Dual-innervated Free Functional Flap Transfer and Mandibular Distraction in Patients with Hemifacial Microsomia

Hemifacial microsomia has been reported as the second most common congenital craniofacial malformation. The aim is to present a representative case of a patient who underwent both surgical procedures for the integrated care of hemifacial microsomia. The surgical technique for dynamic facial reanimation was a two-stage procedure due to masseter function impairment. The first one consisted of a cross-facial nerve graft, which was coapted to the masseteric nerve on the contralateral side, and the second stage consisted of a gracilis muscle transfer, in which the obturator nerve was coapted to the masseteric nerve on the ipsilateral side (a dual-innervated free functional gracilis flap). Mandibular distraction was performed a year after the second stage of facial reanimation. At the five-year follow-up, the patient had sustained a satisfactory, aesthetic, and pleasant result. No further secondary or revision procedures have been needed. Objectively, we observed bite-force enhancement, as demonstrated by electromyography. In our experience, we recommend performing microsurgical facial reanimation first, followed by mandibular distraction, and finally, autologous ear reconstruction.