Long-term results of microvascular free-tissue transfer reanimation of the paralyzed face: three cases.

Abstract

We conducted a retrospective case review at our tertiary care academic medical center to assess the long-term results of microvascular free-tissue transfer to achieve facial reanimation in 3 patients. These patients had undergone wide-field parotidectomy with facial nerve resection. Upper facial reanimation was accomplished with a proximal facial nerve--sural nerve graft, and lower facial movement was achieved through proximal facial nerve--long thoracic (serratus muscle) nerve anastomosis. Outcomes were determined by grading postoperative facial nerve function according to the House-Brackmann system. All 3 patients were able to close their eyes independent of lower facial movement, and all 3 had achieved House-Brackmann grade III function. We conclude that reanimating the paralyzed face with microvascular free-tissue transfer provides anatomic coverage and mimetic function after wide-field parotidectomy. Synkinesis is reduced by separating upper- and lower-division reanimation.

Introduction

Wide-field parotidectomy with resection of the facial nerve and the muscles of facial expression is rarely necessary. When it is required, it is most often performed on patients with malignant parotid tumors or multifocally disseminated benign parotid tumors. (1) Primary nerve repair or interposition nerve grafting techniques are not feasible in this small group of patients)

We describe the long-term results of microvascular flee-tissue transfer of the serratus anterior muscle to achieve facial reanimation in 3 patients who had undergone wide-field parotidectomy with facial nerve resection.

Surgical technique

Exposure. A routine preauricular parotid incision is extended superiorly into the temporal region and inferiorly into a natural horizontal skin crease (figure 1). The cartilaginous external auditory canal is transected, oversewn, and reflected posteriorly if a subtotal petrosectomy is needed. (3) A functional neck dissection is performed, with preservation of a suitable artery and vein that may be used as recipient vessels.

Tumor removal. Distal branches of the facial nerve are identified and tagged adjacent to the periorbital musculature. The entire parotid gland, surrounding facial musculature, and soft tissue of the infratemporal fossa are included in the tumor resection. The facial nerve is transected proximal to the stylomastoid foramen at the distal vertical (mastoid) segment. Tissue samples from any areas in question are taken for frozen-section analysis. The wound is closed in a standard fashion over a suction drain, and a light pressure dressing is applied to the face and neck.

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Facial reconstruction. If the final pathology report confirms clear tumor margins, the patient is returned to the operating room during the same hospitalization. If necessary, re-resection of close margins can be performed prior to reconstruction of the defect.

A long sural nerve graft is harvested through multiple small, transverse leg incisions. The nerve is typically identified 2 to 4 cm anterior to the Achilles tendon on the lateral surface of the ankle (figure 2, A). (4)

A vertical skin incision is made parallel to the anterior border of the latissimus dorsi muscle, and the serratus anterior muscle is identified (figure 2, B). Two to 5 muscle slips can be developed by blunt and sharp dissection. The thoracodorsal artery and vein are preserved in the vascular pedicle, and the long thoracic nerve is protected for the facial neurorrhaphy. The donor bed is closed in layers over a suction drain. (5)

The vertical segment of the facial nerve is sharply divided into two segments consisting of roughly two-thirds and one-third of the diameter of the nerve. The sural nerve is interposed between the one-third part of the facial nerve segment and the periorbital branches that were tagged during the previous procedure. The long thoracic nerve is anastomosed to the larger segment of the facial nerve. Two or 3 slips of the serratus muscle are sutured to the nasolabial crease and the perioral regions for restoration of the patient's smile (figure 3). (6) The vascular anastomoses are performed in the standard fashion in the cervical area. The wound is closed in layers over 2 suction drains. A light noncompressive dressing is used. Reanimation of the upper face is thus separate from reconstruction of the lower face.

Case reports

Patient 1. In 1990, a 25-year-old woman underwent a superficial parotidectomy for a pleomorphic adenoma at another institution. Two years later, a recurrent tumor was resected at the same institution. During the following year, she underwent three additional surgical resections along with adjuvant radiotherapy (55 Gy).

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In 1993, the patient experienced yet another recurrence (figure 4, A), and she was referred to our institution. On Feb. 18 of that year, she underwent wide-field parotidectomy, subtotal petrosectomy, and facial nerve resection. Three days later, she was returned to the operating room for microvascular reanimation of her paralyzed face. All surgical margins were clear of tumor at the time of facial reanimation.

A postoperative follow-up evaluation 7 months later revealed good facial tone without movement, although the patient did report a tingling sensation in the reconstructed area. At the 11-month follow-up, movement of her lower lip was noted, and by 14 months, she was able to smile with her entire lower face. Partial eye closure occurred at 16 months, and complete eye closure, separate from her smiling, was seen at 18 months. At the 2-year follow-up in February 1995, her facial nerve function was classified as House-Brackmann grade III (figure 4, B and C).

On March 27, 1997, a 3-cm recurrence was dissected off the carotid bifurcation. The facial reconstruction was left intact. On April 16, 1998, a petrous apex recurrence was resected via an extended middle fossa approach. On April 30, 2001, surveillance magnetic resonance imaging (MRI) showed no evidence of local recurrence. However, on Aug. 12, 2001, the patient was found to have a 7-cm chest mass. Two weeks later, she underwent subtotal resection of this carcinoma ex pleomorphic adenoma. She died of her disease a few months later at the age of 36 years.

Patient 2. A 14-year-old boy presented with a rapidly enlarging 6-cm right parotid mass and associated facial twitching. He was diagnosed with a high-grade mucoepidermoid carcinoma. On Dec. 10, 1997, he underwent a wide-field parotidectomy, functional neck dissection, subtotal petrosectomy, and facial nerve sacrifice. A microvascular free-flap reconstruction with serratus anterior muscle was performed 6 days later. Postoperative radiotherapy (60 Gy) was completed on March 21, 1998.

The patient was noted to have slight movement of the upper lip at 6 months and partial eye closure at 10 months. At 14 months, good eye closure and separate midface movement (House-Brackmann grade III) were evident (figure 5). Five years postoperatively, the patient remained disease-free.

Patient 3. A 15-year-old girl presented at another institution with residual adenoid cystic carcinoma of the left parotid gland (figure 6, A). On April 14, 1999, she underwent an incomplete tumor resection due to tumor invasion of a normally functioning facial nerve.

The patient was referred to our institution, and on May 20, 1999, she underwent a wide-field parotidectomy, functional neck dissection, and subtotal petrosectomy with facial nerve resection. One week later, she underwent microvascular facial reconstruction with a serratus anterior muscle. On Sept. 7, 1999, she completed postoperative radiotherapy (60 Gy).

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Midface movement was first seen at 4 months postoperatively, and complete eye closure was noted at 7 months. A grade III recovery was recorded at 11 months (figure 6, B), and the patient was able to exhibit a full smile independent of any eye movement.

In March 2006, the patient developed a 1-cm recurrence superior and lateral to her lateral canthus on the involved side. Workup revealed multiple asymptomatic lung nodules suspicious for metastatic disease. She underwent radiosurgery for control of the local recurrence. Two years later, she remained asymptomatic in terms of both her local recurrence and metastatic lung disease.

Discussion

Aggressive surgical resection of the entire parotid gland, facial nerve, and adjacent facial musculature may be necessary in patients with advanced parotid malignancies or diffuse recurrence of benign disease. Static support of the facial soft tissues provides symmetry at rest without voluntary movement, while transposition of the temporalis or masseter muscle results in some facial tone and movement.

Shindo summarized four indications for performing microvascular muscle transfer for facial reanimation: (1) a desire to restore a dynamic, involuntary facial expression, (2) a lack of distal facial nerve branches, (3) the presence of a large soft-tissue defect, or (4) a previous failure to restore facial reanimation. (7)

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If the ipsilateral proximal facial nerve is available, it offers the most natural option for microneurovascular anastomosis. If the ipsilateral proximal facial nerve is not available, cross-facial nerve--sural nerve grafting may be used. (8) Other ipsilateral cranial nerves may also be employed. (9)

In addition to the serratus anterior muscle, distal muscles that have been employed in facial reanimation include, but are not limited to, the rectus abdominis, the pectoralis minor, the latissimus dorsi, and the gracilis. (10) The serratus anterior muscle is considered to be reliable, easy to harvest, and relatively thin and pliable. Moreover, it has a long vascular pedicle and 3 to 5 separate slips that can provide a more natural reanimation of facial segments. (11)

The 3 patients presented in this article underwent facial reanimation by separate sural nerve grafting of the periorbital region with a facial nerve--sural nerve anastomosis and a facial nerve-long thoracic nerve mastomosis for mid- and lower-face reanimation. Separate reanimation of the facial muscle groups reduces the severity of long-term synkinetic movement. No morbidity was seen at any of the donor sites, and all 3 patients attained grade III House-Brackmann facial nerve function within 24 months. The administration of radiotherapy had no detrimental effect on outcomes, as patient 1 had undergone radiotherapy prior to surgery and the other 2 patients received postoperative radiation treatments.

References

(1.) Aviv JE, Urken ML. Management of the paralyzed face with microneurovascular free muscle transfer. Arch Otolaryngol Head Neck Surg 1992;118(9):909-12.

(2.) Ueda K, Harii K, Asato H, Yamada A. Neurovascular free muscle transfer combined with cross-face nerve grafting for the treatment of facial paralysis in children. Plast Reconstruct Surg 1998;101(7):1765-73.

(3.) Leonetti JP, Smith PG, Anand VK, et al. Subtotal petrosectomy in the management of advanced parotid neoplasms. Otolaryngol Head Neck Surg 1993;108(3):270-6.

(4.) Parnes SM. Nerve grafts using the greater auricular and sural nerves. In: Bailey BJ, Calhoun KH, Coffey AR, Neely JG, eds. Atlas of Head & Neck Surgery--Otolaryngology. Philadelphia: Lippincott-Raven; 1996:674-7.

(5.) Derby LD, Bartlett SP, Low DW. Serratus anterior free-tissue transfer: Harvest-related morbidity in 34 consecutive cases and a review of the literature. J Reconstr Microsurg 1997;13(6):397-403.

(6.) Izquierdo R, Leonetti JP, Origitano TC, et al. Refinements using free-tissue transfer for complex cranial base reconstruction. Plast Reconstr Surg 1993;92(4):567-74; discussion, 575.

(7.) Shindo M. Facial reanimation with microneurovascular free flaps. Facial Plast Surg 2000;16(4):357-9.

(8.) Scaramella LF. Anastomosis between the two facial nerves. Laryngoscope 1975;85(8):1359-66.

(9.) Pitty LF, Tator CH. Hypoglossal-facial nerve anastomosis for facial nerve palsy following surgery for cerebellopontine angle tumors. J Neurosurg 1992;77(5):724-31.

(10.) Bove A, Chiarini S, D'Andrea V, et al. Facial nerve palsy: Which flap? Microsurgical, anatomical, and functional considerations. Microsurgery 1998;18(4):286-9.

(11.) Angel MF, Bridges RM, Levine PA, et al. The serratus anterior free tissue transfer for craniofacial reconstruction. J Craniofac Surg 1992;3(4):207-12.

John P. Leonetti, MD; Chad A. Zender, MD; Daryl Vandevender, MD; Sam J. Marzo, MD

From the Department of Otolaryngology--Head and Neck Surgery (Dr. Leonetti, Dr. Zender, and Dr. Marzo) and the Division of Plastic and Reconstructive Surgery (Dr.Vandevender), Loyola Center for Cranial Base Surgery, Loyola University Medical Center, Maywood, Ill.

Corresponding author: John P. Leonetti, MD, Professor of Otolaryngology--Head and Neck Surgery, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153. Phone: [phone]; fax: [phone]; e-mail: [e-mail]