Let me qualify that remark. I’ve have had a spate of complete flaccid paralyses in children following tumor surgeries (intra-cranial and intra-temporal). They have been referred to me roughly a year down the line for advice. Here’s my logic and I’d be really grateful for opinions. 

It is a year down the line, so the facial musculature is still viable. Therefore I plan to permanently “babysit”. Rather than plug the V (masseter) nerve into the proximal VII trunk to try to maintain the whole VII territory, I have been directing this end to side into the branch(es) that innervate the zygomatic and buccal complex. I’ve specifically left the temporal (frontal) and mandibular divisions out of the equation as they are “easy” to treat by contralateral botox or denervation (this will be the subject of another post). The rationale is that the muscle transfer is a great procedure but is still one muscle acting in one vector substituting for a myriad of facial muscles and although my colleagues present really good results they are never perfect. 

By contrast, driving these muscles with V will at least generate normal vectors even if not a spontaneous natural smile. I am hoping therapy would play a role in optimising results.

If I use cross face nerve grafts (XFNG), I think by the time they grow (roughly one year) there will be significant atrophy to the muscles (two years post-injury) and I expect a weaker reanimation. I can combine the babysit with XFNG or do the XFNG later if there is synkinetic or poorly coordinated movement. 

Am I skiing off piste here?