Cross-face nerve transplant.

The two stage principle is one of the most important features of the procedure. It allows starting the operation at a very early stage (one to six months). The donor area in the periphery is very well supplied, therefore as many facial fascicles as necessary can be sacrificed on the healthy side. We have never noticed any functional disturbances. The nerves leading to the buccinator muscle and those which innervate the lateral pull of the mouth are especially suitable. This weakening of the strong pull of the mouth is of great value for symmetry but unfortunately relapse to the original state is common. The selection of the nerve fascicles on the healthy side must be executed in a deep layer below the muscles because all large branches are located here. The end of the sural grafts should positioned far back on the paralyzed side to enable easy anastomoses at the second stage. A face lift incision on the paralyzed side and tightening of the skin are of additional value and provide some support to the elongated muscles. The combination of cross-face nerve transplant with other substitutional methods in which muscles are used for reinnervation is very promising. In our experience physiotherapy is a very important measure. It should be started after the onset of the palsy and continued until restoration of the face is complete. It is usually applied three times a week with exponential current and at a strength of 20 to 60 milliamperes. Each group of muscles receives a 2 to 3 minutes dosage. It is helpful if the patient can use a stimulation apparatus at home daily for short treatments.