We would like to present the following case for your consideration.
This particular patient is a 53-year old man. He was diagnosed with Bell’s palsy on the left-side in 2017 and unfortunately experienced incomplete recovery. Extensive mime-therapy over the past two years has had little effect
We first saw him earlier this year with a House-Brackmann score of 3 and a SunnyBrook Score of 35. Currently, his most important complaints are the asymmetry of the mouth and the fact that he is unable to smile. Clinical examination showed some asymmetry at rest, and no discernable movement on the left side of the mouth.
We performed an EMG-investigation, which showed 80% denervation of the buccal branch of the facial nerve. The frontal branch did slightly better with only 60% denervation.
As the patient is highly motivated for improvement, we have considered dynamic reconstruction with a masseteric branch. However, we struggle with the fact that there is still measurable (although clinically not noticeable) activity in the buccal branch on EMG-investigation.
Does anyone have any experience with dynamic reconstructions in cases such as these? Should we try treating the depressors of the mouth first?

Koen Ingels & Arthur Scheffer
Radboudumc, Nijmegen, The Netherlands