Craniofacial Muscles

280 A.O. Grobbelaar and A.C.S. Woollard
Fig. 15.1 First stage facial
reanimation: The cross-facial
nerve graft is coapted to a
buccal branch of the facial
nerve on the functioning side
and tunneled across the upper
lip to the paralyzed side of
the face. The regeneration of
the axons through the graft
can be traced by a positive
Tinel’s sign
unreliable. We also use a Blair type facelift incision to avoid the need for the
nasolabial inset incisions as described by Labbé.
CFNG were fi rst described by Scaramella in 1970. The arborization between the
zygomatic and buccal branches of the facial nerve is suf fi cient to allow minimal
donor de fi cit and provide synergistic nerve impulses to power the paralyzed side of
the face. Originally this was used to attempt reinnervation of native muscles
(Scaramella 1975 ; Anderl 1976 ) . In 1976, Harii performed the fi rst successful free
transfer of a gracilis into a paralyzed face. This was anastomosed to the deep temporal
vessels and coapted to the existing ipsilateral facial nerve stump. In 1979, he
described the two-stage procedure of a CNFG to contralateral facial nerve and subsequent
free muscle transfer (Harii et al. 1976 ) . This has become accepted as the
gold standard for dynamic reanimation (Figs. 15.1 and 15.2 ). Many muscles have
since been suggested as potential donors (gracilis, latissimus dorsi, extensor digitorum
brevis, pectoralis minor) in an attempt to improve the vector of the recreated
smile and to minimize the bulky contour that resides in the reconstructed cheek.
The two stages can be performed 9–12 months apart and in congenital palsy
cases results are better in children under 10 years. Long-term studies show a wide
variation in improvements with most authors claiming good to excellent results in
51–94% of patients (Terzis and Noah 1997 ; O’Brien et al. 1990 ; Harrison 2002 ;