Free tissue transfer for the treatment of facial paralysis

Long-standing facial paralysis requires the introduction of viable, innervated dynamic muscle to restore facial movement. The options include regional muscle transfer and microvascular free tissue transfer. There are advantages and disadvantages of each. Briefly, the regional muscle transfer procedures are reliable and provide immediate return of movement. However, the movement is not of a spontaneous mimetic nature. Free tissue transfer, in contrast, offers the possibility of synchronous, mimetic movement. It does, however, require a prolonged healing time in comparison with that of regional muscle transfer. The choice is made by physician and patient together, taking into account their preferences and biases. Muscle-alone free tissue transfer is our preferred option for reanimation of uncomplicated facial paralysis without skin or soft tissue deficits. Combined muscle and other tissue (most are skin flap) is another preferred option for more challenging complex facial paralysis with skin or soft tissue deficits after tumor excision. Gracilis flap is the author's first choice of muscle transplantation for both reconstructions. From 1986 to 2006, gracilis functioning free muscle transplantation (FFMT) was performed at Chang Gung Memorial Hospital for facial reanimation in 249 cases of facial paralysis. The main etiology is postoperative complication and Bell's palsy. The innervating nerve comes mostly from contralateral facial nerve branches, few from ipsilateral facial nerve due to tumor ablation, and from ipsilateral motor branch to masseter or spinal accessory nerve due to Möbius syndrome. We have evolutionally used a short nerve graft (10 to 15 cm) to cross the face in the first stage; after a 6- to 9-month waiting period, gracilis FFMT was performed for the second stage of the reconstruction. The technique of evolution has shown encouraging results to achieve the goal of rapid restoration and fewer scars on the donor leg.