Operative Technique in Plastic Surgery – Kevin C.Chung

diminished vertical development of the nasal cavity, and a retrognathically
positioned maxilla after reconstruction with homologous tissue.
FIG 4 • The saddle nose deformity is one long-term
cosmetic complication of cartilage collapse post-
untreated septal hematoma.
COMPLICATIONS
■ Nasal septal abscess, leading to meningitis, orbital cellulitis, intracranial
abscess, cavernous sinus thrombosis, or oronasal fistula
■ External deformity of the nose: saddle-nose type (FIG 4), tip over-rotation
■ Growth inhibition of the midface in children, leading to underdevelopment of
the nose and maxilla, midface retroposition, or retracted columella
■ Nasal obstruction
■ Septal deviation
■ Septal perforation

REFERENCES
1. Sayin I, Yazici ZM, Bozkurt E, Kayhan FT. Nasal septal hematoma and
abscess in children. J Craniofac Surg. 2011;22(6):e17-e19.
doi:10.1097/SCS.0b013e31822ec801.
2. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and
management. Facial Plast Surg. 2011;27(5):483-490. doi:10.1055/s-0031-
1288931.
3. Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in
children. Arch Otolaryngol Head Neck Surg. 1996;122(12):1373-1376.
4. Thomson CJ, Berkowitz RG. Extradural frontal abscess complicating nasal
septal abscess in a child. Int J Pediatr Otorhinolaryngol. 1998;45(2):183-186.
5. Alshaikh N, Lo S. Nasal septal abscess in children: from diagnosis to
management and prevention. Int J Pediatr Otorhinolaryngol. 2011;75(6):737-
744. doi:10.1016/j.ijporl.2011.03.010
6. Hellmich S. Reconstruction of the destroyed septal infrastructure. Otolaryngol
Head Neck Surg. 1989;100(2):92-94.
7. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in
children. Auris Nasus Larynx. 2000;27(4):339-342.

46
CHAPTER
Section XI: Pediatric Neck
Masses
Branchial Cleft Sinuses and
Cysts
Mark Felton, Jugpal S. Arneja, and Neil K. Chadha
DEFINITION
■ Spectrum of congenital sinuses and cysts due to developmental anomalies in
the branchial system.1,2
■ Account for up to 17% of cervical neck masses.3
ANATOMY
■ Branchial arches are akin to ancient gill apparatus (FIG 1).
■ Humans have five branchial/pharyngeal arches, 1 to 4 and 6 (there is no 5th
branchial arch), which form craniocaudally from week 4.
■ Membrane ectoderm externally and endoderm internally covers the arches.
■ Cleft externally separates each arch.
■ Pouch internally separates each arch.
■ Each arch forms an artery, cartilaginous structure, nerve and muscle.
■ Arches 1 and 3 mainly form the face, and arches 3, 4, and 6 form the neck,
with 4 and 6 fusing.
■ Ectodermal clefts obliterate except for the 1st branchial cleft, which forms the
external auditory canal with outer side of the tympanic membrane forming the
medial limit.
■ Branchial pouches form various head and neck organs (Tables 1 and 2).

FIG 1 • Branchial arch and pouches.
PATHOGENESIS
■ Failure of branchial pouch or cleft to obliterate during embryonic development
can lead to fistula, sinus, or cyst formation:
■ A cyst is an epithelial-lined fluid-filled sac.
■ A sinus is a blind-ended epithelial lined tract opening on to skin or mucosa.
■ A fistula is an epithelial-lined tract connecting two surfaces (skin/mucosa).
■ The resultant anomaly from failure of this process relates to the specific arch,
pouch or cleft derivatives.
■ The main branchial anomalies associated with sinuses and fistulae are 1st and
2nd cleft anomalies and 3rd and 4th pouch anomalies.
■ Type 1 branchial anomalies are rare anomalies resulting in duplication of the
external ear canal and are classified as Work’s type 1 or 2.
■ Branchial cleft cysts are regarded as 2nd branchial anomalies. Several theories

exist as to their origin including3:
■ Lymph node inclusion theory—cystic transformation of lymph nodes
■ Branchial cleft remnant theory—remnant of branchial cleft/pouch
■ Thymopharyngeal duct theory—remnant of the connection between the
thymus and 3rd pouch
■ Cervical sinus of His theory—cyst is formed by remains of the cervical sinus.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Branchial sinuses and fistulas may present as a discharging neck punctum +/−
neck swelling.
■ Type 1 branchial anomaly is rare.
■ Often a late diagnosis
■ May present with a mass in parotid or submandibular region
■ Discharging neck punctum or discharging ear
■ Type 2 branchial anomalies are the most common branchial anomaly.
■ Often present at or just after birth
■ External opening in the skin (punctum) along anterior border
sternocleidomastoid muscle +/− discharge
■ Type 3 and 4 brachial sinus
■ Neonates—lateral neck cyst/abscess +/− airway obstruction
■ Child/young adult—thyroiditis/recurrent neck abscess
■ Most commonly diagnosed in childhood (delayed diagnosis)
■ Branchial cysts
■ May present as a cystic neck swelling +/− infection/abscess
Table 1 Branchial Arch and Pouch Derivatives

Arch Derivatives
Pouch
Derivatives
Artery
Cartilage
Cranial Nerve
Muscle
1
Part of
terminal
branches
maxillary
artery
Meckel
cartilage:
malleus
and incus,
anterior
malleolar
ligament,
mandible
template,
V—trigeminal
Muscles of
mastication,
mylohyoid,
tensor tympani,
anterior belly
digastric
Tubo-
tympanic
recess,
tympanic
cavity,
mastoid
antrum,
Eustachian
tube

maxilla,
zygomatic
bone and
squamous
temporal
bone,
mandible
2
Stapedial
arteries
Reichert
cartilage:
stapes,
styloid
process,
stylohyoid
ligament,
lesser
cornu, and
superior
body of
hyoid
VII—facial
Muscles of facial
expression,
stapedius,
stylohyoid,
posterior belly
digastric
Tonsils
3
Common
carotid
arteries,
internal
carotid
arteries
Greater
cornu and
inferior
part of
hyoid
IX—
glossopharyngeal
Stylopharyngeus
Inferior
parathyroid
glands and
thymus
4
Left forms
part of
aortic
arch, right
forms part
right
subclavian
artery
Laryngeal
X—vagus,
superior
laryngeal
Cricothyroid,
pharynx
constrictors
Superior
parathyroid
glands and
possibly
the
calcitonin-
producing
cells of
thyroid
6
Pulmonary
arteries,
ductus
arteriosus
Laryngeal
X—vagus,
recurrent
laryngeal
Intrinsic muscles
of larynx

■ Peak age 3rd decade

■ Most are located anterior to the upper part of the sternocleidomastoid muscle
■ Branchio-oto-renal syndrome is an autosomal dominant syndrome with a
prevalence of 1 in 40 000 people. It is caused by mutations in the EYA1, SIX1,
and SIX5 genes.4
■ Children born with this typically have branchial anomalies, ear abnormalities
(including pits, tags, atresia, hearing loss) and kidney abnormalities (including
hypoplastic/absent kidneys). If suspected, these children require audiometry, an
ultrasound of the renal tract, and genetic counseling.
IMAGING
■ Imaging varies depending on the branchial anomaly.
■ Cysts—ultrasound (USS) is obtained usually, but an MRI may be helpful when
the diagnosis is not clear on USS.
■ Type 1—CT to image middle ear and MRI for soft tissues and course of
sinus/fistula (FIG 2A).
■ Type 2—clinical diagnosis; usually no imaging required.
■ Types 3 and 4—barium swallow/and direct laryngoscopy to assess for
sinus/fistula entrance at the pyriform fossa; USS +/− MRI to assess thyroid
involvement and any cystic component (FIG 2B).
Table 2 Pathophysiology and Sinus/Fistula Course

1st
Branchial
Anomaly
(Work’s
Type 1)
1st
Branchial
Anomaly
(Work’s Type
2)
2nd
Branchial
Anomaly
3rd Branchial
Anomaly
4th Bra
Anoma
Pathogenesis
1st cleft
anomaly,
derived
from
ectoderm
1st cleft
anomaly,
derived from
ectoderm
and
mesoderm
(cartilage
and adnexal
features).
2nd cleft
anomaly
3rd pouch
anomaly,
persistence of
thymobranchial
canal
4th pou
anomal
from
pharyng
canal, w
connec
pharynx
ultimob
body an
PT glan
Course
Tract
runs
Tract runs
from lower
Fistula,
sinus or
Tract runs
through the
Tract ru
the cric

parallel
to
external
auditory
canal,
opening
medial,
inferior
or
posterior
to
conchal
cartilage
and
pinna.
more
anterior in
the neck
than type 1,
is always
superior to
hyoid bone,
coursing
over the
angle of the
mandible,
through the
parotid
gland,
terminating
at or near
the bony
cartilaginous
junction of
the EAC,
and often
entering the
middle ear.
Has a close
relationship
to the facial
nerve.
cyst along
SCM
anterior
border,
pass
superiorly
between
ICA and
ECA, over
the
hypoglossal
nerve (3rd
Arch) and
open into
the
posterior
pillar of
tonsillar
fossa (2nd
pouch)
thyrohyoid
membrane and
above superior
laryngeal
nerve
Opens in
upper/lateral
wall piriform
fossa
membra
the sup
larynge
Opens
apex of
fossa
SCM, sternocleidomastoid muscle; ICA, internal carotid artery; ECA, external carotid artery; PT,
parathyroid; EAC, external auditory canal.
FIG 2 • A. MRI of type 1 branchial fistula. B. Sinogram
of type 3 branchial sinus.

DIFFERENTIAL DIAGNOSIS
■ Type 1 anomaly—parotitis, parotid tumor.
■ For an infected/discharging type I branchial fistula, atypical mycobacterium is
a differential to be considered.
■ For neck swelling associated with type 3/4 branchial anomaly—lymphatic
malformation, thyroiditis, abscess, lymph nodes.
■ Branchial cysts—lymph nodes, abscess, lymphatic malformation, dermoid.
NONOPERATIVE MANAGEMENT
■ Watchful approach may be opted for initially in very young children and those
who are asymptomatic or have only minor symptoms.
■ Treat any infections with antibiotics and avoid incision and drainage because
this may lead to a persistent discharging fistula and/or make future surgical
excision more challenging due to scarring.
■ The majority will require surgical treatment.
SURGICAL MANAGEMENT
Preoperative Planning
■ Review relevant imaging.
■ Examine the patient preoperatively to check if the swelling/sinus/fistula is still
present.
■ Antibiotics are not routinely required for noninfected cases.
■ Facial nerve monitoring should be used for type 1 branchial anomaly
excisions.
Positioning
■ Supine on head ring, with shoulder roll to extend neck
■ Table in reverse Trendelenburg for hemostasis (head 30 degrees above feet)
Approach
■ For branchial fistulas, type 2 branchial sinuses, and branchial cysts, the
treatment of choice is open excision.
■ Type 1 fistulas should be removed by a superficial parotidectomy approach.
Type 1 branchial cleft fistulas may enter the middle ear or external auditory
canal and therefore should be managed in conjunction with an
otolaryngologist.

■ For types 3 and 4 sinuses with a piriform sinus opening, the mainstay of
treatment is now endoscopic sinus ablation via suspension laryngoscopy,
usually performed by an otolaryngologist.5 If initial endoscopic treatment fails,
open resection with possible hemithyroidectomy may be required.
T E C H N I Q U E S
■ Excision of Type 1 Branchial Fistula
■ The facial nerve monitor is used throughout the procedure.
■ Rotate the neck away from the lesion.
■ The neck is prepped with aqueous Betadine. Drape the patient, leaving the
ear, angle of mandible, and operated side of face exposed. The temple and
side of mouth should be left exposed so as to see the facial muscles twitch,
and a clear sterile drape can be used to cover the face.
■ A modified parotidectomy incision (cervico-mastoid-facial incision) is
marked out, descending from the anterior to the tragus, around the earlobe,
continuing down the neck toward the fistula site and finishing by making an
ellipse around the fistula punctum/wound.
■ The incision site is infiltrated with 1% lidocaine with 1 in 100 000
epinephrine (TECH FIG 1A).
■ The skin is then incised with a no. 15 blade, and the ellipse of the skin
around the punctum is removed.
■ Subplatysmal flaps are raised inferiorly and superiorly and retracted using
silk stay sutures. A further stay suture is also used retract the earlobe back
(TECH FIG 1B).
■ Dissect around the fistula punctum and any inflamed tissue to reveal a fistula
tract.
■ Using a fine artery clip, carefully dissect the parotid gland from the tragal
cartilage and mastoid tip, exposing the tympanomastoid suture.
■ Next attention should be turned to finding the facial nerve by dissecting with
an artery clip and microbipolar forceps over the tragal cartilage toward the
tragal pointer. The fascia over the sternocleidomastoid muscle is also freed
and the posterior belly of the digastric muscle is found deep to the
sternocleidomastoid muscle. When dissecting over the upper 1/3 of the

sternocleidomastoid muscle, the greater auricular nerve will be encountered
and the posterior branch of this nerve may need to be sacrificed (TECH FIG
1C,D).
■ Note that the facial nerve may be displaced inferiorly and medially by the
fistula. Use the facial nerve stimulator to aid in finding the facial nerve. The
nerve is usually found:
■ 5 mm deep to the tympanomastoid suture
■ 1 cm deep and inferior to the tragal pointer
■ At the level of the posterior belly of digastric muscle
■ This main branch of the facial nerve is traced to the bifurcation of upper and
lower branches, using a fine artery clip and microbipolar forceps (or a blade)
to remove the tissue superficial to the nerve. The artery clip is advanced
along the nerve with blades open when dividing parotid tissue above the
nerve for good visualization of the nerve. The upper and lower branches of
the nerve are traced in same manor to free them from the fistula tract as
required. The fistula tract will run in close proximity to the nerve, with the
possibility of branches going both lateral and medial to the fistula.
■ If it is difficult to find the facial nerve trunk, retrograde dissection may be
performed, initially by tracing the fistula tract from the punctum and finding
the nerves overlying the tract and then tracing them back to the main trunk in
a retrograde fashion.
■ Once facial nerve branches are dissected from both above and below the
fistula, the surgery progresses to removing the fistula tract, slowly elevating
the tract from over the inferior branches of the facial nerve and carefully
sliding the tract from beneath any overlying branches.
■ The fistula tract is dissected from surrounding tissue using microbipolar
forceps and traced to its origin, which may be into tragal cartilage, the
cartilaginous part of the outer external auditory canal, the bony part of the
external ear canal, middle ear, or a combination of these (TECH FIG 1E).
■ If the fistula ends at the tragus or cartilaginous canal, it can be separated
from the cartilage and the area allowed to heal by secondary intention.
■ If the fistula enters the bony ear canal and middle ear, which will be evident
on CT scanning and preoperative examination, the case should be performed
with someone skilled in Otologic surgery. Middle ear exploration,
tympanoplasty, and possible bony canalplasty may need to be performed to
fully remove the tract.

TECH FIG 1 • Excision of type 1 branchial fistula. A.
Incision planned to excise scar/granulation tissue
around the fistula; the skin in infiltrated with 1%
lidocaine with 1 in 100 000 epinephrine. B.
Subplatysmal skin flaps are raised, and then the
priority is to locate the main trunk of the facial nerve
and follow its branches. C. Facial nerve branches are
seen coursing both over and under the fistula and are
traced and freed from the fistula. D. The fistula is
dissected from lower facial nerve branches on its
undersurface. E. Once free from the facial nerve, the
fistula is traced to its origin at the tragal cartilage and
external ear canal/middle ear. The neck component of
the fistula is excised prior to removing the

middle/external ear component of the fistula.
■ Once the fistula is fully removed, the wound is closed. Exposed facial nerve
may be covered by loosely apposing parotid tissue with 4/0 Vicryl sutures.
Platysmal muscle edges are also apposed with interrupted buried 4/0 Vicryl
sutures. No drain is required.
■ The skin can be closed with a continuous running subcuticular 5-0 Prolene
suture. Both ends of the Prolene suture should be left 1 to 2 cm long outside
of the skin to facilitate removal. ¼ in. 3M Steri-Strips (St. Paul, MN) are
applied to the wound with the cut ends of the suture hidden beneath.
■ The patient can be discharged the same day once they are eating and
drinking.
■ No postoperative antibiotics are required.
■ Excision of Type 2 Branchial Sinus/Fistula (TECH
FIG 2)
■ The neck is prepared with aqueous Betadine.
■ Drape the neck so as to square off the operative site, leaving the neck
exposed from below the punctum to the mentum and lateral to the
sternocleidomastoid muscle.
■ Mark a small horizontal ellipse around the punctum.
■ Inject 1% lidocaine with 1 in 100 000 epinephrine around the incision site.
■ Use a lacrimal probe placed gently through the punctum to identify the
sinus/fistula tract and confirm that it runs upward in the classic pattern
toward the tonsillar fossa.
■ Incise an ellipse of the skin around the punctum and dissect on to the tract
using the microbipolar forceps. The lacrimal probe can be left in the tract to
help follow the tract. Dissect along the tract superiorly using the microbipolar
forceps. Keep close to the tract as it may course over the hypoglossal nerve
and between the internal and external carotid arteries. If access is restricted,
an endoscope or further separate superior “step-ladder” incision may be used
to improve visualization of the tract.
■ The tract is traced through the defect in the mylohyoid muscle. An artery
clip and a 3-0 Vicryl tie are applied above the level of mylohyoid; the tract is

then cut and sent for histology.
■ The skin can be closed with a continuous running subcuticular 5-0 Prolene
suture. Both ends of the Prolene suture should be left 1 to 2 cm long outside
of the skin to facilitate removal. ¼ in. 3M Steri-Strips (St. Paul, MN) are
applied to the wound with the cut ends of the suture hidden beneath.
■ The patient can be discharged the same day once they are eating and
drinking.
■ No postoperative antibiotics are required.
TECH FIG 2 • Excision of type 2 branchial anomaly.
■ Endoscopic Management of Type 3/4 Branchial
Sinuses
■ The patient is intubated.
■ Suspension laryngoscopy is performed using an age-appropriate Parsons
laryngoscope. The laryngoscope is positioned to visualize the pyriform fossa
(TECH FIG 3A,B).
■ If a sinus is identified then a flexible bugbee monopolar cautery needle (size
4/5 French) is placed into the sinus and used to ablate the tract (set at 4–6
watts). Two to three passes of the cautery tip are usually required (TECH
FIG 3C,D).
■ The laryngoscope is then removed and the surgery complete.
■ The patient is observed for any signs of airway compromise on the day unit
and discharged once they are eating and drinking.
■ If endoscopic ablation fails initially, it may be repeated. If revision
endoscopic surgery fails, the patient will typically require open excision of
the cyst/sinus/fistula with possible hemithyroidectomy.

TECH FIG 3 • Endoscopic ablation of type 3 branchial
anomaly. A,B. Endoscopic photograph of the left
pyriform fossa showing start of type 3 sinus tract. C,D.
Ablation of the tract with Bugbee cautery (4–6 watts).
■ Excision of Branchial Cyst
■ Rotate the neck away from the side of the cyst.
■ The neck is prepared with aqueous Betadine.
■ Drape the neck so as to square off the operative site, leaving the neck
exposed from below the supraclavicular notch to the angle of the mandible
and lateral to the sternocleidomastoid muscle.
■ Mark a horizontal incision over the swelling but at least 2 cm below the
angle of the mandible. This will avoid damage to the marginal mandibular
nerve as it runs superficially.
■ Inject 1% lidocaine with 1 in 100 000 epinephrine around the incision site.
■ Incise the skin, through platysma and raise upper and lower subplatysmal
flaps. The flaps are retracted back using either a self-retaining retractor or

silk sutures.
■ Identify the anterior edge of the sternocleidomastoid muscle and instruct
your assistant to retract this posteriorly.
■ You should then identify the cyst. Dissect the cyst from the surrounding
tissue using microbipolar forceps, being careful not to damage or puncture
the cyst wall. The hypoglossal nerve, accessory nerve, jugular vein and
carotid arteries may be in close proximity to the cyst and therefore dissecting
on the cyst wall will avoid damage to these structures.
■ Once all edges of the cyst are freed the cyst can be removed. Bipolar cautery
should be used for hemostasis.
■ The platysmal muscle edges are apposed with interrupted buried 4-0 Vicryl
sutures. No drain is required.
■ The skin can be closed with a continuous running subcuticular 5-0 Prolene
suture. Both ends of the Prolene suture should be left 1 to 2 cm long outside
of the skin to facilitate removal. ¼ in. 3M Steri-Strips (St. Paul, MN) are
applied to the wound with the cut ends of the suture hidden beneath.
■ The patient can be discharged the same day once they are eating and
drinking.
■ No postoperative antibiotics are required.
PEARLS AND PITFALLS
Diagnosis
■ Given the number of differential diagnoses for and complex surgical
anatomy of branchial anomalies, a combination of imaging methods
may be required to formulate a diagnosis.
■ The standard for diagnosing a type 3 or 4 branchial anomaly is direct
laryngoscopy of the pyriform fossa under general anesthetic.
Incision
■ For type 1 fistulas use a modified cervico-mastoid-facial incision,
excising the skin punctum and surrounding inflamed tissue in the
same incision.
■ Place incisions parallel to or over skin creases where possible.
Hemostasis
■ Use of microbipolar forceps for cutting tissues allows accurate
dissection with effective hemostasis.
■ Prior to skin closure, place patient in Trendelenburg position and ask
anesthetist to perform a Valsalva maneuver on the patient to raise

venous pressure and assist identification of any potential bleeding
sites.
Dissection
■ In performing open branchial sinus/fistula or cyst excisions, stay
close to and dissect on the cyst/tract to minimize damage to
surrounding structures.
Closure
■ Closing the final skin layer with interrupted subcuticular 5-0 Prolene
and 3M Steri-Strips (St. Paul, MN) removed at 10–14 days after
surgery minimizes tissue reaction seen through use of absorbable skin
sutures.
POSTOPERATIVE CARE
■ Surgery is performed as outpatient surgery with discharge on the same day.
■ Advice to keep wound dry.
■ Postoperative antibiotics are not usually required, unless there is active
infection at the time of surgical excision.
■ Review with patient at 10 to 14 days with histology results and for removal of
subcuticular Prolene skin suture and 3M Steri-Strips (St. Paul, MN).
■ Follow up as an outpatient 3 months postoperatively.
OUTCOMES
■ Recurrence rates:
■ Type 1—less than 2% although greater for middle ear involvement
■ Type 2—less than 2%
■ Type 3—The success rate for endoscopic management of pyriform fossa
sinus tracts was 89.3% overall in a recent review (90.5% in primary cases and
85.7% in revision cases).5
COMPLICATIONS
■ General—bleeding, infection
■ Type 1—risk of injury to facial nerve (temporary/permanent) and potential
complications from middle ear exploration (perforation tympanic membrane,
hearing loss, temporary altered taste due to damage to chorda tympani nerve)
■ Type 2—risk of injury to hypoglossal nerve, accessory nerve, lingual nerve
■ Type 3—risk of injury to recurrent laryngeal nerve (endoscopic or open);
external laryngeal nerve, parathyroid injury, hypothyroidism (open)
■ Branchial cyst—vascular injury, nerve damage; marginal mandibular, vagus,
hypoglossal, accessory, greater auricular

REFERENCES
1. LaRiviere CA, Waldhausen JH. Congenital cervical cysts, sinuses, and fistulae
in pediatric surgery. Surg Clin North Am. 2012;92(3):583-597, viii.
2. Prosser JD, Myer CM III. Branchial cleft anomalies and thymic cysts.
Otolaryngol Clin North Am. 2015;48(1):1-14.
3. Jarvis S, Pal AR, Al-Qudehy ZA, et al. Branchial anomalies in children. The
Otorhinolaryngologist. 2012;4:148-154.
4. Morisada N, Nozu K, Iijima K. Branchio-oto-renal syndrome: comprehensive
review based on nationwide surveillance in Japan. Pediatr Int. 2014;56:309-
314.
5. Lachance S, Chadha NK. Systematic review of endoscopic obliteration
techniques for managing congenital piriform fossa sinus tracts in children.
Otolaryngol Head Neck Surg. 2016;154:241-246.

47
CHAPTERThyroglossal Duct Cysts
Mark Felton, Jugpal S. Arneja, and Neil K. Chadha
DEFINITION
■ The most common congenital midline neck cyst1
■ Caused by embryological remnants of thyroid gland formation
ANATOMY
■ These cysts can exist anywhere from the base of tongue to the level of the
thyroid gland as they form in remnants of the thyroglossal duct (FIG 1).
■ 75% are at the level of the hyoid bone.
PATHOGENESIS
■ During week 4 of embryological development, the thyroid develops between
the 1st and 2nd pharyngeal pouches from floor of the pharynx at the level of
the foramen cecum (posterior 1/3 tongue) (FIG 2).
■ This becomes a bilobed diverticulum and descends through the neck to reach
final position anterior to the tracheal cartilages. As it descends through the
neck, it leaves a tract.
■ The tract usually atrophies after 5 to 10 weeks.
■ Caudal attachment of the tract may remain as the pyramidal lobe of the
thyroid.
■ Failure of the tract to obliterate can lead to cyst formation at any point
throughout the tract length (FIG 3).
NATURAL HISTORY
■ Thyroglossal duct cysts are present at birth but may not be clinically apparent
until enlarged secondary to infection.

■ They present as a midline neck swelling most commonly in childhood and
adolescents.
■ 90% present as midline neck swellings only, but infection and formation of a
secondary discharging sinus are possible (10%).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Midline neck cyst.
■ May elevate on swallowing and tongue protrusion.
■ With a history of infection, there may be signs of an abscess or sinus formation
with discharge.
IMAGING
■ Ultrasonography of the neck and thyroid to evaluate the swelling and confirm
a normal thyroid is present (FIG 4).
■ In the absence of a thyroid gland, a thyroglossal duct cyst (TGDC) may
contain the only functioning thyroid tissue.
■ Nuclear imaging in the form of radioactive iodine scan can be used if there is
doubt regarding normal functioning thyroid.
■ Thyroid function blood tests are only required if presence of normal thyroid
tissue is in question.
DIFFERENTIAL DIAGNOSIS
■ Midline dermoid cyst
■ Sebaceous cyst
■ Midline branchial cleft cyst
■ Lymph node
■ Ectopic thyroid tissue
■ Laryngocele
■ Thyroid carcinoma within TGDC
NONOPERATIVE MANAGEMENT
■ Conservative watchful waiting in children until over age 12 months
■ Advise there is a risk of infection with possible sinus formation if conservative
approach is taken.
■ Antibiotics with possible aspiration if the cyst becomes infected and forms an
abscess. It is not recommended to incise and drain an infected TGDC because
this risks sinus formation with chronic discharge.

FIG 1 • Clinical photographs of anterior neck showing
TGDC. A. Scar tissue is from previous site of infection
with skin breakdown. B. TGDC with central discharging
sinus.
FIG 2 • Thyroid development.
■ Uncommonly infection and inflammation may actually lead to closure of the
residual duct and resolution of symptoms.

■ Theoretical risk of malignant change of thyroid tissue within TGDC if left
indefinitely, with less than 1% of excised TGDCs having a primary carcinoma
on histology.2
SURGICAL MANAGEMENT
Preoperative Planning
■ Review ultrasound scan result to confirm that normal thyroid tissue is present
in the usual location.
FIG 3 • Pathogenesis of TGDC development.
■ Examine preoperatively to check that swelling is still present.
■ Assess ideal level for placement of a transverse incision that will provide
exposure from the level of the suprahyoid muscles to the superior border of the
thyroid gland for removal of the TGDC (typically approximately midway
between the palpable landmarks of the hyoid and upper thyroid notch).
Positioning
■ Supine on head ring, with shoulder roll for neck extension
■ Table in reverse Trendelenburg for hemostasis (head 30 degrees above feet)

FIG 4 • Ultrasound scan of TGDC (long arrow) overlying
thyroid cartilage (short arrow).
T E C H N I Q U E S
■ Modified Sistrunk Procedure
Preparation of the Neck and Wound Incision
■ Antibiotics are not indicated for routine noninfected cases.
■ The neck is prepared with aqueous Betadine.
■ Drape the neck so as to square off the operative site, leaving the neck
exposed from the mentum to below the sternoclavicular notch and the
sternocleidomastoid muscles laterally.
■ Mark the site of horizontal incision over the cyst, ideally midpoint between
the hyoid and thyroid notch so as to allow adequate access to both the
suprahyoid muscles and the pyramidal lobe of the thyroid. Initially, plan to
incise skin to incorporate the width of the cyst only in case it is identified to
be a dermoid cyst, in which case following a tract superiorly and inferiorly is
not required and cystectomy is adequate (TECH FIG 1A,B)
■ Inject 1% lidocaine with 1 in 100 000 epinephrine around the incision site.
■ An incision is made through the skin and subcutaneous tissue. Subplatysmal
flaps are elevated both superiorly to above the level of the hyoid and
inferiorly to below the level of the cricoid cartilage (TECH FIG 1C). Take
care with this step as the cyst can be superficial, making it easy to puncture,
which is more likely if the cyst is large and under pressure. If a cyst is

punctured, the dissection can continue with a clip on the cyst capsule at the
puncture site.
Exposure of Thyroglossal Cyst and Tract
■ Once the cyst is exposed, if clinically it is a dermoid and there is no obvious
tract or surrounding attachments, the cyst can be removed and skin closed.
Otherwise, the cyst can be left alone and dissection of the tract performed
next, with widening the skin incision for better access if required (TECH
FIG 2A).
■ Identify the infrahyoid strap muscles, usually below the cyst. Identify the
midline and carefully separate the right and left strap muscles, the more
superficial muscle being sternohyoid and deeper muscle being sternothyroid
(TECH FIG 2B,C).
■ Carefully dissect along the medial edge of the sternohyoid and sternothyroid
muscles if necessary, separating them from the cyst. Carefully expose the
medial border of the length of the infrahyoid strap muscles from their hyoid
attachment superiorly as far inferiorly as the superior border of the thyroid
gland. Any tissue between the infrahyoid strap muscles will be removed in
continuity with the cyst and will contain the inferior tract if present.
■ Look for an inferior component of the thyroglossal duct extending inferiorly
from the cyst, which extends to the pyramidal lobe of the thyroid gland. If the
duct extends down to the thyroid gland, remove a small cuff of pyramidal
lobe with the specimen. Even if the tract is not clearly visible, it will be
safely removed by removing all the tissue between the strap muscles from the
cyst down to the pyramidal thyroid lobe inferiorly.
Hyoid and Tongue Base Dissection, With Specimen Excision
■ After completion of this inferior dissection, ensure that the medial borders of
the infrahyoid strap muscles are identified and exposed up to their
attachments to the hyoid bone. The infrahyoid strap muscles are often
adherent to the cyst just inferior to the hyoid bone. When there has been
previous infection, a small portion of infrahyoid strap muscle may need to be
left attached to the cyst and removed with the cyst and specimen. A tract
arising from the superior aspect of the cyst may be seen passing into the
hyoid bone, although the whole cyst may be adherent to the hyoid mid-
portion.
■ The superior muscular attachments of the hyoid bone (predominantly the

mylohyoid and geniohyoid) are then detached from the midportion of the
hyoid bone superiorly, using the medial borders of the infrahyoid strap
muscle attachments as a guide to how far to laterally dissect superiorly,
thereby avoiding the hyoid lesser horns and the hypoglossal nerve.
■ The central portion third of the hyoid bone is resected by cutting through the
hyoid. It is imperative that this cut is precisely vertical and level with the
medial borders of the infrahyoid strap muscles, lateral to the cyst or cyst tract
if identified. An Allis forceps holding the central portion of the hyoid bone
can help stabilize the bone. In small children, bipolar forceps are often
sufficient to cut through the noncalcified hyoid, but in older
children/adolescents/adults, straight Mayo scissors or even bone cutting
forceps may be required cut through the hyoid bone. Cautery and bone wax
can be used to stop any bleeding from the cut edges of the hyoid (TECH FIG
3A,B).
TECH FIG 1 • A. Position of TGDC, relations of the
duct and position for surgical incision (midline collar
incision), with the duct running through the hyoid bone
and ending at pyramidal lobe of thyroid. B. Midline
collar skin crease incision. C. Subplatysmal skin flaps
are raised.

TECH FIG 2 • A. Midline dissection on the TGDC
(black arrow) and tract (white arrow). B. Dissecting out
the TGDC. C. The strap muscles are separated in the
midline. Arrow indicates sternohyoid muscle.
■ Now the inferior tract, cyst, and hyoid bone are free of the surrounding
tissue; a superior tract arising from the superior and posterior aspect of the
hyoid may be seen running into the tongue base. If present, the tract should
be dissected from the surrounding tissue and followed up to the tongue base.
A cuff of tongue muscle (genioglossus muscle) should always be taken with
the midportion of the hyoid and the specimen to complete the excision and
minimize risk of a residual superior tract. There is no need to excise tongue
muscle in complete thickness through to the oropharynx, as originally
described by Sistrunk (TECH FIG 3C,D).

TECH FIG 3 • A. Division of mid third of hyoid bone.
B. The tract is traced to the hyoid and the hyoid (short
arrow) is cut either side of tract in line with the medial
edge of the thyrohyoid muscles (long arrow). C. A cuff

of tongue muscle is taken with the specimen. D.
Specimen.
■ Attention should then be focused on ensuring meticulous hemostasis. The
patient should be placed in the Trendelenburg position (30 degrees head
down) and saline wash poured in to the wound. A prolonged Valsalva
maneuver by the anesthetist will reveal any further bleeding points for
cauterization.
Wound Closure
■ The operating table is then placed in a neutral position for wound closure.
■ The strap muscles are apposed with 4-0 Vicryl and the skin flaps closed with
interrupted buried 4-0 Vicryl sutures. No drain is required (TECH FIG
4A,B).
■ The skin can be closed with a continuous running subcuticular 5-0 Prolene
suture. Both ends of the Prolene suture should be left 1 to 2 cm long outside
of the skin to facilitate removal. ¼ in. Steri-Strips are applied to the wound
with the cut ends of the suture hidden beneath (TECH FIG 4C).
■ The patient can be discharged the same day once they are eating and
drinking.
■ No postoperative antibiotics are required.
Modifications of the Procedure
■ Skin sinus tract—A skin ellipse around the sinus and ellipse of tissue around
the sinus tract is taken, which should be taken in continuation with the rest of
the dissection of the thyroglossal cyst. This may lead to the horizontal
incision site being more superior than ideal, and the incision therefore is
lengthened to facilitate the inferior access.
■ Recurrent cysts—En-bloc wide local of excision around the recurrent cyst,
taking a core of strap muscle on either side down to pretracheal fascia.

TECH FIG 4 • A. Suturing of infrahyoid muscles. B.
Strap muscles reapposed with 4-0 Vicryl sutures. C.
Skin is closed with 5-0 Prolene and Steri-Strips.
PEARLS AND PITFALLS
Incision
■ Initially only make your incision the width of the swelling until the
diagnosis is confirmed in case it is a dermoid cyst, for which a
smaller incision will suffice. Once a dermoid cyst is excluded, the
incision can be widened.
Hemostasis
■ Use of microbipolar forceps for cutting tissues allows accurate
dissection with effective hemostasis.
■ Prior to skin closure, place patient in Trendelenburg position and ask
anesthetist to perform a Valsalva on the patient to raise vascular
pressure and assist identification of any potential bleeding sites. Bone
wax can help oozing from edges of cut hyoid bone.
Dissection
■ Actively look for any extension of the cyst/duct toward the
pyramidal lobe and remove a cuff of the pyramidal lobe if the duct is
in continuation.
■ Dissect along the medial aspect of strap muscles on to the hyoid
bone. Remove the hyoid at the level of the medial aspects of the strap
muscles to avoid damage to the hypoglossal nerve.
■ Look for a tract extending from the hyoid to the tongue base, dissect
along this, and remove a cuff of tongue base with the specimen.
Closure
■ Closing final skin layer with interrupted subcuticular 5-0 Prolene and

Steri-Strips removed at 10–14 days after surgery minimizes tissue
reaction seen through use of absorbable skin sutures
POSTOPERATIVE CARE
■ Day case surgery
■ Advice to keep wound dry
■ Review 10 to 14 days with histology and for removal of Prolene skin suture
and Steri-Strips
■ Follow up outpatients 3 months
OUTCOMES
■ Recurrence rate of 0% to 3% for modified Sistrunk as described above may be
much higher with other techniques such as cystectomy only.1,3
COMPLICATIONS
■ Bleeding, infection, hypertrophic/keloid scar
■ Accidental pharyngostomy
■ Hypoglossal nerve injury
■ Recurrence—treat with en-bloc wide local excision
REFERENCES
1. Oomen KP, Modi VK, Maddalozzo J. Thyroglossal duct cyst and ectopic
thyroid: surgical management. Otolaryngol Clin North Am. 2015;48(1):15-27.
2. Heshmati HM, Fatourechi V, van Heerden JA, et al. Thyroglossal duct
carcinoma: report of 12 cases. Mayo Clin Proc. 1997;72(4):315-319.
3. Ibrahim FF, Alnoury MK, Varma N, Daniel SJ. Surgical management
outcomes of recurrent thyroglossal duct cyst in children—a systematic review.
Int J Pediatr Otorhinolaryngol. 2015;79(6):863-867.

48
CHAPTER
Section XII: Facial
Reanimation
Sural Nerve Harvest
Andre P. Marshall, Jeffrey R. Marcus, and Michael R. Zenn
DEFINITION
■ The sural nerve is a lower limb sensory nerve that provides sensation to the
lateral and posterior distal third of the leg, lateral calcaneal region, lateral foot,
and small toe.1
■ The sural nerve is easily accessible, has several large fascicles, and is the
donor nerve most commonly used in peripheral nerve reconstructive surgery.2,3
■ Unilateral sural nerve harvests can provide up to 40 cm of autogenous nerve
graft.
ANATOMY
■ The sural nerve is a sensory nerve that begins in the lateral aspect of the foot
and coalesces from branches between the Achilles tendon and lateral malleolus.
■ The nerve splits into the medial and lateral cutaneous nerves of the leg along
the posterior leg.
■ The larger contributor, the medial sural cutaneous nerve, arises from the tibial
nerve in the popliteal fossa between the medial and lateral heads of the
gastrocnemius.4
■ The sural nerve runs deep to the investing fascia down the posterior calf
between the two heads of the gastrocnemius muscle and then subcutaneously in
the distal third of the leg.
■ It can be found close to, but deep to, the lesser saphenous vein to the ankle.
■ It is consistently found in the space between the lateral malleolus and the
calcaneus tendon.2–5

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Any history of prior lower extremity operation, either open or endoscopic,
should be elicited from the patient.
■ Physical exam should note any scars or prior incisions on the lower
extremities, or numbness or paresthesias in the distribution of the sural nerve.
IMAGING
■ Prior to sural nerve harvesting, no imaging of the lower extremities is
necessary.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperatively, a comprehensive history and physical exam should be
performed. It is imperative to note any prior lower extremity trauma, fractures,
or previous operations.
■ Patients should be counseled on the expected postoperative outcomes of
cutaneous sensory loss in the sural nerve distribution.
Positioning
■ The donor limb is placed in flexion at the knee.
■ A bump, sandbag, or roll under the ipsilateral buttocks provides additional
access to the posterior leg.
■ In children, prone positioning is usually preferred and well tolerated.
Approach
■ Open
■ Endoscopically assisted
T E C H N I Q U E S
■ Stair-Step Incisions

Video p8-c048
■ The patient is placed in supine or prone position (TECH FIG 1A).
■ An endoscope can be used to facilitate dissection.6
■ A pneumatic tourniquet (optional) is placed around the thigh and the leg
exsanguinated in the usual fashion prior to incision.
■ A 2- to 3-cm transverse or vertical incision is made in the groove made by
the lateral border of the Achilles tendon at the level of the lateral malleolus.
■ The lesser saphenous vein is seen, retracted, and preserved.
■ Blunt dissection is used to identify the nerve.
■ The nerve is dissected of all surrounding tissue moving superior along the
posterior calf.
TECH FIG 1 • A. Preoperative markings and an
outline of the sural nerve and its lateral cutaneous
00:00 / 00:00

branch are shown. The proposed transverse incisions
are shown in addition to the Achilles tendon and
lateral malleolus. B. The sural nerve is shown
following harvest along the transverse incisions.
■ At approximately 10 cm, an additional 2- to 3-cm transverse incision is
made more proximally along the course of the nerve.
■ Proximal and distal dissection of the nerve is made through each incision.
■ Up to two additional transverse incisions are made along the course of the
nerve until adequate length is obtained.
■ The nerve is transected at the popliteal fossa and removed from the leg
(TECH FIG 1B).
■ Incisions are closed in standard fashion, in a minimum of two layers with
absorbable sutures.
■ No drain tubes are necessary.
■ Harvest With a Tendon Stripper4,7
■ A pneumatic tourniquet is placed around the thigh and the leg exsanguinated
in the usual fashion.
■ A 2- to 3-cm transverse or vertical incisions is made in the groove made by
the lateral border of the Achilles tendon at the level of the lateral malleolus.
■ The lesser saphenous vein is seen, retracted, and preserved.
■ Blunt dissection is used to identify the nerve, and then transecting it up to 5
cm distal to the incision to gain additional length.
■ The cut end of the nerve is passed through a tendon stripper.
■ Mild traction is placed on the nerve, and the tendon stripper is passed
proximally until its tip can be felt in the subcutaneous tissues near the
popliteal fossa.
■ The stripper is twisted and counter-pressed until the nerve is felt to give way
and able to slide out of the ankle wound.
■ Optionally, the leading edge of the tendon stripper is tented against the
skin, a stab incision is made, across the end of the stripper to divide the
nerve.

PEARLS AND PITFALLS
Anatomy
■ The sural nerve has many variations during its course.
■ The surgeon must be aware of the variable sural anatomy, particularly
the branches of the medial and lateral cutaneous nerves.
Positioning
■ Sural nerve harvest can be done in either supine or prone position. In
children, prone positioning is well tolerated and can better facilitate
exposure and shorten harvest time.
Dissection
■ Avoid excessive circumferential dissection, which may place the
nerve at greater risk of injury.
■ Superficial dissection is usually adequate to facilitate release from the
overlying subcutaneous tissues.
Graft
processing
■ In most cases, the graft is used intact.
■ Splitting of the graft into multiple grafts and preserving fascicles
longitudinally has been described but is not practiced in our unit.
POSTOPERATIVE CARE
■ Elastic bandages from the foot to the knee are placed and used to provide
compression and help decrease hematoma formation. They are left in place for
48 hours and used thereafter for control of swelling as needed.
■ Patients are encouraged to begin ambulation on postoperative day 1 to help
reduce the risk of deep venous thrombosis. Full activity restrictions are kept in
place for 2 weeks or dictated by the concurrent grafting procedure at the
recipient site.
■ Pain is minimal and managed with a combination of narcotic and non-narcotic
analgesic medications.
OUTCOMES
■ Scars should be expected at the donor site and are permanent. Regular scar
management is recommended.
■ The area of paresthesia and numbness in the ankle and foot is likely permanent
but may decrease in size over time due to contributions from surrounding intact
nerves.1
COMPLICATIONS
■ Postoperative complications are infrequent but include proximal neuroma
formation, hematoma, and deep venous thrombosis. We have not seen cellulitis

in our patient cohort, but it is possible.
■ The iatrogenic sensory nerve deficit along the lateral foot should be expected
and is not considered a complication. It is generally well tolerated by patients
and should be discussed preoperatively.
REFERENCES
1. Lapid O, Ho ES, Clarke HM. Evaluation of the sensory deficit after sural
nerve harvesting in pediatric patients. Plast Reconstr Surg. 2007;119:670.
2. Riedl O, Koemuercue F. Sural nerve harvesting beyond the popliteal region
allows a significant gain of donor nerve graft length. Plast Reconstr Surg.
2008;122:798.
3. Garcia R, Hadlock H. Contemporary solutions for the treatment of facial
nerve paralysis. Plast Reconstr Surg. 2015;135:1025e.
4. Hill HL, Vasconez LO, Jurkiwicz MJ. Method for obtaining a sural nerve
graft. Plast Reconstr Surg. 1978;61:2.
5. Dellon AL, Coert JH. Clinical implications of the surgical anatomy of the
sural nerve. Plast Reconstr Surg. 1994;94:850.
6. Capek L, Clarke HM. Endoscopically assisted sural nerve harvest in infants.
Semin Plast Surg. 2008;22:25-28.
7. Hankin FM, Jaeger SH, Beddings A. Autogenous sural nerve grafts: a
harvesting technique. Orthopedics. 1985;8:9.

49
CHAPTERCross Face Nerve Graft
Michael J. A. Klebuc
DEFINITION
■ Cross face nerve graft—interposition nerve graft utilized to transmit facial
nerve motor axons from a neurologically intact to a paralyzed/paretic,
contralateral hemiface.
■ Utilized to restore motor innervation to denervated muscles of facial
expression and to neurotized free, functional muscle flaps, also can be
employed for sensory restoration.
■ Frequently utilized sources of nerve graft (sural nerve, saphenous nerve,
medial antebrachial cutaneous nerve).
■ Approximately 50% of a facial nerve’s zygomatic and buccal branches can be
selectively transected and their function redirected to the paralyzed hemiface
without producing significant donor weakness (functional reserve).
■ The facial nerve is the only donor nerve that can consistently restore
spontaneous, emotionally mediated facial motion.
ANATOMY
■ Facial nerve (somatic motor efferent component)—innervates the muscles of
facial expression, auricular muscles, occipitalis, posterior belly digastric,
stylohyoid, and stapedius.
■ The facial nerve main trunk emerges from the skull base via the stylomastoid
foramen where it can be identified coursing 1 cm deep to the tragal pointer and
medial to the posterior belly of the digastric muscle.1
■ Within the parotid gland, the facial nerve divides into a temporofacial and
cervicofacial trunk.
■ Distal branches exit the parotid on its anteromedial surface.

■ The following branches innervate the corresponding muscles of facial
expression2:
■ Frontal branch—frontalis muscle
■ Zygomatic branches—orbicularis oculi, zygomaticus major, zygomaticus
minor, levator labii superioris, levator labii superioris alaeque nasi, corrugator
supercilii, procerus
■ Buccal branches—buccinator, risorius, orbicularis oris
■ Marginal mandibular branches—depressor anguli oris, depressor labii
inferioris, mentalis
■ Cervical branches—platysma
■ Muscles of facial expression are innervated on their deep surface with the
exception of the levator anguli oris, buccinator, and mentalis.
■ Zuker point describes the approximate location of the facial nerve branch
supplying the zygomaticus major (FIG 1):
■ Midway point of a line drawn from the root of the helix to the lateral
commissure.
■ Preferentially divided and coapted to a cross facial nerve graft (CFNG) as the
first step in a two-staged free, functional muscle flap reconstruction.3
FIG 1 • The facial nerve branch supplying the zygomatic

major is typically found at a point halfway between the
root of the helix and the commissure (Zuker point).
■ Pitanguy line describes the course of the frontal branch of the facial nerve. The
line extending 0.5 cm below the tragus to 1.5 above the lateral brow with the
nerve running on the undersurface of the temporoparietal fascia.4
■ The marginal mandibular branches—consistently lie on top of the facial artery
and vein 1 to 3 cm below the mandibular border.5
NATURAL HISTORY
■ Axonal growth through the cross face graft proceeds at approximately 1 mm/d.
■ Ten to twelve months is typically required for the axons to traverse the graft.
■ After 18 months of denervation, mimetic muscles undergo significant atrophy
and poor functional outcomes are associated with nerve grafting.
■ A narrow time window is present for the use of cross face nerve grafts as an
isolated procedure to restore innervation to the paralyzed muscles of facial
expression.
■ The therapeutic window of CFNG is enhanced by the addition of a nerve
“babysitter.”6
■ Transfer of an adjacent cranial nerve to the injured facial nerve to achieve
rapid reinnervation and motor end plate preservation.
■ Partial hypoglossal-to-facial nerve transfer with an interposition jump graft
and secondary selective facial nerve branch transection and distal end-to-end
repair to CFNG.
■ Masseter-to-facial nerve transfer with immediate CFNG and distal end-to-end
and/or end-to-side coaptation.7
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Etiology of the facial paralysis:
■ Developmental
■ Traumatic
■ Post-tumor extirpation
■ Bell palsy
■ Ramsay Hunt syndrome
■ Duration of paralysis:
■ Denervation periods greater than 18 months are associated with poor

functional recovery (irreversible muscle atrophy) without utilization of a
muscle flap.
■ Patient age:
■ Peripheral nerve regeneration declines with advanced age.
■ There is no definitive age cut off for cross face nerve grafting; however, after
the age of 50 to 55 years, the ipsilateral motor nerve branch to masseter or
other adjacent cranial nerves often provide a more reliable source of
innervation to free muscle flaps with more powerful muscle flap contraction.
■ Comorbidities impairing nerve regeneration:
■ Smoking—higher risk of skin flap necrosis
■ Diabetes
■ Vascular disease
■ Previous radiation
■ Neurologic disorders
■ History of hypercoagulable state:
■ Patient or family history of pulmonary emboli or deep venous thrombosis
signal the need for a hematologic workup if a subsequent free, functional
muscle flap is planned.
■ Physical Examination
■ A strong smile, normal blink, forceful eye closure, good lip pucker, and
depression without synkinesis should be present on the donor hemiface.
■ Perform a complete cranial nerve exam to look for additional deficits.
■ Examine the eye on the paralyzed side for signs of exposure keratitis.
■ Look for previous incisions that could compromise perfusion to the cheek
flaps elevated during facial nerve exploration.
■ Palpate and Doppler the superficial temporal and facial artery and veins on
the paralyzed hemiface if a subsequent free, functional muscle flap is planned.
■ Palpate lower extremity pulses if sural or saphenous nerve grafts are to be
harvested to rule out peripheral vascular disease.
■ The progressive growth of axons through the CFNG can be monitored by
eliciting a Tinel sign.
■ An active Tinel sign at the distal end of the cross face nerve graft suggests
signals readiness for the next phase of the reconstruction.
IMAGING
■ MRI of brain and facial nerve
■ High-resolution multiplanar T1 and T2 images, gadolinium-enhanced, fat-

suppressed, and internal auditory canal (IAC) protocol
■ Used to evaluate injury to the facial nerve (ie, Bell palsy, tumors, stroke)
■ Computed tomography
■ 0.625-mm or thinner axial images, reconstructions in coronal plane
■ Valuable for imaging temporal bone fractures
■ CT angiogram
■ Useful for evaluating possible sites for microvascular anastomosis in patients
with multiple head-neck surgeries or developmental differences including
hemifacial microsomia.
■ EMG of the facial nerve
■ Look for signs of early facial nerve recovery.
■ Look for signs of reversible muscle atrophy.
SURGICAL MANAGEMENT
Preoperative Planning
■ Facial nerve EMG is obtained to evaluate for irreversible mimetic muscle
atrophy.
■ Facial nerve imaging as guided by the etiology of the paralysis (MRI, CT, CT
angiogram).
■ Determine the number of cross face nerve grafts to be utilized and evaluate the
potential nerve graft donor sites.
■ Discontinue smoking and nicotine products.
■ Discontinue anticoagulants.
Positioning
■ Supine on the operating table with narrow head extension.
■ Head on foam or gel-filled headrest.
■ Nasotracheal intubation with endotracheal tube sutured to nasal columella and
supported on the hair-bearing scalp with foam, silk tape and staples (FIG 2) or
an Oral RAE tube secured to the lower dentition with a 2-0 silk Ivy loop
suture.
■ Oral cavity cleansed with chlorhexidine gluconate mouth wash.
■ Sterile tourniquet applied to the thighs.
■ Sterile calf sequential compression devices.
Approach

■ Preauricular approach is most frequently employed.
■ Aesthetically favorable access incision especially in children and young
adults
■ Permits dissection of all facial nerve braches facilitating nerve stimulation,
creating of a functional map and optimal donor nerve selection
■ Allows retrograde dissection of selected facial nerve branches into the
parotid gland to enhance axonal concentration
■ The nasolabial fold approach is infrequently used.
■ Unaesthetic scarring in children and young adults.
■ Limited ability to select the optimal donor nerve branch.
■ Access to only distal nerve branches with more limited axon counts.
FIG 2 • Nasotracheal intubation with head positioned on
a narrow head-rest. Endotracheal tube sutured to
columella and supported with foam to prevent pressure
on the nasal alae.
T E C H N I Q U E S
■ Exposure and Flap Elevation
■ The anterior border of the masseter muscle is palpated and marked.
■ A pretragal, incision with an extension into the sideburn is now marked with
a surgical pen.
■ An additional point is marked half way between the root of the helix and the

commissure to indicate the general location of the facial nerve branch to the
zygomaticus major muscle (Zuker point) (TECH FIG 1).3
■ A petrolatum gauze dressing is used to occlude the external auditory canal.
■ The subcutaneous tissues in the preauricular, zygomatic, and buccal regions
are infiltrated with a 1:100 000 epinephrine, hemostatic solution (local
anesthetics should be avoided).
■ The preauricular incision with the sideburn extension is made and a skin and
subcutaneous tissue flap is elevated in the preauricular, zygomatic, and
buccal regions caring the medial aspect of the dissection approximated 3 cm
past the medial border of the masseter muscle.
■ An SMAS flap is now elevated with scissor dissection and bipolar cautery.
■ The flap is mobilized to the anteromedial border of the parotid gland where
the zygomatic and buccal branches of the facial nerve are identified.
■ The SMAS flap is released transversely along the inferior zygomatic
border and reflected to facilitate exposure (TECH FIG 2).
TECH FIG 1 • Operative markings. A. Preauricular
incision with a possible submandibular extension (X)
marks Zuker point and the dashed lines represent the
region of skin flap elevation. B. Markings shown on
the patient in the sample case.

TECH FIG 2 • A,B. Extent of the skin-subcutaneous
flap elevation and initial SMAS flap dissection. C.
SMAS flap elevation.
■ Nerve Mobilization and Graft Harvest
■ The operating microscope is brought onto the field to enhance visualization
and microsurgical dissection is used to further explore and mobilized the
facial nerve branches.
■ During the dissection, the transverse facial artery is often encountered. This
is a useful landmark as the zygomatic branches above and below this
structure often produce an excellent smile with little activation of the
orbicularis oculi.
■ The facial nerve branches are encircled with thin segments of microvascular
background to facilitate later identification.
■ Electrical stimulation is now performed. The facial nerve branches are
stimulated at 0.5 to 1 mA at 40 Hz and a functional map of their activity is
created.
■ The largest and most powerful zygomatic branch that produces activation of
the zygomatic major and levator anguli oris muscles without associated eye
closure is identified.

■ It is traced in a retrograde fashion into the parotid gland to maximizing its
caliber (TECH FIG 3).
■ Selective nerve branch transection at this site will be performed later in the
case for smile restoration.
■ If the surgical goals include restoration of eye closure, pucker and lip
depression, then approximately 50% of the facial nerve branches to the
orbicularis oculi, orbicularis oris, and depressor anguli oris and depressor
labii inferioris are selected for eventual transection.8
■ A submandibular extension of the initial access incision may be required to
reach the marginal mandibular branches.
■ Gowns and gloves are changed and new instruments are used to harvest the
nerve grafts under tourniquet control.
■ The sural nerve is approached via a limited access incision approximately 2
cm posterior to the lateral malleolus (TECH FIG 4).
■ The sural nerve is separated for the lesser saphenous vein, ligated with 4-0
silk ties, and divided. A nerve stripping device (Aesculap TEK784, Aesculap
Inc., Center Valley, PA) is used with a gentle back and forth twisting motion
to mobilize the nerve from distal to proximal. If significant resistance is
encountered, an additional counter incision is made and the tethering side
branch released. Grafts measuring 25 to 30 cm are reliable harvested.
TECH FIG 3 • A. The facial nerve branches bordering
the transverse facial artery are frequently selected for

transfer as they often produce an isolated smile with
little or no activation of the orbicularis oculi or
orbicularis oris. B. Isolation of zygomatic facial nerve
branches.
TECH FIG 4 • Sural nerve harvested via a limited
access incision utilizing a nerve-stripping device.
■ Graft Passage and Completion
■ If more than one nerve graft is to be passed through an adjacent tunnel, they
are marked in increments with different colored sutures to facilitate
identification.
■ An alligator, tendon passing clamp is inserted through limited incision in the
contralateral hairline and preauricular region. The clamp is now tunneled

through either the subcutaneous or deep supraperiosteal plane, traversing the
upper lip, lower lip, and submental region as determined by the number of
cross face nerve grafts (TECH FIG 5).
■ Small access incisions may be required in the upper and lower lip to
successfully create the tunnels.
■ These incisions can be used to identify branches of the infraorbital and
mental nerves that can be selectively transected and eventually coapted to the
cross face nerve graft (end-to-side) if desired in an effort to enhance axonal
growth.9
■ The nerve grafts are reversed and the proximal nerve end is ligated with a
colored 4-0 nonabsorbable, monofilament suture (facilitates delayed
identification).
■ The tendon passing clamps are used to gently draw the graft across the face.
■ The donor facial nerve branches are selectively divided, and an end-to-end
nerve repair is made between the facial nerve branch and corresponding
nerve graft with 10-0 nylon suture in an interrupted, epineurial fashion
(TECH FIG 6).
■ The SMAS flap is returned to its native position and secured with 4-0
absorbable suture.
■ The subcutaneous pocket is treated with spray thrombin or fibrin glue, and
the incision is repaired over a closed suction drain.
■ The nerve graft donor site access incisions in the extremities are closed in
layers with absorbable, monofilament suture and covered with cyanoacrylate
tissue adhesive. The incisions are covered with ABD pads and elastic
bandages are utilized to support the feet and calves.
■ Antibiotic ointment is applied to the head and neck incisions and no
dressings are applied.
■ A deep, atraumatic, extubation is then coordinated with the anesthesiologist.
■ Foot sequential compression devices are applied for deep venous thrombosis
prophylaxis.

TECH FIG 5 • Creating of subcutaneous tunnels with
alligator clamps for passage of cross face nerve
grafts.
TECH FIG 6 • A. Cross face nerve grafts for
restoration of eye closure and smile with proximal and
distal end-to-end nerve repairs. B. Cross face nerve
graft in situ. C. End-to-end nerve repair between sural
cross face nerve graft and a zygomatic branch of the
facial nerve.

PEARLS AND PITFALLS
Facial nerve
branch
selection
■ For smile restoration, select the largest facial nerve branch that
produces isolated activation of the zygomaticus major without
associated eye closure.
■ Trace the nerve branch into the parotid gland to increase the axon
density.
Nerve graft
injury
■ If significant resistance is met when harvesting the graft with a
nerve-stripping device, an additional incision should be created.
■ The obstructing side branch is then transected to prevent
accidental nerve graft avulsion.
■ Failure to do this may result in a graft of inadequate length with
disruption of the internal architecture.
Hemostatic
solutions
■ Avoid local anesthetics that contain epinephrine as they will
impair nerve conduction and the ability to create a functional map.
■ A solution of 1:100 000 epinephrine will achieve good
vasoconstriction without impairing nerve conduction.
Avoid
aesthetic
complications
■ Short-acting muscle relaxants are only permitted on induction, if
essential.
■ The need to avoid muscle paralysis must be communicated during
changes of anesthesia providers.
■ Deep, atraumatic, extubation without compressive, face mask
ventilation.
POSTOPERATIVE CARE
■ Patient is maintained a clear liquid diet for 48 hours followed by a soft diet for
4 weeks.
■ The oral cavity is rinsed with chlorhexidine gluconate mouth wash twice a day
for 7 days, after which an electric tooth brush is utilized for oral hygiene.
■ Pressure on the cheeks is strictly avoided.
■ Incentive spirometry is avoided and patients are encouraged to deep breathe. A
pinwheel can be used to encourage pediatric patients to breathe deeply.
■ Ambulation with assistance is usually initiated on the first postoperative day
and pedal sequential compression devices are utilized while in bed.
■ Anticoagulation is generally avoided due to the potential increased risk of
facial hematoma.