From the Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University.
Plast Reconstr Surg. 2019 Aug;144(2):252e-263e. doi: 10.1097/PRS.0000000000005871.
Facial paralysis and postparalysis facial synkinesis both cause severe functional and aesthetic deficits. Functioning free muscle transplantation is the authors' preferred method for reconstructing both deformities.
From 1985 to 2017, a total of 392 patients underwent 403 gracilis functioning free muscle transplantations for facial reanimation. Different motor neurotizers were used: cross-face nerve graft (74 percent), spinal accessory nerve (17 percent), and masseter nerve (8 percent). Smile excursion score, cortical adaptation stage, patient questionnaire, Hadlock lip excursion, and the Terzis evaluation systems were used to assess outcomes.
For smile excursion score, the spinal accessory and masseter nerve groups showed higher scores than the cross-face nerve graft group in the first 2 years, but no difference by 3-year follow-up. For cortical adaptation stage, nearly all cross-face nerve graft patients achieved stage IV or V spontaneity, the spinal accessory nerve group achieved at least stage III (independent) movement, but individuals in the masseter nerve group achieved only stage III or less. The cross-face nerve graft group also achieved higher scores according to the Hadlock system and the Terzis evaluation system compared with the other two groups.
The concept of "sugarcane chewing" where the sweetness is the least at the tail but the most at the head can be simply applied for surgeons and patients in weighing the benefits and drawbacks during the motor neurotizer selection. Cross-face nerve graft-innervated gracilis is analogous to chewing sugarcane from tail to head; despite lower outcome measures earlier, it yields the highest scores at 3 years postoperatively. Masseter-innervated gracilis is akin to chewing sugarcane from head to tail, with greater outcome scores initially but little improvement at longer follow-up. Spinal accessory-innervated gracilis results fall in between these two groups.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
面瘫和面瘫后面肌联带运动都会导致严重的功能和美观缺陷。游离肌肉移植是作者重建这两种畸形的首选方法。
1985 年至 2017 年，共有 392 例患者接受了 403 例股薄肌游离功能移植以进行面部再神经化。使用了不同的运动神经化器：面横神经移植（74%）、副神经（17%）和咬肌神经（8%）。微笑幅度评分、皮质适应阶段、患者问卷调查、哈多克上唇位移和泰尔齐评估系统用于评估结果。
对于微笑幅度评分，在最初的 2 年内，副神经和咬肌神经组的评分高于面横神经移植组，但在 3 年随访时无差异。对于皮质适应阶段，几乎所有面横神经移植患者都达到了 IV 级或 V 级自发性，副神经组至少达到了 III 级（独立）运动，但咬肌神经组患者仅达到了 III 级或以下。与其他两组相比，面横神经移植组在哈多克系统和泰尔齐评估系统中的评分也更高。
“咀嚼甘蔗”的概念可以简单地应用于外科医生和患者，以权衡在选择运动神经化器时的利弊。面横神经移植支配的股薄肌类似于从尾部到头部咀嚼甘蔗；尽管早期结果测量较低，但在术后 3 年时获得的评分最高。咬肌神经支配的股薄肌类似于从头部到尾部咀嚼甘蔗，初始结果评分较高，但在更长的随访中改善较少。副神经支配的股薄肌结果介于这两组之间。
临床问题/证据水平：治疗性，IV。
