slide” far enough to reach the mouth (Labbé 1997 ) .
Initially this was facilitated by an osteotomy of the zygomatic arch which was subsequently
plated, but modi fi cations mean it is no longer required. This procedure
reduces the main patient complaint of a bulge in the lateral cheek, but does require
intense physiotherapy to retrain the muscle to be used for smiling instead of mastication.
We use this procedure in older patients who are keen on a dynamic reconstruction
but where the results of a cross-facial nerve graft and free muscle prove