Phẫu Thuật Tạo Hình (Tập 3): Sọ Mặt, Đầu Cổ Và Nhi Khoa – Neligan (Ấn bản 4)

328.e1
References
References
1. Neligan PC. Strategies in lip reconstruction. Clin Plast Surg.
2009;36:477–485. Injury or surgical trauma can result in significant
alterations of normal lip appearance and function that can profoundly
impact the patient’s self-image and quality of life. Neuromuscular injury
can lead to asymmetry at rest and during facial animation, and distressing
functional disabilities are common. Loss of labial competence may interfere
with the ability to articulate, whistle, suck, kiss, and contain salivary
secretions. For smaller defects, reconstruction can be very effective.
Reconstructing an aesthetically pleasing and functional lip is more
difficult with larger defects.
2. Hauben DJ. Sushruta Samhita (Sushruta’a Collection) (800–600
B.C.?) Pioneers of plastic surgery. Acta Chir Plast. 1984;26:65–68.
3. Hauben DJ. Victor von Bruns (1812–1883) and his contributions to
plastic and reconstructive surgery. Plast Reconstr Surg.
1985;75:120–127.
4. Karapandzic M. Reconstruction of lip defects by local arterial flaps.
Br J Plast Surg. 1974;27:93–97.
5. Gillies H, Millard D. Principles and Art of Plastic Surgery. Boston:
Little, Brown; 1957.
6. Esser JF. Preservation of innervation and circulatory supply in
plastic restoration of upper lip. Ann Surg. 1934;99:101–111.
7. Walton RL, Bunkis J. A free occipital hair-bearing flap for
reconstruction of the upper lip. Br J Plast Surg. 1983;36:168.
8. Sakai S, Soeda S, Endo T, et al. A compound radial artery forearm
flap for the reconstruction of lip and chin defect. Br J Plast Surg.
1989;42:337–338.
9. Renner G. Reconstruction of the lip. In: Baker S, Swanson N, eds.
Local Flaps in Facial Reconstruction. New York: Mosby; 1995.
10. Burget G, Menick F. Aesthetic restoration of one-half of the upper
lip. Plast Reconstr Surg. 1986;78:583–593.
11. Constantinidis J, Federspil P, Iro H. Functional and aesthetic
objectives in the reconstruction of lip defects. Facial Plast Surg.
1999;15:337–349.
12. Ducic Y, Athre R, Cochran CS. The split orbicularis myomucosal
flap for lower lip reconstruction. Arch Facial Plast Surg.
2005;7:347–352.
13. Zufferey J. Anatomic variations of the nasolabial fold. Plast Reconstr
Surg. 1992;88:225–231.
14. Ewart CJ, Jaworski NB, Rekito AJ, et al. Levator anguli oris: a
cadaver study implicating its role in perioral rejuvenation. Ann
Plast Surg. 2005;54:260–263.
15. Marinetti C. The lower muscular balance of the face used to lift
labial commissures. Plast Reconstr Surg. 1999;104:1153–1162.
16. Pessa JE, Zadoo VP, Adrian EK Jr, et al. Variability of the midfacial
muscles: analysis of 50 hemifacial cadaver dissections. Plast Reconstr
Surg. 1998;102:1888–1893.
17. Pessa JE, Zadoo VP, Garza PA, et al. Double or bifid zygomaticus
major muscle: anatomy, incidence, and clinical correlation. Clin
Anat. 1998;11:310–313.
18. Johnson PJ, Bajaj-Luthra A, Llull R, et al. Quantitative facial motion
analysis after functional free muscle reanimation procedures. Plast
Reconstr Surg. 1997;100:1710–1719.
19. Pinar Y, Bilge O, Govsa F. Anatomic study of the blood supply of
the perioral region. Clin Anat. 2005;18:330–339.
20. Mağden O, Edizer M, Atabey A, et al. Cadaveric study of the
arterial anatomy of the upper lip. Plast Reconstr Surg.
2004;114:355–359.
21. Langstein H, Robb G. Lip and perioral reconstruction. Clin Plast
Surg. 2005;32:431–445.
22. Coppit GL, Lin DT, Burkey BB. Current concepts in lip
reconstruction. Curr Opin Otolaryngol Head Neck Surg.
2004;12:281–287.
23. Cordeiro PG, Santamaria E. Primary reconstruction of complex
midfacial defects with combined lip-switch procedures and free
flaps. Plast Reconstr Surg. 1999;103:1850–1856. Free flaps are generally
the preferred method for reconstructing large defects of the midface, orbit,
and maxilla that include the lip and oral commissure; commissuroplasty is
traditionally performed at a second stage. Functional results of the oral
sphincter using this reconstructive approach are, however, limited. This
article presents a new approach to the reconstruction of massive defects of
the lip and midface using a free flap in combination with a lip-switch flap.
This was used in 10 patients. One-third to one-half of the upper lip was
excised in seven patients, one-third of the lower lip was excised in one
patient, and both the upper and lower lips were excised (one-third each) in
two patients. All patients had maxillectomies, with or without
mandibulectomies, in addition to full-thickness resections of the cheek. A
switch flap from the opposite lip was used for reconstruction of the oral
commissure and oral sphincter, and a rectus abdominis myocutaneous flap
with two or three skin islands was used for reconstruction of the
through-and-through defect in the midface. Free flap survival was 100%.
All patients had good-to-excellent oral competence, and they were
discharged without feeding tubes.
24. Williams E, Setzen G, Mulvaney M. Modified Bernard-Burow cheek
advancement and cross-lip flap for total lip reconstruction. Arch
Otolaryngol Head Neck Surg. 1996;122:1253–1258.
25. Williams E, Hove C. Lip reconstruction. In: Papel I, ed.
Facial Plastic and Reconstructive Surgery. 2nd ed. New York: Thieme;
2002.
26. Wilson JS, Walker EP. Reconstruction of the lower lip. Head Neck
Surg. 1981;4:29–44.
27. Krunic AL, Weitzul S, Taylor RS. Advanced reconstructive
techniques for the lip and perioral area. Dermatol Clin. 2005;23:43–
53, v–vi.
28. McGregor I. The tongue flap in lip surgery. Br J Plast Surg.
1966;19:253–263.
29. Zhao Z, Li Y, Xiao S, et al. Innervated buccal musculomucosal flap
for wider vermilion and orbicularis oris muscle reconstruction. Plast
Reconstr Surg. 2005;116:846–852.
30. Webster J. Crescentic peri-alar cheek excision for upper lip flap
advancement with a short history of upper lip repair. Plast Reconstr
Surg. 1955;16:434–464.
31. Abbe R. A new plastic operation for the relief of deformity due to
double harelip. Plast Reconstr Surg. 1968;42:481–483.
32. Estlander J. Eine methode aus er einen ippe substanzverluste der
anderen zu ersetzein. Arch Klin Chir. 1872;14:622.
33. Rea JL, Davis WE, Rittenhouse LK. Reinnervation of an Abbe-
Estlander and a Gillies fan flap of the lower lip: electromyographic
comparison. Arch Otolaryngol. 1978;104:294–295.
34. Johanson B, Aspelund E, Breine U, et al. 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;8:232–240.
35. 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;22:103–111.
36. Sullivan D. “Staircase” closure of lower lip defects. Ann Plast Surg.
1978;1:392–397.
37. Dieffenbach J. Die Operative Chirurgie. Leipzig: FA Brockhams;
1845.
38. Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin
Plast Surg. 1984;11:583.
39. Fujimori R. “Gate flap” for the total reconstruction of the lower lip.
Br J Plast Surg. 1980;33:340–345.
40. Aytekin A, Ay A, Aytekin O. Total upper lip reconstruction with
bilateral Fujimori gate flaps. Plast Reconstr Surg. 2003;111:797–800.
41. Kroll SS. Staged sequential flap reconstruction for large lower lip
defects. Plast Reconstr Surg. 1991;88:620–627.
42. Serletti JM, Tavin E, Moran SL, et al. Total lower lip reconstruction
with a sensate composite radial forearm-palmaris longus free flap
and a tongue flap. Plast Reconstr Surg. 1997;99:559–561.
43. Sadove R, Luce E, McGrath P. Reconstruction of the lower lip and
chin with the composite radial forearm–palmaris longus free flap.
Plast Reconstr Surg. 1991;88:209–214.
44. Furuta S, Hataya Y, Watanabe T, et al. Vermilionplasty using
medical tattooing after radial forearm flap reconstruction of the
lower lip. Br J Plast Surg. 1994;47:422–424.

328.e2
SECTION II
CHAPTER 12 • Lip reconstruction
45. Eguchi T, Nakatsuka T, Mori Y, et al. Total reconstruction of the
upper lip after resection of a malignant melanoma. Scand J Plast
Reconstr Surg Hand Surg. 2005;39:45–47.
46. Jeng SF, Kuo YR, Wei FC, et al. Total lower lip reconstruction with a
composite radial forearm-palmaris longus tendon flap: a clinical
series. Plast Reconstr Surg. 2004;113:19–23. Large, full-thickness lip
defects after head and neck surgery continue to be a challenge for
reconstructive surgeons. The reconstructive aims are to restore the oral
lining, the external cheek, oral competence, and function (i.e., articulation,
speech, and mastication). These authors’ refinement of the composite radial
forearm–palmaris longus free flap technique meets these criteria and
allows a functional reconstruction of extensive lip and cheek defects in one
stage. A composite radial forearm flap including the palmaris longus
tendon was designed. The skin flap for the reconstruction of the intraoral
lining and the skin defect was folded over the palmaris longus tendon.
Both ends of the vascularized tendon were laid through the bilateral
modiolus and anchored with adequate tension to the intact orbicularis
muscle of the upper lip. This procedure was used in 12 patients.
47. Ozdemir R, Ortak T, Koçer U, et al. Total lower lip reconstruction
using sensate composite radial forearm flap. J Craniofac Surg.
2003;14:393–405.
48. Gottlieb LJ, Agarwal S. Autologous alternatives to face transplant. J
Reconstr Microsurg. 2012;28:49–61.
49. Carroll CM, Pathak I, Irish J, et al. Reconstruction of total lower lip
and chin defects using the composite radial forearm – palmaris
longus tendon free flap. Arch Facial Plast Surg. 2000;2:53–56.
50. Yamauchi M, Yotsuyanagi T, Yokoi K, et al. One-stage
reconstruction of a large defect of the lower lip and oral
commissure. Br J Plast Surg. 2005;58:614–618.
51. Shinohara H, Iwasawa M, Kitazawa T, et al. Functional lip
reconstruction with a radial forearm free flap combined with a
masseter muscle transfer after wide total excision of the chin. Ann
Plast Surg. 2000;45:71–73.
52. Kushima H, Iwasawa M, Kiyono M, et al. Functional reconstruction
of total lower lip defects with a radial forearm free flap combined
with a depressor anguli oris muscle transfer. Ann Plast Surg.
1997;39:182–185.
53. Ninkovic M, di Spilimbergo SS, Ninkovic M. Lower lip
reconstruction: introduction of a new procedure using a functioning
gracilis muscle free flap. Plast Reconstr Surg. 2007;119:1472–1480.
54. Bauer T, Schoeller T, Rhomberg M, et al. Myocutaneous platysma
flap for full-thickness reconstruction of the upper and lower lip and
commissura. Plast Reconstr Surg. 2001;108:1700–1703.
55. Lyons GB, Milroy BC, Lendvay PG, Teston LM. Upper lip
reconstruction: use of the free superficial temporal artery hair-
bearing flap: case report. Br J Plast Surg. 1989;42:333–336.
56. Tsur H, Shafir R, Orenstein A. Hair-bearing neck flap for upper lip
reconstruction in the male. Plast Reconstr Surg. 1983;71:262–265.

SECTION II • Head and Neck Reconstruction
13 
Facial paralysis
Ronald M. Zuker, Eyal Gur, Gazi Hussain, and Ralph T. Manktelow
SYNOPSIS
■ Assess clinical problem: functional, psychosocial, and aesthetic.
■ Understand the etiology and natural history of disease processes
associated with facial paralysis.
■ Knowledge of anatomy is imperative for optimizing results.
■ Formulate realistic, attainable, and practical management plan.
■ Surgical management is multifocal and must be individualized for each
patient.
Introduction
Facial paralysis is a complex multifaceted condition with
profound functional deficiencies, devastating aesthetic effects,
and tragic psychological consequences. It may be congenital
or acquired, affect the old and the young, and vary from mild
to severe. In this chapter we will focus on the clinical problem
and the surgical solutions available today.
Access the Historical Perspective section online at

Anatomy
As a backdrop to the clinical management of facial paralysis,
a detailed description of the anatomy of the facial nerve and
the facial musculature is described below.
The facial nerve
The extratemporal portion of the seventh cranial nerve begins
at the stylomastoid foramen. It is in a deep position below the
earlobe but becomes more superficial before it passes between
the superficial and deep portions of the parotid gland. Here
it divides into two main trunks which then further divide
within the substance of the gland. In a series of anatomic
dissections, Davis et al.1 demonstrated several branching pat­
terns of the facial nerve. Traditionally, it is taught that this
results in five divisions of the facial nerve: frontotemporal,
zygomatic, buccal, marginal mandibular, and cervical. In
practice, however, there is no distinct separation between the
zygomatic and buccal branches either in their location or in
the muscles they innervate.
On leaving the parotid, the facial nerve may have eight to
15 branches making up the five divisions. Distally, there is
further arborization and interconnection of these branches
(Fig. 13.1). The net effect is a great deal of functional overlap
between the branches. For example, a single zygomaticobuc­
cal branch may supply innervation to the orbicularis oculi as
well as to the orbicularis oris.
The temporal division consists of three or four branches2
that run obliquely along the undersurface of the temporopa­
rietal fascia after crossing the zygomatriarch in a location
3–5 cm from the lateral orbital margin. The lower branches
run along the undersurface of the superior portion of the
orbicularis oculi for 3–4 mm before entering the muscle to
innervate it.3 According to Ishikawa,2 the upper two branches
entering the frontalis muscle at the level of the supraorbital
ridge are usually located up to 3 cm above the lateral canthus.
The nerves usually lie approximately 1.6 cm inferior to the
frontal branch of the superficial temporal artery. Because there
is relatively little adipose tissue at the lateral border of the
frontalis, those nerves are virtually subcutaneous and suscep­
tible to injury.
The zygomaticobuccal division consists of five to eight
branches with significant overlap of muscle innervations such
that one or more branches may be divided without causing
weakness. These nerves supply innervations to the lip eleva­
tors as well as to the lower orbicularis oculi, orbicularis oris,
and buccinators. Functional facial nerve mapping and cross-
facial nerve grafting require the precise identification and
stimulation of these zygomaticobuccal branches to isolate the
exact branches responsible for smiling. These nerves lie deep
near the parotid-masseteric fascia in the same plane as the
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329.e1
Historical perspective
Historical perspective
Surgical correction of facial paralyses continues to evolve and
improve. Early attempts were directed at static repositioning
to address functional problems around the eye and mouth.
Muscle transplants were initially non-vascularized grafts, but
function was impaired shortly thereafter with the muscle
being revascularized and reinnervated. At first this was via
ipsilateral nerves and later using contralateral nerves. For
facial musculature that has the potential for reinnervation,
nerve transfers were introduced as a very effective method of
maintaining nerve function and muscle activation. Recent
combinations of nerve transfers and muscle transplantation
have been developed.
At present, surgical methods to recover facial nerve
function range from nerve repair, nerve grafting, and nerve
transfer to static slings and muscle transfers and, finally,
functioning muscle transplantation. A variety of combina­
tions have also been introduced, as this complex field con­
tinues to develop with newer and more effective treatment
options.

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SECTION II
CHAPTER 13 • Facial paralysis
Fig. 13.1  A typical pattern of facial nerve branching. The main branch is divided into two components, each of which then branches in a random manner to all parts of the
face. The extensive distal arborization and interconnections are apparent. (Reprinted with permission from ©Elsevier Inc. All rights reserved.)

331
Anatomy
nerve and the Müller muscle, which is a smooth fiber muscle
innervated by the sympathetic nervous system. The orbicu­
laris oculi muscle is one continuous muscle but has three
subdivisions: pretarsal, covering the tarsal plate; preseptal
portions, overlying the orbital septum; and the orbital,
forming a ring over the orbital margin. The pretarsal and
preseptal portions function together when a patient blinks,
whereas the orbital portion is recruited during forceful eye
closure and to lower the eyebrows. According to Jelks and
Jelks,7 the preseptal portion of the orbicularis oculi is under
voluntary control, whereas the pretarsal provides reflex
movement.
The pretarsal orbicularis oculi overlies the tarsal plate of
the upper and lower eyelids. The tarsal plates are thin, elon­
gated plates of connective tissue that support the eyelids. The
superior tarsal plate is 8–10 mm in vertical height at its center
but tapers medially and laterally, whereas the inferior tarsal
plate is 3.8–4.5 mm in vertical height. The skin overlying the
pretarsal orbicularis is the thinnest in the body and is adher­
ent to the muscle over the tarsal plate. The skin is more lax
and mobile over the preseptal and orbital regions. The eyelid
skin also becomes thicker over the orbital part of the muscle.
The preseptal orbicularis provides support to the orbital septa
and is more mobile except at the medial and lateral canthi,
where the muscle is firmly attached to the skin. The orbital
portion of the orbicularis oculi extends in a wide circular
fashion around the orbit. It originates medially from the
superomedial orbital margin, the maxillary process of the
frontal bone, the medial canthal tendon, the frontal process of
the maxilla, and the inferomedial margin of the orbit. In the
upper eyelid, the fibers sweep upward into the forehead and
cover the frontalis and corrugators supercilii muscles; the
fibers continue laterally to be superficial to the temporalis
fascia.8,9 Because this muscle is one of the superficial group of
mimetic muscles,10 in the lower eyelid the orbital portion lies
over the origins of the zygomaticus major, levator labii supe­
rioris, levator labii superioris alaeque nasi, and part of the
origin of the masseter muscle. There are multiple motor nerve
branches that supply the upper and lower portions of the
orbicularis oculi, and these enter the muscle just medial to its
lateral edge.
Freilinger et al.3 extensively studied the three major lip
elevators, zygomaticus major, levator labii superioris, and
levator anguli oris, and provided data on their length, width,
and thickness (Table 13.1).
The zygomaticus major takes origin from the lower lateral
portion of the body of the zygoma; the orbicularis oculi and
zygomaticus minor cover its upper part. Its course is along a
line roughly from the helical root of the ear to the commissure
parotid duct. There are sometimes connections between the
lower branches and the marginal mandibular division.
The marginal mandibular division consists of one to three
branches4 whose course begins up to 2 cm below the ramus
of the mandible and arcs upward to cross the mandible
halfway between the angle and mental protuberance. It has
been well documented2,3,5 that these branches lie on the deep
surface of the platysma and cross superficial to the facial
vessels approximately 3.5 cm from the parotid edge. Nelson
and Gingrass5 described separate branches to the depressor
angularis, depressor labii inferioris, and mentalis, and a vari­
able superior ramus supplying the upper platysma and lower
orbicularis oris.
The cervical division consists of one branch that leaves the
parotid well below the angle of the mandible and runs on the
deep surface of the platysma, which it innervates by entering
the muscle at the junction of its cranial and middle thirds. This
point of entry is 2 or 3 cm caudal to the platysma muscle
branch of the facial vessel.6
Facial musculature
Facial musculature consists of 17 paired muscles and one
unpaired sphincter muscle, the orbicularis oris (Fig. 13.2). The
subtle movements that convey facial expression require coor­
dination between all of these muscles.
The major muscles affecting the forehead and eyelids are
the frontalis, corrugator, and orbicularis oculi. There are two
main groups of muscles controlling the movement of the lips.
The lip retractors include the levator labii superioris, levator
anguli oris, zygomaticus major and minor for the upper lip,
and depressor labii inferioris and depressor anguli oris for the
lower lip. The antagonist of these lip-retracting muscles is the
orbicularis oris, which is responsible for oral continence and
some expressive movements of the lips.
Freilinger et al.3 have demonstrated that the mimetic
muscles are arranged in four layers. The depressor anguli oris,
part of the zygomaticus minor, and the orbicularis oculi are
the most superficial, whereas the buccinators, mentalis, and
levator anguli oris make up the deepest layer. Except for the
three deep muscles, all other facial muscles receive innerva­
tion from nerves entering their deep surfaces.
The muscles that are clinically important or most often
require surgical management in patients with facial paralysis
are the frontalis, orbicularis oculi, zygomaticus major, levator
labii superioris, orbicularis oris, and depressor labii inferioris.
The frontalis muscle is a bilateral, broad sheet-like muscle
5–6 cm in width and 1 mm thick.4 The muscle takes origin
from the galea aponeurotica at various levels near the coronal
suture and inserts on to the superciliary ridge of the frontal
bone and into fibers of the orbicularis oculi, procerus, and
corrugators supercilii. It is firmly adherent to the skin through
multiple fibrous septa but glides over the underlying perios­
teum. The two muscles fuse in the midline caudally; however,
this is often a fibrous junction. Not only is the frontalis essen­
tial to elevate the brow, but also its tone at rest keeps the brow
from descending. This tone is lost in the patient with facial
paralysis, which allows the brow to fall and potentially
obscure upward gaze.
The orbicularis oculi muscle acts as a sphincter to close the
eyelids. Upper eyelid opening is performed by the levator
palpebrae superioris muscle innervated by the third cranial
Table 13.1  Dimensions of the levators of the upper lip
Muscle
Length
(mm)
Width
(mm)
Thickness
(mm)
Zygomaticus major
70
8
2
Levator labii superioris
34
25
1.8
Levator anguli oris
38
14
1.7
(Reproduced from Freilinger G, Gruber, Happak W, et al. Surgical anatomy of
the mimic muscle system and the facial nerve: importance for reconstructive
and aesthetic surgery. Plast Reconstr Surg. 1987;80:686.)

332
SECTION II
CHAPTER 13 • Facial paralysis
Fig. 13.2  The muscles of facial expression are present in two layers. The buccinator, depressor labii inferioris, levator anguli oris, and corrugator are in the deeper layer.
Procerus
Corrugator supercilii
Levator labii superioris
alaeque nasi
Nasalis
Levator labii superioris
Zygomaticus minor
Zygomaticus major
Levator anguli oris
Parotid gland
Buccal fat pad
Buccinator
Masseter, superficial part
Depressor anguli oris
Depressor labii inferioris
Orbicularis oris, labial part
Orbicularis oris, marginal part
Epicranial aponeurosis
Occipitofrontalis, frontal belly
Depressor supercilii
Orbicularis oculi, palpebral part
Orbicularis oculi, orbital part
Levator labii superioris
alaeque nasi
Zygomaticus minor
Zygomaticus major
Risorius
Mentalis
Platysma
Depressor anguli oris
Depressor septi nasi
Depressor labii inferioris
Levator labii superioris
of the mouth, where it leads into the modiolus. The modiolus
is the point of common attachment at which the fibers of the
zygomaticus major and minor, orbicularis oris, buccinator,
risorius, levator anguli oris, and depressor anguli oris come
together. Deep fibers of the zygomaticus major are angled
upward from the modiolus to fuse with the levator anguli
oris, whereas caudal fibers continue into the depressor anguli
oris. The main nerve to the zygomaticus major enters the deep
surface of the upper third of the muscle.
The levator labii superioris originates along the lower
portion of the orbital margin above the infraorbital foramen.
The muscle courses inferiorly, partially inserting into the
nasolabial crease. The lateral fibers pass inferiorly into
the orbicularis oris, and the deepest fibers form part of the

333
Anatomy
oris and its surface. Through fibrous septa, it attaches to the
vermilion and the skin of the middle third of one side of the
lip.9 Its action is to draw the lower lip downward and laterally
and to evert the vermilion (e.g., as in showing the lower
teeth). The depressor anguli oris arises from the mandible
laterally and is superficial to the depressor labii inferioris. The
medial fibers insert directly into the skin at the labiomandibu­
lar crease; the remainder blend into the modiolus.13 It depresses
the angle of the mouth (e.g., in frowning).
Diagnosis and patient presentation
Facial paralysis is a complex clinical problem with numerous
consequences affecting the function, self-image, and social
interactions of those afflicted and their families (Fig. 13.4).
Function of the muscles vital for the protection of the eye,
maintenance of the nasal airway, oral continence, and clear
speech may be lost. These muscles support the face at rest and
enable an individual to wink, pucker the lips, and express
emotions of surprise, joy, anger, and sorrow.
Brow ptosis is more commonly a problem in the older
patient. The weight of the forehead tissue may cause sagging
of the eyebrow inferiorly over the superior orbital margin,
which causes an asymmetric shape and obstructs the upward
gaze. This may be complicated by over activity of the contra­
lateral frontalis muscle, which increases the discrepancy
between eyebrow height. At rest, the depressed eyebrow
gives the impression of unhappiness or excessive seriousness.
With animation, the asymmetry of the brows and wrinkling
of the forehead are accentuated.
The orbicularis oculi muscle is crucial for the protection of
the eye. It enables eyelid closure and provides a physical
barrier against wind and foreign matter. Repetitive blinking
is also important for control of the even spread of tear film in
modiolus. The nerve to this muscle reaches it by first passing
underneath the zygomaticus major muscle to supply the
levator labii superioris on its deep surface.
The levator anguli oris is the third lip elevator. It takes
origin from the maxilla below the infraorbital foramen and
inserts into the modiolus. Because this muscle belongs to the
deepest layer, it is innervated on its superficial surface by the
same branch that supplies innervation to the buccinator.
Three muscles along with the zygomaticus minor serve to
elevate the lip. The zygomaticus muscles move the commis­
sure at an angle of approximately 45°, the levator anguli oris
elevates the commissure vertically and medially, and the
levator labii superioris elevates the lip vertically and laterally
to expose the upper teeth.
The orbicularis oris is a complex muscle that functions as
far more than a sphincter of the mouth; it serves to pucker
and purse the lips. It makes up the bulk of the lip, as skin
overlies it superficially and mucous membrane is attached on
its deep surface. Philtral columns are formed by the insertion
of the orbicularis, and a portion of levator labii superioris, into
the skin.11 The levator labii superioris fibers reach the philtral
columns by coursing above the surface of the orbicularis oris
to insert into the lower philtral columns and vermilion border
as far medially as the peak of Cupid’s bow. Anatomically and
functionally, the orbicularis oris muscle consists of two parts,
superficial and deep. The deep layers of the muscle encircle
the orifice of the mouth and function as a constrictor. The
superficial component also brings the lips together, but its
fibers can contract independently to provide expression.12
The lower lip depressors consist of the depressor labii
inferioris, also known as the quadratus labii inferioris, and the
depressor anguli oris, also known as the triangularis (Fig.
13.3). The mentalis, however, is not a lip depressor. Its indirect
action on the lip is to elevate it.8 The depressor labii inferioris
arises from the lateral surface of the mandible, which is
inferior and lateral to the mental foramen. It runs medially
and superiorly to insert into the lower border of the orbicularis
Fig. 13.3  The depressor anguli oris can be seen in the corner of the mouth.
Muscle contraction pulls the corner of the mouth down as in the expression of
sadness. The depressor labii inferioris goes into the orbicularis oris of the mid
lateral portion of the lower lip and pulls the lip down. The muscle’s function is
apparent in an open-mouth smile showing the lower teeth. The mental nerve lies on
the deep surface of the depressor labii inferioris.
Fig. 13.4  Facial paralysis produces marked asymmetry at rest between the
paralyzed side and the non-paralyzed side. The asymmetry is particularly severe in
the older patient.

334
SECTION II
CHAPTER 13 • Facial paralysis
broken down further into unilateral or bilateral categories.14
In addition, the degree of muscle involvement varies from
total to partial paralysis. More than 50% of patients with facial
paralysis suffer from Bell’s palsy and often recover fully.
Congenital facial paralysis is present at birth. This is the
most common form of facial paralysis seen in a pediatric
setting. It may be isolated with the involvement of the facial
nerve and its musculature only, or it may be part of a
syndrome.
a lateral to medial direction to prevent drying of the cornea.
The effective drainage of tears is also dependent on a func­
tioning orbicularis oculi muscle; its action on the lacrimal sac
establishes a pump-like effect that facilitates the efficient
clearance of tears.
When the eyelids are open, the distance between the upper
and lower eyelid is 9–11 mm at its widest point. In the neutral
gaze position, the upper eyelid covers 2–3 mm of the superior
corneal limbus; the lower eyelid lies at the level of the inferior
corneal limbus. Thus, there is normally no sclera showing.
With eye closure, the majority of movement occurs in the
upper eyelid while the lower lid remains relatively static.
However, with squinting or smiling, there is up to 2 mm of
upward movement in the lower eyelid. The main function of
the inferior orbicularis oculi is the maintenance of lid margin
contact with the globe and assistance with tear damage.
Patients with facial paralysis are troubled by significant
discomfort in the eye because of corneal exposure and desic­
cation. This drying frequently produces a reflex tear flow.
Excessive tears poorly managed by the paralyzed eyelids
result in overflow. Therefore, patients with dry eyes often
present with excessive tearing. This tearing problem can be
distressing and is exacerbated by the downward inclination
of the face (e.g., during reading).
The appearance of the paralyzed eye is also of concern to
the patient. The eye has a widened palpebral aperture and is
unable to convey expression. Thus, when the patient smiles,
the paralyzed eyelids remain open instead of slightly closing.
With the passage of time, the lower eyelid develops an ectro­
pion, causing the inferior lacrimal punctum to pull away from
the eye. An ectropion further exacerbates tearing and increases
the risk of excessive corneal exposure.
The other major concern for patients with facial paralysis
is the inability to control their lips. This affects the patient’s
ability to speak, eat, and drink properly. For example, many
patients with facial paralysis have difficulty producing b and
p sounds. Buccinator paralysis leads to problems in the control
of food boluses. Food tends to pocket in the buccal sulcus of
the paralyzed portion of the face; therefore, many patients
chew only on the contralateral side. This type of paralysis also
severely affects normal facial expressions. The main complaint
heard from patients is their inability to smile. This should not
be regarded as an aesthetic issue. It is a functional disability
because it directly impairs communication. Paralysis of the
orbicularis oris results in drooling and difficulty in controlling
the mouth (e.g., drinking from a glass).
The emotional effects of facial paralysis cannot be overes­
timated. The unilaterally paralyzed face presents obvious
asymmetry at rest, exacerbated by an attempt to smile (Fig.
13.5). As a result, these patients avoid situations in which they
are required to smile. They become characterized as serious
and unhappy, and their psychosocial functioning is frequently
poor. A patient with bilateral facial paralysis has severe dis­
ability because their face cannot convey emotion.
Classification
In the formulation of a treatment plan, it is helpful to have a
practical and clinically oriented classification. This will facili­
tate sound decision making and realistic surgical planning.
Facial paralysis can take many forms. It can be classified
anatomically and as congenital or acquired, and it can be
CA
Fig. 13.5  (A) At rest, the right-sided partial facial paralysis in this young woman
is minimally evident, as seen by a slight deviation of the mouth to her left and a
slightly wider palpebral aperture in her right eye. (B) With smiling, the asymmetry
becomes more apparent.
CB

335
Anatomy
to individual. A thorough history and examination will reveal
the presence of a complete or partial seventh-nerve paralysis
and, if the paralysis is partial, the specific muscles affected
and the extent of the paralysis. Has there been any return of
function? Is this improvement continuing or has it reached a
plateau? The history must include any eye symptoms, such
It is estimated that facial paralysis occurs in 2.0% of live
births.15 In the majority of patients, it is believed to be the
result of intrauterine pressure on the developing fetus from
the sacral prominence. The facial nerve is superficial and
easily compressed. This leads to the panfacial type and buccal
branch variety of congenital facial paralysis. It is believed,
however, that the mandibular branch component and syn­
dromic forms of facial paralysis may have a different etiology.
In the authors’ experience, the cause of unilateral facial
paralysis was congenital in two-thirds of patients encountered
and acquired in one-third of patients. Acquired facial paralysis
resulted from intracranial tumors in 50% of patients, and
acquired facial paralysis from extracranial trauma. The major­
ity of traumas were related to surgical procedures, most
commonly cystic hygroma excision. In infants, the nerve is
superficial at birth and can easily be traumatized through
external compression or surgical misadventure. In contrast,
the cause of facial paralysis for the majority of adults is
acquired, from either intracranial lesions or inflammatory
processes, such as Bell’s palsy.
Congenital facial paralysis may be syndromic. The most
common unilateral syndromic condition associated with
facial paralysis is hemifacial microsomia. All tissues of the
face can be affected to a variable degree, including the facial
nerve musculature. The most common bilateral congenital
facial paralysis is a result of Möbius syndrome. The functional
effects of congenital facial paralysis tend to worsen gradually
as the influence of gravity and aging prevails.
Bilateral facial paralysis may be the result of bilateral intra­
cranial tumors or bilateral skull base trauma, but it is usually
found to be the congenital bilateral facial paralysis or Möbius
syndrome. Various cranial nerves accompany the seventh
nerve’s involvement, specifically the sixth, ninth, 10th, and
12th. Möbius syndrome is also associated with trunk and limb
anomalies in about one-third of patients, the most common
being talipes equinovarus and a variety of hand anomalies,
including Poland syndrome. Cranial nerve involvement is
usually bilateral and severe but often incomplete. There is
frequently some residual function in the lower component of
the face (the cervical and mandibular branch regions). The
incidence of Möbius syndrome is estimated to be about 1 in
200 000 live births.
Acquired facial paralysis may also be unilateral or bilateral
through local disruption of the nerve at various locations.
Damage to the nerve may be intracranial in the nucleus or the
peripheral nerve, extracranial in the peripheral nerve, or the
result of damage to the muscle itself. Intracranial and extra­
cranial neoplasms, Bell’s palsy, and trauma are the most
common causes seen in the adult setting. Although recovery
is the rule in Bell’s palsy, at least 10% of patients are left with
some degree of paralysis. Bilateral acquired facial paralysis is
usually the result of skull base fractures, intracranial lesions,
usually in the brainstem, or intracranial surgery.
Throughout all of these areas, however, facial paralysis
constitutes a spectrum of involvement. It may be complete or
incomplete to varying degrees, obvious in some patients, and
subtle in others (Table 13.2).
Patient selection
Facial paralysis patients present with a broad spectrum of
signs and symptoms. Thus, treatment varies from individual
Table 13.2  Classification of facial paralysis
Extracranial
Traumatic
Facial lacerations
Blunt forces
Penetrating wounds
Mandible fractures
Iatrogenic injuries
Newborn paralysis
Neoplastic
Parotid tumors
Tumors of the external canal and middle ear
Facial nerve neurinomas
Metastatic lesions
Congenital absence of facial musculature
Intratemporal
Traumatic
Fractures of petrous pyramid
Penetrating injuries
Iatrogenic injuries
Neoplastic
Glomus tumors
Cholesteatoma
Facial neurinomas
Squamous cell carcinomas
Rhabdomyosarcoma
Arachnoidal cysts
Metastatic
Infectious
Herpes zoster oticus
Acute otitis media
Malignant otitis externa
Idiopathic
Bell palsy
Melkersson–Rosenthal syndrome
Congenital: osteopetrosis
Intracranial
Iatrogenic injury
Neoplastic – benign, malignant, primary, metastatic
Congenital
Absence of motor units
Syndromic
Hemifacial microsomia (unilateral)
Möbius syndrome (bilateral)

336
SECTION II
CHAPTER 13 • Facial paralysis
Treatment: nonsurgical and surgical
Planning, priorities, and expectations
As has been stressed previously, treatment must be individu­
alized. However, in general, the aims of treatment are to
protect the eye, to provide symmetry at rest, and then to
provide movement. The ultimate goal is to restore involuntary,
independent, and spontaneous facial expression. The goals of
treatment for the eye are to maintain vision, to provide protec­
tion, to maintain function of the eyelids, to improve cosmesis,
and to enable the eye to express emotion. The goals for the
mouth are to correct asymmetry, to provide oral continence,
to improve speech, and to provide a balanced symmetric
smile that the patient will use in social settings. Clearly, the
accomplishment of all these goals is difficult, and they cannot
be achieved completely.
The patient must be counseled as to what are real and
achievable expectations. It is clearly impossible to restore
intricate movements to all facial muscles, and the patient who
is appropriately informed is more likely to be satisfied with
his or her outcome.
Nonsurgical management
Nonsurgical management of the patient with facial paralysis
applies primarily to the eye and can frequently make the
difference between a comfortable eye and a painful one.
Nonsurgical maneuvers can protect the eye while surgery is
being planned and are regularly used in concert with the
surgical management of the eye. In some instances, surgery
may be avoided. Nonsurgical management of the eye consists
of protecting the eye and maintaining eye lubrication
(Table 13.3).
Eye lubrication can be provided by a number of commer­
cially available preparations. This includes clear watery drops
containing either hydroxypropyl methylcellulose or polyvinyl
alcohol along with other agents including preservatives.
These drops function by absorbing into the cornea and lubri­
cating it. Although the duration of action will vary, most are
retained on the surface of the eye between 45 and 120 min.19
Thus, to be most effective, they should be instilled frequently
during the day. Thicker ointments containing petrolatum,
mineral water, or lanolin alcohol are retained longer and can
be used at night to protect and “seal” the eyelids during sleep.
The patient who presents with excessive tearing may in fact
have a dry eye and may benefit from the use of artificial tears.
Corneal ulceration should be managed with prompt referral
for ophthalmologic assessment.
as dryness, excessive tearing, incomplete closure, discomfort
when the patient is outdoors, and use of artificial tears. The
patient should be questioned about the nasal airway, oral
continence, speech, and level of psychosocial functioning and
social interactions.
The patient’s concerns and expectations must be sought.
For some, attaining a symmetric appearance at rest is
more important than achieving a smile. In comparison to
the younger patient, the older patient is more likely to be
worried about brow ptosis, ectropion, and drooping of the
cheek.
The level of injury to the nerve, if it is not known, can be
assessed clinically. Injury to the nerve within the bony canal
may result in loss of ipsilateral taste appreciation, hyperacusis,
and facial weakness because the chorda tympani and nerve
to the stapedius may be injured at this level. Injury to the
seventh cranial nerve near the geniculate ganglion will also
result in decreased secretory function of the nose, mouth, and
lacrimal gland.
Examination of the face begins with the brow. Its position
at rest and with movement must be noted. The superior visual
field may be diminished by the ptotic brow.
The eye must be thoroughly assessed. Visual acuity in each
eye should be documented. The height of the palpebral aper­
ture should be measured and compared with the non-
paralyzed side. The degree of lagophthalmos and the presence
of a Bell reflex will indicate the risk of corneal exposure. The
lower eyelid position should be measured. Tone in the lower
eyelid can be assessed by the use of the snap test. This is done
by gently pulling the eyelid away from the globe and releas­
ing it. The eyelid normally snaps back against the globe;
however, this fails to occur in the patient with poor lid tone.
The position of the inferior canalicular punctum should be
assessed. Is it applied to the globe or is it rolled away and
exposed? In addition, the patient should be examined for
corneal irritation or ulceration.
The nasal airway is examined next. Forced inspiration may
reveal a collapsed nostril due to loss of muscle tone in the
dilator naris and drooping of the cheek. An intranasal exami­
nation should also be done.
Examination of the mouth and surrounding structures
documents the amount of philtral deviation, the presence or
absence of a nasolabial fold, the amount of commissure
depression and deviation, the degree to which the upper lip
droops, and the presence of vermilion inversion. With anima­
tion, the amount of bilateral commissure movement is
recorded; it is also noted how much of the upper incisors
show when the patient is smiling. Speech should be assessed.
An intraoral examination is performed to check dental hygiene
and to look for evidence of cheek biting.
The presence of synkinesis, the simultaneous contraction
of two or more groups of muscles that normally do not con­
tract together,16 should be documented. Synkinesis is thought
to occur from a misdirected sprouting of axons. The most
common types of synkinesis are eye closure with smiling,17
brow wrinkling when the mouth is moved,18 and mouth gri­
macing when the eyes are closed.
An assessment of the other cranial nerves, particularly the
fifth, is also performed. Cranial nerve involvement may
exacerbate the morbidity of facial nerve paralysis. These
nerves should also be assessed as possible donor motor
nerves.
Table 13.3  Nonsurgical maneuvers to protect the eye
Lid taping, particularly while sleeping
Soft contact lenses
Moisture chambers, which can be taped to the skin around the
orbit
Modification of spectacles to provide a lateral shield
Forced blinking exercises in a patient with weak eye closure
Eye patches
Temporary tarsorrhaphy

337
Treatment: nonsurgical and surgical
Brow
There are at least three approaches to a brow lift: direct exci­
sion of the tissue above the brow (direct brow lift), open brow
lift performed through a coronal incision, and endoscopic
brow lift. Unilateral frontalis paralysis may cause a difference
in brow heights of up to 12 mm. A direct brow lift is best able
to correct such a large discrepancy. Direct brow lift involves
excision of a segment of skin and frontalis muscle just above
and parallel to the eyebrow. If the incision is placed just along
the first line of hair follicles, the resulting scar is usually less
noticeable. Frontalis shortening by excision and repair pro­
vides a reliable correction, which minimally relaxes over time.
However, overcorrection is still required. Slight overcorrec­
tion is particularly beneficial if the person’s normal side of the
forehead is quite active during facial expression. Branches of
the supraorbital nerve should be identified and preserved
because they lie deep to the muscle (Fig. 13.6).
In patients in whom there is incomplete facial nerve paraly­
sis or recovering muscle activity after nerve injury, function
may be improved with neuromuscular retraining supervised
by an experienced therapist. This consists of various treat­
ment modalities such as biofeedback, electromyography, and
self-directed mirror exercises using slow, small, and sym­
metric movements.20 Patients can often relearn some facial
movements or strengthen movements that are weak.
Surgical management (Videos 13.1 and 13.2 )
Deciding on a surgical procedure can initially seem daunting.
There are a number to choose from, and selecting the most
appropriate reconstruction may be confusing. It is important
to listen to each patient carefully to identify which aspects of
the paralysis are most troublesome and to treat each region of
the face separately. The age of the patient, duration of the
facial paralysis, condition of the facial musculature and soft
tissues, and status of the potential donor nerves and muscles
will all influence treatment options. One must consider the
patient’s needs carefully and match the needs of the patient
with the skill of the surgeon (Table 13.4).
Table 13.4  Most common surgical options for each region of
the face
Brow (brow ptosis)
Direct brow lift (direct excision)
Coronal brow lift with static suspension
Endoscopic brow lift
Upper eyelid (lagophthalmos)
Gold weight
Temporalis transfer
Spring
Tarsorrhaphy
Lower eyelid (ectropion)
Tendon sling
Lateral canthoplasty
Horizontal lid shortening
Temporalis transfer
Cartilage graft
Nasal airway
Static sling
Alar base elevation
Septoplasty
Commissure and upper lip
Nerve transfer either directly or via nerve graft to reinnervate
recently paralyzed muscles
Microneurovascular muscle transplantation with the use of
ipsilateral seventh nerve, cross-facial nerve graft, or other
cranial nerve for motor innervation
Temporalis transposition with or without masseter transposition
Static slings
Soft-tissue balancing procedures (rhytidectomy, mucosal excision
or advancement)
Lower lip
Depressor labii inferioris resection (on normal side)
Muscle transfer (digastric, platysma)
Wedge excision
CA
CB
Fig. 13.6  (A) Assessment of the amount of brow depression on the paralyzed side
compared with the normal eyebrow on the patient’s left. (B) Excision of skin and a
strip of frontalis muscle to correct brow ptosis. (C) Postoperative appearance.
C

338
SECTION II
CHAPTER 13 • Facial paralysis
with a weight of 0.8–1.2 g, giving the patient a comfortable
eye without weight-related problems.21 The appropriate
weight is selected by taping trial prostheses to the upper
eyelid over the tarsal plate with the patient awake. The light­
est weight that will bring the upper eyelid within 2–4 mm of
the lower lid and cover the cornea should be used. As long as
the patient has an adequate Bell phenomenon, complete
closure is not necessary. The prosthesis is fixed to the upper
half of the tarsal plate by permanent sutures, which pass
through the tarsal plate. Care should be taken not to interfere
with the insertion of Müller muscle (Fig. 13.8). With proper
placement, the prosthesis should be hidden in the upper
eyelid skin crease when the eye is open. The closure produced
by the gold weight is slow, and the patient must be instructed
to relax the levator muscle consciously for 1–2 seconds to
Brow lift may be performed through a coronal incision with
or without a fascial graft to suspend the brow from the tem­
poralis fascia or medially on the frontal bone. Whereas the
scar is concealed, this is a larger operation than a direct brow
lift and may not achieve as adequate a lift.
The authors have had limited experience with endoscopi­
cally assisted brow lifts for facial paralysis. The amount of lift
required in the patient with facial paralysis is usually more
than can be achieved from a unilateral endoscopic brow lift.
It is likely that, with time, there will be gradual drooping.
Therefore, the longevity of results in patients with facial
paralysis has yet to be demonstrated with this procedure,
especially when a large unilateral lift is required.
Weakening of the contralateral normal frontalis muscle by
transaction of the frontal nerve or resection of strips of muscle
is occasionally useful to control wrinkle asymmetry.
Upper eyelid
Several techniques are available for the management of lag­
ophthalmos. These are all directed at overcoming the unop­
posed action of the levator palpebrae superioris. Because of
its relative technical ease and reversibility, lid loading with
gold prosthesis is the most popular technique. The patient’s
eyelid configuration is important in determining whether the
bulge of the gold weight will be visible when the eye is open.
If the amount of exposed eyelid skin above the lashes is more
than 5 mm when the eye is open, the gold weight is likely to
be noticeable to the patient. If the distance is less than 5 mm,
the gold weight will roll back and be covered by the supra­
tarsal skinfold (Fig. 13.7).
Because of its inertness, 24-carat gold is used; allergic reac­
tions are rare, but if they occur, platinum weights are also
available. Prostheses are available in weights ranging from 0.8
to 1.8 g. Adequate improvement in eye closure can be obtained
Fig. 13.7  Right facial paralysis in a young woman with total paralysis of the
orbicularis oculi showing ideal eyelid configuration that allows gold weight
insertion without visibility.
A
Fig. 13.8  (A) Placement of gold weight directly above the cornea on the upper
half of the tarsal plate. (B) Gold weight sutured in place with the knots turned away
from the skin.
CB

339
Treatment: nonsurgical and surgical
The advantage of this procedure is that it is not dependent
on gravity. However, problems with malpositioning of the
spring, spring breakage or weakening, pseudoptosis due to
excessive spring force, and skin erosion have prevented the
widespread use of this procedure. It is certainly a more
involved procedure than insertion of the gold weight, and
results may be dependent on the surgeon’s skill level.
For short-term use, there are implantable devices. These
include magnetized rods inserted into the upper and lower
eyelids and silicon bands sutured to the lateral and medial
canthal ligaments.
Temporalis muscle transposition has the advantage of
using autogenous tissue, thereby avoiding the use of foreign
materials. First described by Gillies,23 this procedure has since
been modified by several authors.24 A 1.5-cm-wide flap of
temporalis muscle based inferiorly is raised along with the
overlying temporalis fascia. Because both the blood supply
and motor nerve innervation enter the muscle on its inferior
deep surface, the flap remains functional. The fascia overlying
the temporalis muscle is then detached. It is sutured firmly to
the superior edge of the temporalis muscle that is about to be
transposed (Fig. 13.11). The flap is passed subcutaneously to
the lateral canthus, where the fascial strips are tunneled along
the upper and lower lid margins and sutured to the medial
canthal ligament (Fig. 13.12). With activation of the muscle,
the fascial strips are pulled tight, causing eyelid closure. This
technique has the advantage of addressing both upper eyelid
closure, and a static sling for the lower eyelid allows better
eyelid closure. It is preferable to use a 2-mm strip of tendon;
fascia appears to stretch, resulting in loss of effective eyelid
movement. The disadvantages of this transfer are that, with
muscle contraction, the lid aperture changes from an oval to
a slit shape; there may be skin wrinkling over the lateral
canthal region and an obvious muscle bulge over the lateral
orbital margin. Movements of the eyelids during chewing
may also be a disturbing feature for the patient. Nevertheless,
allow the eyelid to descend (Fig. 13.9). Complications include
extrusion, excessive capsule formation by causing a visible
lump, and irritation of the eye by the weight. If these occur,
the weight can easily be removed, replaced, or repositioned.
The authors have used the gold weight alone 27 times. The
incidence of complications requiring removal of the weight
was 2%, and 8% required revision of the weight. In 52% of
patients, good symptomatic improvement was obtained. Of
these patients, 64% subsequently required lower lid support
with a static sling. As a result, it has become much more
common to recommend both a gold weight and a lower-
eyelid sling at the same operative sitting, which results in a
95% good improvement in symptoms.
An alternative procedure for the eyelid closure is the pal­
pebral spring originally described by Morel–Fatio, which
consists of a wire loop with two arms.22 One arm is sutured
along the lid margin, and the other arm is fixed to the inner
aspect of the lateral orbital rim. When the eye is open, the two
arms are brought close to each other; when the eyelid is
relaxed, the “memory” of the wire loop moves the arms apart,
causing closure of the eyelid (Fig. 13.10).
CA
Fig. 13.9  (A) Postoperative appearance of patient shown in Fig. 13.7 after a gold
weight has been fixed to the right upper eyelid. (B) Eye closure is shown after gold
weight insertion.
CB
Fig. 13.10  Palpebral spring in right upper eyelid.
Lateral
orbital rim
Fig. 13.11  Elevation of temporalis muscle for transfer to eye.
Cranium
Temporalis
muscle
Four sutures through
region of fused
temporal fascia
Deep temporal
fascia

340
SECTION II
CHAPTER 13 • Facial paralysis
Lower eyelid
The orbicularis oculi muscle, through its attachment to the
canthal ligaments, holds the lower eyelid firmly against the
globe and with contraction is able to raise the lid 2–3 mm.
Ordinarily, the eyelid margin rests at the level of the limbus
of the eye. With paralysis of the orbicularis, tone in the muscle
is lost. Gravity causes the lower eyelid to stretch and sag,
resulting in scleral show. Over time, the lid and inferior cana­
licular punctum roll away from the globe, resulting in an
ectropion (Fig. 13.13). Therefore, management is directed at
resuspending the lid and reapposing the punctum to the
globe.
Pronounced ectropion with lid eversion and more than
2–3 mm of scleral show is usually associated with symptoms
of dryness and aesthetic concerns. This situation requires
support of the entire length of the eyelid. This is best achieved
with a static sling passed 1.5–2 mm inferior to the gray line
of the eyelid and fixed both medially and laterally (Fig.
13.14).26 Tendon provides longer-lasting support with less
CA
Fig. 13.13  (A) Marked bilateral ectropion in lower eyelids in a 52-year-old woman
with Möbius syndrome. (B) Postoperative appearance after tendon sling insertion to
lower eyelids.
CB
Fig. 13.14  (A) Incisions for insertion of static sling. (B) Static sling attachment to medial canthal ligament and periosteal strip on lateral orbital margin. (C) After fixation
of sling.
A
B
C
Fig. 13.12  Transplantation of temporalis muscle and fascia to upper and lower
eyelids.
Fascial strips
crossed under
medial canthal
ligament
Temporalis
muscle
this procedure usually provides an excellent static support,
eye closure on command, and good lubrication of the eye
through distribution of the tear film and consequent corneal
protection. Microneurovascular muscle transplantation for
orbicularis function is a relatively new procedure. Platysma
transplantation procedures that involve revascularization
with the superficial temporal artery and vein and reinnerva­
tion with a cross-facial nerve graft are tedious and complex
and should be reserved for patients for whom simpler tech­
niques have been unsuccessful. Transplantation of the pla­
tysma may also produce some undesirable thickening of the
eyelids.
Historically, lateral tarsorrhaphy has been one of the main­
stay treatments for paralyzed eyelids. The McLaughlin lateral
tarsorrhaphy25 may provide a reasonably acceptable cosmetic
result. However, horizontal lid length is decreased, which
detracts from the aesthetic appeal and obstructs lateral vision.
This procedure consists of resection of a segment of lateral
skin, cilia, and orbicularis from the lower lid and a matching
segment of conjunctiva and tarsus from the upper lid. The
two raw surfaces are sutured together, preserving the upper
eyelashes. At present, the main indication for lateral tarsor­
rhaphy is for the patient with an anesthetic cornea, severe
corneal exposure, or failure of aesthetically more acceptable
techniques.

341
Treatment: nonsurgical and surgical
In patients with isolated medial ectropion that includes
punctal eversion, the lower lid can be repositioned against the
globe by direct excision of a tarsoconjunctival ellipse. This
causes a vertical shortening of the inner aspect of the lower
lid and helps reposition the punctum against the globe. Medial
canthoplasty will also support the punctum.
Nasal airway
Paralysis of the nasalis and levator alaeque nasi combined
with drooping and medial deviation of the paralyzed cheek
leads to support loss of the nostril, collapse of the ala, and
reduction of airflow. Nasal septal deviation, which occurs in
patients with congenital facial paralysis, may further accentu­
ate any breathing difficulties. In the patient who complains of
significant symptoms, correction of airway collapse is best
accomplished by elevation and lateral support of the alar base
with the sling of tendon and by upper lip and cheek elevation
procedures. Septoplasty may be indicated to provide an
improvement in airway patency.
Upper lip and cheek: smile reconstruction
The majority of patients with facial paralysis who present for
reconstruction do so for either correction of an asymmetric
face at rest or reconstruction of a smile. However, significant
functional problems are associated with paralysis of the oral
musculature, including drooling and speech difficulties. The
flaccid lip and cheek can also lead to difficulties with chewing
food, cheek biting, and pocketing food in the buccal sulcus
due to paralysis of the buccinator. However, the main empha­
sis of surgery is usually centered on reconstruction of a smile.
The surgeon and patient must have clearly defined goals.
Some patients only request symmetry at rest and are not
concerned about animation. For these patients, static slings
and soft-tissue repositioning can be most helpful. However,
most patients would prefer a dynamic reconstruction.
Nerve transfers: principles and current use
Dynamic reanimation attempts to restore symmetry both at
rest and while smiling. Three elements are required for the
formation of a smile: neural input, a functional muscle inner­
vated by the nerve, and proper muscle positioning. All three
factor into the decision as to which would be the best for any
given patient.
Reconstructive modalities for facial paralysis can be classi­
fied by two basic criteria. The first is whether reconstruction
is based on the facial nerve or on a different cranial nerve,28
and the second is whether the working muscle unit is the
original facial musculature or a transferred muscle flap.29
Reanimation based on the facial nerve can be on the ipsilateral
or contralateral nerve depending on the presence of a func­
tional and usable branch or stump. The duration of paralysis
is the principal determinant for the need for muscle transfer
or transplant. If duration is less than 12 months, the facial
musculature is assumed to be able to be reinnervated. Muscles
become irreversibly atrophic by 24 months, in which case
muscle replacement is indicated. The effect of the facial mus­
culature can be replaced by static procedures for balance or
by dynamic procedures for animation. The combination of
regional muscle transfer and static positioning procedure has
been recently described.30
stretching than the fascia lata. A 1.5-mm-wide strip of tendon
(a part of either palmaris or plantaris) is sutured to the lateral
orbital margin in the region above the zygomaticofrontal
suture and tunneled subcutaneously along the lid anterior to
the tarsal plate. Proper placement is crucial; too low a position
will exacerbate the ectropion. In the elderly patient with
particularly lax tissues, too superficial or high a placement
may result in entropion. The sling is then passed around the
anterior limb of the medial canthal ligament and sutured to
itself. Subcutaneous tunneling of the tendon graft is facilitated
by the use of a curved Keith needle. This procedure provides
good support to the lower lid. It does not deform the eyelid,
it is not apparent to an observer, and the effect appears to last
well. If the sling is placed too loosely, it may be tightened at
the lateral orbital margin.
Lateral examination of the eye and eyelid will determine
its vector.7 A negative vector occurs when the globe is anterior
to the lid margin and the lid margin is anterior to the check
prominence. In patients with a relatively proptotic eye, the
lower eyelid sling will correct ectropion, but it may not
decrease sclera show. In patients with a positive vector, in
which the globe is posterior to the lid margin and the lid
margin is posterior to the cheek prominence, the sling will be
effective. However, lateral fixation of the tendon graft may
need to be through a drill hole whereby the tendon is woven
back to itself and sutured, 2–3 mm posterior to the lateral
orbital margin, because fixation to the frontal periosteum may
lift the lateral eyelid away from the globe.
The authors have used the lower lid sling on 25 occasions,
and in combination with a gold weight to the upper lid, it
results in 95% improvement in symptoms (Fig. 13.13B). Two
patients have had complications from the lower lid sling
procedure, which required the sling to be tightened. One
patient required revision because the sling exacerbated the
ectropion, and one required epilation of some lower eyelashes
because of entropion. The lower lid tendon sling can be
adjusted fairly readily if it is not in the correct position up to
1 week after placement.
Milder eyelid problems consisting of lower lid laxity and
minimal scleral show may be treated with lateral canthoplasty.
Jelks et al.27 described various techniques of canthoplasty,
such as the tarsal strip, dermal pennant, and inferior retinacu­
lar lateral canthoplasty. The canthal ligament must be reap­
proximated to the position of Whitnall tubercle, which is
situated not only above the horizontal midpupillary line but
also 2–3 mm posterior to the lateral orbital margin.
Horizontal lid shortening may be required to deal with
redundant and stretched lower eyelid tissue. The Kuhnt–
Szymanowski procedure involves the excision of a laterally
placed triangular wedge of lower eyelid with its base being
the lower lid margin. It can be modified not only to excise a
wedge of tarsus and conjunctiva but also by resuspending the
lid margin from the lateral canthus. However, this tends to
distort and expose the caruncle and does not provide a lasting
correction.
Cartilage grafts to prop up the tarsal plate have also been
used. By augmenting the middle lamella and suturing the
cartilage to the inferior orbital margin, there will be less of a
tendency for the lower eyelid to migrate inferiorly. However,
results may be poor because the cartilage tends to rotate into
a more horizontal position rather than a vertical one, produc­
ing a visible bulge and minimal eyelid support.

342
SECTION II
CHAPTER 13 • Facial paralysis
side and result in a more natural appearance. Recently, several
innovative concepts have arisen and will be briefly outlined.
This preservation of facial musculature function can be pro­
vided by another cranial nerve such as the hypoglossal nerve
or portion of the trigeminal, such as the motor nerve to mas­
seter. This is done through a nerve transfer with coaptation of
the selected donor nerve to the facial nerve. The mass involve­
ment provided by this transfer may lead to an unnatural
appearing activation of the intact facial musculature, although
it may provide for adequate tone. To get around this, the
babysitter concept was proposed by Terzis.32,33 The alternate
motors preserve the facial musculature while awaiting appro­
priate, spontaneous, and synchronous innervations from a
cross face nerve graft. In this procedure, a cross face sural
nerve graft is used to relay facial nerve activity across the face
to the paralyzed musculature. Axons from the contralateral
normal facial nerve regenerate through the sheath of the graft
and innervate the muscle over 4 to 8 months. Since muscle
atrophy can develop while the facial nerve regenerates, an
ipsilateral motor nerve (either masseter or hypoglossal) can
be transposed to serve as temporary innervations or “babysit­
ting” (Fig. 13.15). Thus, muscle tone is preserved while
spontaneous smiling will in due course be restored. At the
first operation, two nerve grafts are connected to the upper
and lower trunks of the normal contralateral facial nerve and
tunneled across the face via the upper lip. These grafts are
banked on the paralyzed side. They are carefully labeled
(“upper”/“lower”) and placed in the temporal region to be
retrieved at a second stage. Then at this first operation, a short
nerve graft is used to connect the nerve to masseter or a part
of the hypoglossal nerve to the distal stump of the affected
facial nerve. Within 2–3 months, the paralyzed muscle will
regain tone and then will begin to function in a mass pattern
motion. This mass movement is then converted to softer, more
spontaneous movement through the second surgery. About
6–9 months after the initial procedure,34 the paralyzed side is
re-explored. The two cross face nerve grafts are identified,
split into fascicles, and coapted to the facial nerve branches
distal to the prior masseter-facial nerve repair. Within 3
months, spontaneous facial nerve motion is initiated by the
contralateral facial nerve (Fig. 13.16). With additional time,
Primary facial nerve repair is possible in cases of recent
trauma to the facial nerve.31 A sural cable nerve graft is used
to interconnect ends when there is a gap between the ipsilat­
eral proximal stump of facial nerve to the distal stumps of
zygomaticobuccal facial branches.
When the ipsilateral proximal facial nerve stump is not
usable (brain tumor, head trauma and fractures, Bell’s palsy,
or surgery) and the facial musculature has not become irre­
versibly atrophic and can be reinnervated, a nerve transfer
with or without nerve grafts can be very effective. This can
preserve the function of the musculature on the paralyzed
Fig. 13.15  Illustration of the “babysitter” procedure.
Masseter nerve
Cable graft
Paralyzed side
Normal side
Cross-face nerve graft
Ipsilateral facial
nerve stumps
Contralateral facial nerve
Fig. 13.16  (A) Preoperative photo prior to the “babysitter” procedure. (B) Closed-mouth smile after the “babysitter” procedure. (C) Open-mouth smile after the
“babysitter” procedure.
CA
B
C

343
Treatment: nonsurgical and surgical
also be achieved in a synchronous and spontaneous fashion
through cross face nerve grafting. With this technique, a sural
nerve graft is connected end to side on the normal side to
the upper branch of the facial nerve. It is tunneled across
the upper face with the aid of small eyebrow incisions and
then coapted end to end to the upper branch of the facial
nerve on the paralyzed side. This is done in one single pro­
cedure along with the masseter to lower facial nerve transfer
(Fig. 13.17).
A. Preoperative appearance at rest: Complete right facial
paralysis.
B. Preoperative appearance with attempted smile.
these grafts will take control over the transfer. However, if the
masseter nerve action is still noticeable and unwanted, the
masseter nerve can be transected.
A modification of this technique proposed by Marcus uti­
lizes the motor nerve to masseter to preserve function of the
lower face and periorbital region.35 To avoid the problem of
mass action with a nerve transfer, Klebuc has suggested that
the motor nerve to masseter be transferred to the buccal
branch only of the facial nerve. This is done with a direct end
to end coaptation.36
The upper face (i.e., orbicularis oculi function) can be either
reconstructed with static procedures or muscle transfers as
previously outlined in this chapter. Upper face function can
Fig. 13.17  (A) Preoperative appearance at rest: complete right facial paralysis. (B) Preoperative appearance with attempted smile. (C) Intraoperative – The motor nerve to
masseter (in vessel loop) is to be transected and coapted and directly to the lower buccal branch of the facial nerve (beneath the forceps). (D) Two years postoperatively at
rest with improvement in facial resting tone. (E) Two years postoperatively with smile and natural appearing nasolabial crease from the reinnervated facial musculature.
A
B
C
D
E

344
SECTION II
CHAPTER 13 • Facial paralysis
approach; however, for numerous reasons, they may not
necessarily provide the best results (Table 13.4). If the ipsilat­
eral facial nerve trunk is available, it seems to be an ideal
source of reinnervation for a muscle flap. However, the exact
branches to the lip elevators may be difficult to determine. If
incorrect innervation is used, muscle contraction may take
place only when the patient performs some facial movement
C. Intraoperative – motor nerve to masseter is transferred
to lower buccal branch of facial nerve.
D. 2 years postoperatively at rest with improvement in
facial resting tone.
E. 2 years postoperatively with smile and natural
appearing nasolabial crease from the reinnervated facial
musculature.
Microneurovascular muscle transplantation
It is not possible to restore complete symmetry of all move­
ments because of the complexity of muscle interaction and the
number of facial muscles involved. There are 18 separate
muscles of facial expression, and of these, five are elevators
of the upper lip and two are depressors of the lower lip. A
transplanted muscle can only be expected to produce one
function and movement in one direction.
If the facial nerve is used to reinnervate the transplanted
muscle, the smile with laughter will be spontaneous. When
other nerves are used (e.g., the fifth, 11th, or 12th), teeth
clenching or other movements are required to activate the
smile, at least initially. With time, the smile movement
will often become less of a conscious effort and more
spontaneous.
The patient’s suitability for free muscle transplantation
and reinnervation must be carefully assessed. This includes
an assessment of the patient’s ability to undergo a substantial
operative procedure with general anesthesia as well as an
evaluation of comorbidities that may affect the functioning
of microneurovascular muscle transplantation. The patient
should also be counseled with regard to the time that it could
take to achieve full movement, which is usually around 18
months. It is generally recognized that reinnervation does not
often occur in older individuals. However, it is difficult to
determine which patient should be classified as “older”
because muscle reinnervation can occur at any age. However,
it is the author’s practice to be reluctant to perform function­
ing muscle transplantations on patients who are older than 65
years.
Smile analysis
Preoperative planning is crucial. It is recognized that the
unopposed smile on the normal side in unilateral facial
paralysis will be an exaggerated expression of the same move­
ment after reconstruction of the paralyzed side. Therefore,
careful analysis of the patient’s smile on the non-paralyzed
side will instruct the surgeon in establishing a symmetric
smile. As Paletz et al.37 have shown, individuals have various
types of smiles. It is important to assess the direction of move­
ment of the commissure and upper lip. How vertical is the
movement? What is the strength of the smile and where
around the mouth is the force most strongly focused? What
is the position of the nasolabial fold with smiling? Is there a
labial mental fold? Once these features have been determined,
an estimate of the muscle’s size, point of origin, tension, direc­
tion of movement, and placement can be planned (Fig. 13.18).
Technique options
One-stage procedures for smile reconstruction with free
muscle transplantations would seem to be the most appealing
CA
Fig. 13.18  (A) Patient shown smiling. Note direction of movement of the
commissure and the mid upper lip on the normal left side, location of the fold in
the nasolabial area, and shape of the upper and lower lip. (B) The nasolabial folds
and directions of movement have been marked on the normal left side (N) and
copied on the paralyzed side (P). The desired position of the muscle is outlined by
two dotted lines across the cheek.
CB

345
Treatment: nonsurgical and surgical
Authors’ preferred method: two-stage
microneurovascular transplantation
Cross-facial nerve graft (Video 13.3 )
The first stage of this procedure involves a dissection of the
facial nerve on the unaffected side through a preauricular
incision with a submandibular extension (Fig. 13.19). The
zygomaticobuccal nerve branches medial to the parotid gland
are meticulously identified and individually stimulated with
a microbipolar electrical probe attached to a stimulator source
that allows variable voltage and frequency control (Fig. 13.20).
Disposable stimulators used to identify the presence of motor
nerves do not provide reliable, controlled tetanic muscle
contraction that will allow muscle palpation and clear visual
identification of which muscle is being stimulated. Facial
nerve mapping clearly identifies which nerve fibers stimulate
the orbicularis oris and oculi muscles as well as the lip
other than smiling, such as closing the eyes or puckering
the lips.
Single-stage muscle transplants with innervation from the
contralateral facial nerve have been reported. This technique
requires the use of a muscle with a long nerve segment, such
as the latissimus dorsi or rectus abdominis.38 However, even
the gracilis39 has been used. The nerve is tunneled across the
lip and coapted to the facial nerve branches on the opposite
side of the face. The advantages here are that the patient
undergoes only one operation and there is only one site of
coaptation for regenerating axons to cross. There does not
appear to be any significant denervation atrophy of the muscle
while it awaits reinnervation. However, although the muscle
may function with facial movement, it may not contract when
the patient smiles. This is because the facial nerve branches
used are close to the mouth and are usually found through a
nasolabial incision on the unaffected side. This approach does
not allow thorough facial nerve mapping to be performed;
thus, the most appropriate nerve branches may not be
recruited. Also, this approach does not allow an assessment
of what remaining branches have been left intact.
When there is neither an ipsilateral nor a contralateral
facial nerve available to act as a donor, as in Möbius syndrome
or other causes of bilateral facial paralysis, another cranial
nerve must be used to reinnervate the muscle transplant. It is
our practice to use the nerve to the masseter muscle.39 Zuker
et al.39 have shown that in children this provides a symmetric
smile with excellent muscle excursion. These patients may
never achieve involuntary movement or a truly spontaneous
smile. However, in many children and 50% of adults there
appears to be some cortical “rewiring” such that these people
are able to activate a smile without performing a biting motion
and without conscious effort.
In treatment of younger patients with unilateral facial
paralysis, we prefer to perform a two-stage reconstruction con­
sisting of facial nerve mapping and cross-facial nerve grafting,
followed by a microneurovascular muscle transplantation.
Fig. 13.19  The cross-facial nerve graft is inserted through a preauricular incision.
The parotid gland can be seen immediately in front of the left ear, and branches of
the facial nerve supplying the muscles of the mouth and eye are seen superficial to
the background material.
A
Fig. 13.20  (A) A portable electrical stimulator with variable voltage and frequency
control is put in a sterile plastic bag placed close to the operating site so the
surgeon can adjust the voltage as needed. (B) Bipolar electrical probe establishes
an electrical current between the electrodes and a localized stimulus to a small area
of tissue.
CB

346
SECTION II
CHAPTER 13 • Facial paralysis
retractors. When stimulated, the facial nerve branches that
produce a smile and no other movement are selected (Fig.
13.21). It is sometimes difficult to find “smile” branches that
do not contain some orbicularis oculi function. There are
usually between two and four nerve branches that do not
contain some orbicularis oculi function. There are usually
between two and four nerve branches that activate the zygo­
maticus and levator labii superioris. This allows one or two
branches to be used for the nerve graft coaptation while func­
tion of the normal facial muscles is preserved (Fig. 13.22).
The sural nerve is the usual donor nerve. This is harvested
with the use of a nerve stripper (Fig. 13.23). Stripping of the
nerve does not appear to affect its function as a graft.40
The proximal ends of the donor facial nerve branches are
sutured to the distal end of the nerve graft such that regener­
ating axons will travel in a distal to proximal direction down
the graft. The current practice is to use a short nerve graft,
approximately 10 cm in length, and to bank the free end in
the upper buccal sulcus. This should provide a well-innervated
graft. In addition, the waiting period between the first and
CA
Fig. 13.21  (A) Patient with left facial paralysis under anesthesia. Facial nerve
branches are prepared for functional nerve mapping of her right facial nerve.
(B) Stimulation of a branch of the facial nerve to the zygomaticus major, an ideal
branch for the coaptation to cross-facial nerve graft.
CB
Fig. 13.22  A functional nerve map is made of the branches of the facial nerve
supplying the eye and mouth. The map identifies the muscles that contract when
each branch is stimulated.
1a. Frontalis
1b. Proceris
1c. Orbicularis oculi
5b. Orbicularis oculi
6. Levator and Orbicularis oris
7. Levator and Orbicularis oris
8. Orbicularis oris
9. Orbicularis oris and Buccinator
Parotid duct
2. Orbicularis oculi
3. Orbicularis oculi
4. Orbicularis oculi
5a. Zygomaticus
Fig. 13.23  A nerve stripper is used to harvest a segment of sural nerve. Through
the posterior calf incision, the nerve is identified, dissected up to the popliteal, and
cut. It is put in the stripper and the stripper passed to the midcalf. A second
incision is made and the nerve is identified, cut, and withdrawn.
Table 13.5  Options for microneurovascular muscle
transplantation
One-stage
Muscle innervated by ipsilateral facial nerve (if
available)
Muscle with long nerve segment innervated by
contralateral seventh-nerve branches
Muscle innervated by masseter, hypoglossal, or
accessory nerve
Two-stage
Cross-facial nerve graft followed by the muscle
transplantation
second stages is reduced with use of a short cross-facial nerve
graft from 12 months to around 6 months. Patients who have
had short nerve grafts achieve stronger muscle contraction
than was previously obtained with traditional long cross-
facial nerve grafts (Table 13.5).

347
Treatment: nonsurgical and surgical
Table 13.6  Muscles available for microneurovascular
transplantation
Gracilis
Pectoralis minor
Rectus abdominis
Latissimus dorsi
Extensor carpi radialis brevis
Serratus anterior
Rectus femoris
Abductor hallucis
In addition to using a short nerve, one of the senior authors
has been using the proximal end of the sural nerve as the
cross-face nerve. The proximal segment from the popliteal
fossa to the midcalf is thin, lacks branches, and is an excellent
size match for both the selected branches of the seventh nerve
and the motor nerve to gracilis.
Gracilis muscle transplantation (Video 13.4 )
Many muscles are available for functioning muscle transplan­
tation for lower facial reconstruction (Table 13.6). The muscle
should be transplantable by vascular anastomoses and have
a suitable motor nerve for nerve coaptation to the face. Ini­
tially, surgeons attempted to find a muscle that was exactly
the right size for the face. However, a more suitable approach
is to pare down a muscle to the desired size before transplan­
tation.41 This concept allows the surgeon to use many different
muscles and to customize the muscle to fit the functional
requirements of the face. For example, a lightly structured
face with only a partial paralysis will require a small piece of
muscle. A large face with a strong movement of the mouth to
the normal side and a total paralysis will require a large piece
of muscle.
The gracilis muscle is suitable for facial paralysis recon­
struction. The neurovascular pedicle is reliable and relatively
easy to prepare. A segment of muscle can be cut to any desired
size based on the neurovascular pedicle. This allows the
surgeon to customize the muscle to the patient’s facial require­
ments. There is no functional loss in the leg. Because the scar
is in the medial aspect of the thigh, it is reasonably well
hidden. However, the scar usually does spread. The thigh is
far enough removed from the face that a simultaneous prepa­
ration of the muscle and the face is easily accomplished. The
gracilis is the preferred muscle for transplantation because the
anatomy is well known and the technique of preparing it for
transplantation is well described (Figs. 13.24–13.27).42
The muscle is usually split longitudinally, and the anterior
portion of the muscle is used. The amount of muscle that is
taken varies from 30% to 70% of the cross-section of the
muscle, depending on the muscle size and needs of the face.
The muscle can usually be split longitudinally without
concern; however, on occasion, the vascular pedicle enters in
the middle of the muscle on the deep surface. In this situation,
it may be necessary to remove a portion of the anterior part
of the muscle as well as the posterior to pare down the width
of the muscle. After facial measurements are taken, a piece of
muscle with a little extra length is removed. The end of the
muscle that is to be inserted into the face is oversewn with
CA
Fig. 13.24  (A) Preparation of gracilis muscle in right thigh. The motor nerve is
seen in the right upper corner of the dissection adjacent to the vascular pedicle.
(B) A longitudinal split of the anterior half of the gracilis muscle.
CB
mattress sutures, placing one more than the number of sutures
inserted about the lips.
Attaching the muscle to the mouth is a critical part of the
procedure (Fig. 13.27). It is usually inserted into the fibers of
the paralyzed orbicularis oris above and below the commis­
sure and along the upper lip (Fig. 13.28A,B). Preoperative
smile analysis determines the points of insertion. The preop­
erative smile analysis is also crucial for determining the origin
of the muscle, which may be attached to the zygomatic body,
arch, temporal fascia, or preauricular fascia. Intraoperative
traction on the obicularis oris while the movement of the
mouth is observed will verify the correct placement of the
sutures. The correct tension is difficult to determine because
the mechanical tension within the muscle, the degree of tone
that the muscle develops, and the gravitational and muscle
forces within the face will influence the eventual position
(Fig. 13.28C).
The vascular pedicle is usually anastomosed to the facial
vessels; however, the facial vein may occasionally be absent.

348
SECTION II
CHAPTER 13 • Facial paralysis
There is invariably a large transverse facial vein that may be
used instead. The superficial temporal vessels may also be
used. The gracilis is positioned so that its hilum is close to the
mouth and the motor nerve can be tunneled into the upper
lip. The upper buccal sulcus incision is reopened, and the free
end of the nerve graft is identified and coapted to the gracilis
muscle motor nerve.
Movement does not usually occur until 6 months or more
have elapsed, and maximal movement is usually gained by
18 months. At this stage, an assessment is made of the resting
tension in the muscle and its excursion with smiling. It is not
uncommon for the patient to require a third procedure to
adjust the muscle (i.e., either tightening or loosening), and this
can be combined with other touch-up procedures such as
debulking or an adjustment of the insertion of origin.
With this procedure, patients usually gain around 50%
as much movement on the paralyzed side as on the
A
Fig. 13.27  (A) The muscle is placed in the face and revascularized by vascular
anastomosis to the facial artery and the vein. Nerve coaptation to the cross-facial
nerve graft is accomplished. The muscle is attached about the mouth and to the
preauricular and superficial temporal fascia. (B) Insertion into the paralyzed
orbicularis oris is accomplished with figure-of-eight sutures placed through the
orbicularis oris and behind the mattress sutures at the end of the muscle. This
ensures strong muscle fixation to the mouth, which should prevent dehiscence.
B
A
Fig. 13.25  (A) After removal of the segment of gracilis muscle, the motor nerve
can be seen to the lower left and the pedicle inferiorly. The right-hand side
demonstrates the distal end of the muscle, which has been oversewn with multiple
mattress sutures. (B) Marked muscle shortening is possible in the gracilis muscle
with motor stimulation.
B
Fig. 13.26  The muscle has been removed and placed on the face to demonstrate
its approximate position. The muscle’s motor nerve is placed across the cheek in
the position for coaptation to the cross-facial nerve graft in the upper buccal sulcus.

349
Treatment: nonsurgical and surgical
CA
CB
Fig. 13.28  (A) Anchoring sutures have been placed in the oral commissure and upper lip. The sutures can be seen at the top of the photograph. There is just enough
traction to bring the commissure to an even position with the normal commissure on the right. (B) Traction is being placed on the anchoring sutures to the oral commissure
and upper lip. A simulation of the smile that will occur can be seen. Our goal is to make this activity as close as possible to the normal side in vector and location of
nasolabial crease formation. (C) The muscle is being inserted into the commissure and upper lip. The anchoring sutures are being placed behind the line of mattress
sutures in the muscle so as to anchor the muscle securely and avoid any postsurgical drift of the insertion. (D) The muscle has been secured to the oral commissure and
upper lip, revascularized, and reinnervated. It is now placed under the appropriate tension and secured to the fascia in the temporal and preauricular region. The muscle is
pulled out to length, and just enough tension to barely move the oral commissure is affected. With this, the location of the anchoring sutures to the temporal and
preauricular fascia can be determined. The muscle is then secured in position, the wound thoroughly irrigated, and the flap closed over a Penrose drain.
CC
CD
non-paralyzed side. This provides them with an excellent
resting position and a pleasing smile that is totally
spontaneous.
Muscle transplantation in the absence of
seventh-nerve input
The concept of muscle transplantation in the absence of
seventh-nerve input can be applied to bilateral facial paralysis
and Möbius syndrome. An effective motor nerve must be
used to power the muscle. The use of the 11th and 12th nerve
has been described, but preference is now given to the motor
nerve to the masseter. This is a branch of the trigeminal (fifth
nerve) and as such is almost always normal in patients who
have bilateral facial paralysis, including Möbius syndrome.
The nerve courses downward and anteriorly from the
superoposterior border of the masseter in an oblique fashion.
The nerve is always on the undersurface of the masseter
muscle and enters this surface of the muscle belly approxi­
mately 2 cm below the zygomatic arch. The nerve courses
through the muscle, giving off a variety of branches. Thus, the
nerve can be traced distally, divided, and reflected proximally
and superiorly to be in a position suitable for neural coapta­
tion. The muscle transplant procedure is done much the same
as described in the section on unilateral facial paralysis.
The origin and the insertion are the same, as is the revas­
cularization process. The motor nerve to the transplanted
muscle (segmented gracilis) is coapted to the motor nerve of
the masseter. There is a remarkable similarity in size, and
excellent reinnervation can be achieved. In fact, Bae et al.43
have shown for patients with Möbius syndrome that the oral
commissure movement accomplished by a gracilis transplant

350
SECTION II
CHAPTER 13 • Facial paralysis
Patients with Möbius syndrome are excellent candidates
for this form of surgery as usually they have limited or no
seventh-nerve activity and normal fifth-nerve activity so their
masseter muscles are normal. We prefer to do each side sepa­
rately, spaced at least 2 months apart. The excursion of the
muscle and resultant animation has been very satisfying.
Innervation of the segmental gracilis muscle transplant by the
motor nerve to masseter is now the preferred reconstruction
for these patients. It has proved to be extremely effective in
helping improve lower lip incompetence and drooling as well
as speech irregularities, especially those requiring bilabial
sound production. Most importantly, however, it is effective
in providing the patient with an acceptable level of smile
animation that is not possible with other techniques (Figs.
13.29 & 13.30).
Regional muscle transfer
Patients who are not suitable candidates for free muscle
transplantation may be candidates for regional muscle trans­
fer. These techniques, which have been in use for many
innervated by the masseter motor nerve comes within 2 mm
of normal movement. There is approximately 15 mm of move­
ment normally achieved at the oral commissure. With gracilis
muscle transplantation innervated by the motor nerve to mas­
seter, commissure movement of 13.8 mm on one side and 14.6
on the other side was achieved in 32 patients. With a cross-
face nerve in a similar group of patients, only 7.9 mm of
commissure movement was noted. The benefit of the cross-
facial nerve graft, of course, is that it provides for spontaneity
of activity, whereas the motor nerve to masseter does not and
initially requires conscious activity. With a muscle that is
innervated with cross-facial nerve graft, the patient develops
spontaneous expression because the muscle is controlled by
the facial nerve on the normal side. However, when the mas­
seter motor nerve is used, the smile movement must be
learned as part of a conscious effort. Many patients are able
to animate their face after some practice and biofeedback
without moving their jaws and even without conscious effort.
This is an area that is undergoing further study, but we feel
that there is a significant role for rehabilitative services after
the muscles begin to contract.
Fig. 13.29  (A) Preoperative view of child with congenital facial paralysis at rest. Note slight droop on affected side and shift of upper lip to normal side. (B) With smile.
Note slight tension on affected side but no elevation. (C) Intraoperative view following cross-face nerve as segmental gracilis microneurovascular transport lies on check.
Note vascular pedicle to be anastomosed to facial vessels and motor nerve to be coapted to cross-face nerve graft in upper buccal sulcus. (D) Intraoperative view.
Microneurovascular transplant has been fixed at both ends, revascularized to the facial vessels, and reinnervated with previously placed cross-face nerve graft.
(E) Postoperative view following cross-face nerve graft and microneurovascular muscle transplantation at rest. Note reasonable symmetry with no excess bulk. (F) With
moderate smile. Note reasonable active movement with good commissure elevation and minimal bulk. (G) With full forced smile. Note good excursion and nice nasolabial
crease formation.
A
B
C
D
E
F
G

351
Treatment: nonsurgical and surgical
transfer is the bulge of the muscle present where it passes
over the arch of the zygoma. To avoid these complications,
McLaughlin25 described an antegrade temporalis transfer.
Through an intraoral, scalp, or nasolabial incision, the tempo­
ralis muscle is detached from the coronoid process of mandible
and brought forward. Fascial grafts are used to reach the angle
of the mouth.
Labbe and Huault modified this procedure to create a true
myoplasty with a mobile insertion and fixed origin and
without the use of fascial grafts.45 A further recent modifica­
tion avoids undermining the anterior part of the temporalis
muscle, thus simplifying the procedure and ensuring an
enhanced blood supply. The coronoid is now osteotomized
through the nasolabial incision, avoiding the transverse inci­
sion parallel to the zygoma arch and the osteotomy of the
zygoma.46 One of the key differences is that the temporalis
decades, involve the transfer of either the temporalis or mas­
seter muscle or both. Because these muscles are innervated by
the trigeminal nerve to activate a smile, patients must initially
clench the teeth. With practice they can activate the muscle
without moving their jaws, and some patients may achieve a
degree of spontaneity.
The retrograde or turnover temporalis muscle transfer, as
described by Gillies,23 involves detaching the origin of the
muscle from the temporal fossa and turning it over the zygo­
matic arch to extend to the oral commissure. Frequently, a
fascial graft is required to achieve the necessary length to
reach the mouth. This leaves a significant hollowing in the
temporal region that can be filled with an implant. Baker and
Conley44 recommend leaving the anterior portion of the
temporalis behind to partially camouflage the temporal hol­
lowing. Another aesthetic disadvantage of the temporalis
Fig. 13.30  (A) Preoperative view of child with Möbius
syndrome at rest. (B) With attempted smile.
Commissures actually turn down, giving a grimace
appearance. (C) Postoperative view following
segmental free gracilis microneurovascular muscle
transplantation innervated by the motor nerve to
masseter at rest. Note static support of oral
commissures. (D) With small controlled smile. Note
even elevation and tightening of oral commissures.
(E) With full smile. Note fairly symmetrical
commissure movement with nasolabial crease
formation.
A
B
C
D
E

352
SECTION II
CHAPTER 13 • Facial paralysis
can be made of fascia (tensor fascia latae), tendon, or pros­
thetic material such as Gore-Tex®. In our experience, Gore-Tex®
produces an undesirable inflammatory reaction. When fascia
lata is taken from the thigh, it is preferable to repair the donor
defect or an uncomfortable and unsightly muscle hernia may
develop. The authors’ preference, however, is to use tendon
(palmaris longus, plantaris, or extensor digitorum longus)
(Fig. 13.32). Tendon can easily be harvested and woven
through tissues. Curved, pointed forceps are useful for insert­
ing the tendon through the tissues of the oral commissure and
upper lip and the temporalis and zygomatic fascia. Exposure
can be through a nasolabial combined with a preauricular
approach or a preauricular approach alone.
When tension is applied to the grafts, the force should be
distributed evenly around the mouth with a little overcorrec­
tion. This is done to compensate for the difference in facial
tone when the patient is awake and for postoperative stretch­
ing. The graft is then attached to the temporal fascia or to the
zygoma, depending on the desired direction of pull. Multiple
grafts should be inserted, usually three, to provide an even
lift to the corner of the mouth and upper lip (Fig. 13.30). It is
important to position the sling properly to achieve the correct
elevation with regard to the upper lip and corner of the mouth
(Fig. 13.33). It is possible to insert the static sling too tightly,
particularly in the upper lip, which establishes a corridor
through which air and liquid can escape.
Soft-tissue rebalancing
Soft-tissue procedures are useful adjuncts to both dynamic
and static management. These procedures involve suspension
and repositioning of the lax structures. This will include
rhytidectomy with or without plication or suspension of the
superficial musculoaponeurotic system; midface subperios­
teal lifts may also be beneficial. Procedures on the nasolabial
fold usually do not help define this important structure.
Asymmetry of the upper lips may be corrected by mucosal
excisions. These procedures, which may be minor, will often
be of great benefit to patients.
insertion is tunneled through the buccal fat pad, thus aiding
tendon gliding and consequently commissure excursion. It
may be a good alternative in the older patient or when a
muscle transplant is not possible.
The masseter muscle transplantation as described by Baker
and Conley44 involves transplanting the entire muscle or the
anterior portion from its insertion on the mandible and insert­
ing it around the mouth. Rubin47 recommends separating the
most anterior half of the muscle only and transposing it to
the upper and lower lip. During the splitting dissection, the
surgeon must be cautious not to injure the masseteric nerve,
which enters the muscle on the deep surface superior to its
midpoint.
Good static control of the mouth can be achieved with the
masseter transplantations; however, it lacks sufficient force
and excursion to produce a full smile, and the movement
produced is too horizontal for most faces. Patients frequently
have a hollow over the angle of the mandible.
Rubin47 has advocated transplanting the temporalis and
masseter muscles together (Fig. 13.31). The temporalis pro­
vides motion to the upper lip and nasolabial fold; the masseter
provides support to the corner of the mouth and lower lip.
Static slings
Static slings are used to achieve symmetry at rest without
providing animation. They can be used alone or as an adjunct
to dynamic procedures to provide immediate support. The
goal is to produce a facial position equal to or slightly overcor­
rected from the resting position on the normal side. The slings
Fig. 13.31  Transplantation of both the temporalis and a portion of the masseter
muscle to the periorbital region.
Fig. 13.32  Static slings of plantaris tendon in place to support the mouth and
cheek.

353
Treatment: nonsurgical and surgical
depressor labii inferioris, depressor anguli oris, mentalis, and
portions of the lower lip orbicularis oris. The orbicularis oris
also receives innervation from buccal branches and the
contralateral marginal mandibular nerves. The muscle func­
tion that is missed most by the patient is that of the depressor
labii inferioris. Paralysis of this muscle results in the inability
to depress, lateralize, and evert the lower lip. In the normal
resting position, the deformity is not usually noticeable, as the
lips are closed and the depressors are relaxed. However, when
the patient is talking, the paralyzed side is able to move
inferiorly and away from the teeth. The deformity is most
accentuated when the patient attempts a full smile, showing
his or her teeth.
Problems with speech and eating may occur, but most
patients are concerned primarily with the asymmetric appear­
ance of the lower lip during speech and smiling. The inability
to express rage and sorrow, which require a symmetric lower-
lip depression, is also of concern.
Many techniques have been described for the correction of
marginal mandibular nerve palsy, including operating on the
affected side to try to animate it or operating on the unaffected
side to minimize its function. Puckett et al.48 described a
technique of excising a wedge of skin and muscle but preserv­
ing orbicularis oris on the unaffected side. Glenn and Goode49
described a full-thickness wedge resection of the paralyzed
side of the lower lip. Edgerton50 described transplantation of
the anterior belly of the digastric muscle. The insertion of the
digastric muscle to the mandible on the paralyzed side is
divided and attached to a fascia lata graft that is then secured
to the mucocutaneous border of the involved lip. Conley
et al.51 modified this technique by leaving the mandibular
insertion intact but divided the tendon to the lateral aspect of
the lower lip. As branches of the nerve to mylohyoid innervate
the anterior belly of the digastrics, activation of the muscle
requires a movement other than smiling. This is difficult to
coordinate for most patients, and the result is that the digastric
transplantation tends to act more as a passive restraint on the
lower lip rather than as an active depressor. Terzis and Kalan­
tarin6 have further modified the digastric transplantation by
combining it with a cross-facial nerve graft coapted to a
marginal mandibular nerve branch on the unaffected side,
thereby allowing the possibility of spontaneous activation
with smiling.
In patients in whom the facial paralysis is less than 24
months in duration and there is evidence of remaining depres­
sor muscle after needle electromyography, Terzis recommends
mini hypoglossal nerve transplantation to the cervicofacial
branch of the facial nerve. This involves division of the cervi­
cofacial branch proximally and coaptation of the distal stump
to a partially transected (20–30%) hypoglossal nerve. In
patients with long-standing paralysis with a functional ipsi­
lateral platysma muscle (i.e., an intact cervical division of the
facial nerve), Terzis suggests transplantation of the platysma
muscle to the lower lip.
The approach to depressor muscle paralysis has been to
achieve symmetry both at rest and with expression by per­
forming a selective myectomy of the depressor labii inferioris
of the non-paralyzed side. This was first reported by Curtin
et al.52 in 1960 and later by Rubin,47 although details of their
techniques are not provided. The depressor resection can be
performed as an outpatient procedure under local anesthetic
and can be preceded by an injection of either long-acting local
Lower lip
The lower lip deformity caused by marginal mandibular
nerve palsy may be part of a generalized facial paralysis or
may occur in isolation as a congenital defect or secondary to
trauma or surgery. It is a particular risk during rhytidectomy
or parotid and upper neck surgery. The marginal mandibular
nerve consists of one to three branches and supplies the
CA
Fig. 13.33  (A) Preoperative view of an older patient at rest with marked facial
asymmetry. Previous surgery elsewhere had placed a visible scar in the left
nasolabial area. (B) Improvement in facial symmetry after insertion of static slings
to the mouth.
CB

354
SECTION II
CHAPTER 13 • Facial paralysis
is identified; it is partly hidden by the orbicularis oris, whose
fibers must be elevated to reveal the more vertically and
obliquely oriented fibers of the depressor labii inferioris,
which measures approximately 1 cm in width. Care must be
taken to preserve the branches of the mental nerve during the
dissection (Fig. 13.3). Once the muscle has been identified,
the central portion of the muscle belly is resected. Simple
myotomy will not produce long-standing results, whereas
results from myectomy have been permanent.
The authors have performed depressor labii inferioris
resections on 27 patients, and these were reviewed with a
follow-up questionnaire. Of these patients, 77% stated that
their lower lip was more symmetric with smiling; half of these
patients thought that their smile had changed from being
significantly asymmetric to completely symmetric. Before the
muscle resection, 53% of the patients were concerned about
lower lip asymmetry in expressing other emotions, such as
sorrow or anger. After the muscle resection, 80% of patients
now thought that having a symmetric lower lip in expressing
other emotions was more acceptable. Speech was unchanged
in 73% of patients and improved in 27% after depressor labii
inferioris resection. Some authors have suggested that depres­
sor muscle resection will result in a deterioration of oral
continence. However, in our series, 89% of patients stated that
oral continence was either unchanged or improved. Three
patients reported a slight increase in drooling after depressor
labii inferioris resection.
Postoperative care
The postoperative care of all patients must be individualized
as to their general medical health and postanesthetic manage­
ment. However, some generalizations can be made relative to
specific procedures. Following muscle transplantation, it is
important to maintain an adequate circulating blood volume,
guarded mobilization to prevent hypotension, appropriate
pain control, and perioperative antibiotics. We prefer to
restrict nicotine and caffeine for 6 weeks as we feel they may
cause vasoconstriction and increase the risk of vessel throm­
bosis. In Table 13.7, a typical postoperative order set is outlined
following muscle transplantation to the face.
anesthetic or botulinum toxin into the depressor labii inferi­
oris. This injection allows the patient a chance to decide
whether to proceed with the muscle resection based on the
loss of function of the depressor. As a result of this operation,
the shape of the smile is altered on the normal side, and the
lower lip is now symmetric with the opposite side (Fig. 13.34).
The depressor labii inferioris is marked preoperatively by
asking the patient to show the teeth and palpating over the
lower lip. The muscle can be felt as a band passing from
the lateral aspect of the lower lip inferiorly and laterally to the
chin. Through an intraoral buccal sulcus incision, the muscle
Table 13.7  Postoperative regimen following muscle
transplantation
Fluids to soft diet as tolerated
Bed rest day 1 then up in chair with assistance and gradual
guarded ambulation
Cefazolin in appropriate age-related dosage for 3 doses
Morphine PRN for 48 h
Tylenol scheduled maximum dose for 3 days
No nicotine for 6 weeks
No caffeine for 6 weeks
No pressure on surgical site
Restrict sports or rough activities that may lead to trauma on
surgical site for 6 weeks
After muscle begins to function, active exercises may be helpful
with biofeedback to increase excursion, achieve symmetry, and
facilitate spontaneity
CA
Fig. 13.34  Patient showing a “full dental” smile before depressor resection (A)
and after depressor resection (B), with marked improvement in symmetry of the
lower lip.
CB

355
Further considerations
by using a tendon graft to connect the displaced muscle to the
oral commissure and upper lip. If the muscle is too tight, it
can be released at its origin and slid toward the mouth.
However, this may require a radical freeing of the muscle and
put the neuromuscular pedicle at risk. If the vector is incor­
rect, it can be repositioned but only with great difficulty and
again with significant risk to the pedicle. Whenever the posi­
tion of the muscle is adjusted, one can expect a reduction in
excursion. However, this may be a reasonable price to pay to
correct the distortions imposed by poorly positioned muscle.
Excess bulk at the side of the transferred or transplanted
muscle can be addressed by defatting and shaving of the outer
surface of the muscle. To facilitate this, it is helpful to position
the motor nerve on the deep surface of the muscle at the time
of the muscle transplantation. This is particularly true when
a cross-face nerve graft is used.
When the problem is poor excursion, the options are few.
It may help to tighten the muscle if it has been inserted too
loosely but care must be taken not to distort the mouth.
If this is not possible, then a thorough open discussion with
the patient is required. Is there sufficient support or move­
ment to alleviate the functional problems and position the
mouth evenly at rest? How much movement with muscle
activation is present? Is the patient content with the present
situation, in view of the fact that improvement will not be easy
or perhaps even possible?
If further surgery is requested after a full discussion and
knowledge that improvement will be difficult, one must redo
with transplantation of a second muscle. If the cause of the
failure is not clear, it may be wise to use a motor nerve to
power the new muscle that was not used before. This may be
the motor nerve to masseter in the case of a failed cross-face
nerve graft, muscle transplantation combination. The results
of putting a muscle into scarred bed, and reusing the previous
vessels and possibly nerve, will not be as likely for success as
the primary procedure, but yet may be very helpful for
selected patients.
Further considerations
Facial paralysis crosses many subspecialty lines. Limited eye
closure, tear transport, and ectropion dictate the involvement
of ophthalmologists as well as oculoplastic surgeons. Intra­
nasal airflow may be limited and symptomatic, necessitating
involvement of nasal surgeons often with otolaryngology
background. Otolaryngologists may also be consulted for
associated hearing loss, stapedial malfunction, or other
components involving the middle ear. In certain patients,
brainstem involvement may cause difficulty in dealing with
oral secretions, aspirations, and swallowing. This may occur
congenitally, such as in patients with Möbius syndrome,
or it may be acquired, such as in patients with intracranial
tumors. These situations may require the involvement of
otolaryngologists.
There are other functional issues that may need to be
addressed by subspecialists. For example, feeding may be a
problem for infant or adult patients. Feeding experts from
occupational therapy may be helpful in providing techniques
for mechanical assistance. After surgical intervention, occupa­
tional therapy is also helpful in assisting with an exercise
program to improve muscle excursion and symmetry of smile.
Outcomes, prognosis, and
complications
As in all aspects of surgical intervention, the surgeon and
patient must consider the risk-to-benefit ratio. In facial paraly­
sis reconstruction, we cannot completely replicate normality.
However, we can improve the functional limitations imposed
by the lack of corneal protection, the lack of oral competence
with consequence leading to drooling, speech problems, and
facial expression. Facial asymmetry can also lead to significant
psychosocial problems. When the effects are subtle, however,
one must weigh the benefits to be obtained, and this is often
a function of how severe the paralysis is perceived by the
patient and an assessment of this impact on the patient’s
general well-being. In the study by Bae et al.,43 it was found
that the average commissure movement following cross-face
nerve graft and muscle transplantation was about 75% of the
normal side (12 versus 15 mm). Thus, if an individual has
7–8 mm of movement, the two complex procedures would
only potentially increase movement by 4–5 mm if all went
well. This improvement may be worthwhile in some individu­
als but not in others. Each case must be assessed individually.
The potential complications are numerous but fortunately
not very common. The early complications are bleeding,
infection, and vascular compromise in a muscle transfer or
transplant. The late complications are more common and
much more difficult to deal with. They include firstly incorrect
muscle positioning. This relates to the insertion at the oral
commissure and upper lip which must be accurate and per­
manent, as previously outlined. The origin needs to be accu­
rately placed, spread out to reduce bulk, and lead to the
correct vector of the muscle being created. Secondly, great care
needs to be taken to reduce bulk at the side of muscle place­
ment. This will involve the use of only a small strip of muscle
(5–15 g in a 5-year-old child and up to 15–25 g in an adult).
In addition, the muscle should be spread out at its origin. The
removal of the buccal fat pad and a segment of the deep fat
that will overlie the newly placed muscle may also aid in
lessening the likelihood of excess bulk. Thirdly, the excursion
of either a transferred muscle or transplanted muscle may not
meet the expectations of the surgeon or the patient and be
quite disappointing. We feel that excursion is related to the
power of the motor nerve utilized and to the physical place­
ment of the muscle as it must be under the appropriate tension
to maximize excursion. A poorly functioning muscle may also
be related to the vascularity of the muscle or the effects of a
single or double nerve repair, although it may be related to a
combination of the above factors. Unfortunately, these insuf­
ficient excursion problems are not easy to correct and will be
addressed in the next section.
Secondary procedures
Secondary procedures following muscle transfer or transplant
are often palliative and not curative. The problems can be
listed as incorrect muscle positioning, excess bulk at the side
of the muscle, and poor excursion.
Muscle slippage at the insertion side is the most difficult to
correct. Open reinsertion can be done but may leave the com­
missure too tight and the mouth distorted. This can be avoided

356
SECTION II
CHAPTER 13 • Facial paralysis
facial nerve development. Consequently, there are no genetic
implications. Parents have no predisposition for additional
children with facial paralysis, nor does the patient have any
greater increased likelihood of having a child with facial
paralysis than that of the general population. The same can
be said for patients with unilateral syndrome, which occurs
with hemifacial microsomia, for example. This is thought to
be acquired at an early stage of fetal development because
of environmental factors. Thus, again, there are no genetic
implications. The same is not true, however, for all patients
with Möbius syndrome. Although most are thought to be
sporadic, there has been a surge of interest in the genetics
of the conditions.53 Pedigrees have been described indicat­
ing that certain forms of Möbius syndrome are inherited
by an autosomal-dominant gene with variable expressivity
(Fig. 13.35).
Speech is often affected by facial paralysis. Speech therapy can
help improve articulation errors and provide appropriate lip
placement.
The psychosocial aspects of facial paralysis are enormous.
Surgeons tend to focus on the physical, but it is extremely
important to keep the entire patient in mind. A battery of
psychosocial support personnel should be available to work
with the surgeon for the overall benefit of the patient. This
team should include social workers, clinical psychologists,
developmental psychologists, and psychologists. It is impor­
tant to sort out the various needs of the patient, not just from
a physical standpoint but also from a psychosocial stand­
point. Only then can true success in surgical management be
achieved. A majority of patients with congenital facial paral­
ysis have unilateral and isolated involvement. It is believed
to be the result of a compression of the fetal face that limits
A
B
C
Fig. 13.35  (A,B) Preoperative views of a patient with
Möbius syndrome at rest and with maximum
animation. (C) Postoperative view of a patient after
muscle transplantation to the lower face at rest.
(D) Patient with closed-mouth smile. (E) Patient
smiling and showing teeth.
D
E

357
Conclusions
have been made in these areas, but asymmetry continues to
be a challenge. Further attention needs to be drawn to the
direction of the smile and the positioning of the muscle rela­
tive to the oral commissure and nasolabial crease.
Fundamental to progress in any field is an assessment tool
that is reliable, universally acceptable, and as simple as pos­
sible to use. In facial paralysis, it is necessary to measure
muscle excursion, direction of movement, volume symme­
tries, and contour irregularities to assess the results of repair
and reconstruction. For comparison of results from center to
center, a common tool is needed. Also, to assess results from
a psychosocial standpoint, a reliable common instrument of
evaluation is needed if meaningful conclusions are to be
drawn. Progress has been made on physical measurement
and psychosocial profile tools,56 and there is hope that these
will be universally accepted and applied in the future.
In addition to these technical issues, concepts need to evolve
with respect to new areas of development. Eye expression is
an area that has not as yet been directed at commissure and
upper lip elevation. Orbicularis oris function or reconstruc­
tion of the depressors has not been addressed. Finally, there
is not as yet an effective method of managing synkinesis. This
is an extremely disturbing phenomenon with psychosocial
and functional implications. We are just beginning to see how
Botox injection techniques can be effective in other areas of
muscle overactivity, and perhaps some level of synkinesis
control will evolve with this technique. Much is yet to be done
for the patient with facial paralysis, and further research and
development in this area will continue to yield improvements.
In summary, facial paralysis reconstruction continues to be
an exciting evolving area of surgical development.
Incomplete penetration is also thought to account for the
inconsistency of involvement. Certain chromosomes have
also been identified in specific patients,54 and a reciprocal
translocation between the long arm of chromosome 13 and the
short arm of chromosome 1 has been described.55 A great deal
of interest has been stimulated relative to the genetic aspects
of Möbius syndrome and its relationship to other behavioral
conditions.55,56 Research is under way in these areas and will
undoubtedly shed light on inheritance features as well as the
etiologic factors involved in Möbius syndrome.
Conclusions
Although significant progress has been made in the manage­
ment of facial paralysis, much is yet to be done. Acceptable
commissure movement can be achieved, but upper lip eleva­
tion is far more difficult. The short distance of the muscle
involved and the challenging access have proved difficult to
overcome. However, new techniques are emerging, and work
in this area continues.
Across any nerve repair, there is considerable loss of axonal
continuity. Improved nerve coaptation techniques with the
use of neurotrophic factors will undoubtedly be instrumental
in providing further improvement. From a physical stand­
point, does the length of the nerve graft affect recovery? Does
its vascular nature or the technique of harvest result in altera­
tion of function? Laboratory research in these areas is ongoing
and could again provide some level of improvement in recov­
ery. The placement, anchorage, and direction of movement of
the muscle transplant are critical to success. Improvements
9. Rubin L, ed. The Paralyzed Face. St. Louis: Mosby-Year Book; 1991.
This is a classic text on facial expressions and how to produce them
surgically.
14. Westin LM, Zuker RM. A new classification system for facial
paralysis in the clinical setting. J Craniofac Surg. 2003;14:672–679.
This classification of facial paralysis was created as an aid to the clinician
in understanding the breadth of this diverse condition.
16. May M. Microanatomy and pathophysiology of the facial nerve. In:
May M, ed. The Facial Nerve. New York: Thieme; 1986:63. This classic
text is a must for all students of facial paralysis.
26. Carraway JH, Manktelow RT. Static sling reconstruction of the
lower eyelid. Operative Techniques Plast Reconstr Surg. 1999;6:163.
Eyelid surgery must be precise and well executed to be successful.
28. Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in
adults with free muscle transfer innervated by the masseter motor
nerve: effectiveness and cerebral adaptation. Plast Reconstr Surg.
2006;118:885–899. In this paper, evidence is presented to suggest cerebral
adaptation is a real entity in the adult population.
30. Michaelidou M, Chieh-Han J, Gerber H, et al. The combination of
muscle transpositions and static procedures for reconstruction in
the paralyzed face of the patient with limited life expectancy on
who is not a candidate for free muscle transfer. Plast Reconstr Surg.
2009;123:121–129. This is an excellent article that provides the surgeon
with practical alternatives to complex microsurgical procedures.
33. Terzis JK, Tzafetta K. The “babysitter” procedure: minihypoglossal
to facial nerve transfer and cross-facial nerve grafting. Plast Reconstr
Surg. 2009;123:865–876. This is the first article to resurrect the nerve
transfer principle for facial paralysis. Use of the entire hypoglossal had
serious and permanent negative effects on speech, food manipulation, and
tongue bulk.
39. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in
children with Möbius syndrome after segmental gracilis muscle
transplant. Plast Reconstr Surg. 2000;106:1. This article describes the
problems of the Möbius syndrome from a reconstructive surgeon’s
viewpoint and suggests a surgical procedure for function and animation.
43. Bae Y, Zuker RM, Mantelow RM, et al. A comparison of
commissure excursion following gracilis muscle transplantation for
facial paralysis using a cross-face nerve graft versus the motor
nerve to the masseter nerve. Plast Reconstr Surg. 2006;117:2407–2413.
In this paper the strong input of the masseter motor nerve is shown to
translate into increased commissure excursion.
45. Labbe D, Huault M. Lengthening temporalis myoplasty and lip
reanimation. Plast Reconstr Surg. 2000;105:1289–1297. This is an
excellent article that provides the surgeon with practical alternatives to
complex microsurgical procedures.
Access the complete references list online at

357.e1
References
References
1. Davis RA, Anson BJ, Budinger JM, et al. Surgical anatomy of the
facial nerve and parotid gland based upon a study of 350 cervico-
facial halves. Surg Gynecol Obstet. 1956;102:385.
2. Ishikawa Y. An anatomical study of the distribution of the temporal
branch of the facial nerve. J Craniomaxillofac Surg. 1990;18:287.
3. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the
mimic muscle system and the facial nerve: importance for
reconstructive and aesthetic surgery. Plast Reconstr Surg.
1987;80:686.
4. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy:
anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64:
781.
5. Nelson DW, Gingrass RP. Anatomy of the mandibular branches of
the facial nerve. Plast Reconstr Surg. 1979;64:479.
6. Terzis JK, Kalantarin B. Microsurgical strategies in 74 patients for
restoration of dynamic depressor muscle mechanism: a neglected
target in facial reanimation. Plast Reconstr Surg. 2000;105:1917.
7. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty
patient. Clin Plast Surg. 1993;20:213.
8. Zide BM, McCarthy J. The mentalis muscle: an essential component
of chin and lower lip position. Plast Reconstr Surg. 1989;83:413.
9. Rubin L, ed. The Paralyzed Face. St. Louis: Mosby-Year Book; 1991.
This paper clearly outlines the technique of temporalis myoplasty that has
evolved over the years.
10. Rudolph R. Depth of the facial nerve in facelift dissection. Plast
Reconstr Surg. 1990;85:537.
11. Latham RA, Deaton TG. The structural basis of the philtrum and
the contour of the vermilion border: a study of the musculature of
the upper lip. J Anat. 1976;121:151.
12. Fára M. The musculature of cleft lip and palate. In: McCarthy JG,
ed. Plastic Surgery. Philadelphia: WB Saunders; 1990:2598.
13. Pessa JP, Garza PA, Love VM, et al. The anatomy of the
labiomandibular fold. Plast Reconstr Surg. 1998;101:482.
14. Westin LM, Zuker RM. A new classification system for facial
paralysis in the clinical setting. J Craniofac Surg. 2003;14:672–679.
This is a classic text on facial expressions and how to produce them
surgically.
15. Falco NA, Eriksson E. Facial nerve palsy in the newborn: incidence
and outcome. Plast Reconstr Surg. 1990;85:1.
16. May M. Microanatomy and pathophysiology of the facial nerve. In:
May M, ed. The Facial Nerve. New York: Thieme; 1986:63. This
classification of facial paralysis was created as an aid to the clinician in
understanding the breadth of this diverse condition.
17. Guerrissi JO. Selective myectomy for post paretic facial synkinesis.
Plast Reconstr Surg. 1991;87:459.
18. Neely JG. Computerized quantitative dynamic analysis of facial
motion in the paralyzed and synkinetic face. Am J Otol. 1992;13:
97.
19. Tears Naturale II. Product Information. Alcon Canada. 2001.
20. Diels HJ. Neuromuscular retraining for facial paralysis. Otolaryngol
Clin North Am. 1997;30:727.
21. Manktelow RT. Use of the gold weight for lagophthalmos. Operative
Techniques Plast Reconstr Surg. 1999;6:157.
22. Levine RE. The enhanced palpebral spring. Operative Techniques.
Plast Reconstr Surg. 1999;6:152.
23. Gillies H Experiences with fascia lata grafts in the operative
treatment of facial paralysis. Proceedings of the Royal Society of
Medicine, London, August 1934. London: John Bale, Sons, and
Danielsson; 1935.
24. Salimbeni G. Eyelid reanimation in facial paralysis by temporalis
muscle transfer. Operative Techniques Plast Reconstr Surg. 1999;
6159.
25. McLaughlin CR. Surgical support in permanent facial paralysis.
Plast Reconstr Surg. 1953;11:302.
26. Carraway JH, Manktelow RT. Static sling reconstruction of the
lower eyelid. Operative Techniques Plast Reconstr Surg. 1999;6:163.
This classic text is a must for all students of facial paralysis.
27. Jelks GW, Glat PM, Jelks EB, et al. Evolution of the lateral
canthoplasty: techniques and indications. Plast Reconstr Surg.
1997;100:1396.
28. Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in
adults with free muscle transfer innervated by the masseter motor
nerve: effectiveness and cerebral adaptation. Plast Reconstr Surg.
2006;118:885–899. Eyelid surgery must be precise and well executed to be
successful.
29. Terzis JK, Noah ME. Analysis of 100 cases of free-muscle
transplantation for facial paralysis. Plast Reconstr Surg.
1997;99:1905–1921.
30. Michaelidou M, Chieh-Han J, Gerber H, et al. The combination of
muscle transpositions and static procedures for reconstruction in
the paralyzed face of the patient with limited life expectancy on
who is not a candidate for free muscle transfer. Plast Reconstr Surg.
2009;123:121–129. In this paper, evidence is presented to suggest cerebral
adaptation is a real entity in the adult population.
31. Terzis JK, Karypidis D. Outcomes of direct muscle neurotization in
pediatric patients with facial paralysis. Plast Reconstr Surg. 2009;124:
1486–1498.
32. Yoleri L, Songur E, Mavioglu H, et al. Cross-facial nerve grafting as
an adjunct to hyperglossal-facial nerve crossover in reanimation of
early facial paralysis: clinical and electrophysiological evaluation.
Ann Plast Surg. 2001;46:301–307.
33. Terzis JK, Tzafetta K. The “babysitter” procedure: minihypoglossal
to facial nerve transfer and cross-facial nerve grafting. Plast Reconstr
Surg. 2009;123:865–876. This is the first article to resurrect the nerve
transfer principle for facial paralysis. Use of the entire hypoglossal had
serious and permanent negative effects on speech, food manipulation, and
tongue bulk.
34. Braam MJ, Nicolai JP. Axonal regeneration rate through cross-face
nerve grafts. Microsurgery. 1993;14:589–591.
35. Marcus JR, Masseter motor nerve as babysitter – personal
communication.
36. Klebuc MJ. Facial reanimation using the masseter to facial nerve
transfer. Plast Reconstr Surg. 2011;127(5):1909–1915.
37. Paletz JL, Manktelow RT, Chaban R. The shape of a normal smile:
implications for facial paralysis reconstruction. Plast Reconstr Surg.
1993;93:784.
38. Koshima I, Tsuda K, Hamanaka T, et al. One-stage reconstruction of
established paralysis using a rectus abdominis muscle transfer. Plast
Reconstr Surg. 1997;99:234.
39. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in
children with Möbius syndrome after segmental gracilis muscle
transplant. Plast Reconstr Surg. 2000;106:1. This article describes the
problems of the Möbius syndrome from a reconstructive surgeon’s
viewpoint and suggests a surgical procedure for function and animation.
40. Koller R, Frey M, Rab M, et al. Histological examination of graft
donor nerves harvested by the stripping technique. Eur J Plast Surg.
1995;18:24.
41. Manktelow RT, Zuker RM. Muscle transplantation by fascicular
territory. Plast Reconstr Surg. 1984;73:751.
42. Manktelow RT. Microvascular Reconstruction. Anatomy, Applications,
and Surgical Technique. New York: Springer-Verlag; 1986.
43. Bae Y, Zuker RM, Maktelow RM, et al. A comparison of
commissure excursion following gracilis muscle transplantation for
facial paralysis using a cross-face nerve graft versus the motor
nerve to the masseter nerve. Plast Reconstr Surg. 2006;117:2407–2413.
In this paper the strong input of the masseter motor nerve is shown to
translate into increased commissure excursion.
44. Baker DC, Conley J. Regional muscle transposition for rehabilitation
of the paralyzed face. Clin Plast Surg. 1979;6:317.
45. Labbe D, Huault M. Lengthening temporalis myoplasty and lip
reanimation. Plast Reconstr Surg. 2000;105:1289–1297. This paper
clearly outlines the technique of temporalis myoplasty that has evolved
over the years.
46. Labbe D. Myoplastic d’allongement du temporal V.2. et réanimation
des lèvres. Ann Chir Plast Esthétique. 2009;54:571–576.
47. Rubin L. Re-animation of total unilateral facial paralysis by the
contiguous facial muscle technique. In: Rubin L, ed. The Paralyzed
Face. St Louis: Mosby-Year Book; 1991:156.

357.e2
SECTION II
CHAPTER 13 • Facial paralysis
48. Puckett CL, Neale HW, Pickerell KL. Dynamic correction of
unilateral paralysis of the lower lip. Plast Reconstr Surg. 1975;55:397.
49. Glenn MG, Goode RL. Surgical treatment of the marginal
mandibular lip deformity. Otolaryngol Head Neck Surg. 1987;97:462.
50. Edgerton MT. Surgical correction of facial paralysis: a plea for
better reconstruction. Ann Surg. 1967;165:985.
51. Conley J, Baker DC, Selfe RW. Paralysis of the mandibular branch
of the facial nerve. Plast Reconstr Surg. 1982;70:569.
52. Curtin JW, Greely PW, Gleason M, et al. Supplementary procedures
for the improvement of facial nerve paralysis. Plast Reconstr Surg.
1960;26:73.
53. Kremer H, Kuyt LP, van den Helm B, et al. Localization of a gene
for Möbius syndrome to chromosome 3q by linkage analysis in a
Dutch family. Hum Mol Genet. 1996;5:1367.
54. Slee JJ, Smart RD, Viljeon DL. Deletion of chromosome 13 in
Möbius syndrome. J Med Genet. 1991;28:413.
55. Ziter FA, Wiser WC, Robinson A. Three generation pedigree of a
Möbius syndrome variant with chromosome translocation. Arch
Neurol. 1977;34:437.
56. Jugenburg M, Hubley P, Yandell H, et al. Self esteem in children
with facial paralysis: a review of measures. Can J Plast Surg.
2001;9:143.

SECTION II • Head and Neck Reconstruction
14 
Pharyngeal and esophageal reconstruction
Edward I. Chang and Peirong Yu
SYNOPSIS
■ Pharyngoesophageal defects are most commonly the result of a total
laryngopharyngectomy for squamous cell carcinoma in the laryngeal
region or hypopharynx. Other etiology includes benign strictures,
pharyngocutaneous fistulas, and thyroid cancer involving the esophagus
■ Radiotherapy has become the primary treatment for early stages of
squamous cell carcinoma in these regions. Many pharyngoesophageal
defects are the results of salvage laryngopharyngectomy following
neoadjuvant radiation therapy, making reconstruction more challenging.
■ Commonly used flaps for pharyngoesophageal reconstruction include
the jejunal flap, radial forearm flap, and the anterolateral thigh (ALT)
flap. In recent years, the ALT flap has become the most popular flap
for this type of reconstruction
■ Major complications following pharyngoesophageal reconstruction
include anastomotic strictures and fistulas.
■ The ultimate goals of reconstruction are to provide alimentary
continuity, protection of important structures such as the carotid
artery, and restoration of functions such as speech and swallowing
■ Most patients (greater than 90%) can eat an oral diet after
reconstruction without the need for tube feeding
■ Speech rehabilitation is typically provided with tracheoesophageal
puncture (TEP), and fluent speech can be achieved in greater than
80% of patients. Speech quality is superior with a fasciocutaneous flap
than an intestinal flap
■ Many patients with pharyngoesophageal defects have a frozen neck
due to previous radiotherapy and surgery, making reconstruction
extremely difficult with high surgical risks. Careful planning, use of
transverse cervical vessels as recipient vessels, and a two-skin island
ALT flap to simultaneously resurface the neck for a through-and-
through defect can simplify the procedure and reduce surgical risks.
Introduction
Reconstruction of pharyngeal and esophageal defects
presents unique challenges to the reconstructive surgeon.
Reconstruction is aimed at restoring continuity of the
gastrointestinal tract in order to allow patients to resume
a normal diet postoperatively. A number of reconstructive
options are now available for reconstructing pharyngo­
esophageal defects; however, optimizing outcomes and
postoperative functions require careful consideration of a
variety of different factors. Flap selection, recipient vessel
selection, neck skin resurfacing, and minimizing complica­
tions are critical to achieve maximal function following
reconstruction.
Pharyngoesophageal defects can result from a variety of
etiologies, most commonly tumor extirpation, but can also
result from trauma or ingestion of caustic agents. In the setting
of cancer, such defects are most often associated with laryn­
geal cancer that is often treated with radiation initially. Con­
sequently, reconstruction often occurs in the setting of prior
radiation which can have a significant impact on ultimate
outcomes and postoperative function.
Reconstruction can be accomplished with local flaps or free
flaps, but the modality of reconstruction depends on surgeon
comfort and preference, hospital nursing and operating room
staff, and hospital infrastructure. The first reported cervical
esophageal “reconstruction” was documented by Mikulicz1 in
1886 in which the proximal and distal cervical esophageal
ends were connected with a rubber tube over the neck skin
and the skin was later tubed to close the gap. The Wookey
flap2,3 was popular until the 1960s when Bakamjian4 described
the use of the deltopectoral flap for cervical esophageal recon­
struction. However, these flaps are no longer used for
pharyngoesophageal reconstruction today due to a variety of
problems. The gastric pull-up procedure was introduced in
the mid-1900s to reconstruct thoracic esophagectomy defects
and was later used for pharyngoesophageal defects.5–10 Sub­
sequently, the pedicled colon and jejunum also became
popular flaps for such reconstructions11–13 but have largely
been abandoned due to the need for performing a total
esophagectomy to utilize these intestinal flaps which had
significant comorbidity and risks for complications.
Access video and video lecture content for this chapter online at expertconsult.com

359
Patient evaluation
pharyngoesophageal reconstruction. Since the beginning of
2000s, the anterolateral thigh flap has largely replaced both
the jejunal and radial forearm flaps for pharyngoesophageal
reconstruction and become the new “gold standard” in many
centers due to its many advantages.22–26
This chapter aims to provide a brief global overview of
reconstruction of pharyngeal and esophageal defects focusing
on anatomy, defect classification, reconstruction, and postop­
erative management and complications.
Anatomy
The oropharynx is bounded by the nasopharynx superiorly,
the oral cavity anteriorly, and the hypopharynx and larynx
inferiorly. The superior border of the oropharynx is at the
plane of the soft palate, and the inferior border is defined by
the level of the hyoid bone. The main structures in the oro­
pharynx are the base of tongue, tonsillar pillars, lateral and
posterior oropharyngeal walls, and soft palate. Common
oncologic defects in the oropharynx are the result of surgical
resections of cancers in the base of tongue which may extend
to and involve the pharyngeal wall and tonsillar pillars. Some
of these defects that need not be resurfaced with a free flap
can be allowed to remucosalize spontaneously. The hypo­
pharynx extends from the level of the hyoid bone to the lower
border of the cricoid cartilage and ultimately continues to
become the cervical esophagus caudally (Fig. 14.1). This is a
critical area that is responsible for airway protection and swal­
lowing and speech functions. Common defects of the hypo­
pharynx and cervical esophagus are the result of surgical
resection of cancers in the hypopharynx and larynx, advanced
thyroid cancers, radiation strictures, and chemical injuries.
Isolated tumors in the cervical esophagus, although rare, may
also require segmental esophagectomy and reconstruction
(Table 14.1).
Patient evaluation
Patients anticipated to undergo surgical resection and re­
construction for malignancy should have a thorough history
and physical including preoperative imaging and laboratory
studies. As most laryngeal tumors are treated initially with
The pectoralis major flap became the flap of choice for
pharyngoesophageal reconstruction14–16 in the early 1980s
until free flaps became popular. Although Seidenberg et al.17
reported the first clinical use of free jejunal flaps for cervical
esophageal reconstruction in 1959, it did not gain popularity
until the 1980s.18–21 Although the jejunal flap has several
advantages, such as rapid healing, low fistula rate, and a rela­
tively simpler inset as the jejunum is already a tubular conduit,
its abdominal morbidity and poor speech reproduction with
tracheoesophageal puncture techniques make it less ideal for
Fig. 14.1  The hypopharynx is located behind the larynx and in continuity with the
oral pharynx superiorly and the cervical esophagus inferiorly. The hypopharynx is
arbitrarily divided into three areas for purposes of tumor classification: the
pharyngeal wall (A), pyriform sinuses (B), and postcricoid area (C).
A
C
B
Table 14.1  Types of pharyngoesophageal defects requiring reconstruction
Pathology
Defect location
Type of defect
Primary SCC
Hypopharynx and cervical esophagus
Most commonly partial
Recurrent SCC
Hypopharynx and cervical esophagus
Most commonly circumferential
Advanced or recurrent thyroid cancer
Hypopharynx and cervical esophagus
Most commonly circumferential
Isolated esophageal tumors
Cervical esophagus with an intact larynx
Most commonly partial
Pharyngoesophageal or tracheoesophageal
fistulas
Cervical esophagus or hypopharynx
Most commonly partial
Anastomotic strictures
Cervical esophagus
Most commonly circumferential
Radiation-induced strictures
Hypopharynx or cervical esophagus
Partial or circumferential, depending on
the degree of stricture
SCC, squamous cell carcinoma

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SECTION II
CHAPTER 14 • Pharyngeal and esophageal reconstruction
based flap. While the utility has been questioned, it is impor­
tant to assess adequate hand perfusion prior to harvesting one
of the vessels for pharyngoesophageal reconstruction. Typi­
cally the non-dominant arm is utilized and, therefore, patients
should be questioned regarding which side is their dominant
arm. As most patients will require a tracheostomy in the
immediate postoperative period or permanently in the setting
of a laryngectomy, patients will only be able to communicate
with writing initially and, therefore, the dominant arm should
be preserved, if possible.
Flap selection
The decision for which flap is used for reconstruction is
dependent on a myriad of important factors, not least of
which is surgeon’s preference, experience, and comfort with
flap elevation. In general, a thinner, more pliable flap is rec­
ommended, and the surgical plan should always include an
algorithm in the setting that the primary flap of choice is not
usable. Whether a free flap or a pedicle flap is utilized is
largely dependent on surgeon expertise, and both have been
utilized successfully for pharyngoesophageal reconstruction.
Postoperative function can be restored with either a free or
pedicle flap with most flaps being fasciocutaneous. However,
one unique flap consideration is an intestinal flap either via a
free jejunum or a supercharged jejunum for total esophagec­
tomy reconstruction. The swallowing function is comparable
between fasciocutaneous flaps and intestinal flaps. However,
speech function is superior with fasciocutaneous flaps.24,26
Similar consideration should be given to donor site morbidity
as well. Harvesting of a fasciocutaneous flap is typically well
tolerated with minimal donor site morbidity, while harvest of
a segment of jejunum requires a laparotomy which may pre­
dispose patients to risk of significant fluid shift, adhesions,
bowel obstruction, and an incisional hernia in the future. The
advantages and disadvantages of commonly used free flaps
are listed in Table 14.2.
chemotherapy and radiation, these factors can have a signifi­
cant impact when patients are scheduled to undergo surgical
salvage. Discussion should also include patients’ postopera­
tive function in this setting, as a laryngectomy would have
compromised function compared to an esophagectomy where
the larynx can usually be preserved with relatively normal
postoperative speech function. Questioning should also in­
clude pertinent prior surgeries especially if patients have had
a prior resection or neck dissection which can drastically
complicate salvage surgery and the availability of recipient
vessels.
Other comorbidities also need to be considered in patients
undergoing surgery. The overwhelming majority of patients
who suffer from laryngeal and esophageal malignancy have
a history of tobacco and alcohol use which may contribute
to postoperative complications and impact wound healing.
Further, patients with history of peripheral vascular disease
in conjunction with smoking should be evaluated for donor
sites as well as recipient vessels. As most patients undergo­
ing surgery and treatment of malignancy have already had
imaging studies, the studies should be reviewed to assess the
availability and patency of potential recipient vessels. If pati­
ents are severely malnourished, consideration should be given
to placement of a feeding tube preoperatively in order to op­
timize patients’ nutritional status prior to surgery if possible.
The physical exam should certainly include evaluation of
the donor site and local surgical sites. In the setting of prior
radiation, evaluation of the pliability of the neck skin is criti­
cal. Following a visor type incision to complete the resection
and subsequent reconstruction, there is a definite possibility
that the skin incision cannot be closed primarily without risk
of dehiscence and exposure of vital structures. The physical
exam should also include a thorough vascular exam. In
general the vasculature supplying the thigh and therefore the
anterolateral thigh (ALT) flap are preserved since it is sup­
plied by the profundus femoris artery. Regarding the upper
extremity, an Allen’s test on the upper extremity is commonly
performed prior to reconstruction with a radial or ulnar artery
Table 14.2  Advantages and disadvantages of commonly used free flaps
ALT
Jejunum
Radial forearm
Flap elevation
Moderately difficult
Moderately difficult
Easy
Flap reliability
Good
Good
Good
Flap thickness
Can be too thick
Good
Good
Primary healing
Good
Best
Good
Donor site morbidity
Low
High
Moderate
Recovery time
Quick
Can be slow
Quick
Fistula rates
Low
Low
Moderate
Stricture rates
Low
High
Moderate
TEP voice
Good
Poor
Good
Swallowing
Good
Good
Good
Use for circumferential defects
Yes
Yes
Second choice
Use for partial defects
Yes
No
Yes
Contraindications
Obesity, with a very thick thigh
Severe comorbidity, prior
abdominal surgery
Thin patient with a small arm,
radial dominance
ALT, anterolateral thigh flap; TEP, tracheoesophageal puncture

361
Flap selection
flap can be islandized for inset as well. The main pedicle arises
off the thyrocervical trunk and passes between the sterno­
cleidomastoid and trapezius muscles to supply branches that
will perfuse the overlying skin. The pedicle has been described
to be 1.1–1.5 mm in diameter with a length up to 7 cm, but
the pedicle can maintain a flap up to 35 cm in length. However,
the width is limited to approximately 6 cm in greatest width
to allow primary closure of the donor site (Fig. 14.2). In the
setting where a radical neck dissection has been performed,
or when the neck dissection includes level 5, there is a high
likelihood that the transverse cervical vessels have been
ligated and, therefore, a supraclavicular artery flap is contra­
indicated. Further, if the skin has been involved in prior radia­
tion treatment, the use of the supraclavicular flap is also not
recommended as using radiated tissue to reconstruct a pha­
ryngeal esophageal defect would likely be at high risk for
partial flap loss and subsequent fistula formation.
Internal mammary artery perforator flap
The internal mammary artery supplies a number of perfo­
rators to the overlying skin allowing design of the internal
mammary artery perforator (IMAP) flap.34–36 Multiple studies
have confirmed the second internal mammary perforator is
often the dominant perforator supplying the overlying skin,
and a perforator dissection can provide a pedicle up nearly
10 cm for reconstruction of head and neck defect.37,38 The size
of the skin paddle is limited to the degree of laxity in the chest
allowing for primary closure. The flap is typically thin and
pliable and can be utilized for reconstruction of partial phar­
yngectomy defects or for closure of fistulae.39 Alternatively,
it can also be used for neck resurfacing or tracheal stoma
reconstruction (Fig. 14.3).34 The use of the IMAP flap for cir­
cumferential defects is limited and an alternate flap should be
chosen.
Latissimus dorsi flap
The latissimus dorsi flap can also be used as a salvage flap
when the initial reconstruction failed.40 The dominant pedicle
to the latissimus dorsi muscle is the thoracodorsal artery and
its venae comitantes, a branch of the subscapular artery and
vein. For a muscle only flap, an oblique incision is created
starting in the posterior axilla and extending inferiorly for 10
to 20 cm. The subcutaneous tissue is then dissected free from
the underlying latissimus dorsi fascia to the anatomical
borders of the muscle. The muscle fibers of origin are divided
from the posterior iliac crest and thoracolumbar fascia. The
deep surface of the muscle is then elevated toward the axilla.
As the flap elevation approaches the axilla, the thoracodorsal
vessels are identified on the costal surface of the latissimus
dorsi and protected throughout the remainder of the dissec­
tion. The majority of the tendon of the latissimus dorsi is
divided while maintaining constant visualization of the
underlying thoracodorsal vessels to avoid pedicle injury. A
sleeve of tendon is left intact to take the tension off the vas­
cular pedicle once the flap is transferred to the neck.
A subcutaneous tunnel is created to reach the neck. The flap
is pulled through the tunnel to the neck. A skin graft is used
as lining to repair the pharyngoesophageal defect. The skin
graft is sewn to the remaining pharyngeal mucosa over a
14 mm Montgomery salivary bypass tube as a stent (Fig. 14.4).
Pedicle flaps such as the pectoralis major myocutaneous
flap, deltopectoral flap, internal mammary artery perforator
(IMAP) flap, and supraclavicular flap have been well-
described and performed successfully for pharyngeal and
esophageal reconstruction; however, at our institution, we
typically reserve pedicle flaps for salvage in the setting of a
leak or fistula. However, in the setting of severe carotid ste­
nosis or the lack of recipient vessels, a local pedicle flap may
be necessary in order to reconstruct the defect or resurface the
radiated neck.
Pedicle flaps
The algorithm for pharyngoesophageal reconstruction should
include pedicle flaps which can be used as the primary modal­
ity for reconstruction or in the setting of salvage in the case
of loss of a free flap or pharyngocutaneous fistula.
Pectoralis major myocutaneous flap
The pectoralis major myocutaneous (PMMC) flap has
traditionally been a workhorse flap for head and neck
reconstruction.27–29 In our institution, the PMMC flap is typi­
cally reserved for salvage situations or in situations when a
free tissue transfer cannot be performed. The flap can be reli­
ably harvested as a muscle-only flap for reinforcement of a
pharyngeal closure or for closure of a fistula. An incision is
made in the inframammary fold, and the muscle is identified.
The muscle is released off the chest wall with the aid of a
lighted retractor, and large intercostal perforators are ligated
with hemoclips. The pedicle is readily identified on the deep
surface of the muscle and taken as cranial as possible to the
level of the clavicle. The superficial dissection is performed
next preserving the fascia with the muscle that provides more
robust tissue to hold sutures for the flap inset. The medial
muscle is released preserving 2–3 cm of medial muscle to
avoid the large internal mammary perforators that can lead
to significant bleeding that can be difficult to control if injured.
The lateral muscle is then released and tapered for the pedicle
to islandize the muscle and minimize the bulk of the muscle
proximally. A counter-incision is often made in an axillary
skin fold to release the muscle from its origin at the humeral
attachments. The pectoralis muscle can then be easily rotated
into the neck for coverage of the pharyngeal defect with or
without skin grafting for lining.
A skin paddle can also be harvested; however, the skin
paddle is less reliable distally and can be prone to partial flap
necrosis. Perforators arising from the pectoralis major muscle
can be detected in the skin paddle using a hand-held Doppler;
however, prior studies have demonstrated the utility of intra­
operative indocyanine green angiography to design the skin
paddle over the area of maximal perfusion. The skin paddle
from a PMMC flap can be used to repair a partial pharyngec­
tomy defect; however, circumferential defects are often diffi­
cult to reconstruct secondary to the bulk of the flap.
Supraclavicular artery perforator flap
The supraclavicular artery flap is an axial pattern flap and has
been well-described based off the supraclavicular branches
arising from the transverse cervical vessels. 30–33 The flap is
typically thin and pliable allowing the flap to be tubed for
circumferential defects or as a patch for partial defects. The

362
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CHAPTER 14 • Pharyngeal and esophageal reconstruction
pedicle length to reach the recipient vessels, and the potential
need for vein grafts should also be entertained in the previ­
ously operated and radiated neck.
Anterolateral and anteromedial thigh flaps
The anterolateral thigh (ALT) flap has become the workhorse
flap for head and neck free flap reconstruction. The flap can
typically be harvested at the time of the resection to minimize
operative and anesthesia time. In obese patients, the ALT flap
may be too thick for pharyngeal esophageal reconstruction
and alternate donor sites should be considered. The main
vascular pedicle is the descending branch of the lateral cir­
cumflex femoris artery, which is a branch of the profundus
femoris (Video 14.1
).
Flap harvest
The patient is positioned with the axis of the leg in line and
towel clips can be placed in order to prevent the legs from
The latissimus muscle is then used to cover the skin graft and
the major vessels. In thin patients, a skin paddle can be
included to repair the pharyngoesophageal defect instead of
using skin grafts. The salivary bypass tube is left in place for
6 weeks.
Free flap choices
With the increasing comfort and popularity with perforator
dissection and improved outcomes in free tissue transfer, the
use of free flaps has become the gold standard for reconstruc­
tion of pharyngoesophageal defects. The different donor sites
are virtually endless and depend predominantly on patient
body habitus, donor site morbidity, and surgeon experience.
An algorithm for free flap pharyngoesophageal reconstruc­
tion is outlined in Fig. 14.5. Other considerations that are
critical prior to embarking on a free tissue transfer are the
availability of recipient vessels, especially in the setting of
prior radiation and surgery. The flap should have adequate
Fig. 14.2  The supraclavicular flap. (A) Design of the flap; (B) flap islandized;
(C) primary closure of donor site.
A
B
C

363
Flap selection
A
Fig. 14.3  Internal mammary artery perforator (IMAP) flap for tracheostoma reconstruction. (A) Flap design based on the perforator in the second intercostal space.
(B) Healed reconstruction.
B
external rotation that will affect the location of the perforators
and flap design. The right side is typically used for right-
handed surgeons; however, either leg can be utilized and they
are independent of each other.
A line is drawn connecting the anterior superior iliac spine
(ASIS) to the lateral patella, the so-called A-P line.41 The line
is divided in half marking the location of the “B” perforator.
The “A” and “C” perforators are located 5 cm proximally and
distally, respectively (Fig. 14.6). The perforators can arise
through the vastus lateralis muscle, or they can arise as sep­
tocutaneous perforators between the vastus lateralis muscle
laterally and the rectus femoris muscle medially. The perfora­
tors typically enter the fascia approximately 1.4 cm lateral to
the A-P line. In general, 93% of patients should have at least
one perforator in the A-B-C location allowing for the use of
the ALT flap as a potential donor site.
For circumferential defects, a 9.5 cm wide skin paddle is
often needed in order to provide a diameter of approximately
3 cm (circumference equals diameter × π) to minimize the
chance of stenosis of the conduit and dysphagia (Fig. 14.7A).
For partial defects, the width of the remaining mucosa is
subtracted from 9.5 cm to give the width of the skin paddle.
The anterior skin incision is made and dissection proceeds
down to the fascia (Fig. 14.7B). We typically harvest an addi­
tional 1–2 cm of fascia with the flap that can be used as a
second layer for closure and flap inset (Fig. 14.7C). The fascia
is then elevated laterally to identify the perforators (Fig.
14.7D). The main pedicle, the descending branch of the lateral
circumflex femoral vessels, is identified between the vastus
lateralis and rectus femoris muscles. In general, 8–10 cm
pedicle length can be obtained with the ALT flap. If a more
distal perforator is present, the pedicle length can be
extended. If more pedicle length is needed, the proximal
branches to the rectus femoris muscles can be ligated. The
size of the artery is generally 2.0–3.0 mm and vein,
2.5–3.5 mm. Once the main pedicle and the perforators have
been isolated, the posterior incision is made adjusting the
size of the skin paddle to accommodate either a partial or
circumferential defect.
Once the posterior incision is made, dissection proceeds
down to the fascia, and again an additional 1–2 cm cuff of
fascia is harvested to serve as a second layer to reinforce the
closure and minimize the risk of a leak or fistula. Once the
fascia is incised, the fascia is elevated off the underlying
vastus lateralis muscle until the perforators are encountered.
The perforators are freed from the muscle posteriorly, and the
flap elevation can be completed at this time.
If two perforators are present, the skin paddle can be
divided into two separate skin paddles, one used for recon­
struction of the pharyngoesophageal defect, and the second
dedicated to resurfacing the neck or for monitoring (Fig. 14.8).
If there is only one perforator present, then a distal cuff of the
vastus lateralis muscle can be harvested and utilized as either
a monitoring segment or to resurface the radiated neck along
with a skin graft (Fig. 14.9).
If no usable perforators can be identified in the ALT flap
territory, which occurs in 4.3% of thighs, the medial skin
paddle should be explored through the same incision to pos­
sibly harvest the anteromedial thigh (AMT) flap (Fig. 14.10).42–44
The main vascular pedicle for the AMT flap is the rectus
femoris branch that usually originates from the descending
branch 1–2 cm from its take-off (Fig. 14.11). It travels along
the medial edge of the rectus femoris muscle and sends out
one or two perforators to the skin (Fig. 14.10). Most perfora­
tors are septocutaneous ones or pierce the medial edge of the
rectus femoris muscle. The AMT flap can be harvested inde­
pendently or a multi-component flap (AMT, ALT, vastus
lateralis muscle, rectus femoris muscle) can be harvested
depending on the needs (Fig. 14.12). Overall, AMT perforators
are only present in about half of the cases. However, when
there are no ALT perforators, the chances of finding a usable
AMT perforator are near 100%, avoiding the need for an
entirely new flap. The AMT flap may be thicker as the medial
thigh tends to have thicker subcutaneous tissue than the

364
SECTION II
CHAPTER 14 • Pharyngeal and esophageal reconstruction
as this will decrease the risk of developing a stricture postop­
eratively. For circumferential defects, the ALT flap can be
tubed either in the leg or in the neck depending on the authors’
preference. In general, the flap is inset, placing the seam
posteriorly against the prevertebral fascia that will again
hopefully contain a leak should the patient develop one. This
places the perforator anteriorly and minimizes the risk of
compression of the perforator (Fig. 14.14). The proximal
anastomosis is usually completed first, and it is helpful to cut
the proximal skin paddle in a curvilinear fashion as the proxi­
mal inset into the tongue base typically has a larger length
than the distal inset into the esophageal remnant. Next, the
longitudinal seam is closed suturing the skin paddle to itself
in order to tube the flap. The distal inset is typically performed
with a “dart” in the distal skin paddle that is inset into the
cervical esophagus (Fig. 14.15). A longitudinal full-thickness
A
B
Fig. 14.4  Salvage reconstruction with a latissimus dorsi flap. (A) Failed primary
anterolateral thigh flap reconstruction due to infection. (B) Skin grafting for lining
and bilateral pectoralis major muscle flaps to cover exposed great vessels.
(C) Latissimus dorsi muscle to cover the skin graft for pharyngoesophageal
reconstruction and skin paddle for neck resurfacing. (D) Well-healed reconstruction.
Patient tolerated a soft diet.
C
D
lateral thigh, and the pedicle length is often shorter than the
ALT flap.
Flap inset
The flap inset is typically performed using 3-0 Vicryl sutures
placing the knots inside the lumen and paying careful atten­
tion to invert the skin edge and mucosa as much as possible.
For partial defects, the flap is inset around the entire defect,
and once the flap has been inset, the additional cuff of fascia
that was harvested with the flap can be sutured to the remain­
ing constrictor muscles as a second layer to minimize the risk
of a fistula. The flap can be thinned if necessary (Fig. 14.13).
In most cases, thinning the periphery of the flap is all that is
needed. When more aggressive thinning is desired, thinning
should fan out from the perforator to avoid perforator injury.
It is always critical to preserve a strip of mucosa, if possible,

365
Flap selection
paddle or skin graft is sutured to the posterior tracheal wall
inferiorly and to the neck skin superiorly.
Radial forearm flap
The radial forearm free flap (RFFF) is an excellent choice for
pharyngoesophageal reconstruction especially for partial
defects.45–47 Circumferential defects, however, would require
harvesting of a significant portion of the forearm in order to
have adequate skin to tube the flap, incurring significant
donor site morbidity. Under these circumstances, an alternate
flap may be necessary to avoid the donor site morbidity. For
shorter defects, the flap can be oriented longitudinally so that
the flap can be tubed from distal to proximal rather than from
lateral to medial. Regardless, the RFFF donor site requires a
skin graft to provide coverage of the underlying tendons and
muscles. The pedicle for the RFFF usually is more than ade­
quate with over 10 cm of length. The venae comitantes of the
radial artery are the dominant venous outflow for the flap,
but may be small in certain patients. The venae comitantes
may join into a single larger vein or may converge with the
cephalic vein to provide a larger caliber vein for the microvas­
cular anastomosis. Incorporating the cephalic vein into the
flap is not routinely performed in our practice unless the
distal venae comitantes are less than 1 mm at the level of
the wrist.
Flap harvest
The non-dominant arm is typically used as the donor arm in
order to minimize the donor site morbidity. The arm should
be preserved during the initial consultation to make certain
that lab draws and IVs are not placed into the arm that can
injure the vessels of the flap. The flap harvest can be performed
with or without the use of the tourniquet based on surgeon
preference. Exsanguination with an Esmarch is not necessary,
and elevation prior to tourniquet inflation is adequate.
The dimensions of the flap are outlined based on the size
of the defect. In most cases, the width of the flap allows the
inclusion of the cephalic vein. When a smaller flap is desired,
we explore the venae comitantes at the wrist crease, first by
making a small incision (Fig. 14.18). If one of the veins is larger
than 1 mm, as it is for most cases, the flap can be safely based
on the venae comitantes. Otherwise, the flap design is shifted
more laterally to include the cephalic vein as the draining
vein. The radial vessels at the distal incision are dissected out,
ligated, and divided. Flap dissection from the ulnar side
incision in made in the anterior esophagus, and the dart is
inset into this spatulated esophagus to increase the diameter
of the distal anastomosis and to minimize the risk of develop­
ing a stricture (Fig. 14.16). Once the flap is inset, the additional
cuff of fascia is again used as a second layer to cover the distal
anastomosis. For circumferential defects, a Montgomery sali­
vary bypass tube with a diameter of 14 mm can be placed in
the reconstructed esophagus through the mouth (Fig. 14.17).
It is usually removed 6 weeks after surgery. We only use it in
difficult cases when the distal anastomosis to the esophagus
is below the tracheostoma and the tissue quality is poor and
prone to leakage.
Prior to closure of the neck skin, the wound should be
inspected for hemostasis and irrigated with ample amounts
of normal saline. It is our preference to use antibiotic combina­
tion irrigation also prior to closure as these cases are long and
contaminated. Closed suction drains are also critical to mini­
mize the risk for a seroma that can subsequently become
infected and lead to wound dehiscence and even flap throm­
bosis. The patient’s neck should be taken out of extension, and
the microvascular anastomosis should be inspected one last
time prior to final closure to make certain there is no twist,
kink, or compression of the pedicle or perforator. The trache­
ostoma is then matured to the chest skin anteriorly and to the
neck skin posteriorly using 3-0 PDS sutures burying the car­
tilage under the skin.
If there is not ample laxity of the neck skin to achieve
primary closure, as often happens in the setting of prior radia­
tion, the second skin paddle or the vastus lateralis muscle
with skin grafting can be used to resurface the neck. The skin
paddle and muscle need to be oriented, making certain that
the perforator and pedicle are not twisted. The second skin
Fig. 14.5  An algorithm of flap selection for pharyngoesophageal reconstruction.
Partial defects
Circumferential defects
FOREARM FLAP
(RFF, UAP)
Obese
ALT/AMT flap
ALT/AMT flap
Non-obese
Non-obese
Unavailable
Available
Available
Unavailable
ALT/AMT FLAP
JEJUNAL FLAP
Fig. 14.6  Design of the anterolateral thigh flap. The midpoint of the line
connecting the anterior superior iliac spine and the superolateral corner of the
patella (A-P line) is marked. Perforator B is usually located 1.5 cm lateral to the
midpoint. Perforators A and C are located 5 cm proximal and distal to perforator B,
respectively.

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CHAPTER 14 • Pharyngeal and esophageal reconstruction
Fig. 14.7  The flap is designed to include two or three potential perforators so that a second skin paddle, usually based on perforator C, can be used for neck resurfacing or
monitoring. A lip of the flap is extended proximally (P) to form an elongated oblique opening of the tube flap to accommodate the wider opening in the floor of the mouth
(A). A wider fascia than skin is included in the ALT flap (B) so that the fascia can be used to cover the suture line (C). Subfascial dissection proceeds laterally until the
perforators are seen (D).
A
CB
CC
D
proceeds in a suprafascial plane until the brachioradialis
tendon is reached, at which point in time, the fascia is incised
to gain access to the main pedicle. The radial side dissection
is also carried out in a suprafascial plane until the flexor carpi
radialis tendon is found, and again the fascia is incised. The
sensory branches of the radial nerve should be identified and
preserved to minimize the resultant numbness over the
dorsum of the thumb postoperatively. The thenar branch of
the sensory nerve can only be preserved with the suprafascial
technique. The flap is then elevated from a distal to proximal
direction and small muscular perforators are ligated with
hemoclips. Once the flap is dissected, the incision is extended
toward the antebrachial fossa and the pedicle is dissected
proximally to gain length and caliber. Following release of the
tourniquet, the hand should be assessed for adequate perfu­
sion, checking capillary refill, and palpating a pulse in the
ulnar artery. The inset is similar to that described for the ALT
flap except often there is no additional layer of fascia that can
be utilized to achieve a second layer closure.
Unlike other fasciocutaneous flaps, the donor site for the
RFFF often requires a skin graft for coverage and resurfacing.
A split or full thickness skin graft can be utilized and is
dressed for a minimum of 5 days with either a pressure bolster
or using a negative pressure dressing. A closed suction drain
can be placed depending on surgeon’s preference. The senior
author does not use drains for forearm flap donor sites and

367
Flap selection
CA
CB
C
Fig. 14.8  By including two perforators, the flap can be divided into two skin paddles based on separate cutaneous perforators A and C (A). The forcep indicates where the
division line is (B). The second skin paddle can be used for neck resurfacing (C) or as a monitor (D).
D
seromas have not been seen. The majority of patients do not
suffer any permanent debilitation, pain, weakness, or tem­
perature sensitivity following flap harvest.
Ulnar artery perforator flap
The ulnar artery perforator (UAP) flap represents an excellent
alternative to the radial forearm flap.48,49 Two to three perfora­
tors can usually be found along the ulnar artery in the medial
aspect of the forearm. The UAP flap is a true perforator flap
that also provides thin, pliable skin that is ideal for such
defects and typically provides adequate pedicle length and
vessel caliber for free tissue transfer in head and neck recon­
struction.48,49 The pedicle length of the UAP flap is consider­
ably shorter than the RFFF and on average is approximately
5–7 cm. Careful attention must be paid to avoid any injury to
the ulnar nerve which lies directly adjacent to the main pedicle
ulnar vessels. The UAP flap is beneficial as it often provides
somewhat thicker tissue, is often not hair-baring, and tendon
exposure is rare.
Flap harvest
Like the RFFF, the UAP flap should be harvested from the
non-dominant arm. A line connecting the medial epicondyle
to the pisiform is drawn which marks the axis for the UAP
flap. Typically, the flap is harvested 5 cm proximal to the
pisiform to avoid exposure of the tendons. In our experience,
the location of the perforators are reliably found at approxi­
mately 7 cm, 11 cm, and 16 cm proximal to the pisiform (Fig.
14.19A), namely the A-B-C perforators.48 The “B” perforator
was the most commonly found perforator and was present in
95% of patients.
After elevation exsanguination, the radial incision is made
first, and dissection begins in a suprafascial plane until past
the flexor digitorum superficialis (FDS) tendons. The perfora­
tors arising from the main ulnar vessels should be visible now.
The fascia is then incised exposing the ulnar neurovascular
bundle, which travels between the FDS and flexor carpi
ulnaris (FCU) (Fig. 14.19B). The ulnar nerve is carefully sepa­
rated from the vessels and the use of electrocautery should be

368
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CHAPTER 14 • Pharyngeal and esophageal reconstruction
avoided during the dissection to minimize any trauma to the
ulnar nerve. The pedicle at the distal incision is ligated and
divided. The ulnar side incision is then made, and subfascial
dissection proceeds radially toward the vascular pedicle. The
thin septum with the perforators is carefully dissected off the
FCU, and any muscular branches are clipped and divided
(Fig. 14.19C). The venae comitantes are often of adequate
caliber, and the basilic vein is not routinely included. In our
experience, the arterial diameter was routinely 2 mm with a
vein of 2.5 mm, more than adequate for microvascular anas­
tomoses. The vascular pedicle is dissected proximally to the
bifurcation with the common interosseous vessels where the
median nerve can be seen, which should be protected from
traction injury (Fig. 14.19D). The inset of the flap is performed
as previously described; however, careful attention is impera­
tive as the UAP flap is a true perforator flap, and the perfora­
tors tend to be smaller than the ALT and may be prone to
kinking or traction. A second skin paddle for neck resurfacing
is also possible since there are usually more than one perfora­
tor (Fig. 14.19E). Prior to closure of the neck, as with all head
and neck microvascular free flaps, the head is returned to a
neutral position, and the pedicle and perforators should be
inspected before definitive closure.
CA
CB
Fig. 14.9  When there is only one perforator present, the superficial half of the
vastus lateralis muscle is included to support skin grafts. The descending branch
travels alongside the medial edge of the vastus lateralis muscle. The superficial half
of the muscle is separated from the deep half immediately below the muscular
branches (A). A thin and broad muscle is thus obtained to cover the neck defect
with skin grafting (B). Such a thin muscle produces minimal bulk so as not to
obstruct the tracheostoma (C).
CC
Fig. 14.10  When ALT perforators are inadequate, the anteromedial thigh perforators
are explored over the rectus femoris muscle through the same incision.
Fig. 14.11  The main vascular pedicle of the AMT flap is the rectus femoris branch
that usually originates from the descending branch soon after its take-off.

369
Flap selection
The donor site for a small UAP flap can often be closed
primarily given the more proximal location and redundant
laxity on the ulnar aspect of the forearm. The distal tendons
are not exposed as the flap is designed more proximal and,
therefore, the skin graft can typically be placed directly over
muscle. This minimizes the risks of complications with poor
graft take over the tendons as commonly seen in the radial
forearm flap donor site. The donor site is usually well-tolerated
with no patients suffering from an ulnar nerve palsy or dimin­
ished grip strength in the authors’ experience.
Fig. 14.12  The AMT flap can be harvested independently (A) or with the ALT flap
(B) based on the common trunk proximal to the take-off of the rectus femoris
branch.
A
B
Fig. 14.13  The ALT flap can be thinned by trimming away the subcutaneous
tissue. The trimming should fan out from the perforator to avoid perforator injury.
Fig. 14.14  The tubed flap is positioned with the longitudinal seam facing
posteriorly against the prevertebral fascia. This will also position the perforators
anteriorly to avoid compression.
Fig. 14.15  A dart is created in the distal flap skin.

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CHAPTER 14 • Pharyngeal and esophageal reconstruction
Lateral arm flap
The lateral arm flap is another excellent alternative for pha­
ryngoesophageal reconstruction in the setting that the ALT
flap is too thick as occurs in obese patients, or when a forearm
flap is too thin.50–52 The lateral arm flap has a reliable pedicle
that is typically 5–7 cm in length which is usually adequate
to reach most recipient vessels in the neck. The radial nerve
is within close proximity to the pedicle and must be carefully
dissected away from the pedicle and preserved during the
dissection. The lateral arm flap is more appropriate for partial
pharyngoesophageal defects in order to achieve primary
closure of the donor site unless the patient has lost significant
weight with large amount of redundant skin available in the
upper arm. The main disadvantage of this flap is the small
caliber of the pedicle artery which is usually no more than
1.5 mm. The main advantage of this flap is minimal donor site
morbidity.
Flap harvest
The arm is placed across the patient’s torso, and the deltoid
insertion and lateral epicondyle are marked. The septum is
palpated between the triceps and biceps muscles and the flap
designed centering on the septum (Fig. 14.20A). The posterior
incision is made, and a subfascial dissection is performed from
a posterior to anterior direction. The septum is approached,
and the perforators are identified (Fig. 14.20B). The muscle
fibers of the triceps are detached from the septum. The septum
is then incised close to the periosteum, exposing the vascular
pedicle. Careful attention must be paid to identifying the
radial nerve which travels in close proximity to the pedicle
(Fig. 14.20C). The pedicle can then be dissected as proximally
as possible to obtain longer pedicle length and larger caliber
Fig. 14.16  The cervical esophagus is opened longitudinally for about 1.5 cm to
spatulate the anastomosis.
Fig. 14.17  A Montgomery salivary bypass tube with a diameter of 14 mm can be
used to temporally stent the neopharynx for 2–6 weeks (A,B).
CA
CB
Fig. 14.18  A small exploratory incision was made first at the wrist crease to
confirm the size of the venae comitantes of the radial forearm flap vascular pedicle.
If both venae comitantes are less than 1 mm in diameter, the flap design is shifted
more laterally to include the cephalic vein.

371
Flap selection
A
B
C
Fig. 14.19  Up to three perforators are present in the ulnar artery perforator flap at
approximately 7 cm, 11 cm, and 16 cm above the pisiform, respectively. The flap
designed with the distal margin 5 cm proximal to the pisiform (A). The ulnar nerve
travels closely with the vessels and should be carefully separated (B). The septum
and perforators are dissected off of the flexor carpi ulnaris (FCU) through the
posterior incision (C). The median nerve is near the origin of the vascular pedicle
and should be protected from traction injury (D). A second skin paddle can be
created for neck resurfacing based on a separate perforator (E).
D
E
vessels. Some of the deltoid insertion can be divided in order
to gain further pedicle length if necessary. The anterior inci­
sion is made, and subfascial dissection proceeds posteriorly
toward the septum. The distal pedicle is ligated, and the flap
can be elevated from a distal to proximal direction.
The donor site for the lateral arm flap is closed primarily
over a closed suction drain (Fig. 14.20D). Skin grafting to the
upper arm is not recommended. If a larger flap is needed, a
different flap is chosen.
Free jejunal flap
In circumstances when fasciocutaneous flaps are not an option
for reconstruction of circumferential defects, the jejunal flap
represents an excellent option.53–55 The jejunal segment is
harvested through a midline celiotomy incision but can
also be harvested using a minimally invasive laparoscopic
approach depending on surgeon skill and comfort. The jejunal
flap provides excellent swallowing function as the normal

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CHAPTER 14 • Pharyngeal and esophageal reconstruction
Flap inset
The flap inset is completed in a similar fashion compared to
other circumferential defects using 3-0 Vicryl sutures. The
proximal anastomosis may need to be spatulated to widen the
jejunum to the appropriate size to match the oropharynx.
Conversely, the distal anastomosis may require spatulation of
the esophagus in order to match the size of the jejunum. The
anastomosis is typically performed in a single layer, although
some may prefer to perform an additional layered closure in
a Lembert fashion. The flap should be inset with the neck in
neutral position and with some slight stretch to avoid any
redundancy in the jejunum which can cause dysphagia.
A portion of the jejunum is divided creating a segment of
2–3 cm that remains attached to the terminal arcade vessels
(Fig. 14.21C). This segment is externalized through the neck
skin and wrapped in petroleum impregnated gauze to pre­
serve the moisture within the monitoring segment. The
segment can be used to monitor the viability of the jejunum
both by color, turgor, Doppler, and peristalsis. Prior to dis­
charge, the pedicle to the monitoring segment can be ligated
with a simple suture. We prefer to place a 2-0 silk around the
terminal arcade vessel outside the skin closure. When the
monitoring segment is ready to be removed, one can simply
tighten the silk tie and remove the bowel segment.
A
B
C
Fig. 14.20  The lateral arm flap is designed over the septum between the biceps
and triceps muscles (A). Dissection is carried out through the posterior incision first
to identify the perforator (B). The radial nerve should be carefully separated from the
vascular pedicle as they travel closely together (C). The donor site is closed
primarily over a drain (D).
D
mucosa provides adequate lubrication to facilitate the passage
of the food bolus. It heals well with low risk for fistula forma­
tion and avoids a longitudinal suture line for circumferential
reconstruction. There are, however, several serious disadvan­
tages. Tracheoesophageal speech through tracheoesophageal
puncture (TEP) is difficult and often unsuccessful. Donor site
complication with bowel resection can be more serious than
fasciocutaneous flaps.
Flap harvest
A midline laparotomy incision is made, and the small bowel
is eviscerated in order to visualize the mesentery. Backlighting
of the mesentery allows visualization of the vascular arcades
supplying the jejunum (Fig. 14.21A), and typically the second
arcade is selected as the pedicle for the flap. Once the arcade
is identified, the pedicle is dissected to the root of the mesen­
tery but need not proceed to the origin from the superior
mesenteric trunk, and an injury to the main trunk would be
catastrophic. The branches to the neighboring arcade are
divided up to the serosa which isolates a segment of jejunum
of 10–15 cm (Fig. 14.21B). The bowel is then divided and can
be rejoined using staplers. It is important to mark the proximal
end of the bowel to make certain the inset is performed in
alignment with normal peristalsis.