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Incomplete Facial Paralysis: The Use of the Ipsilateral Residual Facial Nerve as a Donor Nerve for Facial Reanimation

Gur, Eyal, M.D.; Zuker, Ron M., F.R.C.S.(C), F.A.A.P.; Zaretski, Arik, M.D.; Leshem, David, M.D.; Barnea, Yoav, M.D.; Arad, Ehud, M.D.; Yanko, Ravit, M.D.; Meilik, Benjamin, M.D.; Kedar, Daniel J., M.D.; Fliss, Ehud, M.D.

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 202–214
doi: 10.1097/PRS.0000000000004536
Reconstructive: Head and Neck: Original Articles

Background: The reconstructive approach for incomplete facial paralysis is not yet determined. In this article, the authors present a new surgical approach for patients with incomplete facial paralysis in which residual, ineffective movement is detected preoperatively in the ipsilateral buccozygomatic territory of the paretic facial nerve.

Methods: Sixteen patients with incomplete facial paralysis were found eligible for the procedure and underwent one-stage facial reanimation performed by the senior author (E.G.). Reanimation was performed using free gracilis muscle transfer with neural coaptation to an active facial nerve branch(es) responsible for the predetected buccozygomatic residual movement. Patients were reviewed in a systematic fashion using a combined still photographic and video scoring scale for symmetry at rest and at dynamic states.

Results: Following surgery, improved symmetry was observed in the majority of observations of the mouth region at rest and while smiling and of the nasolabial fold region while smiling. There was no significant change in symmetry in the majority of observations of the eye region at rest and while smiling and the nasolabial fold region at rest. Video assessment of dynamic facial symmetry while smiling demonstrated improved symmetry in 91 percent of the observations (n = 191 observations). Comparison of mean scores for dynamic smile symmetry produced a statistically significant improvement of 1.68 points following surgery (p < 0.001).

Conclusion: Based on this series, the authors recommend that use of the ipsilateral facial nerve buccozygomatic residual branch be considered as a donor nerve for facial reanimation using a free gracilis muscle transfer in patients with incomplete facial paralysis with residual preoperative movement in the midface.


Tel Aviv, Israel; and Toronto, Ontario, Canada

From the Department of Plastic and Reconstructive Surgery, Microsurgery Unit, Tel Aviv Sourasky Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University; and the Division of Plastic Surgery, The Hospital for Sick Children, University of Toronto.

Received for publication June 12, 2017; accepted January 22, 2018.

Presented at the 2016 American Society for Reconstructive Microsurgery Annual Meeting, in Scottsdale, Arizona, January 16 through 19, 2016.

Disclosure: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with any of the information presented in the article.

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Eyal Gur, M.D., Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel,

©2018American Society of Plastic Surgeons