The three-stage concept to optimize the results of microsurgical reanimation of the paralyzed face.

From the authors three-dimensional video analyses they had to learn that the advantages of a one-stage procedure is outweighed by far by the disadvantages. A three-stage concept to a one-stage procedure was preferred for the following reasons: 1. Safety of having a cross-face nerve graft to cover the distance from the healthy facial nerve to the nerve of the muscle transplant without problems and without the danger of tension on the nerve suture line because of shortage of the muscle nerve. 2. Independence of anatomical variations like a very proximal muscle hilus in the latissimus dorsi muscle e.g., resulting in a too short muscle nerve. 3. Only face-lift incisions are necessary without the need of an additional incision in the nasolabial fold while using a cross-face nerve graft. 4. Freedom of positioning the muscle graft on the paralyzed side with free choice of the position of the transplant hilus. 5. The superficial temporal vessels can be used for microvascular anastomoses. 6. Prevention of a scar in the submandibular region with its tendency of hypertrophy, especially if it is connected to the preauricular incision. Different functional territories of one muscle transplant for eye closure and for smile is only possible in combination with two cross-face nerve grafts. Further on the three-dimensional video analysis showed clearly that Final surgical corrections for improvement of the static and dynamic symmetry should be performed. when the muscle transplant or the transposed muscle have gained their final functional result, which is often not before one or one and a half year after muscle transplantation. Therefore a three-stage concept is needed for the majority of patients. Detailed analyses of the movements in the different regions and the comparison of both sides clarify preoperatively the indication for the operative techniques to be used, and describe exactly the improvement of the overall result. It is not only possible to show, eg, the better positioning of the alar of the nose by a nasolabial dermal suspension plasty on the paralyzed side in millimeter, but also the influence on the relation of all the different points in the face (Fig. 5). The comparison of the right and the left side gives exact data on the symmetry of the face on rest and during the different movements. Of course, also qualities of facial reanimation like prevention of mass movements or synkinesias are detected in the three-dimensional graphs of all the points at the same time or in the repeated reviews of the original movement in the original video sequence. In conclusion, three-dimensional video analysis of facial movements became an important tool for online planning of operative procedures for the individual patient, and an excellent tool for comparative studies of different operative concepts and alternative operative techniques within a standardized registry of one center treating facial palsy or within international multicenter studies.