Neurovascularized Free Short Head of the Biceps Femoris Muscle Transfer for One-Stage Reanimation of Facial Paralysis

Abstract

The single-stage technique for cross-face reanimation of the paralyzed face without nerve graft is an improvement over the two-stage procedure because it results in early reinnervation of the transferred muscle and shortens the period of rehabilitation. On the basis of an anatomic investigation, the short head of the biceps femoris muscle with attached lateral intermuscular septum of the thigh was identified as a new candidate for microneurovascular free muscle transfer. The authors performed one-stage transfer of the short head of the biceps femoris muscle with a long motor nerve for reanimation of established facial paralysis in seven patients. The dominant nutrient vessels of the short head were the profunda perforators (second or third) in six patients and the direct branches from the popliteal vessels in one patient. The recipient vessels were the facial vessels in all cases. The length of the motor nerve of the short head ranged from 10 to 16 cm, and it was sutured directly to several zygomatic and buccal branches of the contralateral facial nerve in six patients. One patient required an interpositional nerve graft of 3 cm to reach the suitable facial nerve branches on the intact side. The period required for initial voluntary movement of the transferred muscles ranged from 4 to 10 months after the procedures. The period of postoperative follow-up ranged from 5 to 42 months. Transfer of the vascularized innervated short head of the biceps femoris muscle is thought to be an alternative for one-stage reconstruction of the paralyzed face because of the reliable vascular anatomy of the muscle and because it allows two teams to operate together without the need to reposition the patient. The nerve to the short head of the biceps femoris enters the side opposite the vascular pedicle of the muscle belly, and this unique relationship between the vascular pedicle and the motor nerve is anatomically suitable for one-stage reconstruction of the paralyzed face. As much as to 16 cm of the nerve can be harvested, and the nerve is long enough to reach the contralateral intact facial nerve in almost all cases. The lateral intermuscular septum, which is attached to the short head, provides "anchor/suture-bearing" tissue, allowing reliable fixations to the zygoma and the upper and lower lips to be achieved. In addition, the scar and deformity of the donor site are acceptable, and loss of this muscle does not result in donor-site dysfunction.

Double innervated free functional muscle transfer for facial reanimation

“…This may be related to the variability of the number of axons that reach the target muscle since they must grow through two coaptations, thus potentially decreasing the axonal load and the recruitment of potential motor units. To overcome this, a one-stage FFMT for smile reanimation has gained popularity innervated by different donor nerves including the contralateral facial by using a muscle with a long nerve or performing additional manoeuvres to increase the length of the nerve [10][11][12][13][14]. Between other donor nerves (mostly branches of the V, XI, or XII cranial nerves [15][16][17]) used as neurotisers for the FFMT, the motor branch of the masseter nerve has gained popularity worldwide because of its predictable results, rapid muscle innervation, low donor site morbidity, and potential for cortical plasticity [7].…”

Availability of Latissimus Dorsi Minigraft in Smile Reconstruction for Incomplete Facial Paralysis: Quantitative Assessment Based on the Optical Flow Method

“…However, one-stage transfer using the various muscles is developing and becoming the first choice, especially among Asian surgeons. 3,4,[17][18][19] Muscle transfer is more time consuming and labor intensive than cross-face nerve grafting but offers an assured method with which to obtain sufficient power in the cheek to achieve a symmetrical smile. We thus believe that one-stage muscle transfer is better than cross-face nerve graft with or without muscle transfer.…”

Sihler's whole mount nerve staining technique: a review

“…Free flaps for facial reanimation can be obtained from limb and trunk muscles including gracilis (Sassoon et al 1991, Terzis and Noah 1997, Bae et al 2006, Faria et al 2007), latissimus dorsi (Dellon and Mackinnon 1985, Wei et al 1999, Harrison 2002, Faria et al 2007), pectoralis minor (Terzis and Noah 1997, Harrison 2002), biceps femoris (Hayashi and Maruyama 2005), and rectus (Marek and Pu 2004) or oblique (Wang et al 2002) abdominus. This strategy also has considerable potential for treating other skeletal muscle paralyses.…”