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Segmental midface paresis with or without synkinesis reflects incomplete recovery from Bell's palsy, operations on the cranial base or parotid, or trauma, in 25%-30% of cases. To correct the deficit, the masseteric nerve was used to deliver a powerful stimulus to the zygomatic muscle complex, with the addition of a cross-face sural nerve graft to ensure more spontaneous smiling. By doing this, the orbicularis oculi muscle continues to have an appropriate stimulus from the facial nerve, and the zygomatic muscle complex is separately innervated, which considerably reduces synkinesis between the two muscle compartments. For those patients with muscular contractures of the midface, the new healthy neural stimulus relaxes muscles at rest. From January 2011 to March 2017, 20 patients presented with segmental facial paresis of the midface and were operated on using this new technique. All patients were evaluated before and after operation using Clinician-Graded Electronic Facial Paralysis Assessment (eFACE), and they showed considerable postoperative improvements in static, dynamic, and synkinetic variables. Our proposed use of the masseteric nerve to treat segmental facial paresis produces favourable results, but our initial data require confirmation by further studies., (Copyright © 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Recent facial paralyses, in which fibrillations of the mimetic muscles are still detectable by electromyography (EMG), allow facial reanimation based on giving new neural stimuli to musculature. However, if more time has elapsed, mimetic muscles can undergo irreversible atrophy, and providing a new neural stimulus is simply not effective. In these cases function is provided by transferring free flaps into the face or transposing masticatory muscles to reinstitute major movements, such as eyelid closure and smiling. In a small number of cases, patients affected by paralysis are referred late - more than 18 months after onset. In these cases, reinnervating the musculature carries a high risk of failure because some or all of the mimetic muscles may atrophy irreversibly while axonal ingrowth is taking place. A mixed reanimation technique to address this involves a neurorrhaphy between the masseteric nerve and a facial nerve branch for the orbicularis oculi, to ensure a stronger innervation to that muscle, associated with the transposition of the temporalis muscle to the nasiolabial sulcus. This gives good symmetry in the rest of the midface, while smiling movement is achievable, but not guaranteed. This one-time facial reanimation is particularly indicated for those who refuse major free-flap surgery or when that may be risky, as in previously operated and irradiated fields. More extensive procedures based on utilizing a free flap to recover smiling, while adding a cross-face nerve graft to restore blinking, may be proposed for motivated patients. Between 2010 and 2015, five patients affected by complete unilateral facial palsy underwent this technique in the Maxillofacial Surgery Department, San Paolo Hospital (Milan, Italy). Symmetry of the middle-third of the face at rest and recovery of smiling was quite good. Complete voluntary eyelid closure was obtained in all cases. Combining temporalis flap rotation and a masseteric-to-orbicularis-oculi-facial-nerve branch neurorrhaphy seems to be a valid solution for those medium-term referred patients., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Recent facial palsies are those in which fibrillations of the mimetic musculature remain detectable by electromyography (EMG). Such fibrillations generally cease 18-24 months after palsy onset. During this period, facial re-animation surgery seeks to supply new neural inputs to the facial nerve. Neural usable sources were divided into qualitative (contralateral facial nerve) and quantitative (hypoglossus and masseteric nerve), depending on the type of stimulus provided. To further improve the extent and quality of facial re-animation, we here describe a new surgical technique featuring triple neural inputs: the use of the masseteric nerve and 30% of the hypoglossus nerve fibres as quantitative sources was associated with the contralateral facial nerve (incorporated via two cross-face nerve grafts) as a qualitative source in order to restore facial movements in 24 consecutive patients. The use of two quantitative motor nerve sources together with a qualitative neural source appears to improve re-animation after facial paralysis, despite earlier doubts as to whether patients could use different nerves to produce facial movements. In fact, movement was much improved. Smiling according to emotions and blinking seem to be better assured if cross-face nerve grafting is performed in two steps rather than one., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The extracranial facial nerve may be sacrificed together with the parotid gland during a radical parotidectomy, and immediate reconstruction of the facial nerve is essential to maintain at least part of its function. We report five patients who had had radical parotidectomy (two with postoperative radiotherapy) and immediate (n=3) or recent (n=2) reconstructions of the masseteric-thoracodorsal-facial nerve branch. The first mimetic musculature movements started 6.2 (range 4-8.5) months postoperatively. At 24 months postoperatively clinical evaluation (modified House-Brackmann classification) showed grade V (n=3), grade IV (n=1), and grade III (n=1) repairs. This first clinical series of masseteric-thoracodorsal-facial nerve neurorrhaphies has given encouraging results, and the technique should be considered as an option for immediate or recent reconstruction of branches of the facial nerve, particularly when its trunk is not available for proximal neurorrhaphy., (Copyright © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)