title: One-stage dual latissimus dorsi muscle flap transfer with a pair of vascular anastomoses and double nerve suturing for long-standing facial paralysis.
abstract: OBJECTIVE
  Various types of neurovascular free-muscle transfers have been reported as surgical treatments for long-standing facial paralysis. Among one-stage methods, two approaches, that is, latissimus dorsi transfer with nerve suturing to the contralateral facial nerve and gracilis transfer with nerve suturing to the ipsilateral masseteric nerve, have recently become popular. The former method has the advantage of making spontaneous smiling possible, but the contraction strength of the transferred muscle varies, whereas the latter approach has the advantage of guaranteeing voluntary contraction of the transferred muscle, but makes spontaneous smiling difficult. Recently, dual innervation methods have also been reported, but uncertainty remains about the utility of such approaches. To overcome these drawbacks, we devised a hybrid method combining the two previously established techniques.
  
  
  METHODS
  Two latissimus dorsi muscle flaps containing the thoracodorsal vessels from one side are transferred with a pair of vascular anastomoses. The true trunk of the thoracodorsal nerve, which innervates one of the muscle flaps, is sutured to the contralateral facial nerve, while the short branch of the thoracodorsal nerve, which innervates the other muscle flap, is sutured to the ipsilateral masseteric nerve. From November 2011 to October 2013, we used this method in four patients with long-standing facial paralysis.
  
  
  RESULTS
  Smiling was assessed in the three patients who were followed up for more than 1 year, and satisfactory results were obtained (Harii score: 4-5). In one patient, the movement mediated via the contralateral facial nerve was a little weak, but this was compensated for by the muscles controlled by the ipsilateral masseteric nerve.
  
  
  CONCLUSIONS
  Our novel one-stage method, which involves a combination of two previously established methods, guarantees early voluntary smiling, and spontaneous smiling becomes possible later. In addition, it is free from the uncertainty associated with double innervation and does not require nerve grafts. So, stable results can be expected in most patients with long-standing facial paralysis.
authors.forename: Mutsumi
authors.initials: M
authors.lastname: Okazaki
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan. Electronic address: okazaki-m@umin.ac.jp.
authors.forename: Okazaki
authors.initials: O
authors.lastname: Mutsumi
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
authors.forename: Tanaka
authors.initials: T
authors.lastname: Kentaro
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
authors.forename: Uemura
authors.initials: U
authors.lastname: Noriko
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
authors.forename: Usami
authors.initials: U
authors.lastname: Satoshi
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
authors.forename: Homma
authors.initials: H
authors.lastname: Tsutomu
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
authors.forename: Okubo
authors.initials: O
authors.lastname: Alisa
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
authors.forename: Hamanaga
authors.initials: H
authors.lastname: Mayuko
authors.affiliation: Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
authors.forename: Mori
authors.initials: M
authors.lastname: Hiroki
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical / Q000379:methods; D004576:Electromyography; D005154:Facial Nerve / Q000601:surgery; D005158:Facial Paralysis / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D008297:Male; D008488:Medical Illustration; D008875:Middle Aged; D010525:Peripheral Nerves / Q000601:surgery; D010781:Photography; D019651:Plastic Surgery Procedures / Q000379:methods*; D012904:Smiling / Q000502:physiology*; D064171:Superficial Back Muscles / Q000098:blood supply / Q000294:innervation / Q000637:transplantation*; D013524:Surgical Flaps / Q000098:blood supply* / Q000294:innervation*; D013536:Suture Techniques; D016896:Treatment Outcome
keywords: Contralateral facial nerve; Double latissimus dorsi muscle transfer; Facial paralysis; Facial reanimation; Ipsilateral masseteric nerve