Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Defect Etiology and Assessment
The primary etiology of acquired lip defects is malignancy. Over 90% of cases involve the lower lip,
presumably due to its susceptibility to extensive sun exposure. Basal cell carcinoma is the most common
malignancy involving the upper lip, and squamous cell carcinoma is the most common in the lower lip.
The vast majority of patients with lip cancer are male (96%). 7 Other indications for lip reconstruction, in
descending order of frequency, include trauma, burns, and vascular anomalies. When approaching lip
reconstruction, one should first assess the lesion and attempt to determine the amount of skin, muscle,
and mucosa that will be involved. Defects can be divided into superficial skin defects, vermilion-only
defects, small defects involving less than one-third the total lip length, intermediate defects between one-
third and two-thirds the lip length, and subtotal or total lip defects. Choices of donor tissue for lip
reconstruction include the remaining lip segments, the opposite lip, the adjacent cheek, and distant sites.
Goals of reconstruction are focused on providing complete skin coverage and oral lining, producing a
semblance of a vermilion, creating an adequate stomal diameter, restoring sensation, and maintaining a
competent oral sphincter. 8
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Superficial Cutaneous Defects
Options for closing superficial defects involving the cutaneous lip include primary closure, skin grafts,
and local flaps. When closing defects primarily, dog-ears should be excised and oriented in a linear
fashion along relaxed skin tension lines, ideally along anatomic boundaries (e.g., philtral column).
Natural facial contours such as the nasolabial crease or alar groove are difficult to recreate. If possible,
closures should be planned immediately adjacent to these contours to preserve their architecture and help
camouflage scars. To avoid tissue redundancy, partial-thickness defects around the vermilion border are
generally best managed by converting defects into full-thickness wedge excisions. Skin grafts are
generally not required for superficial skin defects because adjacent soft tissue laxity permits the use of
local flaps for primary closure. An exception to this includes defects of the central lip involving large
portions of the philtral groove. Here, local flaps may cause distortion of Cupid’s bow and the philtral
columns. Instead, resurfacing the entire subunit with a full-thickness graft limits contraction and
optimizes appearance. For smaller defects within the philtral groove, healing by secondary intention
generally provides good results and avoids the patch-like appearance of a skin graft. Local tissue
rearrangement techniques generally offer the best match in terms of tissue thickness, color, and texture,
and are generally designed as either advancement or transposition flaps using cheek and/or adjacent lip
tissue. Most common techniques include cheek advancement combined with perialar crescentic excisions,
nasolabial flaps, and lateral V-Y advancement flaps (Figure 41.3). The nasolabial flap is a particularly
good option for recreating a hair-bearing upper lip in male patients; however, the potential for horizontal
hair orientation creates an unnatural appearance.
FIGURE 41.3 Reconstruction of left upper lip cutaneous defect with V-Y advancement flap.
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Vermilion Defects
The vermilion is a modified mucosal surface consisting of a thin layer of nonkeratinized epithelium that
is devoid of hair follicles or sebaceous glands. Its unique color is produced by the dense capillary network
sandwiched between the mucosa and underlying orbicularis oris muscle. The human eye is remarkably
accurate at detecting subtle asymmetries, and the sharp juxtaposition of color at the vermilion-cutaneous
junction makes step-offs as small as 1 mm noticeable at conversational distances. Alignment of the
vermilion border and white roll is essential in any lip procedure, from simple lacerations to complex
reconstructions. To avoid misalignment from tissue distortion, regional nerve blocks (e.g., infraorbital
nerve block) are preferred over direct infiltration. The fine anatomic borders of the uninvolved, marginal
vermilion should be marked to facilitate precise repair. Small defects confined to the vermilion can be
managed with musculomucosal V-Y advancement flaps designed horizontally. Lesions closer to the
vermilion border are preferentially excised perpendicular to the white roll to facilitate alignment of this
landmark. The simplest method for repair of larger, partial-thickness vermilion defects is undermining
and advancement of adjacent buccal mucosa over the remaining orbicularis oris muscle to restore the
mucocutaneous junction. This is often used for lip shave procedures resulting in loss of the entire lower
lip vermilion. The major disadvantages of this technique are inward retraction and thinning of the lower
lip due to mucosa retraction as well as decreased mucosal sensation.
For larger defects that do not involve the white roll, transposition or advancement flaps of vermilion are
generally recommended. These include lip sharing procedures, such as the staged bipedicle mucosa flap,
or the cross-lip mucosal flap (lip switch) (Figure 41.4A). For larger defects that include a portion of
orbicularis muscle, myomucosal flaps of lateral lip vermilion based axially on the labial artery may be
advanced to close the defect (Figure 41.4B). In addition, random buccal mucosal flaps or, more reliably, a
facial artery musculomucosal (FAMM) flap can be rotated from intraorally to reconstruct defects of the
vermilion. 9 The FAMM flap is an axial flap that includes part of the buccinator muscle and can be based
inferiorly (antegrade) or superiorly (retrograde) on the facial vessels. Lastly, tongue flaps are another
method for lip reconstruction and can provide significant bulk; however, they require a second stage for
pedicle division and flap inset. Utilizing the lateral or ventral surfaces of the tongue avoids transferring
the dorsal tongue papillae, which has a rough texture. The biggest drawback of any oral mucosal or
tongue flap for lip reconstruction is the tendency for the tissue to desiccate.
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FIGURE 41.4 Vermilion reconstruction. A. Reconstruction of a partial-thickness upper lip defect using a unipedicle vermilion lip
switch flap. The pedicle is divided 10 to 14 days later at a second-stage procedure. B. Laterally based vermilion
musculomucosal advancement flap supplied by labial artery.
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Small Full-Thickness Defects
The elasticity of the upper and lower lips permits primary closure of small full-thickness defects in many
instances. In the lower lip, 40% of the width can generally be reapproximated using layered closure,
whereas in the upper lip, the distinct topographic landmarks (e.g., philtrum and Cupid’s bow) can only
tolerate primary closure of defects up to 25% without significant distortion. Defects should generally be
converted into a shield excision design so that layered closure at the vermilion border is perpendicular to
white roll for precise alignment. For larger defects, one is able to keep the scar above the labiomental
crease using a W-plasty design (Figure 41.5). During closure, careful approximation of the mucosa,
orbicularis oris muscle, and skin layers ensures a functional repair and good aesthetic result. Wound edge
eversion is critical to prevent notching.
FIGURE 41.5 Wedge excisions of the lower lip using shield (A) and W-plasty designs (B).
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Intermediate-Sized Full-Thickness Defects
Intermediate-sized full-thickness defects represent the most complex decision-making challenge. For
defects involving slightly greater than one-third the width of the lip, primary closure is possible if
combined with perioral skin excisions. The Schuchardt procedure is a sliding-lip reconstruction that
combines medial advancement of the lower lip tissue with bilateral labiomental crease excisions. 10 The
barrel-shaped incision may be extended all the way around the labiomental folds. For central upper lip
defects, Webster’s technique of crescentic perialar cheek excisions move the upper lip without disturbing
lateral muscle function. 11 The Bengt-Johansson staircase technique is a useful, one-stage repair for central
lower lip defects of intermediate width. 12,13 In this technique, neither the orbicularis oris muscle, opposite
lip, nor the labiomental crease are violated. The design includes two to four small squares of the skin and
subcutaneous tissue that are excised in a stair-step fashion descending from medial to lateral at 45° angles
from the base of the defect. Thus, advancement of the flap in the direction of the defect proceeds with
each succeeding higher step in the staircase.
Despite the advantages of these techniques, lip-switch flaps are arguably the best method for
reconstructing full-thickness lip defects of intermediate width. These are axial flaps based on the labial
arteries to reconstruct skin, subcutaneous tissue, muscle, and mucosa of one lip using the same composite
tissue from the other. For defects of the central upper lip, excising the entire central subunit and
interpolating an Abbe flap into the defect is an excellent option. 14 The Abbe flap is a two-staged lip-
switch procedure where a full-thickness flap of up to one-third of the donor lip can be used to reconstruct
up to two-thirds of the recipient lip (Figure 41.6). The flap is rotated 180° on its pedicle (labial artery) and
remains for about 3 weeks, after which the pedicle is divided at a second stage. This technique is effective
at recreating the philtral columns without flattening the upper lip contour. Flaps are designed with their
borders parallel to relaxed skin tension lines and can be based either medially or laterally on the labial
arteries. The height of the flap should match that of the defect and the width of the flap and should be
about half the width of the defect. The reverse Abbe flap based on the superior labial artery is useful for
reconstructing lateral or midline lower lip defects. However, the central part of the upper lip should
never be used for donor tissue, as the philtral columns and dimple are irreplaceable. Instead, a flap from
the junction of the middle and lateral thirds of the upper lip should be used.
FIGURE 41.6 Full-thickness defect involving central upper lip reconstructed with an Abbe flap.
The Estlander flap is a full-thickness, medially based triangular flap from the upper lip used to
reconstruct lateral lower lip defects when the oral commissure is involved (Figure 41.7). 15 Similar to the
Abbe flap, it is designed so that its width equals half the width of the defect. Although incisions can be
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well-hidden within the nasolabial fold, the flap creates a rounded commissure and causes distortion of
the modiolus. Therefore, secondary commissuroplasty is often required.
FIGURE 41.7 The Estlander flap rotates upper lip tissue to the lower but results in blunting of the commissure and loss of the
normal taper of the vermilion.
The Gillies fan flap is a modification of the cross-lip technique. It rotates tissue around the commissure
similar to an Estlander flap, but it includes additional tissue from the nasolabial region. A quadrangular-
shaped flap is designed and the incision is extended from the inferior aspect of the defect laterally around
the commissure and superiorly into the melolabial crease. Modifications of this technique include the
incorporation of a Z-plasty, which allows better turning of the pedicle around the commissure (Figure
41.8). Bilateral flaps are often required for large defects approaching up to 80% of the lip; however,
undesirable sequelae of reconstructing such large defects include significant microstomia and oral
incompetence due to denervation of the orbicularis oris muscle.
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FIGURE 41.8 Z-plasty modification of the Gillies fan flap technique.
The Karapandzic flap is a musculocutaneous rotation advancement flap similar to the Gillies fan flap;
however, with the Karapandzic flap, incisions are limited to the skin and subcutaneous and the
neurovascular bundles are carefully dissected and preserved to maintain muscle function and lip
sensation (Figure 41.9). 16,17 In addition, small separate mucosal-releasing incisions are made to create a
gingivobuccal sulcus, and redundant skin along the outer circumference generally requires excision as a
Burow triangle. These flaps can be used for large central defects up to 80%; however, blunting of the
commissures and microstomia may occur.
FIGURE 41.9 The Karapandzic technique.
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Subtotal or Total Lip Defects
Reconstructing lip defects over 80% is difficult to achieve with regional tissue alone. Attempts at
reconstruction for these defects often leads to poor aesthetic outcome and compromised oral competence
due to a denervated, adynamic lower lip. A number of eponyms exist for the bilateral opposing cheek
advancement techniques described for reconstructing large lower lip defects. 18-21 All consist of horizontal
advancement of cheek skin with removal of Burow triangles as originally described with the Bernard
cheiloplasty in 1853. These techniques may be combined with a buccal mucosal advancement flap to
reconstruct the vermilion. Webster’s modification of the Bernard-Burow technique for lower lip
reconstruction combines triangular skin excisions adjacent to the nasolabial folds with paramental
triangular flaps (Figure 41.10). Benefits of this technique are the ability to produce good contour of the
commissure, place scars within natural skin creases, and preserve the aesthetic region of the chin;
however, drawbacks include incomplete recovery of sensation, vermilion color mismatch, and poor oral
competence. 21,22 To overcome these limitations, current techniques excise the skin and subcutaneous only
and preserve the neurovascular structures to maximize oral competence and sensation.
FIGURE 41.10 Webster modification of the Bernard-Burrow technique.
Various nasolabial flaps have been described for reconstruction of large upper and lower lip defects. 19,20,23
Long segments of skin and subcutaneous tissue based on perforators of angular artery are transposed to
reconstruct full-thickness defects. Examples include Fujimori’s gate flap design, which rotates two
nasolabial island flaps 90° for reconstruction of lower lip defects, 23 and Von Brun interiorly based
nasolabial flaps for reconstructing upper lip defects. 19 These designs pivot on the commissures and often
require a skin graft to line the inner surface. Surgeons must account for significant contraction and
therefore flaps should be made larger than the lip defect. Reconstruction of the vermilion occurs at a
second stage. Despite their ability to recruit large amounts of tissue, nasolabial flaps generally produce
suboptimal oral competence and aesthetics, and the use of multiple local flaps is typically more effective.
24-26 For example, two reverse Abbe flaps of lateral upper lip tissue may be used to reconstruct the lower
lip whereas perialar crescent excisions and cheek advancement are used to close the upper lip Abbe
donor sites. For the upper lip, an Abbe flap from the lower lip may be used to reconstruct the philtrum
and combined with bilateral perialar crescent excisions with cheek advancement.
Regional flaps and free tissue transfer are often employed for total or subtotal lip defects when
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recruitment of local tissue would result in significant microstomia. The submental flap based on the
submental branch of the facial artery can be transferred as an island and interpolated to reconstruct upper
or lower lip defects. This flap is reliable and offers good tissue match. The temporoparietal scalp flap is
best suited for male patients when hair-replacement is desired. 27 The most commonly used free flap for
total or near-total defects of the lower lip is the radial forearm free flap. This flap provides thin, pliable,
hairless skin with reasonably good color match. Oftentimes, a palmaris longus tendon graft is
incorporated with the flap and either attached to the modiolus or anchored to the malar eminence to act
as a sling for oral competence. 28-30 This flap can be made sensate by coaptating the lateral antebrachial
cutaneous nerve to the mental or inferior alveolar nerve. Another option for microvascular reconstruction
is the free gracilis muscle flap. Some surgeons describe prelaminating the gracilis by incorporating a long
strip of fascia lata tendon for lower lip support and placing a silicone sheet along the deep site of the
muscle to create a neomucosal lining before final transfer. 31,32 The use of a reinnervated gracilis muscle
free flap has also been described. 33 Symmetrical spontaneous and voluntary lower lip control was
restored by coaptating the motor branch of the gracilis muscle to the marginal branch of the facial nerve.
A regional mucosal flap (e.g., FAMM flap) is used to replace the vermilion and inner mucosa, and a skin
graft is used to line the external surface of the gracilis muscle.
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Cheek Reconstruction
Preoperative Considerations
The cheeks represent a large proportion of the facial surface area and play an important role in the
aesthetic relationships of the central face. Cheek reconstruction should be meticulously planned and
executed to restore facial contours, camouflage scars, maintain hair patterns, minimize wound healing
complications, and minimize tension to neighboring facial units (e.g., avoiding lower lid ectropion).
Ideally, scars should be planned at the cheek margins or within relaxed skin tension lines. 34 Vertical
incisions placed medial to a line drawn from the lateral canthus remain obvious on frontal view and
ideally should be replaced by incisions along the nasolabial fold or by blepharoplasty incisions. Care
should be taken to avoid placement of hair-bearing skin into non-hair-bearing areas and vice versa.
Patient factors such as smoking, diabetes, immunosuppression, history of radiation, and prior scars may
compromise wound healing and should be considered when planning reconstruction. The potential need
for facial nerve reconstruction should also be anticipated. Furthermore, patients should be counseled
about the possible need for revision to improve contour irregularities, particularly for complex
reconstructions.
Several authors divide the cheek into subunits based on anatomic characteristics and reconstructive
needs, which may be helpful for preoperative planning. 35,36 However, the principles for subunit
reconstructive (e.g., discarding remaining tissues of a subunit) are less applicable to cheek reconstruction.
The central cheek has more complex and subtle contours compared to the lateral cheek. Because these
contours are visually compared to the contralateral side in primary gaze, this region should have a high
priority during reconstruction. On the other hand, because the lateral cheek does not play a role in
framing the central facial units (nose, lips, and eyelids) and cannot be fully compared with the other
cheek, exact symmetry is less important.
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Anatomy
The cheek is bounded laterally by the preauricular skin, medially by the nasal sidewall and nasolabial
fold, inferiorly by the mandibular border, and superiorly by the temple and lower eyelids. Sensory
innervation is provided by the maxillary (V2) and mandibular (V3) divisions of the trigeminal nerve and
from small contributions from the anterior cutaneous nerve of the neck and great auricular nerve. Motor
innervation of the mimetic facial muscles is provided by the facial nerve and its main branches, whereas
the masseter and temporalis muscles are innervated by the trigeminal nerve. The facial nerve is located
deep to superficial lobe of parotid. Beyond this, the distal branches are found just deep to the parotid
masseteric fascia. Perfusion of the cheek is robust and affords the ability to reliably elevate large, random-
pattern flaps for reconstruction of large defects. The arterial supply of the cheek is predominantly
provided by the facial artery, which gives off the angular artery that anastomoses with the infraorbital
artery and infratrochlear artery distally. The superficial temporal artery and the transverse facial artery
supply the superior aspect of the cheek. The lymphatic drainage is via lymphatic channels within the
parotid nodes and those along the facial vessels to the submandibular nodes.
The retaining ligaments of the face are fascial condensations that anchor the superficial tissues to the
facial skeleton and deep fascia. The zygomatic ligaments (McGregor patch) anchor the skin of the cheek
to the inferior border of the zygoma just posterior to the origin of the zygomaticus minor muscle. The
mandibular ligaments tether the overlying skin to the anterior mandible. 37 These ligaments resist
advancement of cheek skin and may require release to mobilize skin flaps for closure of cheek defects.
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Reconstructive Options
Healing by Secondary Intention
The simplest method for closing cheek defects is healing by secondary intention. This is most useful for
small, superficial defects, in inconspicuous areas such as the temple or preauricular region. Concave areas
heal exceedingly better than areas of convexity because of tension and skin laxity and provide better
outcomes as well due to shadows produced by adjacent tissue contours. Larger defects left to heal by
secondary intention are prone to significant scar contraction causing distortion of surrounding structures
and contour irregularities.
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Primary Closure
Primary closure is the best option as long as tension and distortion of surrounding facial units is avoided.
The size of the defect that can be closed primarily depends on location, degree of surrounding skin laxity,
amount of skin undermining that can be performed, and the tolerable length of the linear scar. Elderly
patients demonstrate significant skin laxity, and therefore primary closure is often appropriate even for
larger cheek defects. Scars are ideally placed along relaxed skin tension lines or within natural skin
contours. Scars are not well hidden in structures such as the nasolabial or preauricular crease and instead
obliterate these natural landmarks. Placing incisions/scars immediately adjacent to them (1 mm away and
parallel) is best.
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Skin Grafts
Skin grafts are occasionally used for cheek reconstruction. They are one of the most effective techniques
for covering large defects but may be associated with shiny, patch-like reconstructions with poor color
match and contour deformity. Skin grafts are useful in patients with significant comorbidities and in
patients who require surveillance for recurrence of aggressive tumors. They are primarily reserved for
resurfacing less-critical areas of the cheek, such as the preauricular region. Full-thickness skin grafts
result in less secondary contracture and less contour deformity. A better color match is more often
achieved if skin grafts are harvested from the supraclavicular or preauricular/postauricular skin.
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Local Tissue Rearrangement
Transposition flaps such as banner flaps, bilobed flaps, and rhomboid flaps exploit the mobility of the
cheek to close many medium to large size defects of the cheek. Skin and subcutaneous tissue from
adjacent areas is transferred into the defect and the donor site is closed primarily. Drawbacks include
complex scars, pincushioning, trapdoor scarring, and alterations in hair patterns; however, good results
can be obtained with careful design to place scars within relaxed skin tension lines or adjacent to natural
creases. Banner flaps are the simplest form of transposition flap and are typically used to transfer skin
from the preauricular or nasolabial area to close a defect. The apex of the banner flap is excised to avoid a
standing cutaneous deformity. Bilobed flaps are modified banner flaps that use a secondary flap to help
close the donor site of the primary flap. Flaps are typically designed at 45° angles to one another and are
pivoted on arcs of rotation between 90° and 100°. Scarring from bilobed flaps is complex and
pincushioning can be a problem. Because of the laxity of the cheek and the ability to use flaps that
produce more inconspicuous scar patterns, bilobed flaps are generally not a first choice in cheek
reconstruction. Rhomboid flaps are another modification of the banner flap that are commonly used for
coverage of lateral lower cheek or temporal defects. The classic rhomboid flap requires an excision of a
rhombus defect with 60° and 120° angles. The donor flap bisects one of the 120° angles and is designed so
that the vector of maximum tension is in the direction of adjacent cheek laxity, so distortion of surround
structures is avoided (Figure 41.11). In addition, the flap is planned so that the donor scar is placed within
a relaxed skin tension line or facial crease. Drawbacks with the rhomboid flap are that they have a
tendency to pincushion and the need for multiple incisions creates one or more scars that lie
perpendicular to lines of relaxed skin tension.
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FIGURE 41.11 Rhomboid flap for reconstruction of a left temple defect.
Advancement flaps are particularly useful for preauricular or superomedial defects in patients with
significant skin laxity. A flap of cheek tissue can be directly advanced into the defect with excision of a
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Burow triangle at the base. First described by Esser, V-Y flaps have more recently become a workhorse
flap for cheek reconstruction. 38,39 They are useful for defects of the medial cheek, alar base, and along the
nasolabial fold and provide excellent color and texture match for reconstruction. V-Y flaps have been
shown to provide excellent outcomes in even large, superior cheek/lower eyelid defects, with less
undermining required and improved rates of ectropion compared to Mustarde-type cheek flaps. 40 V-Y
flaps survive on perforators within the subcutaneous pedicle and are designed with curved limbs that
follow the relaxed skin tension lines. One of the limbs is planned along the nasolabial fold for concealed
scar placement. Performing a subcutaneous dissection around the V-Y flap, designing an appropriately
sized flap, and meticulous closure of the donor defect achieves good mobilization for closure with
minimal tension on the closure.
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Regional Flaps
The most common method for reconstructing medium to large defects of the cheek is medially or laterally
based cheek rotation advancement flaps. These flaps utilize loose preauricular and neck skin and are
most useful for defects in the superior medial region of the cheek. Various designs exist depending on the
size and location of defect (Figure 41.12). Wide subcutaneous undermining enables advancement and
rotation, and flap anchoring to the deep fascia helps reduce tension on the repair and to prevent
distortion of surrounding facial units. Standing cutaneous deformities often develop and require excision
of a Burow triangle. Incisions crossing the mandibular border tend to be noticeable and may develop scar
contracture. Here, inclusion of a Z-plasty helps to minimize these issues. Resections performed close to
the lower eyelid are at risk for lower lid edema and ectropion, and concomitant lower eyelid-tightening
procedures should be performed in select patients. Ischemia of the distal flap is the most common
complication and is more likely in smokers. A deep plane approach with composite elevation of the skin,
subcutaneous tissue, superficial muscular aponeurotic system, and platysma improves flap vascularity
and is useful in those at risk for distal flap ischemia; however, facial nerve injury is a significant risk.
FIGURE 41.12 Inferiorly based cervicofacial advancement flaps for reconstruction of a lateral cheek defect.
Cervicopectoral flaps recruit skin of the neck and chest to cover large cheek defects requiring significant
advancement and rotation of donor tissue. 41-43 The upper border of defects suitable for cervicopectoral
flap reconstruction can be estimated by drawing a line connecting the tragus to the lateral commissure;
otherwise, skin necrosis may result. Anteriorly based flaps based on internal mammary perforators are
raised deep to the platysma muscle and include deltoid and pectoral fascia and are used for
reconstructing large defects of the posterior and lower cheek. Posteriorly based flaps are based on blood
supply from the superficial temporal, occipital, transverse cervical, and thoracoacromial vessels and are
used for large anterior cheek defects. These flaps are designed by extending the cervicofacial incision
inferiorly along the sternum, then laterally down across the chest above the nipple-areola complex. Skin
grafting of the donor site is occasionally required to minimize tension on the closure. Other regional flaps
to consider in the armamentarium for cheek reconstruction include the pectoralis major, trapezius, and
supraclavicular flaps, which are useful for lower lateral cheek defects, as well as the submental artery flap
for central cheek defects.
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Tissue Expansion
Tissue expansion has the benefit of transferring well-vascularized skin with similar color, texture, and
hair-bearing status for resurfacing large cheek defects with the least number of additional incisions. It is
particularly useful in secondary revision of existing scars, large benign skin lesions, skin grafts, or skin
paddles of previously performed free flaps. However, tissue expansion in the head and neck region is
associated with high complication rates. 44-46 Good patient selection and careful consideration of the
expander size, placement of incisions, expander pocket location, position of the expander fill-valve, and
ultimate fill volume are keys to success.
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Free Tissue Transfer
Though technically challenging, free flaps are the first choice for complex defects involving multiple
tissue layers. They are also useful for resurfacing large skin defects for patients in whom local flaps are
not available (e.g., facial burns) or advisable (e.g., history of radiation). Commonly used options include
the radial forearm flap, scapular/parascapular flap, anterolateral thigh flap, rectus abdominis
myocutaneous flap, and fibula osteocutaneous flap. The choice of free flap depends on the external skin,
intraoral lining, skeletal stability, and soft tissue contour requirements. Limitations of free flap coverage
include the inability to provide color- and texture-matched skin and the propensity for bulky
reconstructions.
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Questions
1. A 68-year-old man undergoes wide local excision of a squamous cell carcinoma of the lower lip
resulting in a full-thickness defect of the central two-thirds. Margins are free of involvement.
Reconstruction using which of the following techniques is most appropriate?
a. Primary closure
b. Estlander flap
c. Karapandzic flap
d. Nasolabial flap
e. Submental artery island flap
2. A 40-year-old man sustains complete loss of the lower lip following a traumatic blast injury. Which
of the following treatment plans is most likely to restore a competent lower lip with adequate
aperture?
a. Karapandzic flap
b. Innervated anterolateral thigh flap
c. Gillies fan flap
d. Radial forearm flap with tendon graft
e. Prosthetic lower lip appliance
3. A 66-year-old woman is evaluated for reconstruction of a full-thickness defect of the right lateral
lower lip and commissure following resection of a 2.5 cm lesion with clear margins. Which of the
following flaps is most appropriate?
a. Gillies
b. Webster-Bernard
c. Abbe
d. Karapandzic
e. Estlander
4. A 58-year-old man undergoes resection of a basal cell carcinoma of the upper lip with negative
margins, resulting in a full-thickness defect involving three-fourths of the upper central lip. Which of
the following is the most appropriate method of reconstruction?
a. Bilateral Karapandzic flaps
b. Estlander flap only
c. Abbe flap only
d. Bilateral Karapandzic flaps with an Abbe flap
e. Bilateral Estlander flaps with an Abbe flap
5. A 68-year-old woman has a 6.0 cm defect of the central left cheek just below the eyelid after
excision of a lentigo maligna melanoma with clear margins. Which of the following is the most
appropriate method for management?
a. Free anterolateral thigh flap
b. Cervicofacial advancement flap
c. Primary closure
d. Healing by secondary intention
e. Full-thickness skin grafting
1. Answer: c. Karapandzic flaps are appropriate for reconstruction of defects involving one- to two-
thirds of the lower lip, such as in this case. Attempts to reconstruct defects larger than 80% of the
lower lip often leads to microstomia. The one-stage technique involves performing circumoral
incisions and mobilizing the orbicularis oris muscle, while preserving its innervations and vascular
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supply. The main advantage of this technique is that a continuous sphincter of functional orbicularis
muscle is created, helping to restore oral competence. Primary closure of such a defect would likely
result in significant microstomia and is primarily indicated for defects involving less than one-third
of the lower lip. The Estlander flap is a full-thickness, cross-lip transposition flap designed to
reconstruct lateral defects of the lower lip (one- to two-thirds) requiring recreation of the oral
commissure. Nasolabial flaps can be used to reconstruct large full-thickness lower lip defects.
However, they require grafting of the deep surface of the flap, do not provide a functional muscular
oral sphincter, and have a less reliable random blood supply. The submental artery island flap is
based on the submental branch of the facial artery. A paddle of skin and subcutaneous tissue
harvested from the submental area can be used for coverage of large lower lip defects; however, it is
does not contribute to a functional muscular oral sphincter.
2. Answer: d. Functional restoration of a competent and dynamic lower lip is challenging. A
prosthetic lower lip appliance may have an acceptable appearance but does not provide dynamic
function and generally does little to provide oral competence. Gillies fan flaps and innervated
regional advancement flaps such as the Karapandzic flap are not indicated for total lip loss and
would lead to significant microstomia. An innervated anterolateral thigh flap may allow for some
degree of sensory restoration, but it would be bulky and adynamic. Radial forearm flaps with tendon
grafts are capable of achieving oral competence without risking significant microstomia. They can
also be made sensate by coapting the lateral antebrachial cutaneous nerve to the mental or inferior
alveolar nerve.
3. Answer: e. In this scenario, reconstruction of both the lower lip and commissure is required. The
most appropriate flap for reconstruction of the defect is the Estlander flap, which is an upper lip-
switch flap used to reconstruct defects involving the commissure. However, rotation of upper lip to
the lower lip results in a rounded commissure, and often requires additional surgery. The Abbe flap
is a two-staged lip-switch procedure where a full-thickness segment of the lower lip based on the
inferior labial artery is used to fill a central upper lip defect. The Abbe flap can be used to reconstruct
defects up to two-thirds of the upper lip and is designed in the center of the lower lip, thereby
preserving innervation to the orbicularis oris muscle lateral to the defect. The Karapandzic and
Gillies flaps are advancement flaps of the remaining lower lip and are most useful for central defects
of the lower lip. The Karapandzic flap differs from the Gillies flap in that branches of the facial nerve
are dissected and preserved, thereby preserving facial nerve function. Webster-Bernard flap is also
used for reconstruction of central lip defects by removing Burrow triangles bilaterally and advancing
cheek skin toward the midline.
4. Answer: d. In this scenario, the patient has a large resection of the central upper lip. The Abbe flap
alone is insufficient to close a defect this large and the Estlander flap is reserved for reconstruction of
commissure defects, not central defects. The best choice for reconstruction is closure with bilateral
Karapandzic flaps with a central Abbe flap for philtral reconstruction. Inferiorly based Karapandzic
flaps enable transfer of the remaining upper lip while preserving its neurovascular supply. Although
bilateral Karapandzic flaps alone may be useful for defects up to 80% of the width of the upper lip,
they are not an ideal choice in this case because of the concern for microstomia. Furthermore, loss of
the philtrum would result in significant cosmetic deformity.
5. Answer: b. The cervicofacial flap is an inferomedially based flap that transfers large amounts of
cutaneous and subcutaneous soft tissues from the loose preauricular and neck regions to the medial
cheek. By utilizing tissue adjacent to the defect, the flap provides excellent color and texture match
for cheek reconstruction. The incision begins at the superior margin of the defect and extends in a
superolateral vector along the outer canthus toward the zygoma and down the preauricular crease.
The incision ends in the retroauricular hairline or curves anteriorly in the region of the neck. The flap
is advanced and rotated into the defect, and primary closure of the donor site can usually be
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achieved via wide subcutaneous undermining. Anchoring of the flap to the zygoma reduces tension
on the lower eyelid and minimizes the risk of ectropion, which is particularly important in this case.
Primary closure is an effective method for reconstructing small defects of the cheek. Orienting the
incision along lines of minimal tension or natural cheek contours often provides inconspicuous scars.
However, for such a large defect, primary closure cannot be achieved without significant wound
tension and distortion of surrounding structures. Closure by secondary intention would require a
prolonged period of healing. In addition, it would result in significant scar contracture and likely
lower lid ectropion. Full-thickness skin grafts tend to appear patch-like and shiny with a poor
contour match. Free tissue transfer for reconstruction of the aforementioned defect is unnecessary,
would create excessive bulk, and likely result in poor color and texture match.
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References
Neligan, PC. Strategies in lip reconstruction. Clin Plast Surg. 2009;36(3):477-485.
Briedis, J, Jackson, IT. The anatomy of the philtrum: observations made on dissections in the normal lip. Br J Plast Surg. 1981;34(2):128-132.The
anatomical basis of the phitrum are investigated in this anatomic study. The authors discuss the contribution of the vertical fibers of the orbicularis oris
muscle, the intricate intradermal collagen network, the high concentration of elastin fibers, and underlying dentoskeletal framework to the normal
architecture of the philtrum.
Burget, GC, Menick, FJ. Aesthetic restoration of one-half the upper lip. Plast Reconstr Surg. 1986;78(5):583-593.In this article, the authors describe
the anatomic subunits of the upper lip, which include the philtrum and the lateral lip elements. They suggest that defects involving greater than half of a
topographic subunit necessitate removal of the entire subunit and reconstruction with local flaps of like tissue.
Mulliken, JB, Pensler, JM, Kozakewich, HP. The anatomy of Cupid’s bow in normal and cleft lip. Plast Reconstr Surg. 1993;92(3):395-403.
Freilinger, G, Gruber, H, Happak, W, Pechmann, U. Surgical anatomy of the mimic muscle system and the facial nerve: importance for
reconstructive and aesthetic surgery. Plast Reconstr Surg. 1987;80(5):686-690.
Schulte, DL, Sherris, DA, Kasperbauer, JL. The anatomical basis of the Abbe flap. Laryngoscope. 2001;111(3):382-386.
Zitsch, RP 3rd, Park, CW, Renner, GJ, Rea, JL. Outcome analysis for lip carcinoma. Otolaryngol Head Neck Surg. 1995;113(5):589-596.
Tobin, GR, O’Daniel, TG. Lip reconstruction with motor and sensory innervated composite flaps. Clin Plast Surg. 1990;17(4):623-632.
Pribaz, JJ, Meara, JG, Wright, S, et al. Lip and vermilion reconstruction with the facial artery musculomucosal flap. Plast Reconstr Surg.
2000;105(3):864-872.The composite facial artery musculomucosal (FAMM) flap for lip reconstruction is described in this article. The axial pattern
blood supply for both superiorly and inferiorly based flaps is detailed. The buccal mucosa included with the FAMM flap has many similarities to the
vermillion, and the buccinator muscle adds additional bulk for more convexity, which makes the flap an excellent option for lip reconstruction.
Schuchardt, K. Surgery as an aid to orthodontics. Osterr Z Stomatol. 1954;51(11):
 563-565.
Webster, JP. Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast Reconstr Surg.
1955;16(6):434-464.
Blomgren, I, Blomqvist, G, Lauritzen, C, et al. The step technique for the reconstruction of lower lip defects after cancer resection: a follow-up
study of 165 cases. Scand J Plast Reconstr Surg Hand Surg. 1988;22(1):103-111.
Johanson, B, Aspelund, E, Breine, U, Holmstrom, H. Surgical treatment of non-traumatic lower lip lesions with special reference to the step
technique: a follow-up on 149 patients. Scand J Plast Reconstr Surg. 1974;8(3):232-240.
Abbe, R. A new plastic operation for the relief of deformity due to double harelip. Med Rec. 1898;53:477.In this report, the American surgeon
Robert Abbé (1851–1928) publishes on the transposition labial flap harvested from the lower lip for cleft lip repair. This flap is not only the first
musculocutaneous flap described but also the first flap based on a defined vascular supply, the labial vessels. It should be noted that Italian surgeon,
Pietro Sabattini, first performed this operation in 1837 to repair a posttraumatic upper lip defect using composite tissue from the lower lip.
Estlander, JA. Eine methode aus er einen ippe substanzverluste der anderen zu ersetzein. Arch Klin Chir. 1872;14:622.
Karapandzic, M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg. 1974;27(1):93-97.Dr. Miodra Karapandzic reports his
experience reconstructing large lower lip defects in 58 patients between 1967 and 1972 using his modification of the Gillies fan flap. He describes
designing a musculocutaneous rotation advancement flap with careful dissection and preservation of facial artery branches and sensory and motor
nerves to ensure a dynamic reconstruction with good sensation.
Jabaley, ME, Clement, RL, Orcutt, TW. Myocutaneous flaps in lip reconstruction. Applications of the Karapandzic principle. Plast Reconstr
Surg. 1977;59(5):
 680-688.
Ducic, Y, Athre, R, Cochran, CS. The split orbicularis myomucosal flap for lower lip reconstruction. Arch Facial Plast Surg. 2005;7(5):347-352.
Hauben, DJ. Victor von Bruns (1812–1883) and his contributions to plastic and reconstructive surgery. Plast Reconstr Surg. 1985;75(1):120-127.
Dieffenbach, JF. Die Operative Chirurgie. Leipzig: FA Brockhaus; 1845.
Webster, RC, Coffey, RJ, Kelleher, RE. Total and partial reconstruction of the lower lip with innervated musclebearing flaps. Plast Reconstr
Surg Transpl Bull. 1960;25:360-371.
Seo, HJ, Bae, SH, Nam, SB, et al. Lower lip reconstruction after wide excision of a malignancy with barrel-shaped excision or the webster
modification of the bernard operation. Arch Plast Surg. 2013;40(1):36-43.
Fujimori, R. “Gate flap” for the total reconstruction of the lower lip. Br J Plast Surg. 1980;33(3):340-345.
Williams, EF 3rd, Setzen, G, Mulvaney, MJ. Modified Bernard-Burow cheek advancement and cross-lip flap for total lip reconstruction. Arch
Otolaryngol Head Neck Surg. 1996;122(11):1253-1258.
Kroll, SS. Staged sequential flap reconstruction for large lower lip defects. Plast Reconstr Surg. 1991;88(4):620-625; discussion 6–7.
Kiyokawa, K, Takagi, M, Fukushima, J, Kizuka, Y, Inoue, Y, Tai, Y. Surgical treatment following huge arteriovenous malformation extending
from the lower lip to the chin: combination of embolization, total resection, and a double cross lip flap. J Craniofac Surg. 2005;16(3):443-448.
Chang, KP, Lai, CS, Tsai, CC, Lin, TM, Lin, SD. Total upper lip reconstruction with a free temporal scalp flap: long-term follow-up. Head
Neck. 2003;25(7):602-605.
Sadove, RC, Luce, EA, McGrath, PC. Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap.
Plast Reconstr Surg. 1991;88(2):209-214.
Jeng, SF, Kuo, YR, Wei, FC, Su, CY, Chien, CY. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a
clinical series. Plast Reconstr Surg. 2004;113(1):19-23.
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Carroll, CM, Pathak, I, Irish, J, Neligan, PC, Gullane, PJ. Reconstruction of total lower lip and chin defects using the composite radial
forearm–palmaris longus tendon free flap. Arch Facial Plast Surg. 2000;2(1):53-56.
Lengele, BG, Testelin, S, Bayet, B, Devauchelle, B. Total lower lip functional reconstruction with a prefabricated gracilis muscle free flap. Int J
Oral Maxillofac Surg. 2004;33(4):396-401.
Jeng, SF, Kuo, YR, Wei, FC, Su, CY, Chien, CY. Reconstruction of extensive composite mandibular defects with large lip involvement by
using double free flaps and fascia lata grafts for oral sphincters. Plast Reconstr Surg. 2005;115(7):1830-1836.
Ninkovic, M, Spanio di Spilimbergo, S, Ninkovic, M. Lower lip reconstruction: introduction of a new procedure using a functioning gracilis
muscle free flap. Plast Reconstr Surg. 2007;119(5):1472-1480.
Menick, FJ. Reconstruction of the cheek. Plast Reconstr Surg. 2001;108(2):496-505.
Zide, B, Longaker, M. Cheek surface reconstruction: best choices according to zones. Oper Tech Plast Reconstr Surg. 1998;5:26.
Chandawarkar, RY, Cervino, AL. Subunits of the cheek: an algorithm for the reconstruction of partial-thickness defects. Br J Plast Surg.
2003;56(2):135-139.
Furnas, DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83(1):
 11-16.
Pontes, L, Ribeiro, M, Vrancks, JJ, Guimaraes, J. The new bilaterally pedicled V-Y advancement flap for face reconstruction. Plast Reconstr
Surg. 2002;109(6):1870-1874.
Esser, FJS. Island flaps. NY State J Med. 1917;106:264-267.
Sugg, KB, Cederna, PS, Brown, DL. The V-Y advancement flap is equivalent to the Mustardé flap for ectropion prevention in the
reconstruction of moderate-size lid-cheek junction defects. Plast Reconstr Surg. 2013;131(1):28e-36e.
Dyer, PV, Irvine, GH. Cervicopectoral rotation flap. Br J Plast Surg. 1994;47(1):68-69.
Becker, DW Jr. A cervicopectoral rotation flap for cheek coverage. Plast Reconstr Surg. 1978;61(6):868-870.
Anand, AG, Amedee, RG, Butcher, RB II. Reconstruction of large lateral facial defects utilizing variations of the cervicopectoral rotation flap.
Ochsner J. 2008;8(4):186-190.
McIvor, NP, Fong, MW, Berger, KJ, Freeman, JL. Use of tissue expansion in head and neck reconstruction. J Otolaryngol. 1994;23(1):46-49.
Argenta, LC, Watanabe, MJ, Grabb, WC. The use of tissue expansion in head and neck reconstruction. Ann Plast Surg. 1983;11(1):31-37.
Antonyshyn, O, Gruss, JS, Zuker, R, Mackinnon, SE. Tissue expansion in head and neck reconstruction. Plast Reconstr Surg. 1988;82(1):58-68.
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C H A P T E R 4 2
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Facial Paralysis
Leahthan F. Domeshek and Gregory H. Borschel
Key Points
A multidisciplinary approach to the patient with facial paralysis is required to optimize outcomes.
Ocular protection is of utmost importance in patients with facial paralysis. Appropriate conservative
measures must be undertaken and initiated early to protect ocular integrity in setting of exposure.
In traumatic/iatrogenic cases of facial paralysis in which distal nerve stumps are available, nerve
repair or transfer is best performed within 72 hours of injury, prior to depletion of neurotransmitter
in the distal stump.
The standard technique for smile reanimation remains free functional muscle transfer in children.
Local muscle transfers reliably improve resting tone and appearance (in both children and adults)
but ability to animate remains variable and often inferior to that provided by free functional muscle
transfer.
Both nerve to masseter and cross-facial nerve grafts can be used with free functional muscle transfers
to generate powerful, reliable smile. However, only use of cross-facial nerve grafts can lead to smile
under emotional control.
Bell palsy is the most common diagnosis for facial paralysis in adults. It is a diagnosis of exclusion
and likely caused by a latent herpes simplex virus infection. In children, paralysis is more often due
to infection or trauma.
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Background
Facial paralysis is a complicated and potentially devastating condition. It occurs in both the adult and
pediatric populations, may be congenital or acquired, and can present uni- or bilaterally. A myriad of
etiologies exist, including infectious, autoimmune, oncologic, iatrogenic, traumatic, congenital, and
idiopathic. Depending on the cause, paralysis ranges from self-limited to irreversible.
Palsy generates cosmetically disruptive facial asymmetry and impairs facial functions, hampering
nonverbal communication and inhibiting social interactions. The result may be significant psychosocial
distress.
Care of these patients is complex and best approached from a multidisciplinary standpoint, including
therapeutic, medical, and surgical disciplines. In patients who do not recover function with conservative
measures, surgical reanimation should be considered.
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Anatomy and Function of the Facial Nerve
Functional Components
Functionally, the facial nerve consists of four components 1 :
Branchial motor (from the motor nucleus): Accounts for most of the axons of the facial nerve.
Innervates the mimetic musculature of the face as well as the stylohyoid, stapedius, and posterior
belly of the digastric.
Visceral motor (superior salivatory nucleus): Provides parasympathetic control to multiple glands and
mucosal elements of the face. The submandibular and sublingual glands receive fibers via the chorda
tympani. The lacrimal gland and nasal mucosa receive fibers via the pterygopalatine ganglion.
General sensory (sensory nuclei of the trigeminal nerve): Provides sensation to the external auditory
canal and the concha.
Special sensory (solitary nucleus): Contributes taste to the anterior two-thirds of the tongue (via the
chorda tympani).
The facial nerve consists of intracranial, intratemporal, and extracranial components.
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Intracranial Facial Nerve
The motor nucleus of the facial nerve lies in the pons. Upper motor neuron control derives from the
cortex and differs from upper and lower facial functions. Input to the motor nucleus for upper facial
function is from bilateral motor cortices. Control of lower facial function comes from only the
contralateral motor cortex. For this reason, upper motor neuron lesions generally lead to contralateral
lower facial paralysis with preserved forehead function. Distal to the motor nucleus, lesions of the facial
nerve result in paralysis of all ipsilateral distributions.
Intracranially and proximally within the temporal bone, the motor component of the facial nerve runs
separately from the visceral motor, general sensory, and special sensory fibers. These latter three
components combine to form the nervus intermedius, which exits the brainstem between the pons and
inferior cerebellar peduncle, lateral to the motor component.
The motor component and nervus intermedius run in loose approximation from the brainstem toward
the internal auditory meatus, through which they enter the temporal bone.
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Intratemporal Facial Nerve
The intratemporal course of the facial nerve is divided into three segments (Table 42.1 and Figure 42.1).
The most proximal is the labyrinthine, spanning from the fallopian canal to the geniculate ganglion
(which contains taste and sensory nerve cell bodies). At the level of the geniculate ganglion, the nervus
intermedius and the motor component join together. Within this segment, the facial nerve gives off three
branches. The diameter of the labyrinthine segment is small compared with that of the facial nerve,
placing the nerve at risk for compression.
TABLE 42.1
Intratemporal Facial Nerve Branches
Nerve
Intratemporal
Segment of Origin
Function
Greater petrosal
nerve
Labyrinthine
(Geniculate
ganglion)
Parasympathetic innervation to nasal, palatine, lacrimal, and pharyngeal glands, as well as to
the sphenoid, frontal, maxillary, and ethmoid sinuses, and nasal cavity
Taste fibers for the palate (via greater and lesser palatine nerves)
External petrosal
nerve (variably
present)
Labyrinthine
(Geniculate
ganglion)
Sympathetic innervation to middle meningeal artery
Lesser petrosal nerve
Labyrinthine
(Geniculate
ganglion)
Parasympathetic fibers to the parotid gland (via the glossopharyngeal nerve)
Nerve to stapedius
Mastoid
Motor nerve helps to dampen loud noises (innervates stapes muscle).
Of note, cell bodies for this nerve are not located in the motor nucleus and therefore function is spared
in congenital palsies such as Mobius syndrome.
Sensory
Mastoid
Sensation to the external auditory canal
Hitselberger sign: hypesthesia of the external auditory canal (i.e., from tumors generating mass effect
on these fibers)
Chorda tympani
Mastoid
Taste to anterior two-thirds of tongue
Parasympathetics to salivary glands
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FIGURE 42.1 Anatomy of the intratemporal facial nerve.The intratemporal portion of the facial nerve is comprised of three
segments: labyrinthine, tympanic, and mastoid. In both the labyrinthine and mastoid segments, the facial nerve gives off
branches as illustrated.
The facial nerve proceeds to the tympanic segment, which extends to the semicircular canal. The
labyrinthine and tympanic segments meet at an acute angle that is a common location for shearing
injuries to the nerve in trauma involving the temporal bone.
Finally, the nerve enters the mastoid segment, within which the nerve to the stapedius, the sensory
branch to the external auditory canal, and the chorda tympani arise. At the end of the mastoid segment,
the nerve exits the skull base through the stylomastoid foramen.
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Extratemporal Facial Nerve
In adults, the facial nerve is relatively protected by the mastoid tip, tympanic ring, and mandibular
ramus, as it emerges from the stylomastoid foramen. In children, it is more superficial, lacking this bony
protection, and thus more susceptible to trauma in this area.
On exiting the skull base, the facial nerve can be identified in relationship to specific landmarks. It is
located medial to the tympanomastoid suture, running lateral to the styloid process, roughly midway
between it and the posterior belly of the digastric muscle. Additionally, it can be identified in relation to
the tragal pointer (to which it lies 1 cm deep, and just inferomedially).
Prior to coursing anteriorly around the earlobe, the facial nerve gives off branches to the stylohyoid
muscle and the posterior belly of the digastric muscle as well as to the occipitalis and the auricularis
muscles.
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The Facial Nerve in the Face
Preauricularly, the facial nerve enters the parotid gland, where it travels between the deep and superficial
lobes. Within the gland, the nerve divides into two main branches—the temporofacial superiorly and the
cervicofacial inferiorly. These quickly divide into multiple branches that exit the parotid to run deep to
the superficial musculoaponeurotic system (SMAS) (Table 42.2, Figure 42.2).
TABLE 42.2
Facial Nerve Branches, Muscular Targets, and Functions
Facial
Nerve
Division
Injury
Muscle
Function
Temporal
Inability to raise or furrow brows, impaired blink
Frontalis
Brow elevation
Corrugator
supercilii
Medial and inferior
movement of eyebrows
(generate vertical glabellar
rhytids)
Procerus
Inferior movement of
eyebrow (horizontal glabellar
rhytids)
Orbicularis
oculi
Eyelid closure
Zygomatic
Impaired smile and blink
Orbicularis oculi
Eyelid closure
Zygomaticus major
Elevation of commissure
(instrumental in smile)
Buccal
Impaired smile, difficulty chewing, impaired speech,
nasal airway obstruction, impaired oral competence
Zygomaticus major
Elevation of commissure
(instrumental in smile)
Zygomaticus minor
Upper lip elevation
Levator labii superioris
Upper lip elevation
Levator labii superioris
alaeque nasi
Flaring of nasal ala
Elevation of nasolabial fold
Risorius
Assists smile
Buccinator a
Instrumental in chewing
(maintaining food bolus centrally in
mouth for effective mastication)
Levator anguli oris a
Superior and medial migration of
commissure
Nasalis
Dilator component: alar flaring
Compressor component:
compresses nostrils
Orbicularis oris
Lip closure/compression
Depressor anguli oris
Frowning/inferior pull at
commissure
Marginal
mandibular
Impaired lower lip depression (decreased lower
dentition show on full-denture smile), drooling,
inability to evert lip (asymmetric pout)
Depressor anguli oris
Frowning/inferior pull at
commissure
Depressor labii inferioris
Lower lip depression
Mentalis a
Lower lip eversion, pout
Lower lip elevation
Cervical
Impaired lower lip depression (decreased lower
dentition show on full-denture smile)
Platysma
Depression of lower lip
aThese muscles are deep and are innervated on their superior surface. All other mimetic muscles are innervated from their deep surfaces.
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FIGURE 42.2 Facial nerve and mimetic musculature. A.The facial nerve exits the skull base through the stylomastoid foramen
to run between the styloid process and the posterior belly of the digastric muscle prior to coursing anteriorly around the ear to
run between the deep and superficial lobes of the parotid gland to reach the facial musculature.B.The facial nerve gives off the
posterior auricular branch posteriorly. Traveling anteriorly, the facial nerve broadly divides into five main distributions to
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innervate the mimetic musculature of the face.(B. Reproduced with permission from Moore, KL. Essential Clinical Anatomy. 5th
ed. Philadelphia, PA: Wolters Kluwer Health; 2014. Figure 9-11.
Conceptually, the facial nerve is divided into five divisions with distinct functions: temporal, zygomatic,
buccal, marginal mandibular, and cervical. Realistically, however, branching patterns are complex. The
facial nerve exits the parotid as eight to 15 branches, which arborize and communicate as they continue
distally. There is significant functional crossover between terminal branches. Some generate multiple
movements (i.e., eye closure and smile) and there exists considerable redundancy in function. As a result,
distal injury to individual branches may not produce significant functional deficits. This also permits
utilization of distal branches as donors for facial reanimation.
Despite variability among patients, some general anatomic characteristics are recognized for the main
divisions of the facial nerve. These characteristics are useful clinically for identifying and protecting the
nerves in surgery.
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Temporal Division
The course of the temporal branches roughly follows Pitanguy’s line, which extends from a point 0.5 cm
inferior to the tragus to a point 1.5 cm superior to the lateral extent of the eyebrow. 2 As the branches
travel distally, they become superficial.
After exiting the parotid, the nerves travel within the parotidomasseteric fascia. They remain in this plane
as they reach the zygomatic arch, traveling within the innominate fascia (contiguous with the
parotidomasseteric fascia). Two to four branches cross the arch, spanning up to 50% of its length. 3
Crossing the arch, they move superficially, coursing on the undersurface of the superficial temporal
fascia. 4
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Zygomatic and Buccal Division
Although conceptually divided into separate divisions, zygomatic and buccal branches can be, in
practice, very difficult to distinguish from one another both anatomically and functionally and are often
considered together as a single component (the zygomaticobuccal division).
Generally, one to three zygomatic branches exist. The zygomatic and buccal branches run in close
approximation as they exit the parotid, and may emanate from a common trunk. In approximately 10% of
the population, the lower zygomatic branch joins with buccal branches to create a zygomaticobuccal
plexus. 5
The buccal branch(es) run in close proximity to the parotid duct. Most often, the nerve travels inferiorly,
but can be located superior to or, when multiple nerve branches are present, flanking the duct. 6
Identification of the branch of the zygomaticobuccal branch that innervates the zygomaticus major
(integral in generation of smile) can be facilitated through use of Zuker’s point. 7 This is a surface
landmark – 
 the midpoint of the line drawn from the root of the helix to the oral commissure. Generally,
the branch to zygomaticus major will be found within 2.3 mm of this location. This is particularly helpful
in identification of donors for cross-facial nerve grafting (described below) and in identifying a danger
zone in other facial procedures that require dissection in this region.
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Marginal Mandibular Division
The marginal mandibular division runs as two to four branches. 8 They descend from the parotid,
commonly running to a position below the body of the mandible, deep to the platysma. 9 The branches
then turn to travel superiorly, across the inferior border of the mandible to innervate their target
musculature. The nerves run superficial to the facial vessels.
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Cervical Division
Unlike the other divisions, which exist as multiple branches in the face, generally only one cervical
branch is present. It exits the parotid anterior to the angle of the mandible and does not divide until it
passes inferior to the mandibular border. 10 It innervates the platysma from its undersurface, near the
junction between its cranial and middle thirds. 11
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Causes of Facial Paralysis
Causes of facial paralysis are many and varied (Table 42.3). Multiple studies have examined relative
frequencies of different diagnoses. In general, Bell palsy is accepted as the most common diagnosis in
adults. It is an acquired, idiopathic palsy of sudden onset and is a diagnosis of exclusion. Other diagnoses
must be ruled out before settling on Bell palsy, as other etiologies may warrant different intervention and
be at risk for progression if not addressed. Bell palsy is less likely to be the diagnosis in the setting of
bilateral palsy, paralysis of insidious onset, or palsy that is waxing and waning.
TABLE 42.3
Etiological Classification of Facial Paralysis With Examples
Congenital
Syndromic
Hemifacial microsomia (unilateral; may be associated with abnormalities of ear, mandible, orbit, soft tissues of face)
Mobius syndrome (bilateral; cranial nerve (CN) VI palsy, Poland’s; talipes equinovarus)
Traumatic
Use of forceps
Other
Congenital unilateral lower lip paralysis (CULLP)
Acquired
Traumatic
Blunt
Temporal bone fractures
Neurapraxic injuries to extracranial nerve
Sharp
Direct laceration to distal branches
Other
Cerebral event
Idiopathic
Bell palsy (frequently associated with pregnancy, at least partial recovery expected)
Melkersson-Rosenthal syndrome (recurrent facial paralysis, orofacial swelling, fissured tongue)
Infectious
Viral
HSV, EBV, VZV
Ramsay-Hunt syndrome (VZV, sudden onset paralysis, hearing loss, severe pain, ±vesicular rash)
HIV (often bilateral)
Bacterial
Otitis media
Rickettsial
Lyme disease (bilateral)
Autoimmune
Guillain-Barre syndrome (bilateral)
Tumor
Acoustic neuroma (bilateral in NF2), meningioma, cerebellopontine tumors (intracranial)
Cholesteatoma (intratemporal)
Parotid mass (extracranial)
Iatrogenic
Management of facial trauma (especially mandibular fractures)
TMJ surgery
Aesthetic procedures
Resection of intracranial, intratemporal, or extracranial masses
Middle ear surgery
Neuromuscular
Myesthenia gravis
EBV, Epstein-Barr virus; HIV, human immunodeficiency virus; HSV, herpes simplex virus; NF2, neurofibromatosis type 2; TMJ,
temporomandibular joint; VZV, varicella zoster virus.
The underlying etiology of Bell palsy is likely a latent herpes virus. The mainstay of treatment is a course
of corticosteroids (most effective when instituted within 24 hours of symptom onset) and antivirals,
which may help to improve recovery. Most patients begin to experience recovery within 3 weeks of
symptom onset, although some may not see signs of returning function for up to 3 to 6 months.
Approximately 75% of patients experience full resolution of symptoms. The remaining patients suffer
from varying degrees of lasting weakness, spasm, and synkinesis.
The relative frequencies of other etiologies of paralysis vary by report, likely because of specific
populations examined and variable referral patterns among institutions. Infection, trauma, and iatrogenic
injury are often considered the next most common causes of acquired paralysis. However, evaluation of
diagnoses in a series of patients at a facial nerve center with a specialized referral base identified resection
of acoustic neuromas, head and neck malignancies, and iatrogenic injuries to be the most common
etiologies after Bell palsy. 12
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Facial paralysis attributed to acoustic neuromas and malignancies is most often secondary to resection,
although palsy may follow radiotherapy or may be noted pretreatment. Parotid tumors, through mass
effect or direct neural invasion, are the malignancies most commonly directly responsible for paralysis.
Iatrogenic injury to the facial nerve at nearly any point along its course may occur following a variety of
head and neck procedures, especially temporomandibular joint surgery and parotidectomy. Resection of
a variety of benign and malignant processes both intra- and extracranially may result in iatrogenic injury.
Distally, terminal branches are at risk during facial cosmetic procedures and treatment of facial fractures.
Viral, rickettsial, and bacterial infections may also lead to facial paralysis. Varicella zoster virus–
associated facial paralysis may occur with (Ramsay Hunt Syndrome) or without documented prior
vesicular outbreak. Paralysis following acute otitis media is a particularly common finding in pediatric
patients. Lyme disease is a common diagnosis in bilateral paralysis.
Both blunt and sharp trauma may affect the facial nerve. Temporal bone fractures can result in
compression or shearing injury. Extracranially, laceration from penetrating trauma is a risk, and blunt
trauma may directly generate a neurapraxic injury or lead to compression effect on the nerve from soft
tissue changes (i.e., hematoma).
Autoimmune diseases generally lead to bilateral, rather than unilateral facial paralysis, and they can be
recurrent. The most common of these processes is Guillain–Barre syndrome.
The distribution of etiologies in children is different from that in adults. Infectious, traumatic, and
iatrogenic sources have been found to occur more frequently than Bell palsy in the pediatric population.
Additionally, congenital facial paralysis accounts for a larger portion of diagnoses in children compared
with adults.
The most common cause of congenital facial paralysis is birth trauma, frequently from the use of forceps.
Often, these cases resolve fully by 1 month of age. Congenital unilateral lower lip paralysis (CULLP) is an
isolated dysfunction of a unilateral marginal mandibular nerve. In CULLP, also referred to as asymmetric
crying facies, there is generally no significant asymmetry noticed at rest, but obvious deficit of lower lip
depression on the affected side in crying. Etiology can include ante- or intrapartum compression on the
marginal mandibular branch. Syndromic sources of paralysis include hemifacial microsomia (most
commonly) and Mobius syndrome.
Although many diagnoses are shared between unilateral and bilateral facial paralysis, relative
frequencies differ. Although unilateral facial paralysis is most often attributed to Bell palsy, bilateral
paralysis most commonly has an identifiable cause. 13 A recent study of etiologies at a large referral center
for facial palsy found that Bell palsy accounted for approximately one-third of their cases. 13 Among the
more common identified causes were Lyme disease, Mobius syndrome, Guillain–Barré syndrome, benign
neoplastic processes (i.e., neurofibromatosis type 2), vascular malformations, and trauma.
Mobius syndrome is the most common congenital cause of bilateral paralysis. With an incidence of
approximately 1 in 50,000 live births, it involves chest wall and limb anomalies in addition to variable
involvement of other cranial nerves. Poland syndrome and talipes equinovarus are among the more
commonly associated findings. The most commonly involved cranial nerves are the sixth (abducens) and
seventh (facial). The hypoglossal nerve (cranial nerve [CN] XII) is the third most commonly affected, and
the third, fourth, fifth, ninth, and tenth cranial nerves may also be. Although facial paralysis is most
commonly bilateral, it is variable, and may be unilateral. The etiology of Mobius syndrome is unclear, but
it may be ischemic/hypoxic events during development that affects the distribution of the subclavian
artery. Both genetic 14 as well as acquired causes exist. Misoprostol exposure in utero has been identified
as a risk factor for the latter. 15
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Effects of Facial Nerve Paralysis
Upper Face
Ocular damage and degradation of vision from corneal exposure is the biggest concern. Lagophthalmos
results from abnormalities of both the upper and lower eyelids. In the upper lid, unopposed function of
the levator palpebrae superioris (innervated by the oculomotor nerve) impairs downward excursion,
leading to failure to contact lower lid in attempted closure.
Additionally, because the upper facial divisions of the facial nerve are responsible for the efferent
component of the blink reflex (the trigeminal nerve is responsible for the afferent component), decreased
blinking is observed in facial paralysis and impairs the maintenance of tear film over the cornea.
Paralytic ectropion may result over time with the effects of gravity on a paralyzed lower eyelid. With
increasing laxity, the lid everts and falls away from the globe, pulling the canalicular punctum away as
well. The result is increased exposure and lacrimal pump failure, which exacerbates exposure and leads
to excessive tearing (epiphora).
Risk of corneal damage is increased in patients who lack a Bell phenomenon (reflexive upward rotation of
the eye with eye closure or blink) and in patients who have concomitant injury to the ophthalmic division
of the trigeminal nerve (responsible for corneal sensation and epithelial maintenance).
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Lower Face
The greatest concerns are impaired speech (especially difficulty with p and b sounds), difficulty eating,
excessive drooling, and inability to smile. Eating difficulties arise in part from denervation of the
buccinator which impairs control of food boluses during chewing can lead to sequestration of food into
the buccal sulcus.
Loss of smile can have significant implications for nonverbal communication and psychosocial well-
being. This inability is one of the most frequent complaints of patients, and a common indication for
surgery in patients. In children, especially those with bilateral paralysis (i.e., Mobius syndrome), this is
particularly concerning, as inability to emote can seriously impact propensity for social integration.
Other dysfunctions may also present. Nasal airway obstruction results in part from denervation of nasalis
and levator labii superioris alequae nasi, which may lead to collapse of the affected ala. In the setting of
unilateral facial paralysis, this external nasal valve collapse is accentuated by deviation of the nasal tip to
the unaffected side, further obstructing airflow.
In older patients, frontalis dysfunction in the setting of a heavy brow results not only in stark visible
asymmetry, but can contribute to ptosis and impaired field of vision.
Synkinesis may be observed in patients recovering from facial paralysis. As they perform one action (i.e.,
smiling), a second undesired action occurs in tandem (i.e., blinking). This can be quite distressing to
patients and, as with paralysis itself, can have significant psychosocial impacts. Synkinesis likely results
from aberrant axonal sprouting into incorrect muscles, as nerves regenerate following paralysis. It may
also be related to central changes that take place as reinnervation occurs.
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Preoperative Evaluation
A thorough history and physical examination are necessary. Determination of the underlying etiology
informs on potential treatments and likelihood of recovery of facial function. Tables 42.4 and 42.5 include
the key components of patient history and evaluation.
TABLE 42.4
Key points in History and Possible Implications of Findings
Category
Directed Questions/Specific Concerns
Related Events
Recent infections
Viral illnesses
Otitis media
Potential exposure to ticks
Lyme disease
Oncologic history
Space-occupying lesions
Intraneural tumor
Trauma
Blunt (skull base fracture; distal neurapraxic injury)
Sharp (direct laceration to facial nerve)
Iatrogenic injury
Tumor resection
Radiotherapy
Other craniofacial procedures (i.e., facelift)
Congenital
Birth history—trauma from forceps
Associated anomalies (concern for syndromic etiology)
Characteristics of Paralysis
Circumstances of onset
Sudden (Bell palsy, trauma, iatrogenic, cerebrovascular accident, infection)
Gradual (oncologic, systemic)
Congenital
Duration of symptoms
<12 months
Long (concerning for irreversible muscle fibrosis/atrophy)
Waxing/waning/resolution
Improvement or plateau of recovery and time over which symptoms changed (even in the setting of self-
limited processes, improvement is often slow, occurring over several months)
Recurrent
Concerning for Guillain-Barre syndrome, Melkersson-Rosenthal
Specific Deficits
Bilateral/unilateral
Bilateral (more likely to be Lyme disease, Guillain-Barre syndrome, benign neoplastic processes)
Eye
Altered blink/eye closure
Change in lower lid position (paralytic ectropion)
Symptoms of corneal exposure (corneal exposure/degradation of vision/dry eyes/excessive tearing)
Double vision
Nasal airway
Collapse, difficulty breathing
Lower face
Altered smile
Altered speech (particularly difficulty with bilabial consonants, such as p and b sounds)
Drooling
Difficulty eating/cheek biting with chewing
Isolated asymmetric lower lip depression
Other
Altered taste
Hyperacusis (paralysis of stapedius)
Dry mouth (may indicate proximal facial nerve injury)
Associated palsies of other
cranial nerves
Deviation of tongue to one side (CN XII)
Loss of facial sensation (CN V, especially corneal sensation; CN VI)
Abducens (CN VI, concern for Mobius syndrome)
Psychosocial effects
Self-consciousness, difficulty with social interactions, depression, anxiety
Comorbidities
Overall health
Ability to tolerate surgical reconstruction (i.e., long procedures, suitability of vessels for microvascular
reconstructions)
Prior surgeries
Potential for iatrogenic injury (see above)
Potential effects on reconstructive options (i.e., destruction of neurovascular pedicle to temporalis;
destruction of facial vessels)
TABLE 42.5
Key points of Physical Examination
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Basic
movements
Evaluate key facial movements that indicate function of the major divisions of the facial nerve. note presence/absence of
function and symmetry:
Elevate Brows (frontalis)
Close Eyes (orbicularis oculi)
Smile (zygomaticus major, zygomaticus minor)
Purse Lips (orbicularis oris)
Detailed
findings
Note right-left asymmetries. Evaluate the face in repose and animation
Brow ptosis (assess for visual field impairment)
Eye
Height of palpebral aperture in rest and maximal eye closure
Presence of Bell phenomenon
Position of lower lid (paralytic ectropion) – 
 snap test and comparison to contralateral side
Corneal examination (sensory examination; assess for damage/irritation)
Mouth
Symmetry at rest
Dynamic
Ability to smile and symmetry thereof
Oral competence (drooling, eating)
Speech intelligibility
Nasal airway
Collapse of nasal airway with forced inspiration
Presence of synkinesis
Associated
palsies
Cranial nerves III, V, VI, XI, XII
Duration of symptoms and characteristics of onset can help determine the need for adjunctive diagnostic
tools (i.e., blood tests for infectious or immunologic etiologies, imaging in the setting of trauma, or
suspicion of central nervous system disorders) and involvement of additional specialists in management
of the patient. Electrodiagnostic studies are not commonly utilized, but for select patients may provide
information regarding expected recovery (electrodiagnostics are not generally used in pediatrics). In the
setting of suspected Bell palsy (low suspicion for ominous or medically/surgically reversible etiology), it
is advisable to wait 3 weeks prior to obtaining electrodiagnostics (for prognostication) or delving into in-
depth workup. This is because most patients with Bell palsy will regain some function within this time,
precluding the need for invasive and time-consuming tests that may be unnecessary.
Specific functional deficits must be elicited. Regardless of potential for spontaneous recovery of function,
conservative (especially physical therapy) or medical approaches are often used either as sole treatment
or as adjuncts to surgery.
Multiple grading systems have been developed for description of symptom severity and to assist with
reporting on facial paralysis. The most commonly used system is the House–Brackmann scale. 16 This
scale, however, does not differentiate between dysfunction of specific divisions of the facial nerve and
really has little ability to describe pre- and postoperative movement; other scales, such as the Sunnybrook
scale and the Yanagihara scale (popular in Japan), do.
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Management of Facial Paralysis
A multidisciplinary approach to the patient with facial paralysis is critical to optimize outcomes. The
medical team varies depending on the etiology of the paralysis and the affected functions (i.e., the need
for infectious disease, rheumatologic, oncologic treatment, etc). Ophthalmologic intervention should
occur early in the setting of upper facial paralysis. All patients, regardless of their need for surgical
intervention, should undergo physical therapy to maximize their functional recovery. Finally,
psychologic and social work services often play a central role in the care of patients. The psychosocial
effects of facial paralysis should not be underestimated, especially in the congenital population, and they
must be addressed to minimize implications for social function and psychologic well-being.
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Conservative Management
Medical Management and Watchful Waiting
For certain etiologies, such as infectious, autoimmune, and idiopathic, conservative management may be
warranted prior to consideration of surgical treatment. Medical management will be directed by
appropriate specialists depending on diagnosis. Infectious etiologies (bacterial or rickettsial) may benefit
from antibiosis. Patients with Bell palsy or autoimmune etiologies may benefit from steroids, as may
patients with viral causes (with or without the addition of antivirals). Additionally, for all patients,
physical therapy by specially trained therapists can help recovering patients strengthen and relearn
specific movements such as eye closure and smile.
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