Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 22:
Facial Paralysis
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  B. Four to six months later, when the Tinel sign reached the midcheek area on the paralyzed side, the second stage of the operation is begun. The serratus muscle in the upper portion of the diagram is free and ready for insertion onto the paralyzed side of the face. The scapular origin of the muscle will be sutured securely to the temporalis and zygomatic fascia. The muscle is turned over so that the neurovascular pedicle now comes off inferiorly and on the deep surface of the muscle, rather than superiorly and on the superficial surface of the muscle, as it lies on the chest.


C. The upper slip, now 9, is split in two and passed through a subcutaneous tunnel to the central portion of the tarsal plate of the upper and lower eyelids, laminating it on top of the temporalis transfer done in stage one. The eighth slip is sutured to the outer third of the upper lip. The seventh slip is sutured to the angle of the mouth on top of the fascial sling inserted in the first stage.


Case Studies

CASE 1

A 50-year-old woman underwent resection of a left acoustic neuroma, resulting in a left facial palsy.

FIG. 22-01. There is obvious slackness in the left face, and inability to close the eye has been symptomatic. Patient attempts to smile.

 


FIG. 22-02. Patient attempts to close both eyes.


FIG. 22-03. First-stage reconstruction was begun on the unparalyzed side, localizing the branches of the right facial nerve with intraoperative nerve stimulation. The entire marginal mandibular branch is isolated because it is relatively expendable, plus a branch to the upper lip, to neurotize the crossfacial nerve graft.


FIG. 22-04. The sural nerve is tunneled across the lower lip to the nasolabial incision on the paralyzed side. A red rubber catheter is passed through the tunnel and the nerve pulled through with suction on the catheter.


FIG. 22-05. The microneural repairs are performed with 11-0 suture carefully approximating fascicular bundles in the sural nerve to the marginal mandibular and the upper lip branch.


FIG. 22-06. The sural nerve is shown coming out of the nasolabial incision on the paralyzed side.


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