Facial Palsy / Lip & Cheek Reconstruction

Question 1

A 62-year-old woman is evaluated 1 hour after undergoing Mohs micrographic resection of a squamous cell carcinoma of the lower lip. After a clear-margin excision, the resulting defect is a full-thickness 25% central lip defect. Which of the following is the most appropriate repair method for this defect?

A) Coverage using the Karapandzic technique
B) Coverage with a V-Y advancement flap
C) Coverage with an Abbe flap
D) Full-thickness skin grafting
E) Primary closure

Answer 1

The correct response is Option E.

Defects of the lip can be categorized by the percentage of the total lip affected. Small full-thickness defects of the lip (25–33%) as described in this case are best repaired with primary closure using a vertical excision of remaining lip structures to enable a tension-free closure. Care should be taken to precisely realign the lip and repair the white roll to avoid step-offs that are easily noticeable. Larger defects (33–50%) are usually repaired using flaps. These flaps can be categorized as transoral flaps (e.g., Abbe or Estlander flaps) or circumoral advancement/rotation flaps (e.g., Gilles flap or Karapandzic technique). Subtotal lip defects may be repaired with bilateral circumoral advancement/rotation flaps, while total lip defects generally require reconstruction with free flaps. Skin grafts are rarely used for lip reconstruction (particularly if the white roll is involved) because these repairs result in a patch-like appearance that is highly noticeable.

2018

Question 2

An 18-year-old man is brought to the emergency department because of a vertical stab wound to the mid cheek immediately posterior to the level of the lateral canthus. Primary repair is planned within 72 hours. Which of the following is the primary reason to perform the procedure within this time frame?

A) Anatomical location precludes surgical expiration and repair
B) Motor end plates will atrophy
C) Nerve endings will have retracted markedly
D) Neurotransmitter stores will become irreversibly depleted
E) Risk of soft-tissue infection of the face increases markedly

Answer 2

The correct response is Option D.

On the face, and posterior to the lateral canthus, the facial nerve should be repaired as early as possible such that identification of the transected nerve stumps is possible. After 72 hours, the neurotransmitter stores required for motor end plate depolarization are irreversibly depleted. As a result, the target muscles no longer respond to stimulation of the distal nerve stump.

Because of marked arborization and cross-innervation of the facial nerve, injuries anterior to an imaginary line drawn from the corner of the eye to the corner of the mouth commonly recover spontaneously. It takes 18 to 24 months for motor end plates to completely atrophy.

2018

Question 3

A 35-year-old woman is evaluated for long-standing facial nerve palsy. The proximal stump of the facial nerve is not available for use in reconstruction. In addition to gracilis muscle transfer, the surgeon is considering cross-facial nerve graft or using the masseter nerve. Which of the following factors regarding masseter nerve use is often cited as a disadvantage to cross-facial nerve grafting?

A) Decreased excursion of the gracilis muscle
B) Decreased smile symmetry
C) Less spontaneity in smiling
D) Requirement of a craniofacial osteotomy for harvest
E) Significant, permanent weakness in chewing function

Answer 3

The correct response is Option C.

Use of the masseter nerve as the motor source for a gracilis free tissue transfer to restore smile is a single-stage procedure with many advantages over the more traditional use of cross-facial nerve grafting when the proximal stump of the facial nerve is not available for use. Its popularity has increased recently, particularly because it is a single-stage surgery and morbidity is minimal. Use of the masseter nerve, however, requires the patient to clench the jaw to smile, and is much less spontaneous than with cross-facial nerve grafting.

Less excursion of the gracilis muscle graft is incorrect. The masseter nerve is an excellent motor nerve and allows for powerful contraction of the transferred muscle.

Significant, permanent weakness in chewing function is incorrect because harvest of the masseter nerve is partial, and generally results in minimal donor site morbidity.

Craniofacial osteotomy is incorrect because while the masseter nerve is in proximity to the zygomatic arch, an osteotomy is not frequently needed to reach the nerve.

Decreased smile symmetry is incorrect because smile symmetry is comparable with both techniques.

2017

Question 4

A 35-year-old man returns for postoperative evaluation 12 months after undergoing facial nerve reconstruction with free gracilis transfer. Physical examination shows significant hyperkinesis of the contralateral side. In addition to injections of botulinum toxin type A, which of the following measures has been shown to improve facial symmetry?

A) Cryotherapy of facial musculature
B) Mirror biofeedback therapy
C) Oral beta-adrenergic blocker therapy
D) Radiofrequency ablation
E) Selective contralateral facial neurotomy

Answer 4

The correct response is Option B.

Hyperkinesis is generally considered to be the hyperactivity of the contralateral, unaffected side. Mirror biofeedback therapy has been shown to significantly improve facial symmetry when used in conjunction with botulinum toxin injections in the treatment of facial hyperkinesis.

Beta-adrenergic blocker therapy is not indicated for facial hyperkinesis following facial nerve reconstruction.

While selective facial myotomy has been used for improvement in synkinesis, selective contralateral facial neurotomy is not generally indicated for correction of hyperkinesis.

Radiofrequency ablation and cryotherapy have only recently begun to be investigated as an option for improvement of synkinesis, but have not been generally accepted as treatments for hyperkinesis.

2017

Question 5

A 30-year-old primigravid woman at 24 weeks’ gestation, who has a history of Bell palsy, has synkinesis and squinting of the left eye when smiling. She wants to know her treatment options, but is not interested in options that may put her pregnancy at risk or impact her goal of breast-feeding for 1 year after delivery. Which of the following treatment options is most appropriate for this patient?

A) Chemodenervation to the left orbicularis oculi
B) Chemodenervation to the left orbicularis oris
C) Facial neuromuscular retraining
D) Gold weight to the left upper eyelid
E) Selective neurolysis to the temporal branch of the facial nerve

Answer 5

The correct response is Option C.

Chemodenervation is a common treatment for ocular-oral synkinesis and perhaps the most effective. The chemodenervation medications have unknown effects for pregnant or nursing women. Botulinum toxin type A is a class C drug. Permanent surgical selective denervation is not recommended as it could impact eye protection. Surgery may also have risks for the fetus.

This patient would benefit from a physical therapy referral to work on facial neuromuscular re-education, including biofeedback using mirrors and electromyography. Additional strategies such as use of sunglasses and other strategies to avoid squinting can be helpful. These are likely the treatment modalities that this patient is most interested in.

Gold weight insertion would not be appropriate in a patient with symptoms of squinting.

2017

Question 6

An otherwise healthy 20-year-old woman is evaluated 5 weeks after sustaining facial shear injury in a motor vehicle collision. She has a facial nerve palsy on the right and exposed mastoid, zygoma, and zygomatic arch. A photograph is shown. She has had previous debridement and titanium mesh cranioplasty for the traumatic cranial defect of the temporal bone. Multifocal extratemporal facial nerve injuries are suspected. Which of the following is the most appropriate management for the wound coverage and facial nerve palsy?

A) Free tissue transfer for wound coverage with delayed facial reanimation
B) Immediate cross-face nerve grafting with cervicofacial flap for soft tissue coverage
C) Immediate exploration and primary repair of the facial nerve followed by skin grafting for coverage
D) Split-thickness skin grafting for coverage with delayed facial reanimation
E) Temporalis muscle sling with skin grafting for wound coverage

Answer 6

The correct response is Option A.

The patient shown has a large soft tissue defect with exposed bone and hardware. There is friable granulation tissue, and the patient presents several weeks after injury. She has a complete facial palsy and her eye is closed at rest (good eye protection) without taping. The ultimate goals are to address both her wound and her facial palsy, with an aesthetic facial reconstruction.

In this setting, a simple nerve transection that would benefit from a simple neurorrhaphy is unlikely. The tissues are very friable, and tissue planes are not easily identified due to inflammation, extensive damage, and subacute time period. Dissection and exploration would be difficult and could lead to further damage.

Soft tissue coverage is a priority at this point in the patient’s reconstruction. She has a large defect with exposed bone and hardware. Free tissue transfer could provide stable coverage. A skin graft will not provide durable coverage over hardware and exposed bone. Delayed facial reanimation after stable soft tissue coverage will allow for improved healing.

Delaying addressing the facial nerve palsy a few weeks to months can still have good outcomes and there will be an improved healing environment.

2017

Question 7

A 34-year-old woman is scheduled to undergo resection of a left-sided cerebellopontine angle tumor with sacrifice of the facial nerve trunk. Staged cross-facial nerve grafting is planned. Which of the following treatment options is most likely to minimize the risk for permanent facial asymmetry at the time of tumor resection?

A) Free gracilis muscle transfer to the left facial nerve stump
B) Hypoglossal to facial nerve transfer and cross-facial nerve grafting
C) Insertion of a 1.2-g gold weight in the left upper eyelid
D) Percutaneous distal facial nerve branch stimulation
E) Placement of an extended temporalis fascia static sling

Answer 7

The correct response is Option B.

Cerebellopontine angle (CPA) tumor resection often requires intracranial facial nerve sacrifice. For best recovery of spontaneous ipsilateral facial nerve function, cross-facial nerve grafting (CFNG) should be performed from the contralateral facial nerve branches to the ipsilateral facial nerve branches. CFNG often results in delayed and weakened reinnervation of the ipsilateral facial musculature. For this reason, hypoglossal to facial nerve transfer and cross-facial nerve grafting (babysitter nerve transfers) are often employed to minimize muscle atrophy and enhance the strength of the ipsilateral facial musculature. Both hypoglossal nerve and nerve to masseter have been used. The other choices would not augment the ipsilateral facial musculature and would likely result in more pronounced facial asymmetry.

2017

Question 8

A 45-year-old man with a 10-year history of unilateral facial palsy is evaluated for dynamic reanimation of the lower face. Single-stage free gracilis transfer to restore smiling function is planned. The proximal stump of the ipsilateral facial nerve is not available as a donor nerve. Which of the following options is most appropriate for this patient because it is associated with the lowest donor site morbidity/loss of function?

A) Cross-facial nerve transfer
B) Ipsilateral glossopharyngeal nerve
C) Ipsilateral hypoglossal nerve
D) Ipsilateral masseteric nerve
E) Ipsilateral spinal accessory nerve

Answer 8

The correct response is Option D.

In cases of unilateral facial palsy in which the ipsilateral facial nerve is unavailable for use as a donor nerve, nerve transfers are the best option. Of the local options, the ipsilateral masseteric nerve provides the best and most commonly used transfer due to its proximity and relatively low morbidity when harvested. In one study, spontaneous smiling was achieved routinely in 59% of patients and occasionally in 29% of patients by using this technique.

Although the hypoglossal nerve is sometimes used as a donor nerve for ipsilateral facial reanimation, its harvest can be associated with considerable oropharyngeal morbidity due to ipsilateral tongue atrophy.

A cross-facial nerve transfer does not provide for single-stage reconstruction. In many cases where there are sufficient contralateral branches of the facial nerve for cross-facial transfer, this option can provide optimal function, but its use requires a staged approach.

Use of the ipsilateral glossopharyngeal nerve as a donor in this situation would also create significant oropharyngeal function morbidity, and is therefore not commonly used.

Use of the ipsilateral spinal accessory nerve as a donor nerve is rarely used due to the fact that its use often requires uncoordinated movements for function. Ipsilateral masseteric nerve is a significantly better choice.

2016

Question 9

After schwannoma resection with facial nerve sacrifice, which of the following reconstructions provides the quickest restoration of natural reflexive dynamic blink?

A) Cross-facial nerve grafting
B) Functional muscle transfer
C) Gold weight insertion
D) Ipsilateral nerve grafting
E) Nerve transposition

Answer 9

The correct response is Option E.

All of the choices are suitable options for reanimation of the eyelid; however, transfer of a regional nerve, such as the motor nerve to the masseter, will result in the quickest reinnervation of the orbicularis oculi muscle. Nerve grafts may be used to overcome a wide neural gap; however, nerve regeneration proceeds slowly at only 1 mm per day. Cross-facial nerve grafts take an extended period of time to regenerate due to the long distance from the contralateral side. While gold weights are immediately effective, they are static procedures. Restoration of a reflexive blink requires neural input from the zygomatic branch of the facial nerve or direct neurotization of the orbicularis oculi muscle. Functional muscle transfers used for eyelid reanimation include the frontalis and temporalis; however, because they are innervated by nerves other than the facial, coordinated movements are not present.

2016

Question 10

A 60-year-old man is evaluated for a painful unilateral facial rash with blisters, intense ear pain, and complete ipsilateral facial nerve paralysis. Which of the following is the most likely diagnosis?

A) Cholesteatoma
B) Facial myokymia
C) Lyme disease
D) Möbius syndrome
E) Ramsay Hunt syndrome

Answer 10

The correct response is Option E.

This is a case of Ramsay Hunt syndrome, also known as herpes zoster oticus. It is a variant of typical herpes zoster, in that in its reactivation, it affects both afferent neurons as well as motor axons of the facial nerve. A combination of corticosteroids, narcotics, and acyclovir is the standard of care.

Facial myokymia is mainly associated with multiple sclerosis and causes a wormlike motion in the facial muscles.

Möbius syndrome is a congenital condition characterized by, among other nerve conditions, facial paralysis.

Cholesteatoma is a benign growth in the middle or external ear formed from desquamated keratin. It can act locally and be very aggressive, so much so, that if left untreated, it could cause destruction of the facial nerve.

This is not a typical presentation of Lyme disease.

2016

Question 11

A 20-year-old man is evaluated for reconstruction of the lip after sustaining a traumatic blast injury to the face with complete loss of the lower lip. The patient wishes to have a symmetric, dynamic, and competent lower lip. Which of the following treatment plans is most likely to achieve the patient’s desired outcome?

A) Innervated anterolateral thigh flap
B) Innervated gracilis muscle
C) Innervated regional advancement flaps (Karapandzic)
D) Prosthetic lower lip appliance
E) Radial forearm flap with tendon graft

Answer 11

The correct response is Option B.

Total lower lip reconstruction is very challenging. A prosthetic lower lip may have acceptable static appearance but does not afford competency or dynamic function. An anterolateral thigh flap would be bulky and adynamic. Innervated regional advancement flaps are not indicated for total lip loss and would lead to microstomia. A radial forearm flap with a tendon graft can achieve an acceptable appearance and competence. The radial forearm flap is unable to achieve spontaneous lower lip movement that is as symmetrical as that of the functional gracilis muscle flap. If a split-thickness skin graft from the scalp is used, the color match can be superior to radial forearm flap as well. The functional gracilis flap is most likely to achieve this patient’s goals.

2015

Question 12

A 25-year-old woman is evaluated for unilateral facial paralysis after she sustained an episode of Bell palsy that did not respond to oral administration of corticosteroids. Methods for functional reconstruction using a gracilis muscle transfer are discussed. Which of the following is an advantage of this muscle transfer for this patient?

A) Ability of the nerve to reach the contralateral side
B) Ability to incorporate overlying tendon
C) Multiple directions of pull
D) Reliable vascular pedicle
E) Two dominant nerves

Answer 12

The correct response is Option D.

The gracilis muscle has been widely used for facial reanimation because of its many advantages. The muscle is located in the inner thigh, which makes harvest easy in a supine position and keeps the donor site well hidden. It has a single constant vascular pedicle of adequate length for transfer. Although it is able to generate sufficient force for animation, it has only one direction of pull and is thus best suited for restoring only one component of smiling. There is no overlying tendon, and there is a single dominant nerve that is not able to reach the contralateral side of the face.

2015

Question 13

A 5-year-old girl with Möbius syndrome is brought to the office for evaluation of facial paralysis. Physical examination shows masklike facies, inability to animate the face bilaterally, and generalized hypoplasia of the tongue. Which of the following is the most appropriate donor nerve to restore facial function in this patient?

A) Hypoglossal
B) Ipsilateral facial
C) Masseteric
D) Spinal accessory
E) Phrenic

Answer 13

The correct response is Option C.

In the case of Möbius syndrome and most pediatric patients with facial paralysis in which the facial muscles are no longer available, a microneurovascular transfer with a muscle flap is the preferred treatment. The gracilis is the most advocated muscle used for this purpose. Pediatric patients are generally very motivated and do well with microneurovascular transfer with a muscle flap.

In Möbius syndrome, the sixth and seventh cranial nerves are commonly involved. Other cranial nerves may be involved as well. In addition to the facial muscles not being available for reconstruction, the cranial nerves are also not available in patients with Möbius syndrome. Hence, transfer to the ipsilateral or contralateral facial nerve is not a viable option for reconstruction in patients with Möbius syndrome, as the facial nerve does not function.

Use of the hypoglossal nerve in patients with Möbius syndrome is relatively contraindicated due to worsening of tongue function. The “babysitter” technique utilizes the hypoglossal nerve as a donor nerve.

The masseteric nerve is preferred over the spinal accessory and phrenic nerves as it provides better motor strength and lower morbidity in the muscle transfer.

2015

Question 14

A 65-year-old man is evaluated for right facial nerve paralysis. Upper eyelid reanimation is planned. The gold weight prosthesis is selected. Which of the following considerations is most appropriate for this patient?

A) Allowing coverage of the upper limbus at rest
B) Bringing the upper eyelid to within 2 to 4 mm of the lower eyelid
C) Enabling complete closure of the upper eyelid
D) Enabling the most rapid closure of the upper eyelid
E) Providing the best symmetry with the contralateral eye

Answer 14

The correct response is Option B.

Gold weight prostheses are commonly used for upper eyelid reanimation in patients with facial nerve dysfunction. The weight required can be estimated preoperatively by using two-sided tape to secure various test weights to identify the prosthesis that brings the upper eyelid to within 2 to 4 mm of the lower lid and completely covers the cornea. A common mistake is to use a weight that is too heavy in an effort to completely close the upper eyelid, resulting in upper eyelid ptosis and obstruction of field of view. Revision surgery is often needed in these cases. Contralateral symmetry is rarely achieved with gold weights and is not a criterion for assessment. Similarly, the speed with which the upper eyelid is closed is usually slower than the contralateral eyelid and is not a factor in weight selection.

2015

Question 15

A 30-year-old woman comes to the office for evaluation of an asymmetric smile. Two months ago, she underwent primary neurorrhaphy of a facial nerve laceration 2 cm lateral to the oral commissure. Physical examination shows no elevation of the upper lip with smiling on the side of the injury. Which of the following is the most appropriate management?

A) Cross-facial nerve grafting
B) Facial sling suspension
C) Free muscle transfer
D) Injection of botulinum toxin type A
E) Observation

Answer 15

The correct response is Option E.

The injury period is short enough that the potential for the initial neurorrhaphy to work is still likely. Clinical Tinel sign would be helpful to assess this further. Injection of botulinum toxin type A at this point would confuse the picture because it would prevent clinical monitoring of nerve recovery. If the patient does not recover nerve function within the next 6 months, then she is still a candidate for facial reanimation because the injury is not long-standing. A static procedure is not indicated unless the patient has a long-standing injury or is not a candidate for facial reanimation.

2014

Question 16

A 72-year-old man undergoes wide local excision of a squamous cell carcinoma of the lower lip. Margins are free of involvement. A photograph of the resulting defect is shown. Reconstruction using which of the following flaps is most appropriate in this patient?

A) Estlander
B) Facial artery myomucosal
C) Karapandzic
D) Melolabial
E) Submental artery island

Answer 16

The correct response is Option C.

Karapandzic flaps are appropriate for reconstruction of defects involving one to two thirds of the lower lip, such as the one in this patient. The Karapandzic technique involves performing circumoral incisions and mobilizing the orbicularis oris muscle, while preserving its innervations and vascular supply. The main advantage of this technique is that a continuous sphincter of functional orbicularis muscle is created, helping to restore oral competence.

The Estlander flap is a full-thickness, cross-lip transposition flap designed to reconstruct lateral defects of the lower lip (one to two thirds) requiring recreation of the oral commissure.

Melolabial flaps can be used to reconstruct large full-thickness lower lip defects. However, they require grafting of the deep surface of the flap, have a less reliable random blood supply, and do not provide a functional muscular oral sphincter.

The submental artery island flap is based on the submental branch of the facial artery. A paddle of skin, subcutaneous tissue, and fascia harvested from the submental area can be used for coverage of lower face and preauricular defects, as well as inferior and lateral neck wounds. Its use for reconstruction of partial lower lip full-thickness defects has not been established.

Facial artery myomucosal flaps consist of oral mucosa, submucosa, a small amount of buccinator muscle, and a more deeply lying facial artery and venous plexus. They are ideal for reconstructing the inner, most lip mucosa because they consist of similar tissue, with the same color, texture, and moisture. They can also be used for reconstruction of the dry vermilion, although some drying-out and scabbing of the mucosa will occur. They are not indicated for large, full-thickness lower lip defects.

Question 17

A 45-year-old woman is referred by her primary care physician because of left facial paralysis. She was hiking in the woods 2 weeks ago and pulled a tick off her leg at the end of the weekend trip. Three days ago, she had onset of a rash and fever. Since awakening this morning, she has been unable to move the left side of her face and has had painful spasms on the contralateral (right) side of her face when she tries to smile or talk. On physical examination, she is unable to move the left side of the face. Which of the following is the most appropriate management of this patient’s condition?

A) Acyclovir therapy
B) Botulinum toxin type A injection
C) Contralateral facial nerve grafting and free gracilis flap
D) Corticosteroid therapy
E) Doxycycline therapy

Answer 17

The correct response is Option E.

The patient described has new-onset facial paralysis brought on by Lyme disease infection. Neurologic manifestations (early disseminated infection) can show symptoms as early as a few days to a few weeks after initial bite.

Treatment should be directed to the underlying disease, and doxycycline is the antibiotic of choice unless there are contraindications. There is no role for antivirals.

Surgical treatment is contraindicated at this time unless the patient’s facial palsy becomes permanent.

Although botulinum toxin type A is efficacious in treating contralateral facial hyperkinesia, the patient is in the initial stages of Lyme disease, and treatment should be aimed at the primary disease at this time.

Corticosteroids are helpful in reducing inflammation and edema which are thought to contribute to the neurologic manifestations in Bell palsy but not for neurologic manifestations of Lyme disease (Lyme neuroborreliosis).

2014

Question 18

A 7-year-old girl with congenital palsy of the left facial nerve is scheduled to undergo facial reanimation using a free gracilis muscle neurotized by the motor branch to the masseter muscle. Compared with cross-facial nerve grafting from the contralateral facial nerve, use of this procedure is most likely to result in which of the following?

A) Decreased excursion of the reanimated oral commissure
B) Development of a crossbite
C) Increased risk of long-term muscle atrophy
D) Need for additional surgical procedures
E) Unpredictable smile symmetry

Answer 18

The correct response is Option E.

Facial reanimation procedures using free tissue transfer have largely supplanted static procedures for pediatric facial paralysis. Although cross-facial nerve grafting (CFNG) remains an excellent option, many surgeons now prefer using the motor branch to the masseter (trigeminal nerve), since it can be done in a single stage, yields excellent muscle reinnervation, and produces muscle contraction/commissure displacement that typically exceeds that of CFNG. Although this motor branch provides innervation to the masseter, there are no reports of crossbite after its use in facial reanimation. CFNG provides relatively consistent smile symmetry and spontaneity since the stimulus for muscle contracture on both sides of the face comes from the same facial nerve source. In contrast, smile spontaneity and symmetry are much more variable when the motor masseteric branch is used and requires some cortical adjustment and/or behavioral education to develop; younger patients respond much more reliably and naturally than older patients.

2014

Question 19

An 8-year-old boy with congenital right facial hemiparesis is seen in consultation for possible facial reanimation. MRI shows absence of a right facial nerve trunk. A two-stage cross-facial nerve grafting procedure is planned. A sural nerve graft coapted to a buccal branch of the facial nerve with 10-0 nylon is planned. Which of the following factors will have the greatest influence on the outcome of this procedure?

A) Advanced patient age
B) Donor nerve axon density
C) Duration of hemiparesis
D) Length of obturator nerve pedicle
E) Method of nerve coaptation

Answer 19

The correct response is Option B.

While reanimation techniques have been proposed to restore function in nearly every part of the face, the most well-studied and reliable are for restoration of the smile. There are two primary operations to restore a dynamic smile: the two-staged cross-facial nerve graft and the single-stage transfer using nerve to the masseteric branch of the trigeminal nerve. Both utilize free muscles transfer and the gracilis muscle has become the gold standard donor for most surgeons. This muscle is favored largely because it boasts excellent muscle contraction characteristics with limited bulkiness, but it also boasts an anatomically consistent vascular pedicle, a long donor nerve (obturator), and no functional impact from its harvest. The two-stage procedure is well described and utilizes a nerve graft(s), usually sural, coapted to branches of the buccal or zygomatic branches of the facial nerve at or just distal to the anterior edge of the parotid gland. Although various factors can influence the outcome of this procedure, several recent studies highlight the importance of donor nerve (i.e., buccal or zygomatic branches) axonal density. While the results of two-stage facial reanimation in older patients (i.e., adults, especially older adults) are typically inferior to pediatric patients, there is no evidence that age is a major factor in children under 10 years of age. Unlike a patient with acquired or traumatic facial nerve injury, the duration of paralysis has no bearing in this patient with a paralysis secondary to facial nerve agenesis since the muscles of facial animation on the right side would be absent or fibrotic as well. The length of the obturator nerve and method of nerve coaptation would have no effect on the outcome.

2019

Question 20

A 5-year-old girl is evaluated because of acute onset of unilateral facial paralysis including inability to close the left eyelid, lack of smiling, and inability to lift the ipsilateral brow. Which of the following is the most likely cause of this patient’s paralysis?

A) Acute otitis media
B) Bell palsy
C) Cerebrovascular accident
D) Neoplasm
E) Trauma

Answer 20

The correct response is Option B.

There are several described causes of facial nerve paralysis in children, including congenital (delivery traumas, genetic deformity) and acquired (infectious, inflammatory, neoplastic, traumatic or iatrogenic) conditions. In approximately 40-75% of cases, the etiology remains idiopathic. Idiopathic facial paralysis, either in adulthood or childhood, is commonly known by the eponym Bell palsy. The major cause of acute facial nerve paralysis in children is infection, with the majority being a complication of acute otitis media. Trauma is not an uncommon cause, and in the neonatal period is usually from a traumatic delivery. In older children, sports or motor vehicle collisions are common traumatic causes. Both populations overall have an excellent prognosis for recovery unless penetrating trauma has occurred, which necessitates surgical repair. Tumors rarely cause facial nerve weakness in children. Congenital facial nerve paralysis is present since birth and would not present acutely. Cerebrovascular accident is a rare cause in children.

2019

Question 21

A 15-year-old girl is brought to the office for follow-up evaluation 5 months after sustaining facial injuries from being bitten by a dog. She has an abnormal facial nerve examination and cannot generate a smile on the right side. Prior exploration during anesthesia showed missing segments of the facial nerve. Which of the following is the most appropriate management at this time?

A) Babysitter procedure
B) Cross-facial nerve grafting
C) Dynamic reanimation with gracilis free flap
D) Interpositional nerve grafting
E) Primary nerve repair

Answer 21

The correct response is Option D.

The critical components of facial nerve reconstruction are the cause of the injury, timing of the injury, and age of the patient. These generally dictate the management options.

In this case we have a young patient with a traumatic injury that occurred 5 months ago. The goal is reconstruction of the facial nerve with enough time for nerve regeneration prior to loss of the motor end plates of the muscle. This can usually be done if nerve regeneration is anticipated to occur within 18 months of the initial injury.

With a history of missing segments of facial nerve, it is unlikely that primary repair of the facial nerve branches will be feasible.

The proximal facial nerve is available for reconstruction, making cross-facial nerve grafting unnecessary. Without the addition of nerve grafts, a cross-facial nerve graft alone would not restore facial reanimation.

Since the timing of the injury is only 5 months, reconstruction with nerve grafts should be attempted prior to the use of facial reanimation with a gracilis free flap. It could be used in the event that nerve grafting fails.

The babysitter procedure is a procedure that is intended to send strong motor fibers quickly to denervated facial muscles while waiting for cross-facial nerve grafts or dynamic reanimation procedures to complete nerve regeneration and healing. The babysitter procedure preserves muscle bulk while waiting for the cross-facial nerve graft or other mode of reanimation to enable coordinated animation.

2019

Question 22

A 42-year-old woman suffers a dog bite injury to her lower lip. Following adequate debridement, the patient is left with a full-thickness, total lower lip defect, up to the lateral commissure bilaterally. The surrounding tissue is uninjured. Which of the following is the most appropriate method of reconstruction?

A) Abbe (lip switch) flap
B) Bernard-Webster (lip-cheek advancement) flap
C) Cervicofacial rotation advancement flap
D) Estlander (lateral lip switch) flap
E) Karapandzic flap

Answer 22

The correct response is Option B.

Complete lower lip defects can result from cancer resection or trauma. Reconstruction of lip defects relies primarily on local flaps, although free tissue transfer may be necessary in total lip reconstructions or if the surrounding tissue is unsuitable for flap transfer. In lower lip defects with a defect size greater than two thirds of the lip, bilateral lip-cheek advancement flaps are required for reconstruction.

Lip switch flaps are useful for one- to two-thirds lip defects that are centrally located, whereas lateral lip-switch flaps can similarly be used to address lateral defects involving the commissure. Although these flaps can be combined with lip-cheek advancement flaps for reconstruction of the lower lip, they are not sufficient alone for total lip reconstruction. Karapandzic flaps can be used for reconstruction of central defects with up to two-thirds of the lip being absent, but cause significant microstomia in lip defects with greater than two-thirds of the lip absent. Cervicofacial rotation advancement flaps are usually used for cheek reconstruction.

2020

Question 23

A 26-year-old man sustained complete right-sided unilateral facial nerve transection and paralysis from a circular saw 3 years ago. He is now seeking surgery to improve resting symmetry and to recreate a dynamic smile. Which of the following is the most appropriate surgical procedure to achieve these results?

A) Cross-facial nerve graft and delayed free functional muscle transfer
B) Fascial suspension
C) Hypoglossal nerve to facial nerve transfer
D) Ipsilateral nerve graft
E) Nerve repair

Answer 23

The correct response is Option A.

Three years after complete facial nerve transection and paralysis, the facial muscles are nonviable and incapable of reinnervation. Cross-facial nerve grafting and delayed free functional muscle transfer using the gracilis muscle is the procedure of choice in this situation.

Nerve repair, ipsilateral nerve graft, and hypoglossal nerve to facial nerve transfer require viable facial muscles. Static reconstruction, such as a fascial suspension, would not be indicated in a young person when facial reanimation is possible. Static reconstruction is not indicated because facial reanimation with cross-facial nerve grafting and delayed free functional muscle transfer is possible and has not been attempted yet. Static reconstruction is the procedure of choice for elderly patients with multiple comorbidities and a poor prognosis or for patients who have failed facial reanimation surgery.

2020

Question 24

A 30-year-old woman presents to the office with new-onset left facial paralysis from Lyme disease. The most appropriate next step in management is administration of which of the following medications?

A) Acyclovir
B) Dapsone
C) Dexamethasone
D) Doxycycline
E) Fluconazole

Answer 24

The correct response is Option D.

Lyme disease is carried by ticks with Borrelia bacteria. While a “bull’s eye” rash is a common finding, a lack of this rash does not exclude Lyme disease. This patient has new onset facial paralysis brought on by her Lyme disease infection. Neurological manifestations (early disseminated infection) can present as early as a few days to a few weeks after the initial tick bite.

Treatment should be directed to the underlying disease, and doxycycline is the antibiotic of choice unless there are contraindications. There is no role for antivirals.

Surgical treatment is contraindicated at this time unless the patient’s facial palsy becomes permanent.

Early initiation of corticosteroids has been shown to improve outcomes in idiopathic Bell palsy, but it has shown no efficacy for facial palsy caused by Lyme disease (Lyme neuroborreliosis), and in fact, has been associated with worse outcomes.

Antivirals can be used in facial palsy caused by the herpes simplex virus, but they have not been proven to be beneficial alone (antivirals must be used in conjunction with corticosteroids). However, antivirals have not demonstrated efficacy in facial palsy caused by Lyme disease.

Cephalexin is used as a third-line treatment for Lyme disease. Dapsone has been used in post-treatment Lyme disease syndrome.

2020

Question 25

A newborn has unilateral facial paralysis. The remainder of the physical examination shows no abnormalities and there is no evidence of birth trauma. Which of the following studies will most likely reveal the cause of facial nerve paralysis in this patient?

A) CT scan of the head
B) Electromyography
C) Electroneurography
D) Stapedius (acoustic) reflex test
E) Ultrasonography

Answer 25

The correct response is Option A.

The most likely cause of unilateral facial nerve paralysis in a newborn with an otherwise normal physical examination is a temporal bone abnormality. A CT scan of the head and temporal bones is the study of choice to identify a temporal bone abnormality.

Electromyography is a neuroelectrophysiological test used to evaluate the function of the facial nerve. Small needles are inserted into certain facial muscles and patients are asked to contract those muscles. Action potentials are seen in muscles undergoing reinnervation. Fibrillation potentials are seen in muscles that are still alive but awaiting reinnervation, and electrical silence is seen with chronically denervated muscles that cannot be reinnervated.

Electroneurography is another neuroelectrophysiological test used to assess the function of the facial nerve. One electrode is placed over the stylomastoid foramen behind the ear and emits an electrical pulse, and one electrode is placed at the ipsilateral nasolabial fold that detects any signal transmitted by the facial nerve. Electromyography and electroneurography assess the integrity of the facial nerve, but would not reveal the cause of the facial nerve paralysis in a newborn baby.

Ultrasonography is the test of choice to look at soft tissues but will not image the skull base adequately for this purpose. The stapedius or acoustic reflex is an involuntary muscle contraction of the stapedius muscle of the middle ear in response to high intensity sound. The efferent limb of the reflex is the facial nerve, which innervates the stapedius muscle. The rate of return of the stapedius reflex can be used to predict the rate of return of facial nerve function after facial nerve paralysis, but would not identify the cause of facial nerve paralysis.

2020

Question 26

A patient with Möbius syndrome is referred for facial reanimation with free gracilis muscle flaps. Which of the following donor nerves has the lowest morbidity and is used most often for this type of reconstruction?

A) Contralateral facial
B) Glossopharyngeal
C) Hypoglossal
D) Masseteric
E) Spinal accessory

Answer 26

The correct response is Option D.

In cases of facial palsy where the facial nerve is unavailable for use as a donor nerve, nerve transfers are the best option. Of the local options, the masseteric nerve provides the most appropriate and most commonly used transfer because of its proximity and low morbidity when harvested.

While the hypoglossal nerve is sometimes used as a donor nerve for ipsilateral facial reanimation, the process of harvesting can be associated with considerable oropharyngeal morbidity because of ipsilateral tongue atrophy. In addition, the patient in this scenario requires a bilateral facial reanimation procedure, and harvesting of both hypoglossal nerves would paralyze the tongue.

A cross-facial nerve transfer is not an available option in this scenario because the patient has Mobius syndrome with bilateral facial nerve agenesis. Use of bilateral glossopharyngeal nerves as donors would create significant oropharyngeal function morbidity, and, even in cases of unilateral facial reanimation, is not commonly used. Use of both spinal accessory nerves as donor nerves in this case would create significant morbidity. Even in a case of unilateral facial reanimation, use of the masseteric nerve is a significantly better choice.

2020

Question 27

A 25-year-old man sustains a clean cheek laceration that includes transection of the facial nerve. Which of the following is the maximum time after which primary repair is unlikely to result in restored facial nerve function?

A) 3 weeks
B) 6 weeks
C) 6 months
D) 12 months
E) 24 months

Answer 27

The correct response is Option D.

Extracranial facial nerve injuries generally follow the principles of peripheral nerve injury and repair. For a clean, gapless, tension-free, primary repair, optimal motor nerve function outcomes are optimal if the nerve repair occurs within 3 to 6 months from the time of injury.

In contrast to peripheral motor nerve repairs, facial nerve injuries in young patients can tolerate repair at a later date, even up to 12 months post injury. Twelve months is the maximum time of delay where functional recovery would be expected with a tension-free primary repair of a facial nerve transection.

Muscle degeneration (from denervation) usually occurs around 24 months, so primary nerve repair is not even considered at that point, and muscle transfer options need to be considered by then.

2021

Question 28

A 69-year-old man presents to the office with a large (5 x 7-cm) melanoma involving his right cheek. A photograph is shown. After resection with clear margins, which of the following methods of reconstruction will provide the best aesthetic result?

A) Cervicofacial flap
B) Immediate tissue expansion
C) Primary repair
D) Radial forearm free flap
E) Split-thickness skin graft

Answer 28

The correct response is Option A.

Large defects of the cheek are best repaired with local skin when possible. Cervicofacial flaps can be used for moderate to large defects of the cheek with tension free repair (as shown in the photographs), which is vitally important to avoid eyelid-related complications, such as ectropion. Primary repair is useful for smaller cheek defects but would not be possible in this situation. A split-thickness skin graft would not provide optimal soft tissue match, and would undergo significant secondary contracture, resulting in eyelid malposition. They may be used in a temporary situation until definitive reconstruction. Full-thickness skin grafts may be an option; however, they tend to appear shiny and patch-like. Tissue expanders are useful in the head and neck, particularly in the scalp; however, in this particular case it is not advisable to use a tissue expander adjacent to an open wound. There is a significant risk of infection or extrusion. A radial forearm free flap could be an option if local tissue is not available, but would result in an unnecessarily long procedure with secondary donor site.

2021

Question 29

A 16-year-old girl presents to the clinic 3 years after onset of a right unilateral Bell palsy with a chief complaint of absence of commissure elevation and asymmetry of the nasolabial fold when she smiles. She has undergone no previous treatment. Which of the following procedures is most likely to result in spontaneous smile animation with emotion on the affected side?

A) Cross-facial nerve grafting from the unaffected left face to the distal facial nerve branches on the affected right face
B) In-line temporalis muscle transfer
C) Single-stage gracilis free flap with neurorrhaphy to the right-sided motor nerve to the masseter muscle
D) Two-stage reconstruction with cross-facial nerve grafting from the unaffected left face followed by functional gracilis muscle free flap to the right face

Answer 29

The correct response is Option D.

Dynamic reconstruction options that restore the smile function to the face following facial (VII) nerve injury can be categorized as those restoring innervation to the native mimetic musculature and procedures including a muscle transfer. The decision to reinnervate the native facial musculature or to perform a muscle transfer is dictated by the elapsed time since the start of facial paralysis. In cases where facial paralysis is present for less than 12 months, the native musculature may be reinnervated. After 24 months of paralysis, muscles become irreversibly atrophic and a muscle transfer is necessary. In the case described, the facial paralysis has been present for 3 years and the native mimetic muscles can no longer be successfully reinnervated. Therefore, cross-face nerve grafting from the contralateral face to the distal facial nerve on the affected side will not be successful and does not represent a viable treatment for this patient.

Strategies for smile restoration can also be classified as those powered by the facial (VII) nerve and those powered by other cranial nerves. In-line temporalis transfer represents a direct transfer of the temporalis muscle, which is innervated by the trigeminal (V) nerve. Additionally, the nerve to the masseter muscle is another branch of the trigeminal (V) nerve commonly used to reinnervate functional muscle transfers such as a gracilis free flap. To activate both of these reconstructions, patients must actively clench their jaw. With therapy and practice, some patients may achieve the ability to smile without clenching the jaw, but a spontaneous smile with emotion is achieved by few patients.

Innervation from the facial (VII) nerve, whether ipsilateral or contralateral, is more likely to generate a spontaneous emotional smile compared with reconstructions powered by other cranial nerves. In the case described, the ipsilateral facial nerve does not represent a viable source of innervation, but a staged procedure using input from the contralateral facial nerve to innervate a microvascular gracilis muscle transfer represents a viable procedure to restore spontaneous smile function for this patient.

2022

Question 30

A 3-year-old girl with a history of congenital right trigeminal neuropathy is referred for recurrent corneal ulceration of the right eye. Physical examination discloses that she is completely insensate along the right V1 nerve/dermatome distribution. The right cornea is insensate with several areas of mild ulceration. Which of the following procedures is most likely to preserve vision in this child’s right eye?

A) Corneal neurotization with sural nerve graft from left supratrochlear nerve
B) Corneal transplantation
C) Ipsilateral supratrochlear nerve transfer to ophthalmic nerve
D) Laser-assisted in situ keratomileusis (LASIK)
E) Tarsorrhaphy

Answer 30

The correct response is Option A.

Neurotrophic keratitis is a rare vision-threatening condition caused by decreased corneal sensation due to trigeminal neuropathy. Subsequent inflammation and ulceration can lead to corneal opacification and, in young children, amblyopia. Preventing ulceration of affected corneas is critical to maintaining vision. In young children, however, tarsorrhaphy (surgical adhesion of eyelids) can result in deprivational amblyopia and permanent vision loss. Corneal transplantation has been attempted as well. However, without adequate sensation, most transplanted corneas become ulcerated and opacify as well. In the last decade, corneal neurotization has emerged as a means of restoring sensation and preventing persistent ulceration. In this procedure, fibers from the contralateral supratrochlear nerve are redirected via a sural nerve graft (or other graft) to the affected cornea, where they serve to reinnervate the affected eye. In cases with mild corneal ulceration, neurotization can reverse these neurotrophic changes and help restore normal corneal architecture.

Ipsilateral supratrochlear nerve transfer will not work in someone without functional sensation in that nerve. The ophthalmic nerve is upstream of the supratrochlear nerve and is also affected.

Laser-assisted in situ keratomileusis (LASIK) procedure involves reshaping the cornea in order to correct refractive errors. It does not affect sensation.

2022

Question 31

A 48-year-old woman presents to the clinic after Mohs micrographic surgery for a mid-cheek basal cell carcinoma. The defect is 4 cm and abuts the left eyelid-cheek junction. Which of the following is the most appropriate method to close the defect?

A) Cheek neck rotation flap
B) Lateral thigh flap
C) Radial forearm free flap
D) Split-thickness skin grafting
E) Xenografting

Answer 31

The correct response is Option A.

Mohs micrographic surgery is more often performed by the dermatologist, who then refers the patient to the plastic surgeon for closure. It allows for closure of margin-free carcinomas, typically either basal or squamous cell cancers. Defects of the cheek below the orbit can be challenging because ectropion of the lower lid can be a complication of surgery. For that reason, split-thickness skin grafts that can contract are not the first line choice of a large cheek defect below the orbit. An incision that extends upward toward the lateral canthus and then into the preauricular skin and down into the neck allows wide mobilization of the soft tissue to close relatively large defects. Free flap reconstruction is used in head and neck reconstruction, but it may provide soft-tissue reconstruction that is too bulky and a color match that is less than optimal. For those reasons, radial forearm and lateral thigh free flaps are not the optimal choice. There are autologous options, but xenografts are not used because the issues of cicatricial ectropion and graft rejection are overwhelming.

2022

Question 32

A 45-year-old man comes to the emergency department because of new-onset left-sided facial weakness. Two days ago, the patient fell on the left side of his head. He sustained a 3-cm laceration of the left medial cheek near the nose that was repaired. After repair of the laceration, he had full facial (VII) nerve function. On examination today, the patient has normal facial symmetry at rest. When he is asked to animate, there is diminished function of all branches of the left facial nerve. CT scan of the head shows a transverse fracture of the petrous portion of the left temporal bone. Which of the following is the most appropriate next step in management?

A) Administration of high-dose corticosteroids and observation
B) Cross-facial nerve grafting using the sural nerve
C) Decompression of the facial nerve through a transmastoid approach
D) Immediate facial nerve exploration through the repaired laceration
E) Initiation of a 2- to 4-week course of ceftriaxone and observation

Answer 32

The correct response is Option A.

The patient is presenting with a delayed onset of left facial nerve palsy after a fall from elevation with associated medial cheek laceration and ipsilateral temporal bone fracture. His facial nerve palsy is not complete paralysis but rather moderate to severe with a House Brackmann Grade of at least IV. The facial nerve injury is likely proximal due to symptoms of all thirds of the face and therefore associated with the temporal bone fracture. The medial cheek laceration is unlikely to be related, and exploration would risk further injury. The facial nerve travels through the petrous portion of the temporal bone before exiting the stylomastoid foramen and can be affected in 7 to 10% of temporal bone fractures. Within this subset, 38 to 50% of cases are associated with transverse fractures. Surgical exploration may be indicated in the setting of immediate complete paralysis, either through a middle cranial fossa and transmastoid approach, or a translabyrinthine approach, depending on the hearing function of the ear. Delayed paralysis or incomplete paresis should be treated conservatively with high dose corticosteroids with anticipated good prognosis for recovery. Intravenous antibiotics would not be appropriate since the patient’s facial nerve palsy is unlikely to be associated with Lyme disease. Cross-facial nerve grafting is reserved for settings where primary neurorrhaphy or interpositional nerve grafting are not feasible or have failed.

2023

Question 33

A 40-year-old man presents with acute left facial nerve paralysis that began 24 hours ago. In addition to a loss of facial expression on the left side of the face, the patient is most likely to report which of the following symptoms?

A) Crocodile tears
B) Excessive salivation
C) Gustatory sweating
D) Hyperacusis
E) Tongue numbness

Answer 33

The correct response is Option D.

The facial nerve not only innervates the muscles of facial expression but supplies parasympathetic input to the lacrimal gland and submandibular and sublingual salivary glands, as well as motor input to the stapedius, stylohyoid, and posterior belly of the digastric muscles. It also receives special sensory taste fibers from the anterior two-thirds of the tongue and general sensory fibers from the concha of the external ear. As such, intracranial injury to the facial nerve may result in weakness or paralysis of the face, dryness of the eye and the mouth (not excessive salivation), loss of taste (not numbness), pain or numbness in the ear, and increased sensitivity to loud sounds known as hyperacusis. Hyperacusis occurs due to loss of function of the stapedius muscle that normally dampens the movement of the stapes bone, which is one of three bones that transmit sound from the tympanic membrane to the cochlea. Note that because the facial nerve travels within the temporal bone in close association with the vestibulocochlear (VIII) nerve, hearing loss is also a possible symptom of cranial trauma, although not a symptom of facial nerve injury.

Gustatory sweating, also known as Frey syndrome, occurs when there is aberrant reinnervation of the sweat glands of the cheek by cut parasympathetic fibers from the auriculotemporal nerve that previously mediated saliva production by the parotid gland following parotidectomy. It is not associated with acute facial paralysis secondary to Bell palsy. Gustatory tearing, also known as crocodile tears or Bogorad syndrome, occurs when there is aberrant parasympathetic reinnervation of the lacrimal gland rather than of the salivary glands. It is a rare phenomenon and typically presents 6 to 9 months after the onset of Bell palsy.

2023

Question 34

A 51-year-old woman is evaluated because of a 1-year history of a “twitch” in her left cheek. Medical history includes Bell palsy. The patient reports that the twitching happens throughout the day and is worse when smiling or laughing. She states that she has completed six sessions of physical therapy without improvement. MRI of the brain showed no abnormalities. Which of the following is the most appropriate next step in management?

A) Botulinum toxin type A injection
B) Continued physical therapy
C) Expectant management
D) Repeat MRI of the brain
E) Surgical exploration

Answer 34

The correct response is Option A.

Botulinum toxin type A injection is the most appropriate management for this patient. A study was performed in which 41 patients affected by facial synkinesis and hyperkinesis due to facial palsy were treated. The causes of the facial palsy included: 28 Bell palsy cases, nine iatrogenic cases (seven acoustic neuroma surgeries, one tympanojugular glomus tumor removal, and one middle ear surgery), three herpes zoster virus cases, and one case of Melkersson-Rosenthal syndrome. Botulinum toxin type A was used in the treatment. All patients showed some improvement of synkinesis and hyperkinesis after treatment. The mean values of the data obtained, regardless of the method of evaluation, gave statistically significant results. Correlation between objective and subjective evaluation methods was also statistically positive.

Continued physical therapy is not appropriate since the patient underwent physical therapy without improvement. MRI showed no abnormalities, thus repeat MRI is not indicated. She has no new symptoms or events warranting repeat MRI. Surgical exploration is not indicated in this patient. Watchful waiting is not the best treatment option. The patient has been experiencing symptoms for a year, and conservative management has failed.

2023

Question 35

A 12-year-old boy with bilateral facial nerve paralysis secondary to Möbius syndrome is brought to the clinic to discuss facial reanimation. The patient reports psychosocial distress resulting from bullying in school. Which of the following procedures will most likely result in an animated, bilateral smile in the shortest amount of time?

A) Bilateral free gracilis flaps powered by a cross-face nerve graft
B) Bilateral free gracilis flaps powered by the motor nerve to masseter muscle
C) Bilateral hypoglossal nerve-to-facial nerve transfer
D) Bilateral in-line temporalis muscle transfer
E) Bilateral tensor fascia lata graft placement for a facial sling

Answer 35

The correct response is Option D.

Möbius syndrome is a congenital condition causing hypoplasia or absence of the facial (VII) nerve and mimetic musculature. Classically, the abducens (VI) nerve is also involved, but other cranial nerves may be involved. Hypoglossal nerve to facial nerve transfer is not a surgical option in this patient since there is no distal facial nerve branches or mimetic musculature recipient for the transfer. Bilateral free gracilis muscle flaps powered by the motor nerve to masseter muscle is a common procedure employed for facial reanimation for this patient population, but it will not result in the most rapid gain of smile function. Bilateral cases are often staged, and nerve regeneration from the masseter nerve to obturator nerve coaptation will delay the return of motor function. In-line temporalis muscle transfer (Labbé technique) can be completed bilaterally in a single procedure, and since the native innervation to the temporalis muscle is preserved, it offers a more rapid gain of smile function that may benefit this patient. Static sling reconstructions improve the resting tone and position of the face but do not provide a dynamic reconstruction. Finally, a free gracilis flap powered by a cross-face nerve graft offers the best possibility of spontaneous emotional smile responses, but it may not be employed in this case of bilateral facial nerve palsy without a donor facial nerve.

2023