Operative Technique in Plastic Surgery – Kevin C.Chung

division of the facial nerve: Zuker’s point. Plast Reconstr Surg.
2013;131(2):253-257.
4. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance
of its variations in face lifting. Plast Reconstr Surg. 1966;38:352-356.
5. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the
facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg
1962;29:266-272.
6. Terzis J, Tzafetta K. The “babysitter” procedure: minihypoglossal to facial
nerve transfer and cross-face nerve grafting. Plast Reconstr Surg.
2009;123(3):865-876.
7. Garcia RM, Hadlock TA, Klebuc MJ, et al. Contemporary solutions for the
treatment of facial nerve paralysis. Plast Reconstr Surg. 2015;135(6):1025e-
1046e.
8. Conley J. Search for and identification of the facial nerve. Laryngoscope.
1978;88(1 Pt 1):172-175
9. Placheta E, Wood MD, Lafontaine C. Enhancement of facial nerve
motoneuron regeneration through cross-face nerve grafts by adding end-to-side
sensory axons. Plast Reconstr Surg. 2015;135(2):
460-471.
10. Bae YC, Zuker RM, Manktelow RT, et al. A comparison of commissure
excursion following gracilis muscle transplantation for facial paralysis using a
cross-face nerve graft versus the motor nerve to the masseter nerve. Plast
Reconstr Surg. 2006;117(7):2407-2413.
11. Frey M, Giovanoli P, Michaelidou M. Functional upgrading of partially
recovered facial palsy by cross-face nerve grafting with distal end-to-side
neurorrhaphy. Plast Reconstr Surg. 2006;117(2):597-608.

50
CHAPTER
Motor Branch of Masseter
for Innervation of Free
Muscle Flap
Michael J. A. Klebuc
DEFINITION
■ The descending branch of the motor nerve to the masseter muscle (CN V) can
be selectively divided and employed to innervate free muscle flaps, utilized for
smile restoration.
ANATOMY
■ The masseter nerve branches from the mandibular nerve and passes above the
lateral pterygoid muscle where it runs through the mandibular notch to enter
the substance of the masseter muscle.
■ Along its intramuscular path, the main trunk liberates a series of small
proximal branches and terminates in a long descending branch that courses
obliquely in posteroanterior, proximal-distal trajectory.
■ The main trunk of the masseter nerve can be identified at a point 3 cm in front
of the tragus, 1 cm below the zygomatic arch, and 1.5 cm deep to the SMAS
(FIG 1).1
■ The masseter muscle has three lobes (superficial, middle, and deep).
■ The motor nerve to the masseter (CN V) lies on the superficial surface of the
deep lobe.2
■ The main trunk and descending branches contain approximately 2700 and
1550 myelinated motor fibers, respectively.1,3

FIG 1 • Topographic landmarks for masseter nerve
isolation. Main nerve trunk located 3 cm in front of the
tragus, 1 cm below the zygomatic arch, and 1.5 cm
deep to the SMAS.
■ The descending branch of the masseter nerve is usually selectively transected
and employed to innervate free muscle flaps utilized for facial reanimation.
PATHOGENESIS
■ The masseter nerve is frequently selected as a source of innervation in cases of
bilateral facial paralysis and when the facial nerve is unavailable as a donor (ie,
Moebius syndrome, Lyme disease, bilateral temporal bone fractures, brainstem
cavernous malformation, Guillain-Barré).4
■ Often selected over cross face nerve grafts in older patients where the potential
for nerve regeneration is diminished.5
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Etiology of the facial paralysis:

■ Developmental
■ Traumatic
■ Post-tumor extirpation
■ Bell palsy
■ Ramsay Hunt syndrome
■ Patient age:
■ Peripheral nerve regeneration declines with advanced age.
■ There is no definitive age cutoff 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
signals the need for a hematologic workup prior to free, functional muscle
flap reconstruction.
■ The patient’s level of motivation and willingness to comply with postoperative
physical therapy is also important to ascertain.
■ History of temporomandibular joint dysfunction—consider alternative
technique.
Physical Examination
■ Active, forceful, contraction of the masseter and temporalis muscles is
confirmed by palpation.
■ The face is examined for previous access incisions and signs of trauma or
injury to the muscles of facial expression.
■ Dental occlusion and mouth opening are evaluated to rule out
temporomandibular joint dysfunction.
■ A cranial nerve examination is performed to identify additional neurologic
deficits.
■ Palpate and Doppler the superficial temporal and facial artery and veins on the

paralyzed hemiface to verify patency.
IMAGING
■ Imaging studies are seldom required in the presence of a normal physical
examination.
SURGICAL MANAGEMENT
Preoperative Planning
■ Smoking cessation and avoidance of nicotine
■ Discontinuation of oral anticoagulants
■ EMG
■ Concomitant activation of the masseter muscle with attempted smiling (may
predict development of an effortless smile)6
■ Mark the nasolabial folds and smile vectors prior to entering the operating
room.
Positioning
■ Supine on the operating table with arms tucked
■ Narrow head extension with foam- or gel-filled headrest.
■ Nasotracheal intubation with nasal ray endotracheal tube sutured to the
columella and supported on the hair-bearing scalp with foam, silk tape, and
staples (FIG 2)
FIG 2 • Nasotracheal intubation with head positioned on
a narrow headrest. Endotracheal tube sutured to
columella and supported with foam to prevent pressure

on the nasal alae.
■ Oral cavity cleansed with chlorhexidine gluconate mouthwash
■ Preoperative intravenous antibiotic coverage for oral flora (ie, clindamycin)
■ Contralateral lower extremity prepped if a free gracilis muscle flap will be
utilized
■ Sequential compression devices (sterile SCD on the donor leg)
■ Foley catheter
Approach
■ In the standard approach, the masseter nerve is explored via a preauricular
incision after elevation of a cheek skin flap.
■ When a limited preauricular approach is used, the neurorrhaphy is performed
prior to the microvascular anastomosis to facilitate exposure.
T E C H N I Q U E S
■ Standard Preauricular Approach
■ The external auditory canal is occluded with a petrolatum gauze dressing.
■ A preauricular incision with a sideburn extension is made if the superficial
temporal artery and vein will be used as recipient vessels. A submandibular
extension is incorporated if the facial vessel will be used.
■ A skin and subcutaneous tissue flap is elevated in the preauricular,
zygomatic, and buccal regions, extending the medial aspect of the dissection
to the lateral border of the orbicularis oris muscle.
■ A point is marked on the SMAS, 3 cm in front of the tragus and 1 cm below
the zygomatic arch. This landmark reliably corresponds to the general
location of the underlying masseter nerve (TECH FIG 1A).1
■ The operating microscope is brought onto the field to enhance visualization
and microsurgical dissection is utilized to identify zygomatic branches of the
facial nerve that traverse this site.
■ In cases of incomplete facial paralysis, these facial nerve branches are
mobilized and gently retracted to provide access to the deeper tissues. Facial
nerve branches are often absent in cases of developmental paralysis. This

significantly simplifies the dissection (TECH FIG 1B).
■ With the aid of bipolar cautery, the cephalic border of the parotid is released
from its attachments to the zygomatic arch and the gland is reflected
inferiorly exposing the masseteric fascia.
■ A window of the masseteric fascia is excised below the zygomatic arch
exposing the superficial lobe of the masseter muscle.
■ A right angle clamp and bipolar cautery are now utilized to release the
muscle in layers by propagating the dissection through the superficial and
middle lobes of the masseter muscle (TECH FIG 1C).
■ In the deeper portion of the dissection, an electrical stimulator set at 0.5 to 1
mA at 40 Hz is employed to help identify the masseter nerve that usually
resides in the zone of maximal muscle contraction.
■ Small branches of the masseter nerve are frequently encountered and can be
traced in a retrograde fashion back to the main trunk.
■ The main nerve trunk is usually identified resting on the superficial surface
of the deep lobe of the masseter muscle approximately 1.5 cm deep to the
SMAS. Once identified, the main trunk of the masseter nerve is encircled
with a vessel loop and the descending branch is further mobilized with
microsurgical dissection (TECH FIG 1D).

TECH FIG 1 • A. Skin flap elevated and location of the
masseter nerve marked 3 cm in front of the tragus and
1 cm below the zygomatic arch. B. Regional
zygomatic facial nerve branches mobilized and
reflected. May be absent in cases of developmental
paralysis. C. Cross-sectional view of masseter nerve
dissection with the main nerve trunk resting on the
superficial surface of the deep muscular lobe. D.
Masseter nerve identified within the muscle. The
descending branch will be mobilized and selectively
transected. The ascending branch will be preserved to

prevent atrophy.
■ The masseter nerve is accompanied by a sizable artery, and microvascular
clips can prove beneficial in achieving hemostasis and avoiding frustrating
hemorrhaging that impaired visualization.
■ Once the maximal length of the descending branch has been dissected, it is
selectively transected and transposed into a more superficial plane to
facilitate later nerve repair. It is important to preserve the integrity of the
proximal branches to prevent muscle atrophy and the development of a
cosmetic deformity.
■ With the aid of the operating microscope, an end-to-end microsurgical nerve
repair is made in an interrupted, epineurial fashion with 10-0 nylon between
the masseter nerve and the motor nerve of the free muscle flap.
■ Limited Preauricular Approach
■ When a limited preauricular approach is used, the neurorrhaphy is performed
prior to the microvascular anastomosis to facilitate exposure (TECH FIG
2A).
■ TECH FIG 3 shows an extended submandibular dissection to access the
facial artery and vein for recipient vessels.
TECH FIG 2 • A. Preoperative markings. B. Skin flap
elevation for limited, preauricular approach. C.

Superficial temporal vessels isolated. D. Descending
masseter nerve branch isolated and transected. E.
Nerve repair followed by microvascular anastomosis
to facilitate exposure.
TECH FIG 3 • Extended submandibular dissection to
access the facial artery and vein for recipient vessels.
PEARLS AND PITFALLS
Selective
masseter
nerve
transection
■ The descending branch is frequently divided and used to innervate
free muscle flaps. Proximal branches are left intact to prevent
muscle atrophy and development of a cosmetic deformity.
Excessive
power
■ Small muscle flaps should be utilized to avoid excessively powerful
muscle contraction and exaggerated commissure excursion. The
decreased bulk in the midface enhances the cosmetic result.
Inadequate
resting tone
■ Free muscle flaps innervated by the masseter nerve often produce
inadequate facial tone to achieve symmetry in repose. Consider
additional static support with fascia and or tendon grafts.
Patient
motivation
■ Selection of well motivated patients with a strong commitment to
postoperative physical therapy is essential.
Facial
■ Some individuals may notice significant facial motion with

motion with
mastication
chewing. This is often improved by favoring the contralateral cheek
region when eating.
Single-stage
procedure
■ Facial reanimation can be achieved in a single operative setting.
POSTOPERATIVE CARE
■ The patients are maintained on a clear liquid diet for 48 hours and then
transitioned to a soft mechanical diet for 4 weeks.
■ Please refer to Chapter 52 for additional postoperative care after free muscle
flap facial reanimation.
OUTCOMES
■ Single-stage procedure
■ Produces greater commissure excursion than cross face nerve grafts7
■ More reliable motion in the older patient, as compared to cross face nerve
grafts8
■ Dense innervation permits the use of small muscle flaps with less midface
bulk.
■ Potential for cerebral adaptation9
■ In longer-term follow-up, greater than 80% can make a smile without
clenching and more than 50% develop an effortless smile.10
COMPLICATIONS
■ Thrombosis and flap loss (rare)
■ Excess commissure excursion if a large muscle flap is utilized
■ Masseter muscle atrophy if the main nerve trunk is divided with development
of a sharp mandibular angle
■ Separation of the muscle flap from orbicularis oris with retraction into the
midcheek
■ Adhesion of the muscle flap to the dermis if excessively thin skin flaps are
elevated
■ Asymmetry in repose if additional static support is not provided
■ Unwanted facial motion with mastication
REFERENCES

1. Borschel GH, Kawamura DH, Kasukurthi R, et al. The motor nerve to the
masseter muscle: an anatomic and histomorphometric study to facilitate its use
in facial reanimation. J Plast Reconstr Aesthet Surg. 2012;65:363-366.
2. Hwang K, Kim YJ, Chung IH, et al. Course of the masseteric nerve in
masseter muscle. J Craniofac Surg. 2005;16:197-200.
3. Coombs CJ, Ek EW, Wu T, et al. Masseteric-facial nerve coaptation: an
alternative technique for facial nerve reinnervation. J Plast Reconstr Aesthet
Surg. 2009;62:1580-1588.
4. Gaudin RA, Jowett N, Banks CA et al. Bilateral facial paralysis: a 13-year
experience. Plast Reconstr Surg. 2016;138(4):879-887.
5. Garcia RM, Hadlock TA, Klebuc MJ, et al. Contemporary solutions for the
treatment of facial nerve paralysis. Plast Reconstr Surg. 2015;135(6):1025e-
1046e.
6. Schaverien M, Moran G, Stewart K, Addison P. Activation of the masseter
muscle during normal smile production and the implications for dynamic
reanimation surgery for facial paralysis. J Plast Reconstr Aesthet Surg.
2011;64:1585-1588.
7. Bae YC, Zuker RM, Manktelow RT, Wade S. A comparison of commissure
excursion following gracilis muscle transplantation for facial paralysis using a
cross-face nerve graft versus the motor nerve to the masseter nerve. Plast
Reconstr Surg. 2006;117(7):
2407-2413.
8. Klebuc M, Shenaq SM. Donor nerve selection in facial reanimation surgery.
Semin Plast Surg. 2004;18:53-60.
9. Lifchez SD, Matloub HS, Gosain AK. Cortical adaptation to restoration of
smiling after free muscle transfer innervated by the nerve to the masseter. Plast
Reconstr Surg. 2005;115:1472-1479.
10. Manktelow RT, Tomat LR, Zuker RM, Chang M. Smile reconstruction in
adults with free muscle transfer innervated by the masseter motor nerve:
effectiveness and cerebral adaptation. Plast Reconstr Surg. 2006;118:885-899.

51
CHAPTER
Masseter-to-Facial Nerve
Transfer
Michael J. A. Klebuc
DEFINITION
■ The descending branch of the masseter nerve can be transferred to selected
zygomatic-buccal branches of the facial nerve (V–VII) to restore motion in the
midface and perioral region.
■ The V to VII nerve transfer is utilized when intracranial and/or intratemporal
segments of the facial nerve are irreversibly damaged in the presence of intact
distal facial nerve branches and viable muscles of facial expression.
ANATOMY
■ The masseter nerve branches from the mandibular nerve and passes above the
lateral pterygoid muscle where it runs through the mandibular notch to enter
the substance of the masseter muscle.
■ Along its intramuscular path, the main trunk liberates a series of small
proximal branches and terminates in a long descending branch that courses
obliquely in a posterior-anterior, proximal-distal trajectory.
■ The main trunk of the masseter nerve can be identified at a point 3 cm in front
of the tragus, 1 cm below the zygomatic arch, and 1.5 cm deep to the SMAS
(FIG 1).1
■ The masseter muscle has three lobes (superficial, middle, and deep).
■ The motor nerve to masseter (CN V) lies on the superficial surface of the deep
lobe.2

FIG 1 • Topographic landmarks for isolation of the motor
nerve branch to masseter. The main trunk is identified 3
cm in front of the tragus, 1 cm below the zygomatic
arch, and 1.5 cm deep to the SMAS.
■ The main trunk and descending branches contain approximately 2700 and
1550 myelinated motor fibers, respectively.1,3
■ The descending branch of the masseter nerve is usually selected for the V to
VII transfer.
■ 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.4
■ Within the parotid gland, the facial nerve divides into a temporofacial and
cervicofacial trunk.

■ Distal branches exit the parotid along its anteromedial border.
■ The following branches innervate the corresponding muscles of facial
expression5:
■ 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
■ Zuker point-midway point of a line drawn from the root of the helix to the
lateral commissure (FIG 2)6:
FIG 2 • The facial nerve branch supplying the zygomatic
major is typically found at a point half way between the
root of the helix and the lateral commissure.
■ Describes the approximate location of the facial nerve branch supplying the
zygomaticus major muscle.

■ At this location, the zygomatic facial nerve branches coursing above and
below the transverse facial artery are often selected for the V to VII transfer.
PATHOGENESIS
■ Employed when intracranial and/or intratemporal segments of the facial nerve
are irreversibly damaged in the presence of intact distal facial nerve branches
and viable mimetic muscles.
■ Commonly utilized after ablative oncologic surgery or trauma involving the
brainstem and skull base.
■ Etiology of facial nerve injury includes resection of acoustic neuroma, facial
nerve schwannoma, cerebellopontine angle tumors, AVM, cholesteatoma, and
skull base tumors. Unrecovered Bell palsy, mastoiditis, and skull base fractures
are other common causes of facial nerve injury.7
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The duration of the paralysis is one of the most important pieces of
information garnered from the patient’s history, as the masseter-to-facial nerve
transfer must be performed before the muscles of facial expression have
undergone irreversible atrophy.
■ The V to VII transfer is optimally employed immediately at the time of tumor
extirpation yet remains a viable option up to 18 months after the onset of the
paralysis.
■ The patient’s age is also of consequence in surgical planning. Generally, in the
older patient population (greater than 55 years), the V to VII transfer is used in
isolation with fascia lata grafts for additional static support. In younger
patients, the V to VII transfer is often combined with cross face nerve grafts
(CFNG) in a single operative setting. This is performed in an effort to create a
marriage of power (V–VII) and spontaneity (CFNG).8,9
■ A history of diabetes, coronary artery disease, chronic obstructive pulmonary
disease, smoking, underlying neurologic disorders, previous head-neck
radiation, and temporal mandibular joint dysfunction should be noted and
accounted.
■ The patient’s level of motivation and willingness to comply with postoperative
physical therapy is also important to ascertain.
■ On physical examination, active, forceful contraction of the masseter and
temporalis muscles is confirmed by palpation.
■ The face is examined for previous access incisions and signs of trauma or

injury to the muscles of facial expression.
■ Dental occlusion and mouth opening are evaluated to rule out
temporomandibular joint dysfunction.
■ A cranial nerve examination is performed to identify additional neurologic
deficits.
■ The eye is examined for signs of exposure keratitis as adjunctive eye
procedures may be performed with the V to VII transfer to maintain corneal
health.
■ A vascular examination of the lower extremities is undertaken to rule out
significant peripheral vascular disease if fascia lata or sural nerve grafts are to
be harvested.
IMAGING
■ MRI of the 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
■ EMG of the masseter muscle and mimetic muscles innervated by the facial
nerve
■ Look for signs of early facial nerve recovery.
■ Look for signs of reversible muscle atrophy.
■ Look for signs of coordinated activity between the mimetic muscles and the
masseter.
SURGICAL MANAGEMENT
Preoperative Planning
■ Smoking cessation and avoidance of nicotine
■ Discontinuation of oral anticoagulants
■ Facial nerve imaging as guided by the etiology of the paralysis (MRI, CT)
■ EMG
■ Presence of muscle fibrillation (suggests potential, positive response to
reinnervation)
■ Concomitant activation of the masseter muscle with smiling (may predict

development of an effortless smile)
Positioning
■ Supine on the operating table with arms tucked
■ Narrow head extension with foam or gel-filled headrest
■ Nasotracheal intubation with nasal RAE endotracheal tube sutured to the
columella and supported on the hair-bearing scalp with foam, silk tape, and
staples (FIG 3)
■ Oral cavity cleansed with chlorhexidine gluconate mouthwash
■ Lower extremities prepped if nerve or fascia grafts are to be utilized
FIG 3 • Nasotracheal intubation with head positioned on
a narrow headrest. Endotracheal tube sutured to
columella and supported with foam to prevent pressure
on the nasal alae.
■ Sterile calf sequential compression devices
■ Foley catheter
Approaches
■ V to VII retrograde approach with adjacent branch preservation

■ V to VII anterograde approach with distal, selective, facial nerve branch
transection
■ V to VII with fascia lata static suspension
■ V to VII with CFNG
T E C H N I Q U E S
■ Retrograde Masseter-to-Facial Nerve Transfer
■ 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).6
■ The topographic location of the masseter nerve is also marked 3 cm in front
of the tragus and 1 cm below the zygomatic arch (TECH FIG 1A).
■ A petrolatum gauze dressing is utilized 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 to preserve nerve stimulation).
■ 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 extending the medial aspect of the dissection approximated 3
cm past the medial border of the masseter muscle (TECH FIG 1B).
■ A 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 inferior zygomatic and buccal branches of the facial nerve are identified.
The SMAS flap is released transversely along the zygomatic border and
reflected to facilitate exposure.

Video p8-c051
■ The operating microscope is brought onto the field to enhance visualization,
and microsurgical dissection is utilized to further explore and mobilize 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 (TECH FIG 1C).
00:00 / 00:00

TECH FIG 1 • A. Operative markings: preauricular
incision with a possible submandibular extension (X)
marks Zuker point and (asterisk) identifies the general
location of the motor nerve branch to masseter. The
dashed lines represent the anterior border of the
masseter muscle and the region of skin flap elevation.
B. Demonstrates the extent of the skin-subcutaneous
flap elevation and initial SMAS flap dissection. C. 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.

■ These facial nerve branches often merge into a larger common branch. This
is dissected in a retrograde fashion through the parotid gland until it dives
into a deep plane in the preauricular region. At this point, adequate nerve
length is usually present to achieve a primary nerve repair. However, the
facial nerve is left undivided until this can be confirmed.
■ Once the selected facial nerves have been mobilized, attention is focused on
identifying the motor nerve branch to the masseter.
Identifying the Motor Nerve Branch
■ A point 3 cm in front of the tragus and 1 cm below the zygomatic arch is
again marked. The masseter fascia is released from the inferior border of the
zygomatic arch with the bipolar cautery exposing the superficial surface of
the masseter muscle.
■ A right-angle clamp and bipolar cautery are now utilized to release the
muscle in layers, propagating the dissection through the superficial and
middle lobes of the masseter muscle (TECH FIG 2A).
■ In the deeper portion of the dissection, an electrical stimulator set at 0.5 to 1
mA at 40 Hz is employed to help identify the masseter nerve that usually
resides in the zone of maximal muscle contraction.
■ Small branches of the masseter nerve are frequently encountered and can be
traced in a retrograde fashion back to the main trunk (TECH FIG 2B).
■ Once identified, the main trunk of the masseter nerve is encircled with a
vessel loop, and the descending branch is further mobilized.
■ The masseter nerve is accompanied by a sizable artery, and microvascular
clips can prove beneficial in achieving hemostasis and avoiding frustrating
hemorrhaging and impaired visualization.
■ Once the maximal length of the descending branch has been dissected, it is
selectively transected and transposed into a more superficial plane to
facilitate later nerve repair. It is important to preserve the integrity of the
proximal branches to prevent muscle atrophy and the development of a
cosmetic deformity.

TECH FIG 2 • A. The main trunk, proximal ascending
branches, and descending branch of the masseter
nerve are identified via an intramuscular window. B.
Cross-sectional view of masseter nerve dissection
with the main nerve trunk resting on the superficial
surface of the deep muscular lobe.
Dividing the Nerve Branch
■ After verifying adequate length, the previously mobilized facial nerve
branch is divided. With the aid of the operating microscope, an end-to-end
microsurgical nerve repair is made in an interrupted, epineurial fashion with
10-0 nylon (TECH FIG 3).
■ The SMAS flap is now returned to its native location and secured with
absorbable monofilament sutures.
■ The plane of subcutaneous dissection is treated with fibrin glue, and a 10-
French closed suction drain is inserted.
■ A layered closure of the access incisions is now performed, and the incisions
are covered with antibiotic ointment. Stickers cautioning the need to avoid
pressure are applied to the cheek.
■ A deep, atraumatic extubation is then coordinated with the anesthesia
provider.

TECH FIG 3 • A. Microsurgical neurorrhaphy between
the descending branch of the masseter nerve and
selected zygomatic branches of the facial nerve. B.
Masseter nerve location marked on SMAS 3 cm in
front of the tragus and 1 cm below the zygomatic arch.
C. Zygomatic facial nerve branches and the
descending branch of the masseter nerve isolated for
transfer.
■ Antegrade Masseter-to-Facial Nerve Transfer
With Distal, Selective, Facial Nerve Branch
Transection

■ A preauricular incision with a subsideburn extension is created, and a broad
based skin flap is elevated carrying the dissection 2 to 3 cm past the anterior
border of the parotid gland. If additional exposure is required, a
submandibular extension can be added to the original incision.
■ The relatively avascular interval between the posterior border of the parotid
gland and tragal cartilage (cartilaginous portion of the external auditory
canal) is dissected with the aid of bipolar cautery and self-retaining Weitlaner
retractors.
■ The dissection is propagated deeply into the mastoid and retromandibular
region. The main trunk of the facial nerve is identified exiting the skull base
via the stylomastoid foramen approximately 1 cm deep to the tragal pointer
and medial to the posterior belly of the digastric muscle.4 The main trunk of
the facial nerve emerges from the skull base approximately 5 cm from the
skin surface (TECH FIG 4). The depth of this structure is significant, and a
submandibular extension of the access incision can be made to facilitate
exposure, although it detracts from the overall aesthetics of the result.
■ The main trunk of the facial nerve is encircled with a vessel loop and
electrically stimulated to verify the absence of function. Blunt dissection with
a fine right-angle clamp and bipolar cautery is then utilized to trace the nerve
into the substance of the parotid gland. The nerve often transitions rapidly
into a vertical course before separating into two divisions (temporofacial and
cervicofacial) at the pes anserinus. The facial nerve branches are now
dissected in an antegrade manner in a fashion akin to a superficial
parotidectomy. The facial nerve branch mobilization is terminated
approximately 1 to 2 cm from the anterior border of the parotid (TECH FIG
4B).
■ In cases of complete facial paralysis, the main trunk of the facial nerve is
transected at the stylomastoid foramen and transposed anteriorly to provide
unobstructed access for the masseter nerve dissection (TECH FIG 4C).
■ In cases of incomplete paralysis, isolation of the masseter nerve is
significantly more complicated, as the main trunk of the facial nerve is left
intact and the dissection must be propagated between the zygomatic branches
to the eye, without injuring these structures.
■ In cases of complete paralysis, the frontal branch, zygomatic branches
innervating the orbicularis oculi, and the cervical branches are selectively
transected to prevent development of synkinesis.

■ The descending branch of the masseter nerve is now mobilized and
selectively transected (as described above in the retrograde approach). An
end-to-end neurorrhaphy is now created with the aid of the operating
microscope and 10-0 nylon (TECH FIG 4D–F).
■ The parotid fascia is repaired with absorbable monofilament sutures, the
region of subcutaneous dissection is treated with fibrin glue, and the access
incision is closed over a 10-French closed suction drain.
■ “No pressure” stickers are applied to the cheek, and an atraumatic extubation
is coordinated with the anesthesia provider.

TECH FIG 4 • A. Facial nerve trunk identified exiting
the stylomastoid foramen approximately 1 cm below
the tragal pointer. B. The intraparotid portion of the
facial nerve dissected in a fashion analogous to a
superficial parotidectomy. C. Facial nerve trunk
selectively transected to enhance exposure and
frontal, selected zygomatic, marginal mandibular and
cervical branches of the facial nerve divided to prevent

synkinesis. Masseter nerve identified resting on the
deep lobe of the masseter muscle. D. Microsurgical
neurorrhaphy between the masseter and facial nerve
in an end-to-end fashion utilizing the operating
microscope. E. Clinical example of the facial nerve
mobilized within the parotid gland. Arrow and vessel
loop identify the facial nerve branches to zygomaticus
major and levator anguli oris. F. Arrow identifies the
descending branch of the masseter nerve coapted to
facial nerve trunk with 10-0 nylon in an interrupted
epineurial fashion.
■ Masseter-to-Facial Nerve Transfer With Fascia
Lata Grafts
■ Isolated V to VII transfers in adult patients often lack adequate resting tone.
■ In elderly patients, the V to VII transfer is often combined with fascia lata
grafts for provision of additional, static support.
■ The fascia lata graft is harvested from a proximal, lateral thigh incision with
the aid of a lighted retractor. A graft measuring approximately 15 to 17 cm in
length and 3 cm in width is obtained, and the fascial defect repaired with 0
polydioxanone suture. A layered closure is performed over a 15-French
closed suction drain, as the donor site is prone to seroma formation.
■ The graft is frequently divided into three segments that can be used
independently to support the upper lip, commissure, and lower lip.
■ The grafts can be positioned in the subcutaneous plane or delivered through
Bichat-fat pad via a retrozygomatic tunnel.
■ Only mild overcorrection is required as the reinnervated muscles of facial
expression will provide additional support, and limited stretching of the
fascia lata graft will develop.
■ Masseter-to-Facial Nerve Transfer With Cross
Face Nerve Grafts

■ In the younger patient population, the V to VII transfer is frequently
combined with cross face nerve grafts (single-stage operation) in an effort to
enhance spontaneity and resting tone.9
■ The cross face nerve grafts are performed as described in Chapter 49 and the
V to VII transfer as described above.
■ Electrical stimulation of the unaffected, contralateral facial nerve branches is
utilized to create a functional map, and the information is extrapolated to the
“electrically silent” side to guide the distal nerve repairs.
■ Typically, three to four cross face nerve grafts are combined with the V to
VII transfer and target the orbicularis oculi, zygomatics major, orbicularis
oris, and lower lip depressors (TECH FIG 5).
TECH FIG 5 • Three to four cross face nerve grafts
are combined with the V to VII transfer and target the
orbicularis oculi, zygomatics major, orbicularis oris,
and lower lip depressors.
PEARLS AND PITFALLS

Proximal
nerve
branch
preservation
■ Only the descending branch of the masseter nerve should be
transferred. Proximal branches are left intact to prevent irreversible
atrophy and a cosmetic deformity.
Static
support
■ Fascia lata grafts are frequently required in older patients as the V to
VII may not create adequate resting tone.
Sialocele
■ When extensive intraparotid dissection is performed, salivary
collections can develop. This is reduced with the application of
fibrin glue in the subcutaneous plain and usually responds to
glycopyrrolate.
Patient
motivation
■ These techniques are best suited to highly motivated individuals
who are strongly committed to participate in postoperative therapy.
TMJ
dysfunction
■ There is a potential for exacerbation of TMJ dysfunction, and
therefore one should consider an alternate technique.
POSTOPERATIVE CARE
■ No surgical dressings employed; apply antibiotic ointment to incisions for 48
to 72 hours.
■ Avoid pressure on the surgical site (only one thin pillow under the head).
■ Avoid incentive spirometry, and encourage deep breathing.
■ IV antibiotic coverage for skin organisms and anaerobic oral flora (ie,
clindamycin)
■ Sequential Compression Devices (SCDs) and early mobilization
■ Chlorhexidine mouthwash for 5 to 7 days and then electric toothbrush
■ Soft mechanical diet for 4 weeks
■ Once motion develops, the patient must practice smiling in front of a mirror
(visual feedback) for a minimum of 30 min/d.
OUTCOMES
■ Facial tone usually starts to develop at 3 to 4 months and facial motion at 5 to
6 months.7,10
■ In longer-term follow-up (greater than 2 years), 75% of patients can create a
smile without clenching their teeth.
■ Average commissure excursion achieved is 90% of the normal side.

■ Many patients fail to develop adequate resting tone. Static suspension and
cross face nerve grafts are frequently employed to counteract this problem.
■ Donor site problems are rare due to the duplication of function between the
masseter and temporalis muscles and the selective transection of only the
descending branch of the masseter nerve.11
COMPLICATIONS
■ Sialocele formation that usually responds to glycopyrrolate
■ Otitis externa from collection of sanguineous material in the external auditory
canal
■ Masseter muscle atrophy and development of a sharp mandibular angle if the
entire masseter nerve is transected
■ Oral-ocular, synkinetic dysfunction that usually responds favorably to
botulinum toxin injections and is preferable to paralytic ectropion
REFERENCES
1. Borschel GH, Kawamura DH, Kasukurthi R, et al. The motor nerve to the
masseter muscle: an anatomic and histomorphometric study to facilitate its use
in facial reanimation. J Plast Reconstr Aesthet Surg. 2012;65:363-366.
2. Hwang K, Kim YJ, Chung IH, et al. Course of the masseteric nerve in
masseter muscle. J Craniofac Surg. 2005;16:197-200.
3. Coombs CJ, Ek EW, Wu T, et al. Masseteric-facial nerve coaptation: an
alternative technique for facial nerve reinnervation. J Plast Reconstr Aesthet
Surg. 2009;62:1580-1588.
4. Conley J. Search for and identification of the facial nerve. Laryngoscope.
1978;88(1 Pt 1):172-175.
5. Tzafetta K, Terzis J. Essays on the facial nerve: part I. Microanatomy. Plast
Reconstr Surg. 2010;125(3):879-889.
6. Dorafshar AH, Borsuk DE, Bojovic B, et al. Surface anatomy of the middle
division of the facial nerve: Zuker’s point. Plast Reconstr Surg.
2013;131(2):253-257.
7. Klebuc MJ. Facial reanimation using the masseter-to-facial nerve transfer.
Plast Reconstr Surg. 2011;127:1909-1915.
8. Faria JC, Scopel GP, Ferreira MC. Facial reanimation with masseteric nerve:
babysitter or permanent procedure? Preliminary results. Ann Plast Surg.
2010;64:31-34.
9. Garcia RM, Hadlock TA, Klebuc MJ, et al. Contemporary solutions for the

treatment of facial nerve paralysis. Plast Reconstr Surg. 2015;135(6):1025e-
1046e.
10. Spira M. Anastomosis of masseteric nerve to lower division of facial nerve
for correction of lower facial paralysis: preliminary report. Plast Reconstr
Surg. 1978;61:330-334.
11. Klebuc M, Shenaq SM. Donor nerve selection in facial reanimation surgery.
Semin Plast Surg. 2004;18:53-60.

52
CHAPTER
Pediatric Facial
Reanimation Using a
Functional Gracilis Muscle
Transfer
Brad M. Gandolfi, Jeffrey R. Marcus, and Michael R. Zenn
DEFINITION
■ Facial paralysis does not describe a disease but instead the sequelae of
denervation resulting from a spectrum of diseases, congenital defects, and
acquired defects with a similar effect on the facial musculature.
■ Facial nerve paralysis can involve the entire facial nerve distribution or only
certain branches of the facial nerve. The facial nerve may be affected
symmetrically or asymmetrically. The extent of the paralysis may be complete
or incomplete relative to residual motor capacity.
■ The pathogenesis of facial paralysis is complex and dependent on the etiology
of the disease.1,2 That discussion is beyond the scope of this chapter but briefly
can be divided into congenital and acquired facial paralysis (Table 1). An
accurate diagnosis is crucial to selecting the proper surgical (or nonsurgical)
intervention.
■ Facial reanimation is a general term to describe restoration of facial
movement. There are two main distinctions based on the status of native facial
muscles:
■ Nerve transfers—When the denervating event is such that existing native
facial musculature can be amenable to reinnervation with a functioning nerve,
a nerve transfer is warranted. In this setting, the goal may be to restore
multiple facial nerve targets—ie, multiple separate but coordinated
movements.
■ Functional muscle transfer—In long-standing or congenital facial paralysis,

native muscles are not present to perform the function. Therefore, a transfer
of functioning muscle provides reanimation. In such cases, only one facial
movement, rather than multiple, is the goal of the procedure. One muscle
provides one movement.
■ This chapter focuses on free muscle transfer for restoration of smile in the
pediatric population.
ANATOMY
Facial Nerve
■ The facial nerve exits the stylomastoid foramen and enters the posterior
parotid gland, dividing the gland into superficial and deep components.
■ The facial nerve divides into two main branches within the parotid gland: the
frontozygomatic and the cervicofacial trunks. These branches further divide
before exiting the parotid gland.
■ Five branches are classically described as exiting the parotid (frontal/temporal,
zygomatic, buccal, marginal mandibular, and cervical). However, the
branching pattern for each individual is unique, and many of the abovenamed
nerves exist in multiples.3 The average number of branches exiting the parotid
is 7 (FIG 1).
■ Buccal and zygomatic branches begin to arborize and cross within and beyond
the parotid, resulting in redundancy in the functional territory of these buccal-
zygomatic branches.3,4 It is difficult to separate the activity of these branches
as purely buccal or zygomatic because stimulation often results in a mixed
response. Due to mixed nerve function, sacrifice of one nerve for end-to-end
coaptation does not result in functional loss.
■ The target for reanimation of smile is a buccal or zygomatic branch, selected
based on targeted muscle stimulation. Stimulation should ideally identify a
branch that produces vertical and horizontal movement of the commissure and
upper lip consistent with the patient’s natural smile, with minimal extraneous
movement.
■ Zuker point describes a relatively consistent buccal-zygomatic branch that
meets the needs for facial reanimation.4 It is found at the center of a line drawn
from the oral commissure to the helical root.
Nerve to the Masseter
■ The nerve to the masseter arises as a branch of the trigeminal nerve (V3),

passing posterior to the temporalis muscle en route to the deep surface of the
masseter (FIG 2).5,6
Table 1 Causes of Facial Paralysis
Congenital
Acquired
Syndromic
Nonsyndromic Traumatic
Tumor
Inflammatory
Neur
Disea
Developmental
Developmental
Intracranial
Benign
Bacterial
Bacte
Genetic
Genetic
Extracranial
Malignant
Viral
Viral
Intrapartum
Intrapartum


Toxic
Toxic
Idiopathic
Idiopathic


Genetic
predisposition
Gene
predi
FIG 1 • The anatomy of the facial nerve.

■ The nerve is reliably found 3 cm anterior to the tragus, 1 cm inferior to the
zygomatic arch, and 1.5 mm deep to the SMAS.5,6
Gracilis Muscle
■ The gracilis muscle originates along the body and inferior ramus of the pubis,
just below the pubic tubercle.7 It runs along the medial thigh and inserts into
the medial tibial condyle, immediately deep to the sartorius muscle (FIG 3A).
■ The gracilis lies immediately posterior to the much larger adductor longus,
which is easily palpated on most patients.
FIG 2 • The nerve to the masseter is found by splitting
the temporalis and masseter muscles, under the
zygoma. Reprinted from Borschel GH, et al. The motor
nerve to the masseter muscle: an anatomic and
histomorphometric study to facilitate its use in facial

reanimation. J Plast Reconstr Aesthet Surg.
2012;65(3):363-366, with permission from Elsevier.
FIG 3 • Gracilis muscle with the pedicle ex vivo. Note
the length of obturator nerve (left side of image).
■ The muscle is supplied by the medial circumflex femoral artery, a branch of
the deep femoral artery. The pedicle runs underneath the adductor longus en
route to the gracilis.
■ The artery enters the muscle 5 to 12 cm inferior to the pubic tubercle. It is
generally 1 to 2 mm in diameter and may have two or three branches at the
level of the muscle (FIG 3B).
■ The artery is accompanied by two vena comitantes.
■ The artery and the accompanying vein are 5 to 6 cm when dissected to the
deep femoral vessels.
■ The muscle has a minor pedicle at its distal aspect that is not appropriate for
microvascular transfer.
■ A branch of the obturator nerve supplies the gracilis muscle. It splits from the
anterior branch of the obturator behind the pectineus and runs with the branch
to the adductor longus. The nerve joins the muscle from its lateral aspect,
generally at a 45-degree angle to the vascular pedicle. The nerve pierces the
muscle and arborizes within it.
■ The gracilis muscle has a tendinous origin from the pubis, which can be
included with the flap. The muscle can be 3 to 4 cm wide at the level of the
pedicle, requiring some muscle splitting to avoid bulky reconstructions.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The most important initial distinction in the preoperative evaluation of
pediatric patients with facial paralysis is whether the condition is congenital or
acquired. For those with congenital paralysis, the condition may have been
apparent at birth or recognized shortly thereafter (FIG 4). For those with
acquired paralysis, the circumstances and details of the inciting event(s) should
be carefully noted. The timing of functional loss is the most critical detail.
FIG 4 • Photo taken shortly after birth, depicting a left-
side congenital facial nerve paralysis.
■ Functional impairment, including the following, should be noted:
■ Excessive tearing and/or dryness requiring frequent use of lubricating drops
■ Inability to close the eyes fully at night requiring the use of viscous eye
lubricant
■ Oral incompetence (drooling) or speech articulation difficulties
■ Presence and extent of dental caries, which are predisposed on the affected
side
■ Any prior treatments should be noted as well as any progression or
improvement in the condition.
■ Prior medical, neurologic, or surgical history that would potentially be
associated with the condition or the potential surgical treatments that may be
considered should be noted.
■ A focused examination of the function of the facial nerve is performed, taking
care to document both static and dynamic deficiencies. The motor territory
associated with each branch should be graded relative to the completeness of
the paralysis. We prefer the Toronto Facial Grading System to track our
progress.2 If etiology of paralysis is unclear, level of injury can be elucidated
using the Schirmer test, stapedius reflex test, salivary flow test, and taste
examination.
■ Photographs and video of the following should be included in the initial
evaluation:
■ Repose
■ Brow elevation

■ Eye closure (gentle)
■ Eye closure (strong)
■ Smile (lips together)
■ Smile (natural dental display)
■ Full dental display
■ Pucker
■ The ability to close the eyelids such that the cornea is protected must be
assessed. Those who are unable to close fully and require viscous lubrication
should be identified early and treated with priority ahead of smile reanimation.
■ Amblyopia may be seen in as many as 50% of patients with facial nerve
palsies, and thus a thorough ophthalmologic examination is warranted.1 The
eye examination should also assess for corneal pathology due to exposure.
■ The presence of the facial artery should be confirmed. It is palpable in most
patients regardless of age.
■ The temporalis and masseter muscles should be palpated, particularly if
considering the motor nerve to the masseter as a potential donor nerve. Normal
strength and mass should be present.
■ Syndromic associations can be seen in congenital facial paralysis and can
include hemifacial microsomia, Mobius syndrome, and Poland syndrome
among others. Therefore, the examination should include an evaluation of the
facial bones (orbits, zygoma, maxilla, and mandible), soft tissues, and ear.
Mobius syndrome includes the presence of a cranial nerve VI deficit and can
also be associated with a Poland deformity and congenital hand anomalies.
Thus, cranial nerves VI, VII, IX, X, and XII should be evaluated for disability.
IMAGING
■ For candidate patients with long-standing or congenital paralysis, a
radiographic workup is generally unnecessary. For those with associated
congenital anomalies, such as craniofacial microsomia, craniofacial CT may be
valuable for the comprehensive workup.
■ In cases of recently acquired facial paralysis, an EMG may be useful to
establish a baseline, demonstrate improvement, or predict recovery. In
congenital or long-standing cases, EMG does not provide information that
contributes to treatment planning and therefore is not necessary.
NONOPERATIVE MANAGEMENT
■ Nonoperative management plays an important role in partial paralysis. A facial

rehabilitation specialist may be able to obtain a more symmetric smile by
strengthening weaker muscles and de-emphasizing stronger, more active
muscles. Such treatment requires participation of the child.
■ In certain instances of incomplete paralysis, neurotoxins can be used on the
unaffected side as an adjunct to obtain symmetry.
■ Long-standing, complete, and near-complete paralysis in the pediatric
population generally requires surgical management.
SURGICAL MANAGEMENT
■ For the pediatric patient with congenital or long-standing complete paralysis
affecting smile, our preferred treatment is microvascular free functional gracilis
transfer. Using the gracilis, we can obtain satisfactory, and often outstanding,
static and dynamic symmetry of smile.
■ For unilateral facial paralysis, we prefer to use a branch of the facial nerve
from the contralateral (functional) side to power the gracilis by way of a cross
face nerve graft (CFNG). This allows a spontaneous, emotion-driven smile.
■ In cases of bilateral facial paralysis, the nerve to the masseter is coapted to the
obturator nerve, powering the functional gracilis. This nerve is powerful, is
located in the field of dissection, and does not cause a functional deficit.
Although jaw clenching (masseter activation) is required to stimulate activity
in the transferred muscle, with postoperative psychomotor training, the patient
can learn to use this muscle spontaneously. However, in contrast to CN VII
(CFNG), the masseter nerve—which arises from CN V—lacks baseline tone.
Therefore, even a strong smile powered by the masseter nerve will lack
baseline tone in repose and therefore will potentially still be associated with
repose asymmetry including facial shift.
Preoperative Planning
■ As with any operation, the patient and parents should be thoroughly informed
of risks, benefits, and expected outcomes of the procedure. Free flaps in any
population may be lengthy in duration and carry a rare but present risk for early
failure. Even when technically successful, achievement of a long-term
symmetric smile cannot be guaranteed.
■ Families must be briefed on the nature of nerve coaptations, timing of
functional results, and postoperative care necessary. In general, the timing of
nerve regeneration is as follows:
■ Two-stage repair:

• Cross face nerve graft: 6 to 9 months
• In older children, a Tinel sign may be followed. In younger children, it
may not be elicited.
• Free gracilis transfer: 6 to 12 months
■ Nerve to masseter: 2 to 4 months
■ Lack of activity (visible or palpable) beyond the later time limits suggests a
poor prognosis relative to success of the procedure.
■ Preoperatively, the patient is asked to smile, and the vectors of commissure
and upper lip elevation are marked on the normal side (if present). These will
be used to guide the reconstruction. It is important to do this with the patient in
the upright position. Care must be taken not to wash these marks off during the
procedure.
■ In cases of bilateral paralysis, two sequential single-stage procedures using
the nerve to masseter are performed. The vectors of desired pull to obtain a
smile are also marked in these patients, guided by the typical appearance and
location of the nasolabial fold.
■ Given the substantial recovery process required, it is helpful to schedule the
muscle transfer in the summer for school-aged children.
■ As noted, a Tinel sign may or may not be present over the distal aspect of the
CFNG. In the event that the Tinel sign cannot be elicited, intraoperative frozen
section of the CFNG may confirm a normal fascicular pattern, thus confirming
nerve regeneration and readiness for free muscle transfer.
■ The functional muscle transfer of the gracilis is best accomplished with two
surgical teams, minimizing anesthetic time and allowing the procedure to be
accomplished in a safe and efficient manner. One team focuses on the recipient
site preparation, whereas the other harvests the gracilis muscle and prepares it
for transfer.
Positioning
■ Stage 1 of two-stage procedure (CFNG):
■ A discussion with anesthesia team is important. The following needs must be
conveyed:
• No paralytic agents after induction
• Choice of endotracheal tube and method of stabilization should not distort
facial features or interfere with assessment of stimulation during surgery.
The authors prefer nasal or oral RAE for stage 1 procedures.

• The bed is turned 90 degrees to allow all surgeons access to the field. The
circuit must be long enough to accommodate the positioning.
• Corneal protection and lubrication must be provided and accommodated at
each step of the operation.
■ The surgery starts in the prone position, with harvest of the sural nerve.
■ Once the nerve is harvested and the leg incisions closed, the patient is turned
supine for the facial nerve dissection and nerve coaptation.
■ Stage 2 of two-stage procedure or single-stage gracilis transfer (CNV
masseter):
■ The patient is placed in the supine position.
■ The bed is positioned so the anesthesiologist is at the ipsilateral hip (turned
90 degrees), which allows both teams to operate freely.
■ For gracilis harvest, the legs are placed in a frog-leg position, with the hips
and knees gently flexed. The ipsilateral gracilis is used for the following
reasons:
• The direction of the nerve and vascular pedicle are appropriate to allow
muscle to be positioned in line with the facial artery and nerve and with
maximal available obturator nerve length.
• Two teams may operate simultaneously without interference.
Approach
■ First stage (CFNG):
■ The sural nerve is harvested first. We prefer stair-step incisions (3) with a
lighted retractor and direct visualization of the nerve during dissection. The
proximal portion of the sural nerve is preferred due to size match and limited
branching.
■ The facial nerve exploration is accomplished through a preauricular (face-
lift) incision with a 3- to 5-cm extension along the mandibular angle to
facilitate exposure (FIG 5A).
■ The gracilis harvest is accomplished through a 10-cm incision placed over the
medial aspect of the upper thigh.
■ The incision is placed on a line drawn from the inferior ramus of the pubis to
the medial tibial condyle, centered approximately 10 cm below the pubic
tubercle (FIG 5B).
■ Recipient site (paralyzed face) and nerve to masseter
■ Similar to first-stage CFNG, the incision follows a preauricular face-lift

design with an extension 3 to 5 cm along the angle of the mandible.
■ The incision stops 2 cm anterior to the palpable facial artery, which limits the
length of incision while providing adequate microsurgery exposure.
FIG 5 • A. Incision pattern for a first-stage cross face
nerve graft. B. The incision for the gracilis is centered
on the presumed location of the pedicle on the medial
thigh.
T E C H N I Q U E S
Video p8-c052
00:00 / 00:00

■ Cross Face Nerve Graft
■ The field is copiously infiltrated with a dilute solution of epinephrine
(without any local anesthetic). This decreases blood loss, enhancing visibility,
and facilitates the skin flap elevation.
■ A modified face-lift–style incision is made on the normal (nonparalyzed)
side as described above (see FIG 5A).
■ Sharp dissection proceeds in a superficial plane until the border of the
parotid is reached. Skin hooks are used for retraction.
■ Once the border of the parotid is reached, the SMAS is incised, and the
dissection continues in the sub-SMAS plane (TECH FIG 1A).
■ The branches of the facial nerve are identified exiting the parotid with the
help of a nerve stimulator (TECH FIG 1B).
■ A proper donor nerve is identified. The donor nerve should supply the
zygomaticus muscles and the levator labii. Nerves that simultaneously supply
portions of the orbicularis should be avoided, if possible. The goal is to find a
nerve that produces the patient’s natural smile in relative isolation. The
candidate nerves are then followed distally. Stimulation of two or three
candidate branches ensures that enough redundancy exists to preclude
functional loss with sacrifice of the ideal donor selection.
TECH FIG 1 • A. Incision of SMAS to enable donor
nerve dissection. B. Nerve branches are identified on

the nonparalyzed side. C. The sural nerve is passed
through a preperiosteal tunnel across the maxilla
using stepped incisions. Tunneling is facilitated by
securing the end of the nerve to a vessel loupe and
sliding the loupe through the tunnel.
■ A preperiosteal tunnel is then created from the medial extent of the
dissection plane to the superior buccal sulcus. A small incision is made at the
level of the contralateral canine to aide in the dissection.
■ A vessel loop is then passed from the buccal sulcus incision into the edge of
the face-lift dissection site (TECH FIG 1C).
■ The sural nerve is harvested at this time.
■ The nerve graft is reversed and then secured to the end of the vessel loop.
The vessel loop is then pulled back through the subcutaneous tunnel,
delivering the distal end of the nerve graft to the upper buccal sulcus
atraumatically.
■ The distal end of the graft is tagged with a hemoclip and secured to the
periosteum lateral to the canine with a 4-0 nylon suture. This aids in
identification at the second stage.
■ The upper buccal sulcus incision is then closed.
■ The proximal nerve graft is coapted to the donor facial nerve end to end
under the surgical microscope.
■ The cheek flap is then closed using 4-0 Vicryl dermal sutures, followed by 4-
0 nylon skin suture. A short Penrose drain segment is placed for 24 hours.
■ No compressive dressings or head wraps are used.
■ Identification of Nerve to Masseter
■ The nerve to the masseter is identified after cheek flap elevation (described
below in the gracilis muscle inset).
■ An incision is made in the SMAS anterior to the temporomandibular joint,
parallel to the zygomatic arch and just below the arch (TECH FIG 2A).
■ Dissection proceeds through the superficial and intermediate muscle bellies
of the masseter, and a nerve crossing obliquely from zygomatic arch to
commissure is sought. The nerve can be found 3 cm anterior to the helical

root and 1 cm below the arch. A nerve stimulator may be used to help
identify the nerve (TECH FIG 2B).
■ The nerve is traced to its entrance into the undersurface of the masseter,
where it is transected and transposed superficially (TECH FIG 2C).
■ Any excess obturator nerve is trimmed prior to coaptation to the masseteric
nerve to decrease reinnervation time.
TECH FIG 2 • A. The incision to find the nerve to the
masseter is anterior to the TMJ, just below the arch.
B. The nerve to the masseter is identified. C. The
nerve is superficially translocated and coapted to the
obturator nerve.
■ Recipient Site Preparation
■ The field is copiously infiltrated with a dilute solution of epinephrine
(without any local anesthetic). This decreases blood loss, enhancing visibility,
and facilitates the skin flap elevation (TECH FIG 3A).
■ A pretrichial, retrotragal incision is made on the paralyzed face. The incision
follows the pattern of a basic face-lift incision with an extension inferiorly
that allows access to the facial vessels (TECH FIG 3B).
■ The area from the zygomatic arch to the mandible is elevated in a sub-SMAS
plane toward the oral commissure.
■ The buccal fat pad is resected to decrease cheek bulk in anticipation of
muscle placement (TECH FIG 3C). Additionally, deep fat of the cheek is
excised as necessary or available.
■ The facial vessels are identified and isolated. The vessels are dissected to the
level of the commissure to provide length and different diameter choices for

anastomosis (TECH FIG 3D).
■ Using preoperative vector marks as guides, three to four no. 2 Vicryl inset
sutures are placed internally in the upper lip, commissure, and occasionally at
the lower lip. One suture is always placed at the commissure.
■ Generally, two sutures are placed for the upper lip.
■ Depth of suture placement is key, as too shallow a bite will cause lip
eversion and too deep lip inversion.
■ If orbicularis muscle is present, sutures can be placed through the muscle.
In many cases, no muscle is present, and sutures are placed in the
submucosa (TECH FIG 3E).
■ As sutures are placed, traction is placed on the suture to replicate smile.
Suture placement is modified until the vectors of pull and the nasolabial fold
mimics the anticipated smile (TECH FIG 3F).
TECH FIG 3 • A. The dissection plane is copiously
injected with dilute epinephrine. The incision for the
gracilis recipient site on the face mimics a face-lift with
an inferomedial extension along the mandible to

access the facial vessels. B. The gracilis muscle is
measured for size and cut to length in situ. C. The
ipsilateral buccal fat pad is resected to decrease the
bulk deformity of the gracilis muscle. D. The facial
vessels are identified at the border of the mandible. E.
A series of sutures are placed at commissure in
preparation for securing the muscle. F. The location of
the commissure sutures is checked by placing traction
on them and assessing the smile produced.
Determination of the Length of Muscle Needed for the
Reconstruction
■ This is done with slight traction applied to the inset sutures such that a slight
smile is created.
■ For purposes of semantics, we refer to the distal inset at the commissure as
the insertion and the proximal inset along the zygoma as the origin.
■ The muscle is positioned along the proposed vector of the smile—a
reflection of the same vector estimated and drawn on the normal side.
■ The distances from the commissure to the proposed medial and lateral points
of origin along the zygoma are determined (TECH FIG 4A).
■ The distance along the medial point of origin is shorter than that to the
lateral point of origin (TECH FIG 4B).
■ The muscle is taken at the greater length, with an additional 2 cm of length
added (1 cm per side) to accommodate a row of sutures at each end. These
help prevent pull-through of the subsequent inset sutures. The muscle is then
cut on a bias at the proximal end to account for the medial/lateral length
discrepancy.
■ If pedicle position and required muscle length are ideal, the proximal
tendinous portion of the gracilis may be used at the inset origin.
■ Once the segmental length is determined, it must be properly centered over
the pedicle.
■ Three measurements must be made:
■ Total length of muscle (described above, generally around 8 cm)
■ Length of muscle proximal to the facial vessels (approximately 5 cm)
■ Length of muscle distal to the facial vessels (approximately 3 cm)

■ In this way, the dimensions can be transferred to the donor site.
■ The dimensions are conveyed to the donor site surgical team.
TECH FIG 4 • A. Measurements are taken from the
proposed origin to the insertion of the gracilis in
preparation for harvest. B. The gracilis muscle
measurements are measured precisely using the
proposed origins and insertions and their relation to
the facial vessels. Most times, the anterior border of
the muscle (measurement c in the diagram) will be
shorter than the posterior border of the muscle
(measurement a) because the origin is secured
parallel to the zygoma. Measurement b is the length of
the gracilis caudal to the vessel insertion.
■ Gracilis Muscle Harvest
■ The patient is placed in the supine position. The hip and knees are slightly
flexed (frog-leg position).