Functional and aesthetic approach to adult unoperated Möbius syndrome: orthognathic surgery followed by bilateral free gracilis muscle transfers.

Functional and Aesthetic Approach to Adult Unoperated Mo¨bius Syndrome: Orthognathic Surgery followed by Bilateral Free Gracilis Muscle Transfers Sir: We read with great interest the article recently published in your Journal by Chou et al., who reported their experience in the treatment of an adult patient withMo¨bius syndrome.1 This was the first report in the literature of orthognathic surgery in those types of patients, and only one other article has been published.2 Despite the great results obtained by the authors and the innovative approach in Mo¨bius syndrome treatment, we found some points that should be clarified. The authors recommend at the end of the article that the bony procedure be performed before soft-tissue adjustment: although this timing is certainly easier for the surgeon who can perform orthognathic surgery without intraoperative difficulties related to previous muscle transplantation, it could be detrimental to the patient in different ways. Orthognathic surgery should be performed, in Mo¨bius patients and in normal patients, at the end of bony growth, to allow for optimal and stable results, avoiding recurrences and interferences with bony growth, whereas facial animation should be performed as soon as possible (we usually perform it starting from the age of 5 years) to allow for optimal social interactions and psychological development.3 Furthermore, if orthognathic surgery and, in particular, mandibular advancement, is performed before muscle transplantation, the lack of muscular activity in the lower third of the face could lead to a stretching of facial soft tissues and in particular of the inferior lip and pericommissural area that could result in worsening of inferior lip eversion and oral competence. These iatrogenic deformations are very difficult to correct also with muscle transplantation and require special techniques, including lip suspensions with fascia lata strips or commissuroplasty, that complicate soft-tissue rehabilitation and worsen final aesthetic and functional results. It is also important to point out that when gracilis muscle transplanted for facial animation is reinnervated with the motor nerve to the masseter muscle, reinnervation is stronger, safer, and faster than with other donor nerves,4 and there is no interference with the orthognathic procedure that can be safely performed at the end of growth. In conclusion, we commend the authors for their nice job, but we would also like to emphasize that the approach they recommend should be used only for patients in whom Mo¨bius syndrome is diagnosed at the end of growth (such as the one they reported) and not in younger patients, who represent the majority of Mo¨- bius cases. In these patients, facial animation should be performed as soon as possible and orthognathic surgery should be delayed until after patient growth. DOI: 10.1097/PRS.0b013e3182362d4a Bernardo Bianchi, M.D. Andrea Ferri, M.D. Silvano Ferrari, M.D. Chiara Copelli, M.D. Maxillo-Facial Surgery Division Teore Ferri, M.D. Otolaryngology Head Neck Surgery Division Enrico Sesenna, M.D. Maxillo-Facial Surgery Division Head and Neck Department University Hospital of Parma Parma, Italy Correspondence to Dr. Ferr