Safe and effective use of free tissue transfer for facial reanimation in complex facial palsy

Background: In irreversible, dense facial paralysis, facial reanimation surgery to recreate the smile is established as the gold standard. Most patients presenting for treatment will have had little or no prior surgical interventions. A significant minority may have undergone prior surgery, making any attempt at facial reanimation complex. These include patients with previous free flap and neck dissection procedures and where multiple prior procedures have been undertaken, including attempts at facial reanimation. Occasionally, a composite tissue reconstruction is required. In these complex cases, it is challenging to determine the best surgical solution for facial reanimation. Microsurgical techniques utilising free tissue transfer may seem to be relatively contraindicated. Methods: A series of 15 cases where free tissue transfer was used successfully for facial reanimation in complex cases is presented. These patients were otherwise deemed to be suitable for facial reanimation and were defined as complex utilising defined criteria. Results were assessed by using the Sunnybrook scoring system where possible and in all cases by measuring symmetry at rest and modiolar excursion when smiling. Standardised pre- and post-operative photos and videos were also used. Results: The average improvement in Sunnybrook score was 39. The average improvement in resting symmetry was 8.5 mm. Thirteen patients developed facial movement corresponding to a good-quality smile with average improvement of modiolus movement of 6 mm. There were no free flap failures. Conclusions: These results demonstrate that even very complex cases of facial paralysis can be effectively and safely treated with free tissue transfer for facial reanimation. Level of Evidence: Level I