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Background The aim of this study was to review the recipient vessels used in our cases of facial reanimation with free functional muscle transfer and to identify patient variables that may predict when the facial vessels are absent. From this we present a protocol for vessel selection in cases when the facial artery and/or vein are absent.
Conclusions Our algorithm can help to guide vessel selection cases of facial reanimation with free functional muscle transfer. Amongst patients with congenital facial palsy or in those with a previous history of facial surgery or trauma, the facial vessels are more likely to be absent and so the surgeon should then look towards the transverse facial vein and superficial temporal artery as alternative recipient structures.
The aim of this study was to review the recipient vessels used in our cases of facial reanimation with free functional muscle transfer and to identify patient variables that may predict the facial vessels are absent. From this we present a protocol for vessel selection in cases when the facial artery and/or vein are absent.
All patients that underwent free functional muscle transfer for facial reanimation in the treatment of facial palsy between November 2006 and October 2013 were identified retrospectively using the departmental electronic patient system. Patients were excluded if their case notes were unavailable or documentation of the intraoperative findings was incomplete.
A total of 103 patients had undergone facial reanimation during the study period. Eighty-seven were eligible for inclusion amongst which 98 hemifaces were operated upon. Of the eligible patients included in the study, 61% had congenital facial palsy ([Table 1]). Syndromic cases included those with Moebius syndrome (n=13), CHARGE syndrome (n=3), hemifacial microsomia (n=2), Goldenhar syndrome (n=1), first arch syndrome (n=1) and Poland's syndrome (n=1). [Table 2] shows the distribution of free functional muscle transfers used. In a patient who had facial palsy secondary to previous debulking of extensive facial lymphatic malformations, the procedure had to be abandoned due to lack of any suitable recipient vessels. This particular patient had undergone resection of the internal and external jugular veins as part of the surgical resection and had undergone postoperative radiotherapy that made safe mobilisation of the external carotid artery for end-to-side anastomosis impossible. The recipient vessels used are shown in [Tables 3] and .
The facial artery and vein act as our first choice recipient vessels in cases of facial reanimation with free functional muscle transfer due to their locality to the muscle pedicle after inset, their calibre and good handling characteristics. After arising from the external carotid artery, the facial artery runs around the lower border of the mandible just anterior to the masseter muscle and then ascends towards the corner of the mouth in a subcutaneous plane. As such, it is readily identified during dissection towards the modiolus of the mouth. In a recent series of 201 cadaveric dissections, the facial artery was only absent in 2% of cases . Earlier studies have shown that 100% of cadaveric dissections had a facial artery  . Our rate of 10% of patients lacking a facial artery is likely a result of our patient cohort including those with congenital facial palsy and a history of previous facial surgery/trauma. When analysing patients with acquired facial palsy and no history of facial surgery/trauma (n=20), only one patient lacked a facial artery.
Although it was shown in these series     that the branching pattern of the facial artery can vary widely, the initial path of travel from the anterior border of the masseter to the angle of the mouth was consistent. It is within this section of the facial artery that a suitable portion of vessel is selected for anastomosis in cases of free functional muscle transfer for facial reanimation.
The facial vein has been less widely studied. This vessel typically arises from the inner canthus of the eye from the confluence of the supraorbital and supratrochlear veins. The facial vein then descends down towards the angle of the jaw where it joins with the anterior branch of the retromandibular vein . In the cadaveric series by Lohn et al.  the facial vein was absent in only 1% of cases, had a predictable course and was shown to be, on average, 0.7 cm more posterior from the gnathion than the facial artery. The proximity of the two vessels supports their use as first choice recipient artery and vein in cases of free tissue transfer for facial reanimation. Our finding of 18% of patients having an absent facial vein on one or both sides of the face is substantially higher than the findings from cadaveric studies, but can be explained by the cohort of patients included in our study. After exclusion of those with congenital facial palsy or a history of previous surgery/trauma to the hemiface none of the remaining patients lacked a facial vein.
Given the unsuitability of the transverse facial artery, our second choice recipient artery is the superficial temporal artery. Both artery and vein run within the substance of the parotid gland and branch at, or above the level of the zygomatic arch . To reach the position of the pedicle after inset of a pectoralis minor muscle flap the vessels must be dissected out over a sufficient length above and around the parotid gland to be turned down to reach the position of the muscle pedicle. In our series, these vessels were only used in combination with two latissimus dorsi and one gracilis free functional muscle flaps both of which provide longer pedicle length and, in the case of the gracilis muscle, have their pedicle orientated towards to the superficial temporal vessels. We note that other centres commonly use both the superficial temporal artery and vein as their recipient vessels of choice in facial reanimation procedures   . It should, however, be noted that in these studies the gracilis and latissimus dorsi flaps were the only muscles used for the reanimation, both of which provide a longer pedicle to reach the superficial temporal vessels and avoid the need to perform extensive dissection around the parotid gland. This would not be the case when using the pectoralis minor muscle for reanimation.
In cases when the facial artery and vein are absent, alternative recipient vessels are available to permit free functional muscle transfer for facial reanimation. Our algorithm can help to guide vessel selection in such cases and is most suited to when a pectoralis minor muscle is used to reanimate the face. Amongst patients with congenital facial palsy or in those with a previous history of facial surgery or trauma, the facial vessels are more likely to be absent and so the surgeon should then look towards the transverse facial or superficial temporal artery/vein as recipient structures. 59ce067264