Free muscle transfer in partial facial palsy

The term incomplete facial paralysis encompasses a wide range of clinical scenarios that include different degrees of facial paralysis that are not a complete form of facial palsy. These patients typically present with some degree of spontaneous and/or voluntary movement on the affected hemiface with obvious asymmetry at rest and at motion with a wide range of functional abnormalities. Synkinesis and facial muscles hypertonicity is not uncommon and is most likely secondary to abnormal neural regeneration. Current literature on the reconstructive approach for incomplete facial paralysis is quite scarce. Various publications have shown that clinical improvement may be achieved alongside improved patient satisfaction when treating this population with the common facial reconstructive methods used for complete facial paralysis. Several authors presented more specialized procedures for patients with incomplete paralysis in which facial reanimation is performed while efforts are made not to worsen the existing paralysis. We have recently published a novel approach for treating patients with incomplete facial paralysis. The procedure comprises a one-stage free gracilis muscle transfer with neural coaptation to a partially active, residual buccozygomatic branch of the incomplete paretic hemiface. Clinical course and outcome were presented in a series of 16 patients with promising results. Patients with incomplete facial paralysis who present with any degree of spontaneous facial mimetic function in the midface zone may benefit from the suggested procedure. In this chapter, we address the clinical entity of incomplete facial paralysis, review current reconstructive approaches for such patients and elaborate on the use of an ipsilateral residual buccozygomatic facial nerve branch as donor nerve for a one-stage free gracilis muscle transfer, in this sub-group of patients.