Functional Outcomes of Single-Stage Facial Reanimation Surgery With Radical Parotidectomy
Article information
Abstract
Objectives.
Facial nerve sacrifice during radical parotidectomy can impair quality of life. This study assessed the effectiveness of single-stage facial reanimation surgery performed concurrently with radical parotidectomy in restoring facial function.
Methods.
A retrospective analysis was conducted on patients who underwent single-stage facial reanimation combined with radical parotidectomy. The techniques employed included selective reinnervation and orthodromic temporalis tendon transfer. Outcomes were evaluated using the modified House-Brackmann and Terzis grading systems, Emotrics facial assessment, and the Facial Disability Index (FDI).
Results.
Among the 13 patients studied (median age, 54 years; 69% male), 10 underwent selective reinnervation. Of these, nine patients demonstrated improvement, achieving House-Brackmann grade III and Terzis grade 4 or 5. The other three patients underwent tendon transfer and achieved moderate functional outcomes. Emotrics analysis revealed balanced facial symmetry in the selective reinnervation group. Furthermore, FDI scores indicated satisfactory physical and social/well-being functions.
Conclusion.
Single-stage facial reanimation effectively restores facial function in patients undergoing radical parotidectomy. This approach offers meaningful benefits in the early recovery of facial function.
INTRODUCTION
Tumors of the parotid gland are primarily managed with surgery. Malignant tumors often necessitate ablative surgery, which requires sacrificing the facial nerve when it exhibits tumor involvement. In previous studies, the incidence of facial nerve involvement by parotid malignancies has ranged from 12% to 15% [1,2]. Separate research indicates that the rates of temporary and permanent postoperative facial palsy following parotidectomy are 3.7%–21.8% and 0.9%–4%, respectively [3,4]. Facial nerve sacrifice is often required for a sound oncological outcome when a malignant parotid tumor invades the main trunk of the nerve [5]. Nerve sacrifice inevitably leads to facial paralysis, resulting in both functional and psychological impairment. Functional issues associated with facial palsy include corneal injury, visual disturbances, and difficulties with facial expressions, eating, drinking, and speaking [6]. Additionally, many patients with facial palsy experience psychosocial challenges, such as clinically significant levels of anxiety and depression, reduced quality of life, impaired social function, and high levels of appearance-related distress [7].
Reconstruction following ablative surgery for advanced parotid tumors has often been overlooked [8]. Delaying reconstructive surgery can cause prolonged functional discomfort for patients. Extended facial paralysis results in atrophy of the innervated facial muscles, which leads to persistent facial asymmetry. Therefore, prompt or immediate restoration of facial function would benefit these patients. To our knowledge, few research studies have examined single-stage reanimation surgery performed concurrently with radical parotidectomy [9].
The traditional method of facial nerve reanimation involves anastomosis between the main trunk of the facial nerve and each peripheral branch, using an interposition nerve graft such as the sural nerve or the greater auricular nerve. However, this method has limitations, including weak motor power—particularly during smiling—and synkinesis of the facial muscles. Recent research has highlighted the masseteric nerve as a key power source due to its strong motor capabilities and rare association with synkinesis [10]. Selective reinnervation, which employs specific nerves as power sources for eye closure, smile excursion, and maintenance of lower lip tone, can restore facial nerve function while minimizing the risk of synkinesis. When selective reinnervation is not an option, orthodromic temporalis tendon transfer (OTTT) may serve as an alternative for reanimating the smile. The objective of this study was to analyze the outcomes of single-stage facial reanimation surgery performed concurrently with radical parotidectomy, utilizing selective reinnervation and OTTT.
MATERIALS AND METHODS
This retrospective study was approved by the Institutional Review Board at Seoul National University Hospital (No. 2308-086-1458). The research was conducted in accordance with the Helsinki Declaration of 1975 as revised in 1983. Informed consent for participation in this study was waived. However, written informed consent was obtained from the patients for the use of their facial images in the figures included in this manuscript.
Study design
Patients with parotid tumors who underwent a single-stage facial reanimation surgery with radical parotidectomy between September 2019 and October 2022 with at least eight months of follow-up were included. Clinicopathological data including age, sex, histopathology, tumor side, staging, prior surgery, the interval between surgeries, surgical procedures performed, adjuvant therapies, complications, oncologic outcome, preoperative and postoperative facial nerve functions, and patient-rated functional outcomes were reviewed.
Preoperative and postoperative observer-rated subjective facial nerve functions were analyzed with modified House-Brackmann Grading System [11], Terzis Facial Grading System [12], and Chuang smile excursion score. For postoperative objective facial nerve function analysis, Emotrics software (Massachusetts Eye and Ear Infirmary) [13] was utilized at the last follow-up available. Emotrics created the vertical midline perpendicular to interpupillary distance and used 68 points at facial landmarks confirmed and adjusted by the authors. It automatically calculated several distances and angles (Supplementary Fig. 1). Both at rest and during smile activation with jaw clenching, commissure position and commissure height deviation data were collected.
Postoperative patient-rated outcome measure using Facial Disability Index (FDI) was analyzed, including physical and social/well-being function subscales [14]. Subjective pain and cosmetic satisfaction were assessed with visual analog scale (VAS) for pain score (0, no pain; 5, fair; 10, most severe pain) and 5-point Likert scale for cosmetic satisfaction score (1, very unsatisfied; 2, unsatisfied; 3, neutral; 4, satisfied; and 5, very satisfied).
Operative technique
All patients received definitive resection of the gross disease including radical parotidectomy and surgery for facial reanimation simultaneously. Main procedures of the surgeries were conducted by a single otolaryngologist-head and neck surgeon under intraoperative neuromonitoring (IONM) of facial nerve. Needle electrodes were placed in four areas innervated by branches of facial nerve: temporal, zygomatic, buccal, and marginal mandibular branches. Ground and stimulator electrodes were placed at the sternum area. A stimulation probe was available in the operation table. Neuromuscular junction blockade was reversed during surgery. IONM assisted surgeon to identify the main trunk and each branch of the facial nerve during radical parotidectomy. Peripheral branches of the facial nerve were traced and identified to their greatest possible number and extent before severing the portion involved by the tumor. Mastoid drilling was conducted by otologists when temporal bone resection or subtotal petrosectomy were indicated for the resection of the primary tumor or when there was a need to expose more proximal part of the facial nerve due to involvement of the main trunk. Therapeutic neck dissections were performed for clinically positive lymph nodes. Elective neck dissections were performed for T3–4 tumors. After severing the portion of the facial nerve involved by the tumor, facial nerve reanimation was performed simultaneously either by selective facial nerve reinnervation (triple/dual reinnervation) or OTTT.
Selective facial nerve reinnervation (Selective neurorrhaphy between nerve to zygomaticus major muscle-masseteric nerve [5-7] & nerve to orbicularis oculi muscle-proximal facial nerve stump [7-7])
For selective reinnervation of nerve to zygomaticus major muscle, masseteric nerve was identified with the help of the IONM stimulator (Supplementary Video 1). Tension-free epineural neurorrhaphy was applied between the masseteric nerve and the nerve to zygomaticus major muscle. An autologous interposition nerve graft was utilized to fill the gap in nerve continuity between the nerve to orbicularis oculi muscle and proximal facial nerve stump (7-7). Nerve grafts were harvested from the operating field if available, for example, the greater auricular nerve graft (n=4, case No. 1, 3, 8, 10) from the field of neck dissection, the antebrachial cutaneous nerve (n=2, case No. 2, 9) from radial forearm free flap donor site, or the sural nerve (n=4, No. 4-7) when the former two nerves were unavailable or when its generous length was necessary. When available, the nerve to orbicularis oris muscle was anastomosed to ansa cervicalis nerve (12-7) to maintain the tone of the lower lip. Dual reinnervation refers to reinnervations of nerve to zygomaticus major muscle with masseteric nerve and nerve to orbicularis oculi muscle with proximal facial nerve stump. Triple reinnervation refers to the procedure of dual reinnervation plus reinnervation of nerve to orbicularis oris muscle with ansa cervicalis nerve (Fig. 1).
Selective (triple) reinnervation. (A) Schematic illustration of triple reinnervation. (B) Intraoperative view following selective reinnervation. (1) An interposition graft connects the main trunk of the facial nerve to the nerve innervating the orbicularis oculi muscle. (2) The masseteric nerve is coapted to the nerve of the zygomaticus muscle. (3) The ansa cervicalis nerve is coapted to the nerve of the orbicularis oris muscle.
Orthodromic temporalis tendon transfer
When selective reinnervation was unavailable, OTTT was conducted for dynamic reconstruction of the midface and smile. The coronoid process, the insertion point of the temporalis muscle, was identified. Coronoidectomy was conducted to mobilize bone segment with the attached temporalis tendon. After mobilizing the temporalis tendon with coronoid process, a hole was created to the bone segment using a drill. To extend the reach of the temporalis tendon, the palmaris longus tendon harvested from the radial forearm free flap donor site or a strip of the fascia lata from the anterolateral thigh flap donor site was used. The palmaris longus tendon or the strip of the fascia lata was fixed to the temporalis tendon using a hole created at the coronoid process. The other end of the palmaris longus tendon or the fascia lata strip was divided into two branches. These branches were fixed to the upper lip and the lower lip at the philtrum through submucosal tunnels (Fig. 2).
Orthodromic temporalis tendon transfer. (A) Schematic illustration of orthodromic temporalis tendon transfer. (B) Intraoperative view after orthodromic temporalis tendon transfer.
Statistical analysis
Statistical analysis of quantitative measurements obtained from Emotrics software was conducted using SPSS version 27 (IBM Corp.). Postoperative Emotrics data of selective reinnervation group were compared between the affected side and the normal side using paired t-test. All statistical tests were two-sided and statistical significance was defined as P<0.05.
RESULTS
Patient characteristics
We identified 14 patients with parotid tumors who underwent single-stage facial reanimation surgery concurrent with radical parotidectomy. One patient had a follow-up period shorter than 5 months and was thus excluded. Consequently, a total of 13 patients were included in the analysis. Table 1 details the demographic data, histopathologic information, and preoperative facial nerve grades for these patients. Most patients were male (n=9, 69%), with a median age of 54 years (range, 21–73 years). The final histopathologic diagnoses were most commonly malignant tumors (n=10, 76.9%), including adenoid cystic carcinoma (n=3, 23.1%), salivary duct carcinoma (n=3, 23.1%), acinic cell carcinoma (n=1, 7.7%), mucoepidermoid carcinoma (n=1, 7.7%), secretory carcinoma (n=1, 7.7%), and squamous cell carcinoma (n=1, 7.7%). Benign histopathologic diagnoses included facial nerve schwannoma and recurred pleomorphic adenoma. All tumors had either invaded or completely encased the facial nerve, necessitating its sacrifice. Among the patients with malignant tumors, the final pathologic T stage according to the American Joint Committee on Cancer, eighth edition, was T4a for seven patients and T3 for three. Six patients had previously undergone surgery, with the interval between procedures ranging from 2 months to 30 years. The preoperative facial nerve grades, as determined by the House-Brackmann grading system, varied from stage I to V.
Demographic and histopathologic data, preoperative facial nerve grade, and surgical procedures performed
Surgical procedures
Table 1 details the facial reanimation procedures performed by patient. All patients underwent radical parotidectomy including facial nerve sacrifice. In eleven patients (except for patient No. 5 and 11), mastoid drilling was conducted, and the proximal facial nerve was identified. Facial reanimation surgery was performed in a single-stage manner. Ten patients (No. 1–10) received single-stage, multiple selective reinnervations (either dual or triple reinnervation) that utilized the masseteric nerve. The remaining three patients (No. 11–13) were treated with OTTT.
Among the 10 patients who underwent selective reinnervation, dual reinnervation was conducted for four, while triple reinnervation was employed for six. Various local or free flaps were utilized, including the sternocleidomastoid muscle rotational flap in four cases and the temporalis muscle rotational flap in one case. Vascularized free flaps, such as the radial forearm free flap (n=3) and the anterolateral thigh free flap (n=4), were employed to cover avascular nerve grafts and concurrently reconstruct facial contours for patients who required postoperative radiation therapy. After harvesting, the free flaps were de-epithelialized and then inset as adipofascial flaps to augment the facial volume.
Regarding the three patients who underwent OTTT, this option was selected because selective reinnervation of the nerve to the zygomaticus major muscle with the masseteric nerve was not feasible intraoperatively. In patient No. 11, a recurrent tumor had invaded the distal portion of the nerve extending to the zygomaticus major muscle. Consequently, facial reanimation was attempted using OTTT with a palmaris longus tendon graft. In patient No. 12, selective reinnervation was not practical due to the patient’s long-standing preoperative facial palsy, which was rated as House-Brackmann grade V. Thus, OTTT was the chosen intervention. For patient No. 13, selective reinnervation was not possible because the zygomatic and buccal branches of the facial nerve were affected by the tumor, as indicated by frozen section analysis. Consequently, OTTT with fascia lata was performed.
Facial functional results
The median postoperative follow-up period was 14 months, with a mean of 17.2 months and a range of 8 to 30 months. Postoperative facial functional results are presented in Table 2, reflecting the functional outcomes at the latest follow-up. Among the 10 patients who underwent reinnervation, the facial function was rated as modified House-Brackmann grade III and Terzis grade 4 to 5 in nine patients (grade 4, n=4, 40%; grade 5, n=5, 50%) (Supplementary Video 2). Patient No. 3, who exhibited House-Brackmann grade IV facial nerve palsy before surgery, displayed postoperative facial function of modified House-Brackmann grade V and Terzis grade 1. The patients treated with OTTT demonstrated results including modified House-Brackmann grade IV or V and Terzis grade 2 (Supplementary Video 3).
Functional outcomes
The results of the Emotrics analysis for the selective reinnervation group are presented in Fig. 3. In the selective reinnervation group, the mean (±standard deviation) oral commissure positions on the affected and normally functioning contralateral sides were 27.53±3.14 mm and 29.62±6.41 mm (P=0.147) at rest and 31.28±5.41 mm and 33.19±6.45 mm (P=0.341) when smiling, respectively. These measurements indicate no significant difference between the affected and normal sides. Similarly, the mean oral commissure heights on the affected and normally functioning contralateral sides showed no significant difference, measuring 10.48±4.79 mm versus 8.13±4.17 mm at rest (P= 0.101) and 8.23±6.13 mm versus 7.46±4.20 mm when smiling (P=0.670). In the orthostatic temporalis tendon transfer group, the mean oral commissure positions on the affected and normal sides were 33.30±10.42 mm and 33.29±5.55 mm (P=0.998) at rest and 31.57±3.86 mm and 37.02±5.30 mm (P=0.023) when smiling, respectively. The mean oral commissure heights on the affected and normal sides were 4.99±4.57 mm and 4.01±1.88 mm at rest (P=0.650) and 5.08±3.77 mm and 1.09±4.13 mm when smiling (P=0.416), respectively.
Postoperative Emotrics results for the selective reinnervation (A) and orthodromic temporalis tendon transfer (OTTT; B) groups.
Patient-rated outcomes
Postoperative patient-rated outcome measures, including the FDI, pain VAS, and cosmetic satisfaction score, were available for all but two patients (patients No. 1 and 12), as detailed in Supplementary Table 1. The median follow-up period for postoperative patient-rated outcome assessment was 10 months (range, 3–22 months). All subjective pain scores were at or below 4. The cosmetic satisfaction score indicated that six patients were content with their cosmetic results, with two very satisfied and four satisfied. Four patients reported neutral feelings, and one patient was very unsatisfied. The mean scores for the FDI physical subscale, FDI social/well-being subscale, and total FDI were 68.2±18.5 (range, 30–100), 63.3±23.5 (range, 24–96), and 131.5±37.1 (range, 74–186), respectively.
Adjuvant treatment and oncologic outcomes
For postoperative adjuvant treatment, five patients received only radiotherapy, while three underwent concurrent chemotherapy. One patient was treated with chemotherapy alone due to prior concurrent chemoradiotherapy before salvage surgery. At the most recent follow-up, seven patients displayed no evidence of disease, while the remaining six patients exhibited disease progression. Three patients had developed distant metastases to the lungs, and one patient had metastases to both the lungs and spine. In two cases, radical parotidectomy and facial reanimation were performed as salvage procedures following the failure of initial concurrent chemoradiation therapy. These two patients had already developed lung metastases prior to salvage surgery. Consequently, metastasectomy or stereotactic ablative radiotherapy was employed to manage lung metastases after parotid surgery. Despite these interventions, disease progression occurred in both patients; one experienced local recurrence and lung metastases, while the other had local recurrence and distant metastases to the lung, femur, and ribs.
DISCUSSION
This study explored facial function outcomes following single-stage facial reanimation surgery performed concurrently with radical parotidectomy. Selective reinnervation and OTTT were employed for facial reanimation. Both clinician-based and automated facial assessment tools were used to evaluate the results. The findings indicated favorable clinician-based functional outcomes, with nine of the 10 selective reinnervation cases demonstrating a modified House-Brackmann grade of III and a Terzis grade of 4 or 5. Automated assessment using Emotrics revealed no significant difference in postoperative oral commissure position when comparing the operated side to the normal contralateral side.
While ablative surgery for parotid tumors can necessitate the sacrifice of the facial nerve [1,2], its immediate functional restoration has received relatively little attention [8]. A previous study revealed that 68.8% of patients undergoing total parotidectomy with facial nerve sacrifice do not receive concurrent facial reanimation. Minimal research has examined the functional outcomes of single-stage reanimation surgery performed simultaneously with radical parotidectomy [9]. To our knowledge, this study is the first in East Asia to investigate the functional outcomes of single-stage facial reanimation surgery with radical parotidectomy.
When reconstructive surgery is delayed after facial nerve sacrifice, the patient may experience prolonged facial paralysis and functional deterioration. Such extended paralysis can lead to the atrophy of facial muscles and permanent facial asymmetry. Immediate facial reanimation benefits patients by reducing the duration of facial paralysis. Moreover, previous research indicates that early facial reanimation is associated with superior functional outcomes. For instance, performing early neurorrhaphy (within 1 year) using an interposition nerve graft has been shown to yield better facial function compared to delayed treatment [15]. In another study that examined hemihypoglossal-facial neurorrhaphy with and without grafts, as well as masseter-facial nerve transfer, surgery conducted more than 2 years after the injury was linked to inferior outcomes [16]. Simultaneous facial reanimation can also be advantageous for reconstructive surgeons. The technique involves no adhesions, and the peripheral branches of the facial nerve can be readily identified during parotidectomy, increasing the feasibility of selective reinnervation.
In the present study, the patients who underwent selective reinnervation demonstrated relatively favorable postoperative functional outcomes. Traditionally, facial reanimation has involved anastomosis between the main trunk of the facial nerve and its peripheral branches, established using an interposition nerve graft. However, when this technique is applied at the main trunk level, synkinesis between the upper and lower divisions is a potential limitation. Synkinesis refers to involuntary movements, such as oral excursion when one attempts to close an eye, leading to persistent discomfort and functional impairment. Since treating synkinesis is challenging, its prevention is a key concern of facial reanimation. Selective reinnervation, which employs distinct nerves as power sources for eye closure, smile dynamics, and lower lip tone, can prevent this issue. Recent studies have emphasized the masseteric nerve as a useful power source for restoring dynamic smile movement [10]. A retrospective study that compared interposition nerve graft with masseteric nerve transfer found that the latter resulted in strong oral commissure excursion and avoided obvious synkinesis [17]. In our study, utilizing the masseteric nerve for the reinnervation of the zygomatic major muscle also yielded good functional outcomes regarding lip movement, as evidenced by Emotrics analysis. Overall, the clinician-assessed functional outcomes of selective reinnervation appeared superior to those of OTTT.
However, patient No. 3 exhibited poor functional outcomes even after selective reinnervation with the masseteric nerve. For 14 months, this individual had experienced preoperative facial paralysis of modified House-Brackmann grade IV, attributable to previous surgery for salivary duct carcinoma of the parotid gland. Despite undergoing single-stage selective reinnervation with the masseteric nerve, functional assessment 7 months postoperatively indicated a decline to modified House-Brackmann grade V and Terzis grade 1, signifying an absence of facial movement recovery. Thus, the duration of pre-existing facial paralysis may represent an indicator of poor facial functional outcomes, a finding that aligns with the existing literature [16].
In this study, three patients underwent OTTT. When tumor invasion is too extensive to preserve the branches of the facial nerve, or when the patient exhibits long-standing facial palsy with distal atrophy, selective reinnervation may not be feasible. In such cases, regional muscle transposition can be considered as an alternative, potentially involving the temporalis, masseter, or anterior belly of the digastric muscles. Temporalis muscle transfer, in particular, is widely performed. Traditional “antidromic” temporalis muscle transfer involves detaching the muscle from its calvarium insertion site, transferring it to the zygomatic arch, and attaching it to the modiolus and lateral nose. However, this technique has been associated with donor site deformity and excessive tissue bulk in the zygomatic arch area. Addressing these issues, “orthodromic” temporalis muscle transfer detaches the temporalis muscle from the coronoid process insertion site and reattaches it to the oral commissure. This procedure is less extensive than free flap transfer and enables a clenching smile after rehabilitation, thus facilitating social interaction through facial expression. Therefore, OTTT can be a viable surgical option for the restoration of irreversible facial paralysis when selective reinnervation is impractical.
The FDI comprises 10 Likert-type items designed to assess physical and social/well-being functions. The physical function scale ranges from −25 to 100, while the social/well-being scale ranges from 0 to 100. A higher score indicates a more favorable outcome [14]. In a study of 30 patients with unilateral facial palsy and stable facial function, approximately two-thirds of whom had undergone facial reanimation procedures, the mean FDI score for physical function was 63.8, while the mean score for social/well-being function was 63.3 [18]. In our study, the mean scores for FDI physical function and social/well-being function were 68.2 and 63.3, respectively, which are comparable to the prior results. Research suggests that the FDI score for social/well-being function is poorly correlated with observer-assessed facial function [18,19]. Consequently, even when observer-rated and physical function scores are favorable, the FDI score for social/well-being function may be relatively low. In the present study, such a discrepancy could have arisen because most patients had not experienced facial palsy prior to surgery, potentially creating high expectations for the functional outcomes of facial reanimation. Further prospective studies are necessary to improve both objectively assessed functional outcomes and patient-rated subjective outcomes.
In this study, we focused on the functional outcomes of single-stage facial reanimation surgery following radical parotidectomy, utilizing both clinician-based assessments and automated facial assessment tools. To date, no randomized studies have compared selective reinnervation to interposition nerve graft. Such research is challenging due to the rarity of cases involving radical parotidectomy with extensive facial nerve root sacrifice, as well as the inherent variability in surgical outcomes. Despite these obstacles, our study highlights the potential benefits of selective reinnervation, which may offer more consistent and satisfactory functional results. Further comparative studies are necessary to objectively evaluate facial reanimation methods, with the aim of optimizing functional outcomes and improving quality of life for patients who undergo parotidectomy with facial nerve sacrifice.
In conclusion, in radical parotidectomy with facial nerve sacrifice, single-stage facial reanimation surgery with selective reinnervation utilizing the masseteric nerve or OTTT yielded favorable outcomes in terms of facial function. This surgical approach could benefit patients by facilitating earlier restoration of facial function.
HIGHLIGHTS
▪ This study examined the functional outcomes of single-stage facial reanimation following radical parotidectomy.
▪ Selective reinnervation yielded favorable outcomes regarding both clinician-based and automated facial assessment tools.
▪ Facial Disability Index scores suggested fair physical and social/well-being functions.
Notes
No potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conceptualization: JYJ, EJC. Data curation: JYJ, MKP, MWS, SHA, EJC. Formal analysis: JYJ. Methodology: JYJ, SDK, EJC. Visualization: SDK. Writing–original draft: JYJ. Writing–review & editing: all authors. All authors read and agreed to the published version of the manuscript.
Acknowledgements
The authors wish to express their gratitude to faculty members John Yoo and Damir Matic at the London Health Sciences Centre in London, Ontario, Canada, for sharing their surgical techniques.
This research was supported by the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare (grant number HI22C1323), and by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (grant number 2023R1A2C1007783).
SUPPLEMENTARY MATERIALS
Supplementary materials can be found via https://doi.org/10.21053/ceo.2024.00094.
Postoperative patient-rated outcome measures
Emotrics analysis of postoperative resting (A) and big smile expression state (B).
Selective reinnervation (Dual reinnervation) surgical procedures. The masseteric nerve is identified and confirmed by intraoperative nerve stimulation. Tension-free epineural neurorrhaphy is applied between the masseteric nerve and the nerve to zygomaticus major muscle. An autologous interposition nerve graft, the antebrachial cutaneous nerve harvested from the radial forearm free flap donor site in this video, is placed between the nerve to orbicularis oculi and facial nerve trunk and neurorrhaphy is conducted.
Postoperative functional result of selective reinnervation.
Postoperative functional result of orthodromic temporalis tendon transfer.