A 38-year-old has complete facial paralysis 16 months after proximal facial-nerve sacrifice. There is no recoverable proximal stump, but needle EMG shows viable facial musculature. What is the best dynamic option?
Facial reanimation is chosen by muscle viability, available donor nerves, duration and goals; viable native muscle makes nerve transfer a strong dynamic option.
A. Static sling alone: This improves resting symmetry but does not reanimate viable mimetic muscle.
B. Direct end-to-end facial repair: The proximal stump is unavailable and the gap/timing preclude this.
C. Cross-facial nerve graft alone and wait indefinitely: A graft requires a distal motor target strategy and may not supply timely axonal input at this duration.
D. Free gracilis transfer is mandatory because native muscle is always non-viable after 12 months: EMG viability means nerve transfer can still be considered; a calendar threshold is not absolute.
E. Masseteric-to-facial nerve transfer, with adjunctive procedures tailored to eye closure and symmetry: When native muscle remains viable and no proximal facial input exists, masseteric transfer supplies robust axons and relatively rapid movement.
If EMG showed irreversible denervation and severe muscle atrophy, free functional muscle transfer would be favoured.
Independent Clinora educational preparation material; not official JCIE content, an accredited programme, or a substitute for local policy and specialist clinical judgement.
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