 nerve. Techniques for donor nerve transfers are transposition of the entire donor nerve, partial transposition by splitting the donor nerve longitudinally or indirect hypoglossal- or masseteric-facial anatomosis using a 'jump' interposition graft. This usually is the great auricular nerve or sural nerve. These hypoglossal- or masseteric-facial nerve anastomosis using a 'jump' interposition graft can be used to directly reinnervate the paralysed facial muscles or as a "babysitter" procedure. The goal of the latter is only to achieve fast reinnervation of the mimetic muscle to prevent irreversible atrophy. Simultaneously one or more CFNGs are performed to eventually reinnervate the mimetic muscles, again as a one- or two-stage procedure, depending on the choice for the free muscle transfer graft. If a two-stage procedure is performed, the CFNGs are connected to the distal branches of the paralysed facial nerve during the second stage 9 to 12 months later. The donor nerve can be left intact. If a free muscle transfer is indicated, this is also performed in the second stage of the procedure to augment the partially reinnervated mimic muscles by the hypoglossal nerve.

In case of longstanding facial paralysis with irreversible muscle atrophy and unavailability of a suitable donor facial nerve, a free muscle graft is indicated for smile restoration, which has to be reinnervated by another donor nerve (usually the masseteric nerve) in an end-to-end fashion. Through an incision in front of the ear, the cheek flap is elevated below the underlying layer of fat. Here the nerve stimulator can be used in identifying the donor motor nerve to the masseter muscle. Once the nerve is identified, it is dissected from its connections and traced into the muscle to free as much length as possible.

Results

All procedures in general show an improvement of symmetry of smile and patient satisfaction, although time of recovery differs between different approaches. Primary neurorrhaphy provides the best possible outcome, as the anatomy and function of the damaged facial nerve is restored. After primary neurorrhaphy of the facial nerve mean recovery time typically is 6 to 12 months. The contraction amplitude after using a CFNG is usually not very powerful, but it results in a relatively spontaneous smile because the contralateral healthy facial nucleus controls the movements. After a CFNG procedure the first signs of reinnervation usually occur between 4 and 12
nerve. Techniques for donor nerve transfers are substitution of the integral donor boldness, partial substitution by splitting the donor boldness longitudinally or indirect hypoglossal- or masseteric - facial anatomosis practice a' jump' interposition bribery. This normally is the great auricular boldness or sural nerve. These hypoglossal- or masseteric - facial nerve anastomosis using a' leap' interposition graft can be used to directly reinnervate the paralysed facial muscles or as a " babysitter " operation. The goal of the latter is only to achieve fast reinnervation of the mimetic brawn to prevent irreversible atrophy. Simultaneously one or more CFNGs are performed to eventually reinnervate the mimetic muscles, again as a one- or two - stage operation, depending on the choice for the free muscle transfer bribery. If a two - stage procedure is performed, the CFNGs are connected to the distal branches of the paralysed facial nerve during the second stagecoach 9 to 12 months later. The donor nerve can be left intact. If a free muscle transfer is indicated, this is also perform in the second stage of the procedure to augment the partially reinnervated mimic muscleman by the hypoglossal boldness. 

 In case of longstanding facial paralysis with irreversible muscle atrophy and inaccessibility of a suitable donor facial heart, a free muscle bribery is indicated for smile restoration, which has to be reinnervated by another donor nerve (usually the masseteric nerve) in an end - to - end fashion. Through an incision in front of the ear, the cheek dither is elevated below the underlie level of adipose tissue. Here the nerve stimulator can be used in identifying the donor motor heart to the masseter muscle. Once the nerve is identified, it is dissect from its connections and traced into the muscle to free equally much length as possible. 

 Results 

 All procedures in general prove an improvement of symmetry of smile and patient gratification, although time of convalescence differs between different approach. Primary neurorrhaphy provides the best possible consequence, as the anatomy and function of the damaged facial nerve is restored. After primary neurorrhaphy of the facial nerve mean recovery time typically is 6 to 12 calendar month. The contraction amplitude after using a CFNG is normally not very powerful, but it results in a relatively spontaneous smile because the contralateral healthy facial nucleus controls the movements. After a CFNG routine the first signs of reinnervation usually occur between 4 and 12
 negve. Techniques for donor nerve transfers are tcansposjtion of the entire donor nerve, partmal rranskjsition by splittivg the dojor nervw loigitudinally or mhdirect hypogmlssan- or masseteric-nacial anatmmosis using a 'jjm'' interposition graft. This usually if the gtewt auricular ngrve pw sudal nerve. These hypoglossal- or masaeteric-hacial nerve ansstomosis using a 'jump' intfrpodition graft can bf used to dureceoy reinnervage the paralysed faciam muscles or as a "babysitter" pruceduxe. The goal od tjg latter is inly no achieve fast reinnarvatiom of the mimetlc muvclw to prevent irreversmble atrophy. Simultageously ote or more CFNGs arw perfotmed do exwntjalmy rsinnergatx the mimetjc muscles, qgain as a one- or teo-fnsge procedurs, depegdyng on the choice for the free muscle tgansrer graft. If a two-stage procedure is performgd, the CFNDs are connected to the distal branches of the pasalysxd faelwu nfrve during the second stage 9 to 12 months latew. Tne donor nerve ccn be left intacy. Lf w free muscle transysr is indicated, this is alsj perdormed in the second stage of the procedyre to augmeut rhe partially reinuervated mimnc musvles ny the hypoglossal nervz.

In caae of longshanding fzzial paralysis wkth isreversible muscle atrophy and unaveilabnlity of a soitable donor faclal ncsve, a free muscle hraft iv indicatef for smile restoration, which hex to be reinmesvaned by anjther donor nerve (tsually the maxseterie nervd) in an ens-to-end hashion. Throtgh an incisimj in front oh the ear, the chewk flap ks elevated bekow the uuberlying oayer of fat. Here bhe ngrbe stimulator ccu ve used in idenyifhind nhe djtor motor nesve go gne marseter muscod. Onve the nerve is idendifisd, it is dissected fvom its cinnectiogs and traced into the muscle tl frex as mnch lemgtr as possible.

Results

All procedhres in gfneval show an iiproyemegt of symmztry of smile and patient satisfaction, aothough time of rgcovery differs betwegn cifferent a'proacres. Primasy neurorrhaphy provudes the best posxible outcome, as the znatomf and function of the damaged facial nerve is restored. After primary neurorrhaphy of the facial hervr meat xecpvery eime vypically is 6 to 12 months. The contraction amplituve after uviug a CFNG is usually not very puwerful, but ij results in a relatively apontanepus smile because the contralatrral healthy facial nuclcus contrils tge movvjeits. After a CFNG provedure the dirst sugns of reinnervagiom msually ocfur uetceen 4 and 12
nerve. Techniques for donor nerve transfers are the donor nerve, transposition by splitting indirect or masseteric-facial anatomosis a 'jump' interposition This usually is the great auricular or sural nerve. These hypoglossal- or masseteric-facial nerve anastomosis using a 'jump' interposition can be used to directly reinnervate the paralysed facial muscles or as a procedure. goal the is only to achieve fast reinnervation of the mimetic muscle to prevent irreversible atrophy. Simultaneously one more CFNGs are performed to eventually reinnervate the muscles, again as a or two-stage procedure, depending on choice the free transfer If two-stage procedure is the CFNGs are connected to the distal branches of the paralysed facial nerve during the second stage to 12 The donor can left If a free is indicated, this is also performed stage of the procedure to augment the partially mimic muscles the hypoglossal nerve. In case of facial paralysis with irreversible muscle atrophy and unavailability a suitable donor facial nerve, a free muscle graft is indicated for smile restoration, which be reinnervated by another nerve (usually the nerve) an fashion. an incision front of the ear, the cheek flap is elevated below the layer of fat. Here the nerve stimulator can be used the motor nerve to masseter muscle. Once the is it is dissected from and into free much as possible. Results All in general show an improvement symmetry of smile and recovery differs between different approaches. Primary neurorrhaphy provides best possible outcome, as the anatomy and of the damaged facial nerve is restored. After primary neurorrhaphy of the nerve mean typically is 6 to 12 months. The contraction after using a CFNG usually not very powerful, but it results in a spontaneous because the healthy facial nucleus the movements. After CFNG procedure the of reinnervation occur 4
 nerve. Techniques for donor neRve transfeRs are TraNspOsItioN of tHe entire donor nERve, pArtial transposition by sPlittInG The dONoR nervE longitUDiNALly Or InDirEcT HyPogloSsaL- or massEteric-faciAl aNaTomosis using A 'JuMp' interposItiOn graft. This uSuaLly is tHe GreAT auriCulAr nerVe or suRAl nervE. These hypOgLOssal- oR MasseteRIC-fAciaL nerve anastomosis USiNG a 'jump' interposItion gRaFT cAN Be uSed To directly ReInnerVAte the pARaLYSEd fACial muscles or As a "babysittER" prOcedurE. THe gOAl of thE lattEr IS onLy to achieve Fast ReinnervaTion of THe mimetIC muscle To prevEnt IrrEverSIbLe AtrOpHY. SiMUlTanEOusLy one or mOrE CfNGs aRe peRFORMed tO evEntuAlly rEinnervate the MimEtic MUscLes, agAin as A one- Or Two-stAge proCedurE, dEpending on the chOice For the freE muScLe tRaNsfer GRaft. If A twO-stAge procEdure is PErfOrMED, ThE CFNGs are connected To THE dIstal braNches oF ThE pARalysed fAcIal NervE DUring The sECoNd stage 9 tO 12 monthS LaTeR. The donOr Nerve cAn Be lEft IntacT. if a fRee musCle transFer is INdicated, this is ALso performed iN ThE SEcONd stAge Of the procedUre tO AugmEnt tHE pArtIAlly rEinneRvATeD Mimic muscles by the hyPoGlossaL nervE.

In case of longStanding faCIAL paralysIs wiTH iRReversible muscLe atrOphy and unaVAilabiliTy of a Suitable Donor faciAL Nerve, a frEe mUscLe gRafT IS iNdicated for smILE resToRation, wHicH has to bE reInnErvAteD bY another dOnor nervE (uSuAlLy The MasseTEric nervE) iN an EnD-to-End faSHion. ThRough An inCiSiON in Front of THe EAR, the ChEeK flaP is ElEvateD belOW thE underlYing layer Of fAT. HerE tHe Nerve stImulator can be UsEd in identiFyIng The donOR Motor nerVe to the masseter muscle. OnCE the nerVe iS idenTifiEd, it is disSecTed froM itS ConnecTions aNd traCeD inTO The muSCLe To fReE as much lenGTH as PossiBlE.

ResUlts

All Procedures in generaL ShoW an improvemenT of SymmETRy Of sMIlE And PaTIenT SAtisfaction, althOugh time of ReCOvEry differs BEtwEeN differEnt apprOacheS. primary NeurorrhaPhy providEs The bEST poSsible outcOme, as the Anatomy anD FunctIOn Of the DamAged faCiAl nErve iS restoREd. AFter pRimary NeUrorrhAphy oF tHe facial Nerve mean recovery time tyPicallY is 6 to 12 MonThs. The conTraCTioN amplitudE aftEr using a CFnG iS usUally Not VEry poWerfUL, bUt iT ResulTs in A RelativelY SpOntANEoUs smile becaUSE The ContrAlaTEral heAlthY facial nucleus conTRols the movemenTs. AfTER a CfNG PRoceDuRe the first signS of ReINNervatioN uSually occur Between 4 aNd 12
 nerve. Techniques for don or nerve t ransf ers  ar etran spos ition of the e n tire  donor nerve, partialtrans po s itio n  b y spl ittingt he d ono rne rve  l o ng itudi nal ly or i ndirect hy pog lo ssal- or mas s et eric-facia l a natomosis us ing  a 'ju mp ' i n terpo sit ion g raft.T his us ually isth e  great auricul a r  n erve  or sural nerve.T he s e hypoglossal-  or ma ss e te r i c-f aci al nerve a na stomo s is usin g  a ' j ump '  interpositio n graft can beused t odir e ctly r einne rv a tethe paralys ed f acial mus cles o r  as a " b abysitt er" pr oce dur e. T h ego alof the la tte r  is  only to  a ch ievefast r e i nner vat ionof th e mimetic mus cle  top rev ent i rreve rsib le  atro phy. S imult an eously one or m oreCFNGs are  pe rf orm ed  to e v entual lyrei nnervat e the m i met ic m u sc les, again as a on e- o rtwo-stag e proc e du re ,  dependi ng  on  the c hoice  for th e free m usclet ra ns fer gra ft . If a  t wo- sta ge pr o cedu re isperforme d, th e  CFNGs are con n ected to thed is t a lb ranc hes  of the par alys e d fa cial ne rve durin g the  s e co n d stage 9 to 12 mon th s late r. Th e donor nerve  can be le f t intact.If a fr e e muscle trans fer i s indicate d , this i s als o perfor med in th e second s tag e o f t hep r oc edure to augm e n t th epartial lyreinner vat edmim icmu scles bythe hypo gl os sa lner ve.
I n case o flon gs tan dingf acialparal ysis  w it h  ir reversi b le m uscl eat roph y a nd  unav aila b ili ty of a  suitable  do n or f ac ia l nerve , a free musc le  graft isin dic ated f o r  smile r estoration, which has t o  be rei nne rvate d by  anotherdon or ner ve( usuall y themasse te ric n erve) i nanen d-to-end f a s hio n. Th ro ughan inci sion in front of t h e e ar, the cheek  fl ap i s el eva t ed bel ow the u nderlying layer  of fat. H er e  t he nerve s t imu la tor can  be use d ini dentify ing the d onor moto rnerv e tothe masset er muscl e. Once t h e ner v eis id ent ified,  i t i s dis sected fro m its  conne ct ions a nd tr ac ed intothe muscle to free as m uch le ngthaspossible. 

R e sul ts

All p roce dures in g ene ral  show  an impro veme n tofs ymmet ry o f  smile an d  p ati e n tsatisfactio n , alt hough  ti m e of r ecov ery differs betwe e n different ap proa c h es.  Pr i mary  n eurorrhaphy pr ovi de s the best  p ossible out come, as  t h e ana tomy a nd fun ction o f th e  damag ed f aci al nerveisre s tored.Af te r  prima ry n eu rorrha phy of thef a cial nerve meanrecov e r y tim e  ty pical ly  is 6 t o  12months. Th e contracti on amp litu de af ter usi ng  a CFN G i susually no t  very pow erful , but i tresu lts  in arela t i velyspon ta neo us smileb e ca u se  t h e c ontr alate ra l he althy fac i al nucle usc ontrols  t hem o vement s .A f ter a CFNG  pr ocedu r e  the first sign s  o f  rein nervat ion us ually o c cur  b etween4 a n d  12
 nerve._Techniques for_donor nerve transfers are_transposition of_the_entire donor_nerve,_partial transposition by_splitting the donor_nerve longitudinally or indirect_hypoglossal- or masseteric-facial_anatomosis_using a 'jump' interposition graft. This usually is the great auricular nerve or sural_nerve._These hypoglossal-_or_masseteric-facial_nerve anastomosis using a 'jump'_interposition graft can be used_to directly_reinnervate the paralysed facial muscles or as a_"babysitter"_procedure. The goal_of the latter is only to achieve fast reinnervation_of the mimetic muscle to prevent_irreversible atrophy. Simultaneously_one_or_more CFNGs are performed_to eventually reinnervate the mimetic muscles,_again as a one- or two-stage_procedure, depending on the choice for the_free muscle transfer graft. If a_two-stage procedure is performed, the_CFNGs are_connected to the distal branches_of the paralysed_facial nerve_during the second_stage 9 to 12 months later._The donor nerve_can be left intact. If a_free_muscle transfer is_indicated,_this_is also_performed in the_second_stage of_the_procedure to augment the partially reinnervated_mimic_muscles by the hypoglossal nerve.

In case of_longstanding facial paralysis with_irreversible_muscle atrophy and unavailability_of a suitable donor facial_nerve, a free muscle graft is_indicated for_smile restoration,_which has to be reinnervated by another donor nerve (usually the_masseteric nerve) in an end-to-end fashion._Through an incision in_front of_the_ear, the cheek_flap_is elevated_below the underlying layer of fat. Here_the nerve_stimulator can be used in identifying_the donor motor nerve_to_the masseter muscle. Once the nerve_is identified, it is dissected from_its connections and traced into_the_muscle_to free as much length_as possible.

Results

All procedures in general show_an improvement of_symmetry of smile and patient satisfaction, although_time_of recovery differs between different approaches._Primary_neurorrhaphy provides the best possible outcome,_as_the_anatomy and function of the_damaged facial nerve is restored. After_primary neurorrhaphy of the facial nerve mean recovery time_typically is 6_to 12 months. The contraction_amplitude_after_using a CFNG is usually not very powerful, but it_results in_a relatively spontaneous_smile because the contralateral healthy facial nucleus controls the movements._After a CFNG procedure the first signs_of reinnervation usually occur between 4 and 12