Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

CHAPTER 14 — Head a nd Nec k Reconstruction
153
evaluate the ability of a patient to protect the airway. In
patients with extensive maxillofacial reconstruction involv­
ing the oronasal cavity, a tracheostomy can safely be estab­
lished prior to surgical intervention. Although attempts
have been made to circumvent the use of a tracheostomy by
employing nasopharyngeal endotracheal intubation. The
need for tracheostomy is frequently necessary during or
prior to the hospitalization in trauma, oncologic resection,
and congenital deformity.156 Implementing endotracheal
intubation for scalp and periorbital reconstruction is ideal.
It is important to note that prolonging intubation and seda­
tion during recovery is not recommended, as the risks of
ventilator-associated pneumonia, sedative-related hypoten­
sion, delirium, and other intensive care unit morbidities are
too high to see the benefit in flap outcomes. Although
minimizing flap movement with prolonged sedation is
tempting to the microsurgeon, there is no evidence to
support such measures to improve outcomes. Nevertheless,
minimizing biomechanical forces that may compromise the
flap is feasible. Mechanical compression should be avoided,
specifically avoiding circumferential neck ties. Suction
drains within the reconstructed anatomic site should be
used to avoid accumulation of fluid that can lead to hydro­
static mechanical compression to the vascular pedicle.
Liberal use of external sutures is encouraged to maintain
tracheostomy fixation, drain fixation, and incision closure
reinforcement. Shearing forces from excessive head move­
ment can negatively affect wound healing, and closed mouth
sneezing and coughing can increase intracranial pressure
and risk vascular blowout of the anastomosis. Preventing
such actions is integral to microsurgical free flap care.
Therefore, patients are educated preoperatively regarding
postoperative care, and similar concepts are reiterated to
patients during the post surgical period.
Multiple methods of free flap monitoring exist, although
most are not routinely used in clinical monitoring of
craniofacial free flaps.157 The gold standard of free flap
monitoring is a physical examination by an experienced
microsurgeon. The head and neck region poses a challenge
compared with other regions of the body because some
flaps may be internalized or “buried,” making them more
difficult to monitor. Near infrared spectroscopy158 or an
implantable Dop­pler system159 can provide objective mea­
surements, but these modalities are susceptible to interob­
server variability, movement of the probes, false reassurance,
and increased cost. Therefore, conventional bedside moni­
toring methods including clinical assessment of skin color,
turgor, temperature, capillary refill, hemorrhage quality fol­
lowing flap puncture, and external handheld Doppler
examination should be the standard of care.
The role of anticoagulants, antiplatelet therapy, and phos­
phodiesterase inhibitors has not systemically shown to
improve free flap outcomes.160 Deep venous thrombosis pro­
phylaxis is recommended for routine postoperative manage­
ment. Sequential compression stockings should be avoided
in a free fibula donor site.
Following dentoalveolar and dentomandibular recon­
struction, concepts such as deglutition, feeding, dental
rehabilitation, and physical therapy are integral to the
recovery process. Nasogastric (NG) tube decompression
should be initiated during surgery, but removal of the NG
can tolerate absence of the fibula, donor site morbidity may
occur. Lower extremity sequelae following FFF harvest
include decreased ankle mobility, ankle instability, leg weak­
ness, and great toe contracture.155
POSTOPERATIVE CONSIDERATIONS
An intimate understanding of potential complications helps
the surgeon establishing consistent methods of routine post­
operative care, which helps limit both minor and major
complications. The head and neck surgeon must carefully
Figure 14.12  Deep circumflex iliac artery (DCIA) anatomy depicting
the bifurcation of the DCIA and deep circumflex iliac vein (DCIV), and
relationship to the lateral femoral cutaneous nerve.47
Transversus abdominis
Rectus
abdominis
Internal oblique
Ascending branches of
deep circumflex iliac
artery and vein
Deep circumflex iliac
artery and vein
Inferior epigastric
artery and vein
External iliac vein
External iliac artery
Iliacus
Lateral femoral
cutaneous nerve
Iliac bone
Right common
iliac artery

154
PART 3 — RECONSTRUCTION
complications unique to the head and neck region can pres­
ent early and are devastating, whereas other complications
are insidious and require long-term management. As men­
tioned earlier, the ability to protect and maintain a secure
airway is of paramount importance in the management of
maxillofacial reconstruction. Following inset of the free
flap, fluid shifts and responses to brief ischemia time will
result in edema, which can occlude the endotracheal tube
or allow it to migrate. Tracheostomies are utilized to obvi­
ate this concern. Immediately following reconstruction, the
focus of flap viability is dependent on vascular pedicle
patency. The aforementioned conventional and novel
methods of flap monitoring aid the microsurgeon in early
recognition of venous thrombosis or arterial insufficiency.
Susceptible sites of major vascular complications included
anastomotic sites and any graft conduits used to gain length
for anastomosis. Carotid artery blowout, although rare, is a
major vascular complication that requires prompt interven­
tion. Predisposing factors include prior radiation therapy,
extensive surgery, wound breakdown, local infection, and
tumor recurrence.162 Because the aforementioned compli­
cations occur less frequently, the surgeon must maintain a
low threshold to detect airway and vascular complications
in order to intervene as early as possible.
Once the immediate hospitalization has passed, rou­
tine follow-up provides the microsurgeon with a critical
tube can be completed within 24 h. At this point, if oral
secretions are being swallowed, then a liquid diet may be
initiated within 48 h of surgery. In the presence of sialor­
rhea, the surgeon should cautiously consider any advances
in diet. A small portion of patients with oromandibular and
oromaxillary defects will need a gastrostomy tube for early
decompression and long-term nutritional supplementa­
tion. The decision to proceed with gastrostomy place­
ment pre­operatively is based on assessment of patients’
nutritional status, extent of defect, functional compromise,
and potential planning for early surgical revisions. Physical
rehabilitation of the facial structures begins 7–10 days fol­
lowing surgery. Range of motion and stressing the elements
of reconstruction are important for functional restoration
of muscles, bones, and joints. Finally, dental rehabilitation
is typically addressed during secondary revisions. Because
the FFF may provide inadequate bone height for dental
implants, low-profile miniplates can improve long-term
implant integration.161
COMPLICATIONS
The overall success rates of free tissue transfer to the head
and neck has progressively improved throughout the last
20 years, reaching success rates of up to 97%.33 However,
Figure 14.13  (A–D) Deep circumflex iliac artery flap inset for a critically sized mandibular defect. (Adapted from Rodriguez ED, Martin M,
Bluebond-Langner R, et al. Microsurgical reconstruction of posttraumatic high-energy maxillary defects: establishing the effectiveness of early recon­
struction. Plast Reconstr Surg 2007;120(7 Suppl 2):103S–17S. Wolters Kluwer Health, 2007.)47
A
B
D
C

CHAPTER 14 — Head a nd Nec k Reconstruction
155
prophylactic antibiosis longer than 48 h does not improve
outcomes.163–165 Infections, fluid collections, or fistulas
require urgent attention, debridement, and drainage in the
early stages of infection to salvage the free flap. However, if
hardware is seeded, infections and fistulas may fester and
manifest months and years down the road if not earlier. As
in scalp reconstruction, prosthetic material may need to be
changed after a final washout and closure procedure. Edu­
cating patients on flap hygiene during each inpatient and
outpatient visit is strongly encouraged.
Unique to the neck and craniofacial region is a high
concentration of vital structures. Free flap failure or partial
necrosis of flaps remains a devastating consequence in the
head and neck region because of the potential for exposed
vital structures such as brain, dura, bone, carotid or jugular
vessels, sinuses, or the eyes. Exposed structures require
immediate attention and are likely to require intervention
within 7 days. Local flap rearrangement or skin grafting may
achieve sufficient soft tissue coverage, but if total flap failure
is the etiology of exposed vital structures, then a new free
flap is necessary.
Figure 14.14  (A,B) Computed tomography images of a patient with a right mandibular defect. (C,D) Computed tomography images following
mandibular reconstruction using the DCIA composite tissue free flap. The natural iliac contour resembles that of the native jaw. (Reprinted from
Rodriguez ED, Bluebond-Langner R, Brazio P, et al. Near-total mandible reconstruction with a single DCIA flap containing fibrous dysplasia in McCune
Albright Syndrome. J Craniofac Surg 2007;18:1479–82. Wolters Kluwer Health, 2007.)143
A
B
C
D
assessment of craniofacial components, which may reveal
complications that develop over time. These include soft
tissue changes that can affect periorbital, maxillary,
and midface reconstruction. The weeks following perior­
bital reconstruction may reveal secondary challenges such
as ectropion, which can lead to xerophthalmia and corneal
erosion, and may comprise vision. The soft tissue weight of
a bulky flap may unintentionally expose the sclera, despite
carefully selected medial and lateral canthal tendon attach­
ment and appropriate cheek projection. Moreover, patients
who are expected to undergo radiation therapy are at an
even higher risk for soft tissue atrophy, scarring, and devel­
opment of ectropion.154 Ectropion should be addressed
during soft tissue rearrangement during revision surgery,
especially if the initial reconstruction utilized a bulky flap.
In cases that involve the oral cavity, native salivary secretions
and the bacterial burden increase the likelihood of develop­
ing infection and fistula formation. Such complications
affect 26–48% of cases and are likely to arise within days or
weeks following surgery. Perioperative antibiotics are rou­
tinely administered, but there is evidence that shows

156
PART 3 — RECONSTRUCTION
Figure 14.15  (A) Immediately following reconstruction of soft tissue only. (B,C) At 3 months after the initial injury demonstrating total
midface collapse due to inadequate skeletal support. (D) Three-dimensional computed tomographic scan of the maxillary defect. (E,F) Post­
operative photograph and 3-D computed tomographic scan at 12 months following the DCIA-based iliac bone flap with an internal oblique
muscle flap. (Adapted from Borsuk DE, Christensen J, Dorafshar AH, et al. Aesthetic microvascular periorbital subunit reconstruction: beyond primary
repair. Plast Reconstr Surg 2013;131:337–47. Wolters Kluwer Health, 2013.)120 (From Rodriguez E, Martin M, Bluebond-Langner R, et al. Microsurgi­
cal reconstruction of posttraumatic high-energy maxillary defects: establishing the effectiveness of early reconstruction. Plast Reconstr Surg
2007;120(7 Suppl. 2):103S–117S.)47
A
B
C
D
E
F
OUTCOMES
Advances in microsurgical technique, 3-dimensional model­
ing, hardware, anesthesia, critical care, and oncologic treat­
ment, continue to elevate the success of craniofacial
microsurgery. Depending on the specific series, successful
outcomes range between 93% and 97%.33,166,167 Increased
technical success is encouraging, but the results must be
scrutinized with validated and detail-oriented assessments
specific to cosmesis, function, and quality of life outcomes.
By emphasizing that the goal is not to just simply “fill in”
the defect but to reestablish optimal function and cosmesis,
reconstructive surgeons are able to offer patients a better
quality of life with craniofacial microsurgical techniques.

CHAPTER 14 — Head a nd Nec k Reconstruction
157
Figure 14.16  Various reconstructed defects based on the Rodriguez Maxillary Defect Classification System.47 (A) Class I defect reconstruction
with either a fibula or iliac crest flap. (B) Class II defect reconstruction with a fibula flap. (C) Class III defect reconstruction with either a fibula
or iliac flap.
A
B
C

158
PART 3 — RECONSTRUCTION
Figure 14.17  (A) Preoperative image following chin augmentation with an iliac crest bone graft. (B) Computed tomography scan demonstrating
non-vascularized iliac crest bone graft affixed to the mandibular reconstruction plate. (C) Postoperative image 6 months following total man­
dibular reconstruction using a free fibula flap with (D) a corresponding computed tomographic image. (From Borsuk D, Christensen J, Dorafshar
A, et al. Aesthetic microvascular periorbital subunit reconstruction: beyond primary repair. Past Reconstr Surg 2013;131:337–47.)120
A
B
C
D
A 27-year-old woman undergoes Mohs’ excision for a micro-
cystic adnexal carcinoma, resulting in partial absence of the
frontalis muscle, paramedian, and central forehead subunits.
An ulnar forearm flap was used to reconstruct the soft tissue
defect followed by two revision procedures, including flap
lipectomy and local tissue rearrangement (Fig. 14.1).
CASE 14.1  Forehead Reconstruction
Using the Ulnar Free Flap
A 45-year-old woman required multiple conventional recon-
structive procedures to the right periorbital region following
a motor vehicle collision. She underwent an ulnar forearm
free flap with a 4 × 3 cm skin island to reconstruct a periorbital
soft tissue defect. Revision surgery included flap debulking
and soft tissue rearrangement (Fig. 14.6).
CASE 14.2  Periorbital Reconstruction
Using the Ulnar Free Flap

CHAPTER 14 — Head a nd Nec k Reconstruction
159
Figure 14.18  (A) Perioperative image of the right orbital defect. (B) Reconstruction of the superior and inferior orbital rim was performed with
a fibula osteocutaneous flap. (C) A postoperative view of the reconstruction with three osseointegrated anchors for the prosthesis. (D) The final
result shows successful incorporation of the orbital prosthesis.
A
B
C
D
A 32-year-old patient had undergone a left temporal lobec-
tomy 14 years prior with subsequent exposure and infection
of the methylmethacrylate prosthesis requiring removal of the
prosthesis. Titanium prosthetic material and an ALT free flap
were used to restore skull contour (Figs 14.7, 14.8).
CASE 14.3  Scalp Reconstruction Using
the ALT Free Flap
A 48-year-old man diagnosed with adenocystic carcinoma of
the left orbit underwent radical resection of the lesion with
orbital exenteration. The patient opted to forgo the use of an
orbital prosthesis. Reconstruction involved an ALT myocuta-
neous flap for dead space obliteration with a 5 × 18 cm skin
paddle for superficial skin closure. He then underwent radia-
tion therapy and two revision operations including flap deb-
ulking and advancement of the surrounding soft tissue
(Fig. 14.9).
CASE 14.4  Orbital Reconstruction Using
the ALT Free Flap
A 29-year-old man underwent multiple reconstruction pro­
cedures for a right facial deformity resulting from a child-
hood malignancy followed by radiation therapy. A right
periorbital and cheek reconstruction was performed using a
free groin flap. At the 6-month follow-up, excess soft tissue was
debulked and 7 months thereafter, an additional suction-
assisted lipectomy of the right periorbital region was com-
pleted (Fig. 14.10).
CASE 14.5  Periorbital and Cheek
Reconstruction Using the
SCIA-Based Free Groin Flap
A 40-year-old woman with a history of multiple facial infections
was referred for facial resurfacing after a previously failed free
flap with concomitant ectropion release, performed by a refer-
ring surgeon. The patient suffered from persistent and severe
scar contracture resulting in recurrent ectropion. Despite
multiple prior procedures, her deformity persisted. She then
underwent two SCIA-based free groin flaps, with a 1 month
time interval between reconstruction of the left and the right
cheek. At 3 months after each respective free flap reconstruc-
tion, each flap underwent a standard debulking proce-
dure. At 8 months following the initial groin flap, the patient
underwent bilateral temporal midface and brow suspension
to treat midface ptosis from excess weight of the groin flaps
(Fig. 14.11).
CASE 14.6  Bilateral Cheek
Reconstruction Using Bilateral
SCIA-Based Free Groin Flaps

160
PART 3 — RECONSTRUCTION
A 40-year-old woman sustained a self-inflicted gunshot wound
to the submental midline. The patient had bilateral naso-
orbito-ethmoid, maxillary, and mandibular fractures. Initial
reconstruction included stabilization of the skeletal injuries
and palatal obturation. A vascularized DCIA-based iliac crest
with internal oblique muscle flap was used to reconstruct the
maxilla and eliminate an oronasal fistula. She subsequently
underwent nasal reconstruction with a calvarial bone graft and
a paramedian forehead flap (Fig. 14.15).
CASE 14.7  Maxillary Reconstruction
Using the DCIA-Based Iliac
Crest and Internal Oblique
Flap
An 18-year-old patient with McCune–Albright syndrome
underwent resection of a mandibular osteosarcoma requiring
resection from the left angle to the right parasymphysis and
was reconstructed with a titanium plate and cadaveric cortical
humerus grafts. Two and a half years later, the patient devel-
oped a recurrence requiring resection of the right angle of
the mandible. A mandibular plate spanning from the right to
left angle was fixed to any remaining mandibular bone. She
had undergone a non-vascularized iliac bone transfer to the
chin, by another surgeon, without improvement in cosmesis
or function. Total mandibular reconstruction required the
use of a right-sided 21 cm free fibula bone flap with a 21 × 2 cm
skin paddle, while preserving the prior iliac bone graft
(Fig. 14.17).
CASE 14.8  Mandible Reconstruction
Using the Free Fibula Flap
A 23-year-old man sustained a gunshot wound to the right eye.
Orbital skeletal buttresses were reconstructed using a 10 cm
fibula bone flap and a 15 × 3 cm skin paddle. Secondary revi-
sions included flap debulking and cheek advancement to
match skin color and to create a cul-de-sac for an orbital
prosthesis. The patient required three osseointegrated
anchors to stabilize an implant-supported orbital prosthesis
(Fig. 14.18).
CASE 14.9  Orbital Reconstruction Using
the Free Fibula Flap
Expert Commentary 
Paul N. Manson, MD
The principles of soft tissue and bone reconstruction evolved
out of facial injury and facial tumor treatment, and have been
greatly improved by reliable microvascular tissue transfer, CT
imaging, improved bone fixation, and a knowledge of the
proper timing and treatment of soft tissue defects. Early
reconstructions were initiated for victims of the two World
Wars, and provided the basis for modern techniques. In the
1980s and 1990s, high energy facial and avulsive injuries
received new treatment protocol with immediate bone fixa-
tion in stable position, and early soft tissue and bone replace-
ment, allowing the soft tissue to recover from the injury and
reconstruction as a single event, with a uniquely superior
quality of appearance and function.
Similarly, the 1980s and 1990s saw the advent of revolu-
tionary principles of facial defect analysis and soft tissue
management and reconstruction, applied first to the face,
then to the nose, then to the lips, forehead, and cheeks.
These techniques greatly improved the aesthetic and func-
tional results obtained with facial defect reconstructions.
In the last 25 years, all of the principles have been com-
bined into a composite set of strategies for head and face
soft tissue replacement. Many of these have been the result
of applying and combining the principles of high energy
defect reconstruction, aesthetic concepts of nose, lip, and
face reconstruction to the science of free tissue transfer to
the head and neck, and no one has brought these principles
into focus more than Eduardo Rodriguez and his
colleagues.
Those principles are stated in the current chapter, and
represent the addition of microvascular technology to the
described synthesis of the ideas for facial injury and facial
tumor management occurring in the last half of the 20th
century.
When composite bone and soft tissue injuries and/or
defects exist, anatomic repair or replacement of both the
bone buttress system and properly contoured soft tissue
overlaid with the proper facial skin provides the best appear-
ance and function. Timing of repair and technique of replace-
ment are critical to achieving good results, for the occurrence
of scarring and contractures from multiple surgeries or inad-
equate structure mars the appearance and the function of
soft tissue – without supple, properly anchored, and con-
toured soft tissue, appearance is lost.
The contour of the face must depend on the proper recon-
struction of its underlying system of bone buttresses of the
face, as described in the original descriptions for facial injury
treatment. Stability and shape of the buttresses is achieved
with rigid fixation, and the vascularized bone provides a
stable framework on which to shape, drape, and contour soft
tissue. The soft tissue must be anchored to the skeleton like
the original tissue. The choice of the soft tissue and bone
provided must create a mirror image of what is missing, in
order to most accurately re-create the original architecture.
One must also take into consideration the aesthetic units of
the face, in order to take advantage of more natural junction
areas for blending and disguising the reconstruction, allow-
ing it to integrate and interface more naturally with adjacent
anatomic areas of the face.
Finally, when certain structures such as the lips, eyelids,
or the complete face are badly scarred or completely missing,
only the possibility of partial or full facial transplantation
offers hope for the irreversibly disfigured.

CHAPTER 14 — Head a nd Nec k Reconstruction
161
KEY REFERENCES
7. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft.
A clinical extension of microvascular techniques. Plast Reconstr
Surg 1975;55:533–44.
12. Koshima I, Soeda S, Yamasaki M, et al. The free or pedicled
anteromedial thigh flap. Ann Plast Surg 1988;21:480–5.
31. Rodriguez ED, Bluebond-Langner R, Park JE, et al. Preservation
of contour in periorbital and midfacial craniofacial microsurgery:
reconstruction of the soft-tissue elements and skeletal buttresses.
Plast Reconstr Surg 2008;121:1738–49.
39. Hidalgo DA, Rekow A. A review of 60 consecutive fibula free
flap mandible reconstructions. Plast Reconstr Surg 1995;96:
585–602.
52. Manson PN, Clark N, Robertson B, et al. Subunit principles in
midface fractures: the importance of sagittal buttresses, soft-tissue
reductions, and sequencing treatment of segmental fractures.
Plast Reconstr Surg 1999;103:1287–306, quiz 307.
53. Gruss JS, Antonyshyn O, Phillips JH. Early definitive bone and
soft-tissue reconstruction of major gunshot wounds of the face.
Plast Reconstr Surg 1991;87:436–50.
76. Ozkan O, Coşkunfirat OK, Ozkan O. Midface reconstruction.
Semin Plast Surg 2010;24:181–7.
77. Rihani J, Lee MR, Lee T, et al. Flap selection and functional out­
comes in total glossectomy with laryngeal preservation. Otolaryn­
gol Head Neck Surg 2013;149:547–53.
131. Muresan C, Dorafshar AH, Rodriguez ED. A reappraisal of the
free groin flap in aesthetic craniofacial reconstruction. Ann Plast
Surg 2012;68:175–9.
132. Rodriguez ED, Bluebond-Langner R, Martin M, et al. Deep cir­
cumflex iliac artery free flap in mandible reconstruction. Atlas
Oral Maxillofac Surg Clin North Am 2006;14:151–9.
Expert Commentary
Richard E. Hayden, MD
Reconstruction of large complex defects around the head
and neck is more challenging than that of any other region.
This region is unique because of its critical functions (alimen-
tation, speech, and respiration), the location of special
senses (sight, hearing, smell, and taste) and its role as each
human’s identifiable interface with society.
Patients with three common defects (absences of the ante-
rior mandibular arch, the total tongue, and laryngopharyngo-
esophageal complex) had no viable reconstructive options in
the 1970s. These unfortunate patients were left with devastat-
ing debility and disfigurement. Today, patients with any of
these defects can expect near normal appearance and
socially acceptable function. This dramatic change can be
largely attributed to the advent of free tissue transfer.
The 1970s saw strong resistance to the new free flap
techniques. The 1980s were characterized by widespread
surgical enthusiasm for the many new flaps, often accompa-
nied by contentment with simple flap survival. Thankfully, the
1990s saw a winnowing of the number of truly useful flaps
and a more critical surgical oversight of optimal aesthetic and
functional outcomes. The millennium has witnessed an
expected high standard of outcomes with near consensus
on the current “workhorse” flaps. With a personal experience
of more than 3000 free flaps used for head and neck recon-
struction, my flap choices are similar to most surgeons, with
fibula followed by scapula and DCIA flaps for oromandibular/
maxillary reconstruction and ALT or radial/ulnar forearm flaps
for most soft tissue defects.
Disturbingly, the millennium has also seen an abuse of
the use of free flaps by some surgeons for reconstruction
of small defects, which would have had superior outcomes
with primary closure or healing by secondary intention. In
contrast, an objective review of the “reconstructive ladder”
over the past decade has produced, in some centers, a de-
escalation of the complexity of the chosen reconstructive
flap. Historically, underutilized, simple, quick, reliable pedi-
cled flaps such as the submental, FAMM, and supraclavicular
flaps, often provide not only equal but, in fact, superior
reconstructions in selected cases.
For example, we have employed over 300 submental
flaps in our head and neck practice, replacing the use of
radial/ulnar or ALT free flaps for assorted defects with
demonstrably equal or superior outcomes, both functional
and aesthetic.
I believe that the future will belong to regenerative medi-
cine and surgery. In the near term, missing tissues will be
fabricated from patients’ own stem cells with the aid of bio-
reactors and 3D tissue printers. For now, the modern head
and neck reconstructive surgeon with a complete “toolbox”
of surgical techniques adhering to the sound principles out-
lined in the chapter will provide optimal functional and aes-
thetic outcomes for these patients in need.

CHAPTER 14 — Head a nd Nec k Reconstruction 161.e1
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162
Facial Reanimation:
Evolution and Refinements
Julia K. Terzis  |  Dimitrios Karypidis
15 
INTRODUCTION AND HISTORIC REVIEW
Facial paralysis (FP) is a devastating condition which strips
the human face from all emotional expressivity, leading to
severe consequences in the quality of life, interpersonal
communication, and psychological development of the
afflicted patient (Fig. 15.1). The most important advances
in the treatment of FP during the last century included the
introduction of restorative microsurgery with atraumatic
manipulation of injured nerves, cross-facial nerve grafting,
which allowed coordinated animation, and free muscle
transfers for denervated target substitution.
NERVE TRANSFERS
The first accessory to facial nerve anastomosis in FP was
performed by Drobnick in 1897,1 and popularized by
others.2,3 In all these cases, the entire accessory nerve was
used and the function of the sternocleidomastoid and tra­
pezius muscles was always impaired. In contrast, Terzis4 has
always used part of the accessory nerve to the sternocleido­
mastoid and the trapezius (40% through a perineurial
window), avoiding the functional downgrading of these
muscles.
The first hypoglossal-facial transfer was performed in
1901 by Korte.5 In 1927, Bunnel6 first described end-to-end
repair of the facial nerve.
Thompson7 in 1971, first attempted muscle to muscle
neurotization of muscle autografts. Lexer and Eden8 first
used the temporalis muscle for eye sphincter reanimation
and Sir Gillies9,10 used the temporalis muscle to reanimate
the oral sphincter in 1934. Conley11 made important contri­
butions in extratemporal facial nerve repair, immediate
reconstruction and nerve grafting techniques in 1961 and
popularized the hypoglossal nerve transfer. Three years
later, Kurze12 a neurosurgeon, and Smith13 a plastic surgeon,
reported independently the use of the operating micro­
scope in nerve surgery. Edgerton14 first transferred the ante­
rior belly of digastric muscle to dynamically correct lower
lip depression.
Fisch15 established the repair of the intratemporal portion
of the facial nerve. In the early 1970s, working indepen­
dently, Scaramella16 and Smith,17 reported the technique of
cross-facial nerve grafting (CFNG) for restoration of a coor­
dinated smile, an ingenious concept, later popularized by
Anderl.18 Tamai19 transferred the first muscle in the experi­
mental animal in 1970 and Terzis20 in the rabbit model
showed that transferred free muscle not only survives trans­
plantation, but it can produce useful work.
These achievements inspired Harii et al.21 in 1976 to
transfer the first free gracilis muscle to the face; how­
ever the motor donor used was the deep temporal nerve.
Three years later Terzis,22 introduced the pectoralis minor
muscle for both eye and lower face reanimation. In 1980,
O’Brien and colleagues23 proposed the use of CFNG as
motor donor for their transferred extensor digitorum
brevis muscle, however, this muscle lacked bulk for ade­
quate smile restoration.
It was soon realized that CFNGs yielded desirable
results only if preformed within 6 months from the onset
of paralysis. For later cases, up to 2 years, this challenge
was successfully addressed in 1984 by Terzis,24,25 who intro­
duced the “babysitter” procedure, in which a portion
(40%) of a powerful ipsilateral motor donor is used, most
often the ipsilateral hypoglossal nerve, in an end-to-side
Figure 15.1  A 25-year-old patient with complete left facial paralysis
following the resection of an acoustic neuroma 8 years ago and a
second resection of a recurrence 6 years ago. Note the profound
facial asymmetry between the normal and the affected side of the
face. Being a wind instrument musician, facial paralysis has also been
detrimental to his professional life.
PART 3  —  RECONSTRUCTION

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
163
3. The infranuclear part consisting of the rest of the intra-
pontine efferent part of the nerve and the cerebellopon­
tine angle.
Intracranial causes could be various brain tumors32
such as hemangioblastomas, craniopharyngiomas, choroid
plexus papillomas, and vascular abnormalities and tumors.
Intracranial may also be the origin of developmental anom­
alies, dysplasia or even total agenesis of the facial nerve
nuclei. Other causes may include trauma and degenerative
disease of the central nervous system.
INTRATEMPORAL
The intratemporal portion is where the facial and the inter­
medius nerves exit from the posterior pons acquiring a
ventral direction and then enter the temporal bone along
with the vestibulocochlear nerve. Their course is at the sub­
arachnoid level and continues in the internal auditory canal
along with the inferior anterior cerebellar artery and vein.
In the internal auditory canal, the facial and the intermedi­
ate nerves enter the fallopian canal separating from the
vestibulocochlear nerve. The first 4 mm in the fallopian
canal comprise the labyrinthine segment, which is perpen­
dicular to the temporal bone; the next 1 cm is the tympanic
segment, which extends horizontally at the medial wall of
the tympanic cavity; and the mastoidal segment, which runs
vertically for approximately 1.5 cm.
The intratemporal causes of FP include tumors32,33
such as acoustic neuromas (also known as vestibular
schwannomas), which account for approximately 80% of
cerebellopontine angle tumors. Meningiomas comprise
the remaining 20%. Rare cases of cholesteatoma, glomus
tumors, vascular tumors, lipomas, and metastatic lesions
have also been observed (<0.1%). Developmental abnor­
malities, trauma with or without fracture of the temporal
bone and skull base may also be included in the intratem­
poral causes of FP. Rare intratemporal causes of FP could
be various viral or bacterial infections and iatrogenic
mishaps. Systemic and autoimmune diseases such as sar­
coidosis, periarteritis nodosa, temporal arteritis and osteo­
porosis may also cause FP by impairing the blood supply
and/or the normal course of the facial nerve (e.g., by
being responsible for stenoses in the intratemporal canals
or foramina).31
EXTRATEMPORAL
The extratemporal portion begins at the exit of the facial
nerve through the stylomastoid foramen and includes all
facial nerve branches that innervate the facial musculature.
Trauma, malignant tumors of the parotid gland, skin and
soft tissue tumors are included in the extratemporal causes
of FP. Primary facial nerve tumors (cylindromas), intrapa­
rotid facial nerve schwannomas (0.8%) and neurofibroma­
tosis also comprise possible FP causes. Systemic and
autoimmune diseases are also present here and may cause
FP in severe cases. Bell’s palsy, also known as idiopathic
unilateral facial nerve paralysis, is the most common extra­
temporal cause of FP (>80%), as it has been associated with
inflammation and pressure on the facial nerve at or after its
exit through the stylomastoid foramen.34 The aforemen­
tioned systemic (diabetes mellitus) and autoimmune (sar­
coidosis) diseases, as well as certain viral infections (HSV1,
manner, to reinnervate the recently denervated but elec­
trophysiologically present facial muscles, in order to pre­
serve the facial musculature, while CFNGs regenerate
across the face. At a second stage, 9–12 months later, sec­
ondary microcoaptations take place between the CFNGs
and selected branches of the affected facial nerve. In con­
trast, the classical hypoglossal to facial nerve transfer, pop­
ularized by Conley and Baker26 in 1979, had considerable
undesirable sequelae, including severe synkinesis, tongue
hemiatrophy, speech, mastication, and swallowing prob­
lems. Therefore, the concept of finding powerful motor
donors for nerve transfer prevailed in recent years, espe­
cially in cases of bilateral FP, in which the contralateral
facial nerve was also involved.
In 1989, Zuker and Manktelow27 proposed the use of
the masseteric nerve as motor donor for free gracilis rein­
nervation. Terzis28 refined the use of the masseteric nerve
as a motor donor by always performing an end-to-side
coaptation to avoid downgrading the muscles of mastica­
tion. The biggest disadvantage with the use of the masse­
teric nerve is the difficulty in obtaining coordinated
animation. In rare cases when all three nerves (hypoglos­
sal, accessory, masseteric) are involved, Terzis29 has used
components of the ipsilateral C7 as motor donors for
facial dynamic restoration. This is a challenging procedure
which involves the selective use of the anterior and poste­
rior division fibers to the affected side. In cases of bilateral
FP, similar division fibers innervate the same specific
targets on each side.
Recently, the use of the masseteric nerve has gained again
attention. In 2012 Biglioli et al.30 in a preliminary study,
reported the restoration of emotional, coordinated smile in
patients with long standing paralysis in a single stage using
the gracilis muscle innervated by both the ipsilateral mas­
seteric nerve and the contralateral facial nerve through
a CFNG.
ETIOLOGY OF FACIAL PARALYSIS
A clinically oriented presentation of the etiology of FP
includes the classification of the etiologic factors according
to the location of the facial nerve damage.
ETIOLOGY AND LESION LOCATION
The causes of the facial nerve lesion could be located at any
part of three anatomically distinct portions of its pathway:
the intracranial, intratemporal, and extratemporal parts
(Table 15.1; see Figs 10.10, 10.11).31
INTRACRANIAL
The intracranial portion is subdivided into the:
1. The supranuclear part which includes corticobulbar fibers
from the precentral gyrus of the frontal lobe projecting
to the facial nucleus
2. The nuclear part comprised by the upper part, which
receives corticobulbar fibers bilaterally and innervate pri­
marily upper face muscle targets and by the lower part,
consisting of crossed fibers which innervate lower face
muscle targets

164
PART 3 — RECONSTRUCTION
Table 15.1  Facial palsy etiology depending on the location of the lesion and the mechanism of injury
Tumor
Trauma
Developmental
Systemic
Infectious
Iatrogenic
Idiopathic
Toxic
Intra-cranial
Meningioma
Acoustic
neuroma
Metastatic
Millard–Gublera
Cranial base injury
Aplasia/
hypoplasia/
agenesis of
facial nerve
nuclei
Moebius
syndrome
Multiple sclerosise
TTPf
HIV
Encephalitis
Meningitis
Syphilism
Lyme
encephalopathy
Gnathostomiasism
Embolization
Intra-
temporal
Primary facial
neuroma
Cholesteatoma
Metastatic
Temporal bone
injury
Forceps delivery
Neurofibromatosis
HFMb
ACFc
CHARGEd
Moebius
syndrome
Acute porphyriag
Sarcoidosish
Temporal arteritisi
Periarteritis nodosai
TTP
HHNj
External otitis
Otitis media
Mastoiditis
CMVn
Epstein–Barrn
Rubellan
Mumpsn
Tuberculosis
Lymeo
Mastoid surgery
Post-immunizationp
Bell’s
CMTq
DSr
Thalidomides
Arsenict
Alcoholu
Diphtheriav
Extra-
temporal
Parotid gland
lesions
Primary facial
neuroma
Sarcoma
Metastatic
Head and neck
injury
Forceps delivery
Facial injuries
Neurofibromatosis
HFM
ACF
CHARGE
Moebius
syndrome
Sarcoidosis
Temporal arteritis
Periarteritis nodosa
TTP
HHN
Dystrophia myotonica
Myasthenia gravisk
Diabetes mellitusl
Hyper- and
hypothyroidism
Acute porphyria
Hypertension
Vitamin A deficiency
CMV
Epstein–Barr
Rubella
Mumps
Cat scratch
Tuberculosis
Lyme
Post-tonsillectomy
adenoidectomy
Dental
local anesthesia
Parotid surgery
Mandibular block
anesthesia
Post-immunization
Botulinum toxin
Bell’s
CMT
DS
Alcohol
Diphtheria
aMillard–Gubler syndrome: brainstem lesion due to tumors, bleeding, and, rarely, by infarction secondary to occlusion of the basilar artery.
bHFM (Hemifacial microsomia): associated with mesodermal dysplasia, temporal bone canals atresia, and facial anatomic defects.
cACF (Neonatal asymmetric crying faces): facial nerve compression or faulty muscle and/or nerve development.
dCHARGE: coloboma of the iris or retina, heart defects, atresia of the choanae, retardation of growth, and/or development, genitalia anomalies, ear anomalies.
eBrainstem lesions in the pontine tegmentum.
fTTP (Thrombotic thrombocytopenic purpura): bland thrombi in the microvasculature of the nerve, central nervous system involvement possible.
gPeripheral type of acute motor axonal neuropathy.
hNeurosarcoidosis: cranial nerve mononeuropathy direct nerve compression by parotid gland swelling or by a lesion within the facial canal.
iArteritis: nerve microvascular compromise.
jHHN: hereditary hypertrophic neuropathy.
kAntibodies against nicotinic acetylcholine receptor in the motor end-plate.
lPeripheral diabetic neuropathy.
mSyphilis and gnathostomiasis: central nervous system, meningeal involvement obliterative endarteritis of terminal arterioles with resultant inflammatory and necrotic changes.
nViral infections: antibodies against nerve, inflammation is within the fallopian canal.
oLyme disease: peripheral neuropathy.
pPolyneuritis due to development of antibody to myelin basic protein (vaccine for rabies, anti-tetanus serum).
qCharcot–Marie–Tooth Disease (CMT): genetic defect of myelin sheath.
rDejerine–Sottas Disease (DS): genetic defect of myelin sheath.
sThalidomide: atresia of intratemporal canals (Miehlke syndrome).
tArsenic intoxication: peripheral neuropathy/electrophysiological changes.
uAlcohol: Alcoholic neuropathy: axonal Wallerian degeneration, oxidative stress.
vDiphtheria: Diphtheritic neuropathy is an acute demyelinating polyneuropathy.

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
165
UPPER FACE
FRONTALIS MUSCLE
This muscle is actually the frontal belly (in some patients
two separate bellies) of the occipitofrontalis muscle, which
extends over the forehead area from the anterior aspect of
galea aponeurotica down to the orbicularis oculi muscles
(OOM) where it inserts. By wrinkling the forehead and
raising the eyebrows it participates in the broad spectrum
of facial emotional expressivity. Additionally, at rest, the
frontalis muscle stabilizes the eyebrows and the supraorbital
area by antagonizing the action of the eyebrow depressors
(corrugators, procerus, lateral/vertical segment of the
OOM). This ability is lost in patients with FP.
EYE SPHINCTER
Major aspects of clinical presentation include the inability
to voluntary close the eyelids, the absence of blink, and the
decreased tear production. Impaired eye closure (lagoph­
thalmos) and the lack of the protective role of blinking and
tear production result in dryness of the cornea and conjunc­
tiva and subsequent inflammation. Corneal infections are
due to the lack of the antimicrobial properties of the tears.
Corneal opacity and ulcer formation have also been ob­
served. The loss of tone of the OOM leads to ectropion,
epiphora, and chronic conjunctivitis. In severe cases, where
the nasociliary branch of the ophthalmic division of the
trigeminal nerve is involved, corneal sensibility is decreased
or absent leading to neurotrophic keratopathy and amblyo­
pia. Cornea without sensibility is susceptible to injury while
the reparative and healing mechanism is impaired. There­
fore, substituting the function of the eye sphincter aims at
protecting the eye and preserving vision, as well as restoring
the behavioral role of eye closure and blink (emotional
expressivity).
NORMAL BLINK REFLEX
Stimuli from the upper eyelid, the forehead, and periorbital
area are carried by supraorbital and supratrochlear nerves
to the trigeminal ganglion. Similarly, stimuli from the sclera
and the cornea are carried to the trigeminal ganglion via
the short and long ciliary nerves. From the trigeminal gan­
glion, two internucleus neuronal pathways begin. The first
carries signals via the trigeminal motor nucleus to the facial
nucleus and is responsible for the initiation of the ipsilateral
blink due to OOM contraction. This is an oligosynaptic
pathway and initiates the early, ipsilateral R1 response at
about 10 ms. The second pathway carries signals via the
spinal trigeminal tract to the contralateral facial nucleus,
which initiates the contralateral blink. This is a polysynaptic
pathway, responsible for the bilateral delayed R2 response
at about 30 ms. There is also an internucleus pathway
between the facial and oculomotor nuclei, which mediates
the initial relaxation of the levator palpebrae superioris
muscle via the oculomotor nerve, before the initiation of
OOM contraction.43
MIDDLE FACE
LEVATOR MUSCLES OF THE UPPER LIP AND
ORBICULARIS ORIS (OOrM)
This group of muscles are primarily responsible for the
elevation of the upper lip (levator labii superioris,
VZV)35,34 have been identified as possible reasons for the
acute onset of Bell’s palsy and for the syndromic form of the
palsy (Ramsay–Hunt syndrome),36 which presents also with
vestibulocochlear dysfunction and herpetiform eruptions.
In more than 85% of cases, Bell’s palsy resolves, leaving a
small degree of functional impairment (in 10% of the
cases).
Overall, developmental abnormalities37,38 during the
fetal period comprise the second most common cause
(after Bell’s palsy) followed by trauma38 and tumor. Apart
from the isolated form of developmental FP, the broad cat­
egory of developmental causes also include several syn­
dromic presentations such as Moebius and Goldenhar
syndromes.37,38
MECHANISM OF INJURY AND IMPAIRMENT
Regardless of location, tumors may impair the function of
the facial nerve by compressing or distorting its course as
space occupying lesions or by infiltrating it and disrupting
its anatomic and/or electrophysiologic continuity.31,39,40
Additionally, especially when the facial nerve is infiltrated
by the tumor and oncologic resection requires additional
nerve length sacrifice in order to achieve tumor free margin
excision, the postoperative defect may be considerably
larger altering the prognosis and treatment strategy for
facial nerve reconstruction.32
Trauma may include direct facial nerve disruption by the
induced mechanical forces or by fragments of bone result­
ing from local fractures which may cut, or entrap the facial
nerve in their new position. Additionally, trauma may cause
extended vascular damage leading to the formation of large
hematomas, aneurysmal dilatation and peripheral ischemia,
which could be detrimental to the anatomic and functional
integrity of the facial nerve. Intoxication caused by chemical
factors primarily affect cellular metabolism at the molecu­
lar level and affect the physiology of nerve conduction.
Idiopathic causes include conditions of multifactorial or
inconclusive origin, genetic predisposition or of unknown
etiology.41 Iatrogenic mishaps are caused by medication or
the interventions of a physician surgical or non-surgical
(Table 15.1).
CLINICAL PRESENTATION
The functional problems that emerge in the paralytic
face greatly affect facial emotional expressivity, inter­
personal interaction, verbal and non-verbal communica­
tion, and psychological development of the patient.40
Emotions can only be expressed by coordinated move­
ments from all constituent parts of the face. A unilateral
insult to the facial nerve disrupts this functional and aes­
thetic symmetry.
This loss of facial symmetry at rest and during voluntary
motion could further impair the socialization of the patient
by increasing distress and fear of embarrassment. The sever­
ity of FP, therefore, depends on its extent (e.g., partial or
complete, uni- or bilateral). Consequently, it has been
shown that the clinical and behavioral importance of the
eye sphincter, levator anguli oris, oral sphincter, and depres­
sor complex function determines the severity and prognosis
of FP.42

166
PART 3 — RECONSTRUCTION
high-pitched or loud noises, loss of taste over the front of
the tongue, and decrease in salivary secretion.
Salivary secretion may also be affected in lesions of the
lesser petrosal nerve, a branch from the geniculate ganglion
which innervates the parotid gland. Lesions of the greater
petrosal nerve, the first branch from the geniculate gan­
glion which innervates the lacrimal gland, result in decreased
tear production which, in combination with the inability for
eye closure and blink, may lead to neurotrophic keratopathy
and ultimately loss of vision.
PATIENT EXAMINATION
PHYSICAL EXAMINATION
The diagnostic approach of patients with FP includes the
detailed investigation of medical, surgical, and obstetric
history; of the onset and the etiology of the paralysis (e.g.,
injury, tumor, developmental); as well as the meticulous
documentation and analysis of the clinical presentation.
Full neurologic assessment of all cranial nerves and any
previous treatments should be included. The goal of the
meticulous initial assessment is to pinpoint the prognosis
and to provide an individualized treatment plan for the
patient. Specific imaging and electrophysiological studies
precede the examination with the specialist.
IMAGING STUDIES
In the early 1980s, bilateral temporal bones tomograms
were used for all developmental and traumatic (intratempo­
ral) cases.37 This technique was also used if there was suspi­
cion of facial nerve neuroma, which remains a diagnostic
challenge. The systematic use of bilateral computed tomog­
raphy (CT) scans of the temporal bones started in the mid-
1990s, along with the occasional use of magnetic resonance
imaging (MRI) in cases of possible central nervous system
tumors.
Polytomograms and CT scans of bilateral temporal bones
could greatly aid the investigation of facial nerve lesions,
primarily due to abnormalities of the adjacent osseous
structures including middle and inner ear developmental
craniofacial malformations, internal auditory canal stenosis,
cranial deformities, and syndromic anomalies such as in
hemifacial microsomia, CHARGE, Treacher–Collins, and
Goldenhar syndrome.38
Imaging studies have greatly contributed to the identifi­
cation and differential diagnosis of developmental facial
paralysis. Some of the signs may include dysmorphic,
smaller temporal bone, constricted fallopian canal, absent
or shorter vertical and/or mastoid segment or fallopian
canal ending at a blind pocket in the mastoid process
on the affected side.37 These signs along with the absence
of generalized craniofacial malformations, inner ear de­
formities and multiple cranial nerve involvement more
likely indicate simple rather than syndromic developmental
mishap.
ELECTROPHYSIOLOGICAL STUDIES
Preoperative electrophysiological evaluation invariably
includes needle electromyography (EMG) of all the native
zygomaticus minor) and the corner of the mouth (levator
anguli oris, zygomaticus major) which play a central role in
smiling. Levator muscles are functionally and anatomically
linked with the OOrM participating in basic functions such
as speaking, kissing, lip puckering, and other oral move­
ments and expressions. The zygomatic and buccal branches
of the facial nerve provide innervation. The constellation of
symptoms that follows paralysis of these muscles include
an inability to articulate phonemes (dysarthria) and speak
properly, to smile, to kiss, and produce the plethora of
perioral movements, such as whistling, sucking a straw or
blowing. Additionally, oral incontinence characterized by
drooling and inability to keep food in the mouth may be
present. In cases where the ipsilateral antagonists (depres­
sor complex) retain their function, drop of the corner of
the mouth may be observed. In unilateral FP, mild to severe
mouth asymmetry may be noted due to the prevailing func­
tion of the muscles on the unaffected side.
The restoration of a symmetric, natural, voluntary smile
depends on the functional restoration or substitution of this
group of muscles. According to Rubin,44 smile is classified
as the: (a) “Mona Lisa” type, where the direction of the
smile is along the zygomaticus major; (b) “canine” type,
where the levator labii superioris dominates in the produc­
tion of the smile; and (c) “full denture” dominant smile.
The last category of smile requires also restoration of the
depressor complex.
LOWER FACE
DEPRESSOR COMPLEX
This group of muscles depresses the lower lip and modiolus
and participates along with the levators and the orbicularis
oris in the perioral movements, in speaking and retaining
oral continence. The primary goal of reanimating this
group of muscles aims at the restoration of a full denture
smile, expressing disappointment, sadness, disgust, doubt,
disdain, irony, anger, or rage. Voluntary lip depression,
involves the downward motion of the lower lip for about
5.6 mm and the inversion of the vermillion border; both
disappear with injury of the marginal mandibular branch.45
Consequently, the affected lower lip stays elevated and flat­
tened, while the normal side remains depressed.
PLATYSMA
Although no critical facial function is associated with the
platysma, it plays a significant role in swallowing and com­
missure depression. Platysma is innervated by the cervical
branches of the facial nerve and involvement of these
branches may lead to the obliteration of neck rhytides or
vertical platysma bands, and to neck skin shagging and
flattening.
ADDITIONAL SYMPTOMS
The nerve to the stapedius muscle, which dampens the
sound vibrations to the inner ear, a posterior auricular
sensory branch, and the chorda tympani, which provides
taste sensation to the anterior two-thirds of the tongue and
parasympathetic innervation to the submandibular and sub­
lingual glands are all branches originating from the mastoid
segment of the facial nerve. Lesions result in intolerance to

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
167
documentation by video recordings and photographs is per­
formed. Meticulous grading and comparisons of the entire
clinimetric evaluation (physical and behavioral) takes place
by independent investigators who have the skills to perform
clinimetric evaluations but are not previously aware, or in
any way involved, with the specific conditions, study, or
methodology.
The grading scales (clinimetric tools) that are used to
evaluate the functional outcomes in FP patients are estab­
lished and validated and they are function specific.45–47
Grading scales for eye sphincter function and blink,
smile and depressor complex function are shown in
Tables 15.2–15.4.
facial muscles and nerve conduction studies. Axonal discon­
tinuity results in predictable electrophysiological patterns
and changes which are time-related following the progress
of denervation. Usually, needle EMG is performed 2–3
weeks post-injury because Wallerian degeneration may elicit
spontaneous electrical discharges initially, which do not
allow reliable examination.
Postoperative and follow-up needle EMGs and nerve con­
duction studies are as essential as in the preoperative assess­
ment. Evaluation of the interference pattern and degree of
electrogenesis are taken into consideration. Evoked EMG
may show decreased or absent response, fibrillations or
motor unit potentials in the affected musculature.
Initial electrophysiological studies during the preopera­
tive consultation include the assessment of function of
bilateral facial nerves and of neighboring cranial nerves
for possible motor donors, including the trigeminal (nee­
dle EMG of temporalis and masseters), accessory (needle
EMG of the sternocleidomastoid and trapezius), and hypo­
glossal (needle EMG of ipsilateral tongue) nerves. If there
is suspicion of multicranial nerve involvement, needle
EMGs are performed of the ipsilateral pectoralis, triceps
and latissimus muscles in order to confirm that compo­
nents of the cervical plexus (C7) can be used as motor
donors.
Results from the EMGs are tabulated and correlated with
intraoperative findings, in order to confirm the diagnosis.
Follow-up visits include repeat electromyographic evalua­
tions by the same electrophysiologist. Preoperative and post­
operative EMGs are also compared in order to assess the
improvement in muscle function. Intraoperative data is col­
lected, meticulously documented and analyzed along with a
review of operative notes, operative drawings, surgical pho­
tographs and videos, and histological reports obtained
during the exploration.
Electrophysiological studies contribute considerably in
arriving at an accurate diagnosis and in assessing objectively
functional restoration following reanimation procedures.
BEHAVIORAL EVALUATION
Preoperative evaluation includes black and white and
colored photographs along with standardized video docu­
mentation. Eye closure and involuntary blinking, is video­
taped with the patient in a seated position, in a custom-made
head restrainer. The patient is then asked to look straight
at the camera and to perform a specific series of functions
including closing their eyes lightly and then tightly several
times. In order to record involuntary blinking, each patient
is asked not to blink deliberately or close the eyes, for 4 min
while the camera is recording.
Smile restoration is videotaped using a standard protocol
with the face at rest, then exhibiting a series of facial expres­
sions, conversing, and watching a funny movie.
For depressor complex documentation and functional
restoration, each patient is videotaped and photographed
in a standardized fashion while demonstrating a full denture
smile and then depressing their bilateral lower lips without
smiling.
At all subsequent follow-up visits, the same standardized
methodology of evaluation is followed (physical exami­
nation, neurologic assessment ) and the same detailed
Table 15.2  Scoring system for eye closure
and blink
Group
Grade
Designation
Description
Grading of eye closure
I
1
Poor
No eye  
closure (no
contraction);
maximal scleral
show
II
2
Fair
Poor eye closure
(min. contraction);
2/3 scleral show
III
3
Moderate
Incomplete eye
closure; 1/3
scleral show
IV
4
Good
Nearly complete
eye closure;
minimal scleral
show
V
5
Excellent
Complete eye
closure; no
scleral show
Grading of blink
I
1
Poor
No blink
II
2
Fair
Minimal blink
(contraction)
III
3
Moderate
Initiation of blink
present but only
1/3 amplitude
IV
4
Good
Some
coordinated blink
but only 2/3
amplitude
V
5
Excellent
Synchronous and
complete blink
present
(From: Terzis JK, Bruno W. Outcomes with eye reanimation
microsurgery. Facial Plast Surg 2002; 18(2):101–112.)

168
PART 3 — RECONSTRUCTION
Table 15.3  Aesthetic and functional grading
system used for smile
Group
Grading
Result
Description
I
1
Poor
Deformity, no
contraction
II
2
Fair
No symmetry,
bulk, minimal
contraction
III
3
Moderate
Moderate
symmetry and
contraction, mass
movement
IV
4
Good
Symmetry, nearly
full contraction
V
5
Excellent
Symmetrical smile
with teeth
showing, full
contraction
(From: Terzis JK, Noah ME. Analysis of 100 cases of free-muscle
transplantation for facial paralysis. Plast Reconstr Surg 1997;
99(7):1905–1921.)
Table 15.5  Scoring system used for the
evaluation of speech intelligibility in
patients with Möbius syndrome
Score
Description
1
No intelligibility, inarticulate sounds
2
Minimal intelligibility, most phonemes omitted
or distorted, no compensation
3
Some intelligibility, many phonemes distorted,
good compensation
4
Good intelligibility, a few distorted phonemes,
excellent compensation
5
Maximum intelligibility, comprehensible
speech
Table 15.4  Aesthetic and functional
grading system used for
the depressor muscle
Grade
Description
Scale
Designation
0
Poor
Total paralysis
0.5
Fair
Trace contraction with no
movement
1
Moderate
Observable movement but
inadequate excursion and
without symmetry
1.5
Good
Almost complete excursion of
lower lip with depression and
full denture smile
2
Excellent
Normal symmetric movement
of lower lip
(From: Terzis JK, Kalantarian B. Microsurgical strategies in 74
patients for restoration of dynamic depressor muscle
mechanism: a neglected target in facial reanimation. Plast
Reconstr Surg 2000; 105(6):1917–1931.)
SPEECH EVALUATION
Speech evaluation comprises an integral part of assessment,
especially in patients with multinuclear paralysis and involve­
ment of multiple cranial nerves such as in Moebius syn­
drome.48 These nerves, in addition to the facial nerve,
include: the trigeminal nerve (responsible for facial sensa­
tion); the vestibulocochlear (for hearing); the glossopha­
ryngeal, vagus and accessory nerves (for the elevation of the
palate, the function of larynx, pharynx, vocal cords and
swallowing); and the hypoglossal (for tongue movement).
The speech assessment protocol is standardized to contain
a wide range of words and phrases, the same for each
patient. Scoring is based on the degree of intelligibility of
phonemes and on the number of omitted and compensa­
tory (a,a) phonemes. For patients under the age of 6 years,
speech intelligibility is compared with the normally antici­
pated speech milestones for the corresponding age (a).
Preoperative and postoperative videotapes of each patient
are then reviewed by independent investigators, using the
grading system shown in Table 15.5. The videotapes are
identical and the conditions of reviewing are the same for
all reviewers.48
ADDITIONAL TESTS
Additional tests for the investigation of the level (branch or
facial nerve segment) and degree of facial nerve lesion
invariably include the Schirmer test for testing the lesser
petrosal nerve, the test for the stapedius reflex, taste exami­
nation for testing the chorda tympani, and the salivary flow
test for testing the chorda tympani and greater petrosal
nerves.
MICROSURGICAL MANAGEMENT
STRATEGIES OF FACIAL PARALYSIS
ACUTE POST-TRAUMATIC FACIAL PARALYSIS
Facial nerve injuries associated with sharp/penetrating
force (e.g., knife, gunshot and post-facelift injury, etc.) ini­
tially require extensive early exploration. Injuries secondary
to blunt force trauma are treated initially by close obser­
vation. At the end of the 4th week, if complete recovery
has not occurred, needle EMGs and nerve conduction
studies should be performed and comprise the baseline for
future evaluations. If at 12 weeks, complete recovery is not

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
169
contralateral unaffected facial nerve can serve as motor
donors by providing motor fibers through CFNGs to cor­
responding branches of the affected facial nerve, thereby,
reinnervating similar targets; these elongating fibers serve
as the “pacemakers” for animation of the affected side. At
9–12 months later and after electrophysiological confirma­
tion, secondary microcoaptations take place with corre­
sponding branches of the affected facial nerve. In an
exemplary CFNG procedure, an eye only branch and zygo­
matic and mandibular branches from the unaffected side,
are used as motor donors for the eye sphincter, smile and
depressor complex, respectively. Thus 3–4 CFNGs are placed
in the first stage for functional restoration of the upper and
lower sphincter and depressor (Fig. 15.2). Thus, the CFNG
procedure is a two stage procedure.
Denervation Time of 6–27 Months
(“Babysitter” Procedure)
In later cases over 6 months and up to 27 months, the
denervated period can be disastrous, resulting in irrevers­
ible muscle atrophy and fibrosis. For these cases, the babysit­
ter procedure introduced by Terzis in 1984, is strongly
recommended. This is a two-stage procedure involving a
partial hypoglossal transfer to the ipsilateral facial nerve, in
an end-to-side fashion, combined with the CFNGs proce­
dure as describe above (Fig. 15.3).
The advantage of this procedure is that it rapidly salvages
the facial musculature until nerve regeneration across
CFNGs reaches the affected side and without postoperative
ipsilateral tongue paresis. The “babysitter” principle involves
observed, evaluation should proceed with repeat EMG
studies. Presence of motor units potentials in EMGs indi­
cates that spontaneous reinnervation can be expected and
further observation of these patients is usually advised.
Absence of motor units potentials (clinical and electrophysi­
ological signs of reinnervation) should be followed by surgi­
cal exploration.
Nerve lesions due to crush injuries are usually associated
with considerable soft tissue damage. Difficulty to assess the
extent of the injury and to the prioritization of restoring
vascular and soft tissue reconstruction, nerve repair may be
delayed up to 3 weeks. At that stage, the zone of injury is
much easier to identify due to consolidation of damage.
Exploration is performed proximal and distal to the site
of the nerve lesion until normal nerve tissue is identified
intraoperatively. In cases where there are multiple injury
sites, the entire nerve and its branches are explored.
PRIMARY NERVE REPAIR
Primary nerve repair by end-to-end coaptation has been
shown to yield the best results. After the excision of the
injured zone, nerve stumps are brought together (see also
Ch. 24 for different techniques of nerve repair). If tension­
less approximation is possible, the repair proceeds. Epineu­
rial repair has functional results comparable with fascicular
repair in monofascicular nerve stumps. In polyfascicular
nerve stumps, interfascicular repair is preferred in order to
secure optimal approximation and alignment of the nerve
ends. If the alignment is not optimal, misdirection of regen­
erating fibers may lead to synkinesis, which corresponds to
undesirable co-contraction of muscle groups when another
muscle group intentionally contracts. The more proximal
the repair, the higher the possibility of synkinesis. If the
nerve stumps cannot be approximated without tension,
mobilization of the nerve ends is performed. The effect of
tension is detrimental; exceeding 10% of the resting length
of the peripheral nerve decreases blood flow to the nerve
by 50%.
INTERPOSITION NERVE GRAFTS
If despite mobilization there is a nerve gap, then the defect
is bridged using interposition nerve grafts. Each end of
an interposition nerve graft is coapted end-to-end in a
tension free manner with one of the two stumps. The sural
(see Fig. 13.19) and/or saphenous (see Fig. 55.1) cutaneous
nerves are often used as donors. Attributes of an interposi­
tion nerve graft include non-critical sensory deficit, long,
unbranched segments, easily accessible and reliably located
consisting of large fascicles with little interfascicular connec­
tive tissue.
LATE FP
CROSS-FACIAL NERVE GRAFTING (CFNG)
Denervation Time of Less Than 6 Months
There are cases where the injury or the nerve is so extensive
that the proximal facial nerve stump is no longer available,
for example, when a large acoustic neuroma requires exci­
sion of most of the intracranial part of the facial nerve. In
these cases, and as long as the denervation time is within 6
months, the selectively neurectomized branches of the
Figure 15.2  Cross-facial nerve grafting (CFNG) procedure in a
21-year-old patient with a history of right facial paralysis secondary
to cholesteatoma resection. The number of CFNGs depends on the
reanimation requirements and the preoperative deformity. Note the
dedicated graft (first graft from the top) for upper and lower eye
sphincter for contralateral eye closure and blink restoration; the
second and third grafts dedicated for contralateral smile restoration;
and the fourth (lowest) graft for depressor restoration. The grafts are
tunneled at a subcutaneous level. After the CFNGs have been passed,
the distal end of each CFNG is anchored at the preauricular area on
the affected side, while the proximal end of each CFNG is coapted
end-to-end with the previously selected neurectomized facial nerve
branches on the normal side. Secondary microcoaptations with the
corresponding facial nerve branches on the paralyzed side will take
place 9–12 months later, after electrophysiological confirmation of
nerve regeneration across the CFNGs.

170
PART 3 — RECONSTRUCTION
nerve is coapted with the corresponding CFNG, which
receives innervation from the contralateral facial nerve,
thus preserving coordinated reanimation. If contralateral
facial nerve motor donors are not available, as in bilateral
developmental palsy (Moebius), other ipsilateral cranial
nerves (hypoglossal, masseteric, accessory nerves) can be
used as motor donors, if not involved in the lesion, as well
as the C7 root. It is important to mention than harvesting
of ipsilateral motor donors is carried out through an end-
to-side coaptation to avoid further downgrading of function
(see ‘Procedures’ section). Panfacial reanimation dictates
functional restoration of each part of the face (upper,
middle, lower) and can be achieved using different recon­
structive strategies.
Upper Face Reanimation (Eye).  For eye sphincter reanima­
tion, Terzis49 introduced, in the early 1980s, the contralat­
eral frontalis (Fig. 15.4) and free platysma (Fig. 15.5).
Additionally, minitemporalis, occipitalis, extensor brevis,
and free gracilis subunits have been used. Disadvantages of
minitemporalis include the bulk over the lateral orbital
area, the slit-like deformity of the palpebral fissure during
eye closure, the synkinesis of the eyelids during mastication,
and absence of blink. The frontalis muscle is homologous
to the OOM, has an advantageous location and its final inset
and pull are appropriate for eye closure. The occipitalis
muscle is available in facial trauma cases, where the use of
the frontalis is contraindicated. The harvest is challenging
because of the complexity of the region and transfer requires
preparation in the anatomy laboratory. To our knowledge,
in our Center the successful use of a slip of the free extensor
digitorum brevis, a segment of the free occipitalis, and a
sliver of the free adductor longus for eye sphincter substitu­
tion were achieved for the first time.
the use of ipsilateral powerful motor donors which serve to
salvage and maintain the bulk of the affected facial muscu­
lature until the contralateral facial nerve fibers reach the
resuscitated targets. The most significant disadvantages in
the classical hypoglossal to facial nerve transfer is the result­
ing hemiglossal atrophy, which leads to mastication, swallow­
ing and speech difficulties and severe synkinesis. In contrast,
in the babysitter procedure, only 40% of the hypoglossal
nerve is used, thereby the function of ipsilateral tongue is
preserved.
When the hypoglossal is not available, other ipsilateral
motor donors include the masseteric or accessory nerves. In
cases of bilateral multinuclear nerve involvement (severe
Moebius syndrome), the ipsilateral cervical motors, i.e. the
C7 root on each side can be used as a source of motor
donors. If the involved facial nerve is in continuity, and the
preoperative EMG discloses fibrillations, the babysitter pro­
cedure can be executed up to 2 years and 3 months, follow­
ing the onset of FP. If the facial nerve was transected during
tumor extirpation, then the babysitter procedure can be
carried out at denervation times of up to 12 months and as
long as preoperative needle EMGs show fibrillations. If the
denervation time is over 12 months, or preoperative EMGs
are silent (which signal fibrosis), then the surgeon needs to
combine CFNGs with foreign muscle importation for sym­
metrical coordinated reanimation.
Denervation Time Over 27 Months
(Muscle Substitution)
If the denervation time is over 2 years, such as in develop­
mental FP or late FP post-tumor extirpation, and the preop­
erative needle EMGs are silent, CFNG procedure is followed
9–12 months later, by muscle transfers either pedicled/
regional or free vascularized muscle transfers. The muscle
Figure 15.3  The “babysitter” procedure. The upper portion of the hypoglossal nerve is split longitudinally and 40% of the nerve is harvested
and turned posteriorly and cranially and coapted directly to the affected ipsilateral facial nerve trunk (white arrow in B). (A) The configuration
of the technique is also shown, the distal stump of the affected facial nerve (yellow) is coapted end-to-end with 40% of the hypoglossal nerve
segment (blue). (B) Intraoperative photograph of the minihypoglossal to facial nerve transfer component of the “babysitter” procedure. The
concomitant placement of 2, 3, or 4 CFNGs completes the “babysitter” procedure.
XII Hypoglossal nerve
VII Facial nerve
B
A

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
171
muscles have an advantage when used for eye sphincter
substitution.
In pediatric patients, the use of the upper slip of the
pectoralis minor neurotized by a separate cross-facial nerve
graft carrying contralateral eye fibers has been used in our
Center. Selecting the final anchoring sites and proper
tension is demanding, but the resulting blink restoration is
rewarding.
In cases of V and VII nerve paralysis with anesthetic
cornea, neurotrophic keratopathy severely affects corneal
health. The technique of direct cornea neurotization using
as sensory donors the contralateral supraorbital and supra­
trochlear nerves has been developed in our Center, which
provides a permanent solution in the afflicted patients.50
Static procedures for the upper and the lower eyelid, aid
eye closure passively without actively restoring the blink.
These include the gold weight implant and the palpebral
eye spring for the upper eyelid51 and the minitendon grafts
for the lower eyelid have been widely used.52
Middle Face Reanimation.  The recommended regional
muscle that is used for smile reanimation is the temporalis
muscle (minitemporalis). Advantages of this muscle are the
appropriate strength and direction of its pull, and the ability
to sculpture it according to the needs of the patient. Disad­
vantages are its bulk and the difficulty to “pace” its action
to the contralateral facial nerve using CFNGs, even after
cutting the deep temporal nerves which provide its primary
innervation. Transfer of the masseter muscle, has also been
reported but the results have been poor. The free muscle
The platysma, frontalis, occipitalis and orbicularis oculi
muscles share the same embryologic origin from the meso­
derm of the second brachial arch. Their innervation comes
from facial nerve branches, and they are all capable of vol­
untary and involuntary reflex actions. The density of neu­
romuscular junctions and consequently of innervation
for the platysma and frontalis has been shown to be compa­
rable to that of the orbicularis oculi muscle.49 Thus, these
Figure 15.4  Frontalis muscle transfer for eye sphincter reanimation.
Second stage reconstruction of a 24-year-old patient with left devel­
opmental facial paralysis and left hemifacial microsomia. (A) Note the
subgaleal dissection to the level of the left and right supraorbital rims,
the harvesting of the frontalis muscle flap and the sculpturing and
shaping of the muscle into one medial and one lateral slips. The nerve
of the frontalis (left N arrow) carefully identified and preserved. Large
N arrow indicates the upper CFNG. (B) The muscle is then rotated
medially and each slip is passed through the previously created
subcutaneous tunnels along the glabella to the medial canthal inci­
sion and subsequently through the upper and lower eyelids to the
lateral canthus, so as to reproduce a complete sphincter around the
eye. The overlapping ends of the slips are sutured around a periosteal
flap at the lateral orbital rim. The previously positioned CFNG dedi­
cated for eye reanimation is then coapted to the frontalis nerve
providing contralateral motor fibers and enabling synchronous, coor­
dinated eye closure, and blink.
A
B
Figure 15.5  Free platysma transfer for eye reanimation. Third stage
reconstruction in a 27-year-old patient with late left facial paralysis
(>27 months), secondary to surgery for left acoustic neuroma. A
segment of the right platysma is carefully harvested after the identi­
fication and incorporation of the perforating branches of the facial
artery and of the cervical branch of the facial nerve. The caudal part
of the muscle is divided into two slips to form an eye sphincter. The
muscle is turned over, so that its deep surface is lying superficial and
the two separate slips are tunneled into the previously created sub­
cutaneous tunnels along the upper and lower eyelids, respectively.
The nerve stump of the platysma is coapted with the previously
placed upper CFNG dedicated for eye reanimation restoring synchro­
nous and coordinated eye closure and blink. The vascular pedicle of
the muscle is anastomosed to the superficial temporal vessels. The
platysma is considered an excellent choice for eye reanimation due
to its common embryological origin with the orbicularis oculi muscle.

172
PART 3 — RECONSTRUCTION
has to be near the midline so as to reach the contralateral
face. To address this difficulty, some authors connect the
muscle to an ipsilateral motor donor such as the masseteric
nerve which, again, is a one-stage procedure with a single
coaptation to a strong motor donor. However, this option
has severe disadvantages, including the absence of sponta­
neity in movement and emotional expression and the lack
of coordinated function of the free muscle with the unaf­
fected side, which requires intensive motor re-education.
Lower Face Reanimation.  The lower lip is animated through
a complex interaction and coordination of orbicularis oris,
depressor labii inferioris, depressor anguli oris, mentalis,
and platysma muscles. The lower lip moves about 5–6 mm
in the direction of depression. A lesion of the marginal
mandibular branch results in inability to draw the lower lip
downward and laterally or to evert the vermilion border.
If the facial paralysis is <12 months’ duration, and there
is evidence of muscle presence by needle electromyography,
then restoration of the depressor muscle complex is achieved
by a cross-facial nerve graft if a proximal stump is not
available.
In patients with incomplete depressor complex recovery,
or in patients with facial paralysis of 24 months’ duration,
but with evidence of remaining muscle after needle EMG,
a minihypoglossal nerve transfer to the cervicofacial branch
of the facial nerve is recommended, or direct neurotization
of the depressor muscles with hypoglossal nerve fibers via a
nerve graft coapted to the minihypoglossal by an end-to-side
coaptation.
In long-standing facial paralysis (i.e. >30 months’ dura­
tion with silent needle EMGs), the transfer of the ipsilateral
platysma muscle is advocated, if the platysma is proven
viable and adequate for transfer (Fig. 15.8). In patients with
transfers that are favored in our Center include the free
gracilis for the adults (Fig. 15.6) and the free pectoralis
minor for the children (Fig. 15.7). The free latissimus dorsi
has also been used elsewhere in selected cases with its own
neurovascular pedicle. This may have the advantage of
being a one-stage procedure with a single coaptation site
but there are serious disadvantages in insetting the muscle
due to limited length of the neurovascular pedicle, which
Figure 15.6  Free gracilis muscle transfer for smile restoration. A
14-year-old patient with Moebius syndrome. Intraoperative photo­
graph showing the position of the left gracilis on the right cheek
before its being insetted in the right cheek subcutaneous pocket. The
slips are insetted at the alar base, philtrum, upper lip, commissure
and lower lip. The longest slip is for the lower lip, and the shortest
for the commissure. The gracilis muscle has been the workhorse in
smile reanimation. In the authors’ Center, the gracilis is used primarily
in adults. Use of the muscle in children is reserved only for cases that
its vascular pedicle is not transferable.
Figure 15.7  Free pectoralis minor transfer for smile restoration.
Second stage facial reanimation in a 5-year-old patient with left devel­
opmental facial paralysis. Intraoperative photograph showing the
right pectoralis minor on the left cheek. Pectoralis minor is an excel­
lent choice for smile restoration in pediatric patients because of its
ideal size, its four-slips, fan-like anatomic configuration, which allows
insetting in the infraorbital rim, alar base, upper lip, commissure and
lower lip, its minimal requirement for debulking, and its dual nerve
supply, which allows reinnervation by two separate CFNGs resulting
in a more refined coordinated facial expressivity.
Figure 15.8  Note the 180° of anteromedial rotation of the lateral
two-thirds of the platysma to the lower lip and the oblique orientation
of its axis reproducing the direction of the pull of the contralateral
depressor complex. Also note the subcutaneous tunnel from a lateral
submandibular incision to a lateral intraoral incision through which
the muscle will pass and then anchored to the ipsilateral lower lip by
several slips.

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
173
developmental unilateral lower lip paralysis and absence of
a functioning platysma muscle, transfer of the anterior belly
of the digastric muscle is recommended for depressor sub­
stitution (Fig. 15.9).
SURGICAL TECHNIQUES
CROSS-FACIAL NERVE GRAFTING
On the unaffected side, the entire extratemporal facial
nerve is exposed through a modified facelift incision. Intra­
operative microstimulation is then performed using a Nerve
Locator (Neuro-Pulse 0003Y) starting from the branch to
the frontalis and continuing from lateral to medial until all
branches have been stimulated and all muscle targets have
been mapped. No two neighboring branches are neurecto­
mized. Usually a dedicated branch for the upper and lower
eye sphincter is set aside for contralateral eye reanimation.
A dedicated branch for smile, without eye participation is
selected for contralateral smile restoration. Finally, one of
the branches of the marginal mandibular nerve is used for
depressor restoration on the affected side. Each CFNG is
tunneled at a subcutaneous plane using custom made nerve
passers with the help of constant irrigation. The distal end
of each CFNG is anchored at the preauricular area on the
paralyzed side and appropriately tagged with small hemo­
clips for easy identification. Usually four and no less than
three CFNG, are used. After the nerve grafts have been
passed across the face, the operating microscope is moved
in the operating field and the proximal stumps of each
neurectomized branch are coapted in an end-to-end fashion
with the proximal end of the CFNGs (most often sural or
saphenous nerve grafts).The actual number of CFNGs
depends on the reanimation requirements and the preop­
erative deformity.
Figure 15.9  Digastric muscle transfer for depressor restoration. Third stage facial reanimation in a 22-year-old female patient with left post-
traumatic facial paralysis. Intraoperative photograph showing the harvested anterior belly of the digastric muscle, the mandibular origin is cut
and the tendinous insertion is severed at the level of the hyoid (A). (A) Its tendon is subsequently split into four slips. Care has been taken to
preserve the vascular pedicle. (B) The previous placed lower CGNG is coapted end-to-end with the digastric nerve near its entry point into the
muscle.
A
B
DIRECT MUSCLE NEUROTIZATION
Direct muscle neurotization is performed by implanting the
interposition nerve graft directly into the substance of the
muscle. The proximal end of the nerve graft is connected to
the motor donor nerve. The distal end, which is destined to
neurotize the muscle, is split into two or three fascicular
groups, and each fascicle is implanted through a separate
incision within the epimysium and maintained in place with
9-0 suture. In direct neurotization of the OOM, the distal
end of the interposition graft is usually divided into two seg­
ments, which are further divided into two to three fascicles.
One segment is for the upper and the other for the lower
orbicularis oculi muscle. Motor donors are usually the selec­
tively neurectomized branches of the contralateral unaf­
fected facial nerve or, in cases of bilateral palsy, an ipsilateral
unaffected motor donor. Levator anguli oris muscle can
similarly be neurotized by the corresponding contralateral
zygomatic branch and the depressor anguli oris by the con­
tralateral marginal mandibular branch, both via cross-facial
nerve grafts. In cases of bilateral facial paralysis (Moebius
syndrome), contralateral motor donors are unavailable, and
thus ipsilateral motor donors are used, such as the XII, V,
and XI cranial nerves if they are not involved or motor fibers
from the ipsilateral brachial plexus (C7 root).
OTHER NERVE TRANSFERS
THE BABYSITTER PROCEDURE
On the affected side, through a submandibular incision, the
hypoglossal nerve is identified under the tendon of the
posterior belly of the digastric muscle. Under high magni­
fication, using the diamond knife, the upper portion of the
hypoglossal nerve is split longitudinally and about 40% of
the nerve is traced distally. The distal end is sharply tran­
sected and brought laterally to be coapted directly to the

174
PART 3 — RECONSTRUCTION
is used for skin closure. Bacitracin ophthalmic ointment is
applied to the suture line and cold compresses overnight to
control swelling.
Palpebral Spring
The placement of the palpebral spring is performed with
the patient under sedation, as the exact adjustment of the
device requires the participation of the patient in opening
and closing the eye. The palpebral spring is constructed
specific to the patient’s eyelid utilizing 0.010 inch diameter
stainless steel dental wire. A 5 mm loop is made in the wire
with the limbs of the wire at different angles, from 60° to
90° based on the degree of lagophthalmos and the shape of
the patients eyelid (Fig. 15.11).
affected facial nerve trunk. In addition, the CFNGs proce­
dure is carried out at the same time as described above.
ACCESSORY NERVE TRANSFER
The head and neck of the patient are turned away from the
affected side and a curvilinear neck incision is made along
the posterior border of the sternocleidomastoid muscle
approximately 5 cm below the margin of the mandible. The
accessory nerve is identified as it emerges from the lateral
border of the sternocleidomastoid muscle cranial to the C4
spinal nerve. Intraoperative stimulation is used for confir­
mation. The spinal accessory nerve then proceeds caudally,
under the anterior border of the trapezius muscle.
Following the identification of the motor branches of the
accessory nerve under high magnification, perineurial
window and partial neurectomies of each motor branch is
carried out. Interposition nerve grafts are coapted end-to-
side at that site after having been tunneled to the face. In
cases where the accessory nerve is used as a “babysitter”, the
two branches are coapted end-to-side to the interposition
nerve grafts.
C7 NERVE ROOT TRANSFER
An S-shape incision is carried out along the posterior border
of the sternocleidomastoid muscle and the supraclavicular
plexus is identified between the anterior and the middle
scalene muscles. The C5 and C6 roots are identified. The
C7 root is located caudally and posterior to the C6 root and
it is mobilized from the surrounding tissue. The C7 root is
exposed from proximal to distal until its division into the
anterior and posterior division. Using intraoperative micro­
stimulation, the fascicles of each division are mapped. Fas­
cicles that supply wrist extension are preserved. Fascicles
that supply the triceps and/or pectoralis major and latissi­
mus dorsi muscle are tagged. Under high magnification,
perineurial windows or partial neurectomies of bundles
from each division are performed and coapted to the previ­
ously placed interposition nerve grafts. In cases of bilateral
FP, motor donors from each side are chosen in a similar way
for corresponding facial targets.
EYE
STATIC PROCEDURES
Gold Weight
The appropriate size of the gold weight51 for the patient is
selected by taping the weight in position on the upper eyelid
using Steri-Strip with the patient sitting upright and holding
a mirror. The weight used ranges from 0.6 g to 1.0 g with
an average of 0.8 g. The minimum weight that produces
maximal closure without pseudoptosis is selected. The
placement of the gold weight is performed under general
anesthesia and is usually combined with other revisional
procedures. The orbicularis muscle is split along its fibers
entering the pretarsal space and a pocket large enough to
admit the gold weight is prepared. The exact position of the
pocket is along the superior margin of the center of the
tarsal plate (Fig. 15.10). It is anchored to the upper portion
of the tarsal plate through the three holes in the implant
using 9-0 monofilament polypropylene sutures. The orbicu­
laris oculi muscle is closed over the implant with interrupted
8-0 and a subcuticular 7-0 absorbable polydioxanone suture
Figure 15.10  Gold weight. Third stage facial reanimation in a patient
with Moebius syndrome. Note the gold weight on the upper eyelid,
which will be placed at a submuscular pocket along the superior
margin of the tarsal plate. The appropriate size of the gold weight is
selected preoperatively.
Figure 15.11  Eyespring. A 26-year-old man with right facial paraly­
sis secondary to excision of pontine cavernous hemangioma. Note
the two 20G spinal needles with their trocars in place, one from the
superior orbital rim incision and the other from the medial upper lid
margin incision, both exiting at the lateral canthal incision. The trocars
are then removed and the arms of the spring are inserted simultane­
ously into the spinal needles. The needles are then carefully removed.
The end of the superior limb is anchored to the superior orbital rim
while the medial end is trimmed to size and flattened into a small
loop. Extra caution is recommended to avoid trauma to the eye. The
function of the spring is tested several times with the patient in a
sitting position and appropriate adjustments in the angle are made.

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
175
the frontal nerve is then carefully identified. Electrical stim­
ulation is used to confirm contraction of the frontalis
muscle. A tunnel is created over the glabella from the supra­
orbital rim of the normal side to a contralateral medial
canthal incision. Subcutaneous tunnels are then created
along the upper and lower eyelids from the medial to the
lateral canthal areas. Once fully dissected, the frontalis
muscle is sculptured and shaped into appropriate medial
and lateral segments, assuring each half remains vascular­
ized and innervated. Each slip of the frontalis is passed
through the glabellar tunnel to the medial canthal incision
and then each segment is subsequently tunneled across the
upper and lower eyelid to the lateral canthal region. The
two ends of the frontalis are passed through the lateral
canthal incision and tension adjusted, so as to reproduce a
complete sphincter around the eye. The overlapping ends
of the frontalis muscle are finally sutured at the level of the
lateral canthal tendon and around a periosteal flap at the
lateral orbital rim. The previously placed cross-facial nerve
graft dedicated for reinnervation of the eye sphincter is
then identified and coapted to the frontal nerve of the
frontalis muscle under high power magnification using 11-0
nylon sutures. The scalp and orbital incisions are then
closed in layers (Fig. 15.13).
Platysma for Orbicularis Oculi Substitution
The free microneurovascular transfer of a segment of the
contralateral platysma muscle comprises another procedure
for orbicularis oculi substitution. The blood supply to the
platysma is derived from a branch of the facial artery and
its venae comitante, which supply the substance of the
muscle as well as the subcutaneous tissue and overlying skin.
A preoperative angiogram of the external carotid is indi­
cated to delineate the status of the recipient superficial
temporal vessels on the paralyzed side. A temporal scalp
incision on the patient’s paralyzed side is performed and
the superficial temporal vessels are identified. The previ­
ously placed cross-facial nerve graft is also identified through
this same incision. A second surgical team simultaneously
approaches the contralateral normal side by performing a
submandibular incision to expose the lateral border of the
platysma muscle. The cervicofacial branch of the facial
nerve is identified, electrically stimulated and preserved.
The perforating branches of the facial artery are identified
at the level of where the facial artery curves around the
mandible. The cervical branch of the cervicofacial segment
of the facial nerve is then identified and electrically stimu­
lated as it enters underneath the lateral margin of the pla­
tysma muscle 2–3 cm below the ramus of the mandible. A
platysma segment is harvested laterally to incorporate the
perforating vessel at its base and adequate innervation and
vascularization along its length. The caudal part of the
muscle is divided into two slips, making sure they both con­
tract upon stimulation of the cervical branch of the facial
nerve. Tunnels are then created from the temporal incision
to the lateral canthus and then along the upper and lower
eyelids toward the medial canthus. Once the neurovascular
pedicle is transected, the previously sculptured platysma
segment is transferred to the recipient site and flipped over,
so that its deep surface is now lying superficial. The two
separate slips are then tunneled into the upper and lower
eyelids, respectively. A microvascular anastomosis is then
performed to the superficial temporal vessels under high
Prior to wound closure, the patient is brought to the
sitting position and asked to open and close the eyes. At this
point, final adjustments are made so that the palpebral
aperture is symmetric with the normal side. After the func­
tion of the spring is again tested and appropriate adjust­
ments in the angle are made, the wounds are closed in layers.
Minitendon
For details of the minitendon technique for suspension of
the lower eyelid, the reader is referred to Terzis and Kyere.52
The tendon graft, once harvested, is usually split in half and
a piece is passed through the tunnel from canthus to
canthus. Medially, it is passed behind the medial canthal
ligament and around the bipedicled periosteal flap and
sutured to itself using 6-0 non-absorbable suture. The cana­
liculi are protected throughout this procedure by insertion
of lacrimal probes (Fig. 15.12). Lateral canthal fixation is
performed with the tendon marked under moderate trac­
tion in order to slightly overcorrect the lid laxity. The
tendon is secured and anchored to the lateral orbital rim
by a mini Mitek anchor.
ORBICULARIS OCULI MUSCLE (OOM) SUBSTITUTION
Frontalis for Eye Sphincter Substitution
Transferring the contralateral, unaffected frontalis muscle
to the paralyzed orbicularis oculi as a pedicled muscle trans­
fer is performed through a bicoronal skin incision well pos­
terior to the hairline from one auricle to the other. A
subgaleal dissection is carried out to the level of the left and
right supraorbital rims. A subcutaneous pocket is developed
over the area of the unaffected normal frontalis muscle,
which when extended laterally, allows for identification of
the frontal nerve branches. Once the frontal flap is devel­
oped to the supraorbital rim, the supratrochlear vessels are
identified. The frontalis muscle dissection is then continued
just beyond the midline. Under high power magnification,
Figure 15.12  Minitendon. Third stage reconstruction in a 43-year-
old patient with left Bell’s palsy. Intraoperative photograph showing
the palmaris tendon graft inserted in the subciliary tunnel. The excess
tendon is trimmed off. The tendon is passed medially around the
medial canthal ligament and sutured on itself. Lateral canthal fixation
takes place with the tendon under moderate tension to slightly over­
correct the lid laxity.

176
PART 3 — RECONSTRUCTION
gracilis tendon on the medial tibial condyle. The dominant
pedicle enters the muscle from its deep surface approxi­
mately 10 cm inferior to the pubic tubercle and along with
the motor nerve (obturator) to the muscle is identified and
preserved (see also Ch. 49). The minor pedicles are
power magnification using interrupted 11-0 nylon sutures.
The previously placed CFNG is then coapted to the cervical
branch supplying the platysma muscle also using 11-0
sutures. The platysma is then anchored laterally along the
lateral orbital rim and at the medial region by sewing the
two slips to each other around the medial canthal tendon.
All incisions are closed in layers (Fig. 15.14).
Temporalis for Eye Reanimation
Through a temporal incision, a segment of the temporalis
muscle is raised with the superficial fascia preserved and the
deep fascia and a section of the pericranium retained as
extensions of the flap. The distal segment of the muscle is
then carefully sculptured and divided into two separate slits,
one for each eyelid. With the cornea shielded, 1 : 100 000
solution of epinephrine is infiltrated in the field. A 1 cm
incision is made at the lateral canthus and the lateral orbital
rim is exposed and subcutaneous tunnels across each eyelid
are created. The tunnels have adequate width, so as to
enable the passage of the muscle slits without compressing
it. The slits are passed through the tunnels, having occasion­
ally their lateral margins sutured on the underlying tissue
so as to retain their width (not get folded) and length along
the eyelid. The temporalis is then anchored laterally along
the lateral orbital rim and medially by sewing the two slips
to each other around the medial canthal tendon. All inci­
sions are closed in layers.
SMILE
GRACILIS
A medial thigh incision is made along the proximal two-
thirds of the thigh and a much smaller one is also made at
the medial aspect of the knee over the insertion of the
Figure 15.13  Frontalis muscle transfer to the left eye for eye closure and blink restoration. (A) A 2-year-old girl with right developmental facial
paralysis. Note the complete absence of eye closure on the right side. She had cross-facial nerve grafting (CFNG) ×3. Eighteen months later
she underwent left frontalis muscle transfer for right eye sphincter substitution followed by a free pectoralis minor transfer for smile restoration
1 year later. Sixteen months later she had revisional surgery. (B) The patient at 16 years and 12.5 years after the frontalis transfer, shown with
adequate right eye closure and excellent synchronicity in eye closure and blink.
A
B
Figure 15.14  Free platysma transfer for eye reanimation. (A) A
31-year-old woman with left developmental facial paralysis. She had
multiple static procedures elsewhere prior to referral to our Center.
She underwent cross-facial nerve grafting (CFNG) ×3 followed by a left
gracilis free muscle transfer to the left cheek and a right free platysma
muscle transfer to the eye 1 year later. Note the lagophthalmos and
the inability to close her left eye. (B) The patient, 17 months after the
free platysma transfer, showing adequate eye closure and blink.
A
B

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
177
second surgical team prepares the cheek pocket on the
affected side.
Prior to insetting, the muscle is irrigated with heparinized
saline and brought in the pocket created in the patient’s
face. It is then anchored by 5-0 to 3-0 non-absorbable
Prolene sutures, which had been previously placed through
the slips of the pectoralis minor muscle. Once the insetting
takes place, microvascular anastomoses take place on the
outer surface of the muscle at the correct tension. The
dedicated CFNG, carrying “smile” fibers, is then coapted to
the medial and/or lateral pectoral nerve with interrupted
11-0 nylon epineurial sutures. Prior to wound closure,
the motor nerves are stimulated; adequate contraction of
the transferred muscle is a good prognostic indicator
(Fig. 15.16).
TEMPORALIS TO AUGMENT SMILE
Through a temporal incision, a segment of the temporalis
muscle (more often the middle-third is raised under the
superficial temporal fascia which is preserved. The deep
fascia is peeled off the temporalis, and fixed to its cranial
edge, together with the pericranial extension with two rows
sacrificed. The gracilis muscle is then freed, the nerve is
traced as proximally as possible and the vascular pedicle is
dissected atraumatically under the adductor longus muscle
and traced up to the profunda femoris vessels. Marker
sutures are placed at 1 cm intervals along the superior
border with the muscle in situ, and will be measured again
following transfer in the new position in the paralyzed face,
so that the muscle is inserted under in situ tension.
Following this, the proximal part of the muscle is sculpted
in situ according to the mold that was designed on the
cheek so that the muscle fits in the recipient area. The
fibrous origin of the gracilis, at the pubic symphysis, is split
up into fascia slips, which correspond to the ones that will
be inserted at the alar base, philtrum, upper lip, commis­
sure, and lower lip. The longest slip is for the lower lip, and
the shortest for the commissure. The obturator nerve is
then divided and the tendinous slips are prepared using 6-0
Prolene® mattress sutures, where the anchoring is deter­
mined to be. The muscle is completely detached from its
origin, the pedicle is divided, and the distal part and poste­
rior half of the muscle is removed, and the thigh incisions
are closed.
The muscle is then transferred to the cheek pocket that
has been prepared by a second surgical team and the inset­
ting begins with fixation of the tendinous strips, starting
with the lower lip at the midline, followed by the insertion
at the modiolus, the upper lip at halfway between cupid’s
bow and commissure, at the philtrum of the upper lip, at
the alar base and medially at the naso-orbital area. The
correct tension is applied, monitored by the marker silk
sutures being apart at 1 cm, and the muscle is anchored
superiorly at the inferior orbital rim and the deep tempo­
ral fascia at the infraorbital rim. Three 3/0 Prolene sutures
are placed along the preauricular region. The artery is
flushed with heparinized normal saline, and microvascular
anastomoses take place with the facial vessels using 10/0
Nylon sutures. The nerve coaptation usually takes place
close to its entry site into the muscle unit. The exact posi­
tion of the pedicle and the anastomotic site is marked with
a temporary suture on the skin to facilitate postoperative
Doppler monitoring and the cheek flap is closed in layers
(Fig. 15.15).
PECTORALIS MINOR
A small 4 cm incision is made posterior to the contralateral
anterior axillary fold. Dissection is carried down under­
neath the lateral margin of the pectoralis major towards
the pectoralis minor muscle (see Fig. 11.1). Dissection pro­
ceeds to its origin off the coracoid process and insertion
into the 3rd, 4th, and 5th ribs. The lateral margin of the
pectoralis minor is then lifted and the lateral thoracic and
the thoracoacromial vessels are identified. The dominant
artery is confirmed, more often the lateral thoracic. The
medial pectoral nerve is identified with the lateral thoracic
artery and the lateral pectoral nerve is identified with the
thoracoacromial artery. The in situ tension is recorded by
placing 6-0 sutures on its inferior margin every 1 cm. The
insertion is then detached from the coracoid process and
the fascial origin slips from the ribs are released attempting
to preserve the fascia slips as long as possible. The entire
muscle is left on its pedicle until the time of transfer. A
Figure 15.15  Free gracilis muscle transfer for smile restoration.
(A) A 34-year-old woman with right facial paralysis secondary to
brainstem arteriovascular malformation removal. With a denervation
time of 2 years and 6 months, she first underwent a “babysitter”
procedure (CFNGs ×3 and a split hypoglossal to facial nerve transfer).
Inadequate smile restoration necessitated a free gracilis transfer to
the right face for smile restoration. At 21 months later she had revi­
sional surgery. The patient is shown after the temporalis transfer and
before the free gracilis transfer. Note profound asymmetry when
smiling. (B) The patient 9 months post-free gracilis transfer, showing
an acceptable smile and an adequate commissure pull.
A
B

178
PART 3 — RECONSTRUCTION
the clavicle. The great auricular nerve and the external
jugular vein are preserved. At the lateral border of the
upper-third of the muscle, the cervical branch of the facial
nerve that supplies the platysma is isolated. The platysma is
then freed inferiorly and the flap is brought cranially. The
dominant artery to the muscle lies 2 cm below the mandibu­
lar margin, and is carefully preserved. The muscle, once
freed caudally is sculptured in two segments distally up to
the level of its vascular pedicle. Subsequently, a wide subcu­
taneous tunnel is formed from the submandibular incision
to the ipsilateral modiolus. Additional tunnels are created
from the modiolus to the contralateral commissure. The
two slips of the platysma are then guided to the intraoral
incision at the ipsilateral modiolus and then through the
upper and lower lips to the contralateral commissure.
The lateral slip of the muscle is passed across the philtrum
to the contralateral side while the medial slip is passed
across the lower lip to the contralateral modiolus. The two
slips are anchored in place, to the remnants of the OOrM
with non-absorbable 4/0 sutures, thus substituting the
paretic oral sphincter.53
DEPRESSOR
Minihypoglossal to Cervicofacial Nerve Transfer
The hypoglossal nerve is explored through a submandibular
incision. The main nerve trunk proximal to the ansa is iso­
lated. The cervicofacial branch of the ipsilateral facial nerve
is then identified in the cranial part of the wound. Under
magnification, using a diamond knife, the epineurium and
perineurium of the hypoglossal nerve is split and a perineu­
rial window made. The cervicofacial branch of the facial
nerve is cut proximally just at the bifurcation of the facial
nerve into its two main branches. The distal end of the
divided cervicofacial branch of the facial nerve is brought
inferiorly and is subsequently coapted in an end-to-side
fashion to the hypoglossal nerve, at the perineurial window
by using 9-0 nylon sutures.
Platysma Transfer
The platysma muscle is exposed using the same technique
as described above. After the vascular pedicle is identified,
the dissection is performed above and underneath the
muscle. A subcutaneous tunnel is made from the lateral
submandibular incision to a lateral intraoral incision. The
lateral two-thirds of the muscle are usually harvested by
splitting the distal platysma along its long axis to the level
of its vascular pedicle. The muscle is then guided through
the tunnel and anchored to the ipsilateral lower lip by
several slips. The insetting tension is estimated from experi­
ence and by studying the preoperative videotapes.
Digastric Transfer
The anterior belly of the digastric muscle and the digastric
tendon are mobilized through a curved incision in the sub­
mandibular triangle. The anterior belly of the digastric
muscle is mobilized up to the inferior border of the man­
dible, with care taken to preserve the neurovascular bundle
that enters the muscle laterally on its deep surface. It is
important to include the whole extent of the digastric
tendon with the transferred muscle to guarantee adequate
length for insertion into the ipsilateral lower lip. Attention
of 5-0 propylene horizontal mattress sutures. The attached
fascia-pericranium extension is then divided into several
slips, on the basis of the movements that needs augmenta­
tion so that symmetry while smiling is achieved. Tunnels are
created of adequate width for the easy passage of the tem­
poralis and its fascial sips. If the minitemporalis transfer was
preceded by a free muscle at an earlier stage, then tunneling
is carried out underneath the free muscle. The temporalis
is more often guided over the zygomatic arch and less often
tunneled underneath. Often, the thickness of the arch is
lessened, so as to diminish any noticeable bulk of the trans­
ferred muscle. Through intraoral incisions the fascial slips
are anchored under appropriate tension to the modiolus
and/or upper lip depending on the preoperative deformity
and meticulous intraoperative evaluation of the patient’s
videos. In all cases, a degree of overcorrection is achieved
which decreases with time. Customized external splint that
supports the anchoring points is used by all patients.
Blended diet for the first month, physical therapy for smile
training starting at 6 weeks and systematic follow-up is
scheduled for all patients.
PLATYSMA FOR ORAL SPHINCTER RESTORATION
The anterior surface of the platysma is exposed through a
submandibular incision. Inferiorly, the dissection extends to
Figure 15.16  Free pectoralis minor transfer for smile restoration. (A)
A 7-year-old boy with right developmental facial paralysis. Note
asymmetry and deformity when smiling. The patient underwent
cross-facial nerve grafting (CFNGs) ×3, followed by a left free pecto­
ralis minor transfer to the right cheek 1 year later. One year after that,
he underwent revisional surgery. (B) The patient 3 years and 7 months
after the free pectoralis minor transfer pleasing and rewarding smile
symmetry.
A
B

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
179
The distance from the coaptation to the tip of the ipsilateral
side of the tongue is measured, and about 3–4 cm of extra
graft length is allowed to take care of the movements of the
neck and tongue. A malleable metal tunneler is then passed
from the neck incision progressing to the base of the tongue
and subsequently to the tip of the tongue. The tunnel
follows the normal path of the hypoglossal nerve along its
ending at the tip. Through a stab incision, the metal tun­
neler is expressed at the tip of the ipsilateral tongue. The
distal end of the sural nerve is sutured to the hole at the
end of the tunneler at the neck incision. While using saline
irrigation, the nerve graft is tunneled from the neck incision
to the tip of the tongue. Its distal end is divided in two to
three fascicles, which are then implanted to the tip of the
tongue and allowed to ramify. The stab incision is closed
with 7-0 polydioxanone suture. An end-to-side coaptation
through a perineurial window and partial neurectomy are
performed with the accessory nerve, and an end-to-end
coaptation is carried out with the C7 root. At the completion
of the neurorrhaphy, the neck incision is closed in two
layers.
REVISIONS
Panfacial reanimation includes a wide range of challeng­
ing multistage procedures with functional and aesthetic
outcomes, which on occasion require enhancement and
refinement due to factors such as the multiplicity and
advanced level of procedures that sometimes even skillful
surgeons can meet with difficulty; the severity of the defor­
mity; the patient’s brain plasticity; the patient’s compliance;
and the patient’s inherent healing potential. These second­
ary interventions are usually procedures at the third or
rarely higher stage of reconstruction and require meticu­
lous planning after taking consideration of the desires of
the patient and the degree of functional and aesthetic
outcome.
The strategy during revisions include a systematic evalu­
ation of all three facial regions, the sites that need muscle
strengthening and final refinements for restoration of a
harmonious facial symmetry and panfacial reanimation.
Muscle function augmentation is achieved by the provision
of additional innervation from an ipsilateral motor donor
(other than the facial nerve) via an interposition nerve
graft or by direct neurotization, which involves the implan­
tation of the motor donor graft directly into the muscle.
Revisions for eye closure and blink usually assist the
dynamic procedures for eye sphincter reanimation that pre­
ceded them. This category includes static procedures such
as the gold weight and eye spring for the upper eyelid and
the minitendon graft to suspend the lower eyelid. Local
Z-plasties, lateral and medial canthoplasties, conjunctivecto­
mies, lacrimal punctum repositioning, wedge excisions,
browlifts, webbing corrections, and blepharoplasties, may
also be included in the final revisions for the improvement
of function and aesthetics of eye reanimation.
Muscle substitution refers to the substitution of either the
denervated or irreversibly weak native facial muscles or addi­
tional transfers of regional or free muscles which substitute
or assist the previously transferred muscle. Example of the
latter is the minitemporalis muscle transposition to the oral
is taken to preserve the submental branch of the facial
artery and the accompanying vein. The nerve to the digas­
tric muscle is severed and tagged for coaptation with the
previously placed cross-facial nerve graft. Subsequently, the
mandibular origin of the digastric muscle is severed and the
muscle is transferred laterally, so that the direction of down­
ward pull will reproduce the excursion of the contralateral
lower lip. A tunnel is made from the submandibular incision
to a lateral intraoral incision placed laterally on the ipsilat­
eral lower lip. The digastric tendon is then split longitudi­
nally into four strips and each strip is tunneled separately
and anchored to the orbicularis oris muscle at four different
sites. The length of each tendinous strip is determined
by viewing preoperative videos and attempting to repro­
duce the depressor function of the contralateral lower lip
(Fig. 15.17).
TONGUE MOVEMENT AND BULK
First, the identification of the accessory or of the ipsilateral
C7 root is achieved through an incision along the posterior
border of the sternocleidomastoid. Intraoperative micro­
stimulation and nerve identification takes place. Nerve
grafts are brought in opposition to the respective donor.
Figure 15.17  Digastric muscle transfer for depressor restoration.
(A) This is a 4-year-old boy with right developmental facial paralysis.
Note the absent depressor function on the right side and lower
face asymmetry. The patient underwent cross-facial nerve grafting
(CFNGs) ×4 followed by a free gracilis transfer for smile restoration,
12 months later. At 14 months later, the patient underwent digastric
muscle transfer for depressor complex substitution along with other
revisional surgery. (B) The patient 3 years after the digastric transfer
showing symmetrical and coordinated lower lip depression.
A
B

180
PART 3 — RECONSTRUCTION
patients to smile and then bite and smile in cases where the
mini temporalis has been transferred to the upper lip, or
asking them to push their tongue against their front teeth
and activate the hypoglossal nerve and smile in cases where
the babysitter procedure has been performed. High brain
plasticity and capacity to embrace new muscle targets play a
central role in re-education and training the new muscle
and this is the reason why children need very little retrain­
ing in comparison with the adults who have decreased brain
plasticity capabilities.
DISCUSSION
Facial expressivity is the cornerstone of socio-psychological
development and overall emotional well-being due to its
fundamental role in interpersonal communication and
interaction. Facial palsy eradicates the functional and emo­
tional potential of the face and deprives the patient from a
fundamental “organ” of personal growth and prosperity.
Moreover, in a society which is so focused on external
appearance the restoration of symmetry and synchronous
animation is a highly desirable goal.
Therefore, the rapidly increasing interest in facial reani­
mation procedures since the early 20th century, is expected
and well justified.
Nevertheless, many Centers have focused primarily on
the restoration of smile, neglecting reanimation of the eye
sphincter, blink, and depressor complex. In the past, paraly­
sis of depressor muscle function has been addressed by
surgeons trying to achieve static symmetry by selective myec­
tomy or neurectomy of the normal side. Such approaches
often led to bilateral depressor function paresis, functional
incompetency, and drooling of the oral sphincter.
In contrast, in our Center, we aim at panfacial reanima­
tion of all three facial regions. The dynamic restoration of
the depressor function has always had an integral place in
facial reanimation. The use of CFNG introducing fibers
from the contralateral selectively neurectomized facial
nerve branches is the preferred way of reconstruction, with
or without a hypoglossal babysitter, depending on the
denervation time.
On the other hand, Klebuc54 recommends, the use of the
masseteric nerve as an ideal motor donor (either as a baby­
sitter along with CFNGs or alone) for innervating free
muscles used for facial muscle substitution because it has
collateral branches (no interposition grafts needed), it pro­
duces stronger (than the CFNGs) contraction and com­
prises a single stage procedure. It may not lead to a
spontaneous smile but he claims that the muscle is activated
without biting in >80% of patients and that >50% require
no conscious effort to produce a smile. Singham and col­
leagues55 had previously reported satisfactory results in chil­
dren with Moebius syndrome but it was not possible to
compare results with contralateral facial motor donors due
to the syndromic bilateral FP. Although the fact that it is a
single stage procedure is an undeniable advantage, the
claim that 80% recover coordinated bilateral smile is debat­
able if not questionable.
In the authors’ Center, CFNGs remain the backbone of
facial reanimation procedures and provide optimal motor
fiber input of the same developmental pathway and origin
commissure following the previously performed free gracilis
transfer for levator substitution (see above).
In some cases, although the muscle that was transferred
to substitute a native facial muscle has optimum innervation
and contractility, its pull still needs augmentation or
refinement. In these cases, muscle repositioning and/or
re-anchoring corrects the tension and direction of the oth­
erwise fully functional muscle and augments its function
and final aesthesis.
Selective neurectomies and myectomies are also included
in cases where the disproportionate force of a free muscle
needs to be diminished to achieve symmetry. Alternatively,
the same result is achieved by providing additional muscle
to counteract the excessive pull of the muscle on the oppo­
site side or the pull of an antagonist muscle on the same
side (e.g., contralateral platysma flap transposition to the
opposite commissure to counteract excessive pull by free
gracilis for smile). Botox injections to the overactive muscle
also help but their result is temporary and diminishing
in time.
Additional local revisions on the midface and lower face
may include cheek defatting and debulking using liposuc­
tion or surgery, alar base repositioning, rhinoplasty, carti­
lage grafts to nasal ala, dermal fat graft in the lips for
vermillion deformities, or fat injection in the cheek for
cheek contouring, vascularized fascia flap transfer either
folded (like a burrito) and filled with harvested fat for bulk
restoration or used to envelope a free muscle and facilitate
gliding and eliminate cheek “wrinkles or pleats.” Addition­
ally, facelifts, cheiloplasties, scar revisions at the nasolabial
fold, chin and malar implants, neck defatting, and platysma
plication, may be performed as needed to maximize the
result.
POSTOPERATIVE REHABILITATION
Early postoperative care includes: the uneventful recovery
of the patient from anesthesia; the application of the neces­
sary head dressing and/or customized external splint that
maintains the free muscle (if included in the operation);
flap monitoring per standardized protocol using Doppler;
meticulous physical examination during the first 3 days; and
eventual discharge with a rhytidectomy-type face mask.
Patients are allowed to consume blended food for 1 month
with minimal mastication. At 6–7 weeks following surgery,
ultrasound therapy begins for 6 weeks to enhance healing,
facilitate gliding, and decrease edema and scar formation.
Long-term postoperative rehabilitation aims to re-educate
the patient to use the new neural pathways or new muscle
targets for synchronous, coordinated panfacial animation.
Patients who experience delay in the appearance of contrac­
tions of the transferred muscle (>6–8 months) or patients
who had direct neurotization of partially denervated
muscles, are put on a slow-pulse stimulator. The longer the
denervation, the longer the pulse width required to gener­
ate a contraction. The setting of the stimulator is calibrated
during the postoperative visit after repeat needle EMG.
By the time the first contractions appear, patients start
practicing a set of standardized exercises in front of a mirror
that correspond to the special functions of the new muscles
and the donor motor nerves. Examples include asking the

CHAPTER 15 — Facial Reanimation: Evolution a nd Refinements
181
2. Patients’ age, denervation time and FP etiology deter­
mine the prognosis of the condition, and the type and
success of the applied treatment.
3. Immediate primary nerve repair yields the best out­
comes. If denervation time is ≤6 months, the native facial
muscle can be effectively reanimated by means of CFNGs.
In patients with FP of >6 months’ to <27 months’ dura­
tion, with evidence of remaining facial muscle function
after needle EMG, the babysitter procedure combined
with CFNGs is strongly recommended. If the denervation
time is over 27 months and the preoperative EMG is
silent, without any fibrillations, CFNGs are used for neu­
rotization of free (or pedicled) vascularized muscle trans­
fer for native facial muscle substitution.
4. For motor donors, the contralateral selectively neurecto­
mized facial nerve branches are selected first, followed
by ipsilateral powerful cranial nerves (hypoglossal, tri­
geminal, accessory nerve) and lastly by the C7 root.
CFNGs enable the synchronous coordinated animation
because they carry the contralateral motor fibers which
play the role of pacemaker for simultaneous bilateral
contraction. Other motor donors may enable strong but
not synchronous, coordinated function.
5. Revisions and ancillary procedures, early and long-term
postoperative monitoring and rehabilitation, as well as
the systematic short- and long-term follow-up and docu­
mentation are crucial factors that determine the func­
tional and aesthetic outcome.
6. Ultimate goal in the treatment of FP is restoration of
coordinated panfacial animation and symmetry and res­
toration of emotional spontaneity and expressivity at all
three levels: upper face, midface, and lower face.
(according to embryological evidence), that “wire” the free
muscle centrally with the facial nerve nucleus and enable
the spontaneous and coordinated muscle contraction that
restores a coordinated spontaneous animation. For those
patients who are older with comorbidities or not fit to with­
stand prolonged surgery, or patients who prefer a one-stage
procedure and desire to have early results, and those who
already had a free muscle transfer and obtained inadequate
results, regional muscle transfers are the reasonable alterna­
tive. The choice of which muscle to use, depends on the
preoperative condition of the muscle as depicted by needle
EMGs and the direction of required pull. A significant dis­
advantage is the fact that the transferred muscles that are
innervated by other cranial nerves, produce movements
that are not coordinated with the animation of the normal
face and require the patients’ conscious efforts to activate
the muscle, for example, by biting or raising their shoulder
when they smile. With extensive re-training, especially in
compliant adults, the brain will eventually incorporate the
new muscle function and some degree of coordinated
movement may develop. Younger motivated and compliant
patients with long-standing paralysis are the best candidates
for free muscle transfers after CFNGs. Figure 15.18 sum­
marizes our treatment algorithm.
CONCLUSIONS
1. Meticulous preoperative evaluation (history, physical
examination, imaging, EMG studies) is of paramount
importance in order to establish the optimal individual­
ized reconstructive strategy.
Figure 15.18  PANFACIAL reanimation treatment algorithm.
Denervation time 6 months
9–12 months later
OR
OR
9–12 months later
9–12 months later
CFNG’s procedure: 2–4
grafts for eye, smile and
depressor restoration
If augmentation of
function needed:
neurotizations: eye
sphincter, depressor,
levator
Proceed with revisions
Adequate results
Adequate results
Adequate results
Secondary microcoaptations
Denervation time with a range of
6 months to 27 months
“Babysitter” procedure: (40% of the ipsilateral
XII nerve) + CFNGs procedure (2–4)
Inadequate results
Eye: palpebral eye spring or gold weight implant  minitendon graft
Smile: minitemporalis
Smile: Free muscle (gracilis)  1 CFNG
Eye: eye sphincter substitution (platysma
or temporalis)  1 CFNG
PANFACIAL reanimation treatment algorithm
Denervation time 27 months
CFNG’s procedure: 2–4 grafts
for eye, smile and depressor
restoration

182
PART 3 — RECONSTRUCTION
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of facial paralysis. Plast Reconstr Surg 1974;53:384–7.
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restoration of dynamic depressor muscle mechanism: a neglected
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1917–31.
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1905–21.
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Plast Surg 2004;18(1):39–46.

183
Breast Reconstruction
Maurice Y. Nahabedian 16 
INTRODUCTION
Autologous options for breast reconstruction have greatly
expanded since the initial descriptions of the latissimus
dorsi musculocutaneous flap and the transverse rectus
abdominis musculocutaneous (TRAM) flap. In many ways,
these two flaps have provided the cornerstone for many of
the autologous options that are currently available. Through
ingenuity and innovation, plastic surgeons have pioneered
a variety of flaps that are currently in use in order to reduce
donor site morbidities and to maintain high aesthetic
quality. Perforator and muscle-sparing flaps are now derived
from virtually all territories of the body and include the
abdomen, posterior and lateral thorax, gluteal region, as
well as the medial and posterior thigh. Some of these flaps
are robust and can provide large volumes for total breast
reconstruction and others are ideally suited for partial
breast defects.
Given the diversity in flap characteristics and the various
donor sites, the ability to properly evaluate and select
patients for autologous reconstruction is important. This
entails evaluation of the anatomy, breast volume require­
ments, and donor site considerations. This chapter will
focus primarily on the various autologous options that are
currently in use for breast reconstruction with an emphasis
on principles and techniques.
ANATOMY OF THE BREAST
An understanding of breast anatomy is an important con­
sideration for the reconstructive surgeon. The breast
borders extend from the inframammary fold to the 2nd rib
and from the midaxillary line to the medial sternal border
(Fig. 16.1). It is important to appreciate the natural foot­
print of the breast when considering autologous reconstruc­
tion. The breast is comprised of lobes, lobules, ducts, and
fat that are enclosed within the investing fascia of the breast.
Preservation of the subcutaneous adipose tissue and subder­
mal vascularity is important to maintain the quality of the
post-mastectomy skin envelope. The vascularity of the breast
is derived from multiple sources that include the internal
and lateral mammary perforators, pectoral perforators, and
the thoracoacromial vessels (Figs 11.1, 11.2). The innerva­
tion to the breast is via the medial and lateral pectoral
nerves, as well as the long thoracic nerve. Cutaneous sensa­
tion to the breast is derived from the sensory branches of
the 1st through 6th thoracic rami (Fig. 11.2). Lymphatic
ducts of the breast drain toward the axillary, supraclavicular,
and internal mammary lymph node basins.
PREOPERATIVE CONSIDERATIONS
When evaluating women for autologous breast reconstruc­
tion, several factors should be considered that are related
to specific characteristics of the patient and breast.1 These
include breast volume and contour, body habitus, recon­
structive volume requirements, donor site considerations,
medical comorbidities, tumor characteristics, patient pref­
erences and expectations, as well as the potential need for
adjuvant therapy. Many women are now choosing to have
prophylactic mastectomy and as a result, aesthetic expecta­
tions are high. Thus, it is important that plastic surgeons
select options and operations that they are comfortable
with, are safe and effective, are predictable and reproduc­
ible, and are associated with high rates of success and good
outcomes.
Perhaps the most important determinant of a good
outcome following autologous reconstruction is proper
patient selection. With the myriad autologous options avail­
able and the wide variation in body habitus, there is usually
a flap that will be suitable for most patients. With the epi­
demic nature of overweight and obese patients, the abdomen
remains the most commonly used donor site for most plastic
surgeons. Prior to flap selection, it is important to perform
a thorough physical exam, calculate BMI, and obtain appro­
priate diagnostic tests on all patients considering breast
reconstruction. In women with a BMI <30, immediate autol­
ogous reconstruction can usually be safely performed
assuming that there is sufficient donor site tissue and that
there are no oncologic contraindications. In patients with a
BMI ranging from 30–39, immediate autologous reconstruc­
tion can still be performed but will be dependent upon
other comorbidities such as diabetes mellitus and tobacco
use, as well as cardiac or pulmonary disorders. In these
patients, appropriate medical management and control of
comorbidities is recommended before reconstruction is
offered. In patients that are morbidly obese (BMI >40),
immediate reconstruction is usually not recommended
because of the higher incidence of adverse events. These
PART 3  —  RECONSTRUCTION

184
PART 3 — RECONSTRUCTION
who are overweight or obese, a flap can still be performed;
however, the flap should be tailored to sustain its perfusion
requirement and to minimize the incidence of fat necrosis.
Abdominal flaps may be contraindicated in the presence of
multiple scars, especially when located in the vicinity of the
primary vascular pedicle or the principal adipocutaneous
perforators.2 In these patients, preoperative vascular imaging
should be considered. A large abdominal pannus or extreme
lipodystrophy may also preclude autologous reconstruction.
patients are usually advised to proceed with the mastectomy
but consider delayed reconstruction following a defined
period of weight loss.
When considering flap selection, an important assess­
ment on physical examination is a sufficient quantity of skin
and fat in order to reconstruct a breast that will meet expec­
tations. Although a woman may be slender with a paucity of
fat, she may still be a candidate for autologous reconstruc­
tion if the breast volume requirements are low. In women
Figure 16.1  Anatomy of the breast. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Anatomy of Breast
Lymphatic drainage of breast
Axillary pathway
Interpectoral pathway
Internal mammary pathway
Thoracic duct
Scapular lymphatics
Thoracodorsal vessels
External mammary
lymphatics
Lateral thoracic vessels
Long thoracic nerve
Pectoralis major m.
Breast
Internal mammary
vessels and lymphatics
Latissimus dorsi m.
Serratus anterior m.
External oblique m.
Rectus abdominis m.
Cervical lymphatics
Supraclavicular
lymphatics
Pectoralis
minor m.
Interpectoral
lymphatics

CHAPTER 16 — Breast Reconstruction
185
preoperative imaging and was the first of the highly accurate
methods of perforator assessment.5,7,8,10 Its use has been
primarily directed toward abdominal flaps to identify perfo­
rator location but can also be used in the gluteal, posterior
thorax, and thigh regions. The benefits of CTA include
anatomic localization of the perforators, determination of
the course of the perforator through the muscle, compara­
tive assessment of the right and left vascular anatomy, and
elucidation of anatomic detail of the medial and lateral row
perforators (Fig. 16.2). CTA will not reduce complications
related to the anastomosis, flap failure, occurrence of fat
necrosis, and complications relayed to dehiscence or delayed
healing. CTA is especially useful in the setting of prior
abdominal surgery. Paramedian abdominal incisions have
been demonstrated to be the most disruptive to the perfora­
tors and the primary source vessels, whereas, laparoscopic
incisions were the least disruptive.
MAGNETIC RESONANCE ANGIOGRAPHY
Magnetic resonance angiography (MRA) represents a non-
ionizing option for vascular imaging.9,11–13 When compared
The most common autologous donor sites include the
abdomen, posterior thorax, gluteal region, and thigh.
For women that are in need of partial breast reconstruc­
tion, the options are adjusted because the volume require­
ments are usually less.3 In these cases, the posterior or lateral
thorax is usually considered rather than the abdomen
because these donor sites supply less tissue than the
abdomen and also because the abdomen is usually pre­
ferred for total breast reconstruction. Typical flaps for
partial breast reconstruction include the latissimus dorsi
(TD); thoracodorsal artery perforator (TDAP); intercostal
artery perforator (ICAP); and internal mammary artery per­
forator (IMAP) flaps. An important consideration in these
patients is the location of the defect. Most of these posterior
thoracic flaps are excellent for lateral or inferior defects but
may be not be possible for medial defects because of the
limited arc of rotation. The IMAP flap is sometimes a better
option for medially based defects.
INDICATIONS FOR AUTOLOGOUS
RECONSTRUCTION
The indications for autologous reconstruction are variable
and include women that do not want prosthetic reconstruc­
tion, have a sufficient quantity of donor site tissue, have had
a prior failed prosthetic reconstruction, or have had prior
radiation to the breast or chest wall. In the United States
these women constitute approximately 25% of the patients
who have breast reconstruction following total or partial
mastectomy.4
PREOPERATIVE IMAGING
Preoperative imaging of the vascular architecture has been
demonstrated to be useful for operative planning (Table
16.1). It enables surgeons to identify suitable perforators
and to determine the patency of primary source vessels. It
is often considered for the abdominal and gluteal flaps.
Imaging modalities that are currently available include
duplex ultrasound, computerized tomographic angiography
(CTA), and magnetic resonance angiography (MRA).5–13
COMPUTERIZED TOMOGRAPHIC ANGIOGRAPHY
Computerized tomography angiography is considered by
many plastic surgeons to represent the gold standard for
Figure 16.2  CT angiogram demonstrating the anatomy, location,
and course of the deep inferior epigastric artery and vein.
Table 16.1  Comparative chart of the various preoperative imaging modalities
Test
X-Ray
Contrast
Caliber
Location
Flow
Course
Accuracy
Doppler
No
No
No
Yes
No
No
Low
Color duplex
No
No
No
Yes
Yes
No
Moderate
CTA
Yes
Yes
Yes
Yes
No
Yes
High
MRA
No
Yes
Yes
Yes
No
Yes
High
CTA, computerized tomographic angiography; MRA, magnetic resonance angiography.

186
PART 3 — RECONSTRUCTION
demonstrate perfusion patterns within the flap. However,
there has been no quantitative method to evaluate flap
perfusion in the period immediately prior to or following a
microvascular anastomosis.
FLUORESCENT ANGIOGRAPHY
Fluorescent angiography is a relatively new technology that
allows direct visualization of perfusion within a cutaneous
territory.14–17 This application can be used on tissue that is
elevated as a flap or on a cutaneous territory that has not
been elevated (Fig. 16.4). The images are captured follow­
ing the intravenous injection of indocyanine green (ICG).
with CTA, MRA has lower spatial resolution but greater
contrast resolution. This enables MRA to detect very small
perforators that might otherwise be missed on CTA. As with
CTA, MRA provides useful information regarding perfora­
tor location, size, and distance from the umbilicus. Its accu­
racy and reliability are high based on preoperative and
intraoperative analysis in which all perforators visualized on
MRA using a gadolinium-based contrast agent were found
intraoperatively. In all patients, the location of each perfora­
tor was within 1 cm of that predicted using MRA. MRA can
also successfully predict the preferred use of an SIEA flap
instead of the DIEP flap based on imaging characteristics.
MRA is also useful for imaging gluteal flaps and can assist
with the decision to choose an IGAP or an SGAP. One study
demonstrated that the superior gluteal artery was respon­
sible for 57.5% of all gluteal perforators,13 the inferior
gluteal artery was the source for 35% of the gluteal perfora­
tors, and the deep femoral system was the source for 7.5%
of the perforators.
DUPLEX ULTRASOUND
Duplex ultrasound remains a useful tool but is less com­
monly utilized than either CTA or MRA.6,7 Its primary appli­
cation is for abdominal flaps such as the pedicle and free
TRAM, and is able to provide useful information related to
the location, caliber, and flow patterns of the perforators. It
is also useful to differentiate between arterial and venous
flow patterns. The differentiating benefit of duplex ultra­
sound compared with CTA and MRA is the ability to deter­
mine flow direction and velocity. Studies evaluating
perfusion of the TRAM, DIEP, and SGAP flaps, have dem­
onstrated that the highest flow and velocity was achieved in
the TRAM flap following by the DIEP and SGAP flaps.
Typical flow measurements for the vessels that perfuse these
flaps include the deep inferior epigastric artery (10–11 mL/
min), the superior gluteal artery (9–11 mL/min), and the
internal mammary artery (25–30 mL/min). The principal
limitation of the color duplex is that it cannot provide
3-dimensional or architectural detail of the perforator
system. Other limitations include a relatively high number
of false-positive results (46%) using the handheld Doppler
for localization of perforators. Comparative studies have
demonstrated that CTA was superior to Doppler, based on
visualization of the DIEA, its branching pattern, and the
perforators.
INTRAOPERATIVE ASSESSMENT AND
MONITORING TOOLS
There are a variety of methods and techniques that can be
used to assess flap perfusion intraoperatively. Traditionally,
surgeons have evaluated the color of the flap to determine
if the perfusion is normal, congested, or pale. Surgeons
have also employed the handheld acoustic Doppler and
auscultated the signals of the pedicle and the cutaneous
perforators (Fig. 16.3). Arteriovenous bleeding from the
cut edges of the flap is generally regarded a sign of adequate
perfusion. Zone 4 of the abdominal free flap is often poorly
perfused and cannot be reliably transferred because of
the risk of fat necrosis. A fluorescent Woods lamp can
Figure 16.3  The pencil Doppler is used to monitor the arterial and
venous signals following free flap reconstruction.
Figure 16.4  Fluorescent angiography is used to detect zones of
perfusion and relative perfusion gradients vascularized flaps.

CHAPTER 16 — Breast Reconstruction
187
ABDOMEN
DIEP FLAP (see Ch. 57)
The deep inferior epigastric perforator (DIEP) flap has
become the most commonly utilized option for autologous
breast reconstruction.18–23 The blood supply to the anterior
abdominal wall is derived from the superior and inferior
epigastric vascular systems (Fig. 16.5). The inferior system
is composed of the deep inferior epigastric artery and vein
as well as the superficial inferior epigastric artery and vein.
The deep system is usually the dominant and is therefore
preferred in the majority of cases. The superficial system is
less predictable, often not present, and therefore less com­
monly used; however, in some cases (<5%) the superficial
system provides the dominant venous drainage to the adi­
pocutaneous component of the anterior abdominal wall.
This fact may explain the problem of venous congestion that
is observed in some DIEP flaps, despite a patent venous
anastomosis.24
An understanding of the perforating system and primary
source vessels for abdominally based flaps is critical when
considering their use. The “Gent” consensus described the
five most common perforator types based on location,
branching patterns, and diameter.25 In general, for a DIEP
flap to be successfully harvested and transferred, a single
perforating artery and vein of at least 1.5 mm in diameter
is recommended. If a dominant perforator arising from the
deep system is not identified, it may be because the super­
ficial inferior epigastric system is the more dominant.
Successful harvest of a DIEP flap requires precise perfora­
tor identification, dissection, and preservation. Specific
techniques will vary from surgeon to surgeon but in general,
are based on similar principles and concepts. Only a few
surgical instruments are necessary that include a fine tip
mosquito clamp, Weitlaner retractors, fine scissors, tissue
forceps, and a low set mono- or bipolar electrocautery unit.
The selected perforator should be ideally located near the
center of the flap in order to obtain equidistant perfusion.
A minimal perforator diameter of 1.5 mm is usually recom­
mended. When several perforators are available, sequential
occlusion can be performed to assist with the selection
process (Fig. 16.6). Multiple perforators can be considered
when they are aligned in series or in close proximity. Medial
row perforators are preferred when the reconstruction
requires the inclusion of Zones 3 and 4 on the opposite side
of the midline. Perforators in the lateral row are usually
more closely intertwined with the intercostal motor nerves
of the rectus abdominis muscle, and excessive dissection
in that area may predispose to nerve injury and motor
weakness.
When initiating the perforator dissection, the location of
the tendinous inscriptions is important. Sometimes the per­
forator penetrates this region of the anterior rectus sheath
and, in those cases, including a small cuff of the anterior
rectus sheath (1–2 mm) around the perforator is recom­
mended (Fig. 16.7). During the dissection it is imperative
to preserve the lateral intercostal nerves as they pierce the
rectus abdominis muscle at the junction of the lateral and
central longitudinal segments. Failure to do so will likely
result in abdominal weakness or bulge. Motor nerve
branches that cross the perforator or the source vessel
should be sharply divided in order to elevate the flap.
An image-capturing laser is then positioned a few inches
above the cutaneous territory to be imaged. This device is
linked to a computer that analyzes the data and generates
a real-time image based on the fluorescence of the ICG.
Images are obtained about 15 s after the ICG injection. In
the setting of flap reconstruction, the images can be cap­
tured prior to, during, and following flap elevation, as well
as postoperatively.
Evaluation of the reliable vascular territory of the cutane­
ous portion of an abdominal flap was one of the first appli­
cations of fluorescent angiography in the setting of
autologous reconstruction. It was demonstrated that classic
perfusion zones described by Hartrampf were not quite
accurate in that the distal segment of the flap laterally adja­
cent to Zone 1 was better perfused than the medially adja­
cent territory on the other side of the midline. Other clinical
applications have included assessing perfusion in various
free tissue transfer operations that include the TRAM, DIEP,
SIEA, and SGAP. It was demonstrated that areas with relative
hypoperfusion went on to develop areas of necrosis or
eschar formation. Inflow and outflow of the microvascular
anastomosis are easily visualized to confirm patency.
Fluorescent angiography is also useful in evaluating viabil­
ity of the mastectomy skin flaps in the setting of immediate
breast reconstruction. Fluorescent angiography is able to
determine the perfusion thresholds of the skin following
mastectomy and predict whether the skin will remain viable
or not. Fluorescent angiography is beneficial, especially in
cases of mastectomy with nipple areolar preservation. Alter­
ations in perfusion can be noted despite what appears to be
normal. In patients with a history of tobacco use or with
connective disuse disorders, fluorescent angiography can
help determine if further debridement is necessary.
SURGICAL PROCEDURES
The abdomen is the preferred donor site for the majority
of breast reconstruction procedures and is the source for
the pedicle TRAM, free TRAM, DIEP, and SIEA flaps. Inher­
ent to understanding these flaps is an appreciation for the
various types of muscle preservation techniques. Classifica­
tion of muscle sparing is based on the amount of rectus
abdominis preserved (Table 16.2). Most muscle-sparing
operations will require free tissue transfer. The next section
focuses on the various flaps based on body region of harvest.
Table 16.2  Classification of muscle sparing
Muscle sparing
technique
Definition (rectus abdominis)
MS-0
Full width, partial length
MS-1
Preservation of lateral segment
MS-2
Preservation of lateral and medial
segment
MS-3 (DIEP)
Preservation of entire muscle
DIEP, deep inferior epigastric perforator.

188
PART 3 — RECONSTRUCTION
dissection continues within the retromuscular plane and
progresses from the lateral edge of the muscle toward the
iliac vessels. Some surgeons prefer to dissect the source
vessel to its origin in order to optimize the length and the
caliber of the vascular pedicle (Fig. 16.9). Some surgeons
prefer to dissect the pedicle to the length and caliber that
is necessary in order to perform a successful anastomosis.
Whether or not to coapt the severed nerve is controversial.
Some advocate using a microsuture for coaptation, whereas
others prefer to allow the cut end of the motor nerve to
neurotize into the adjacent medial segment of the rectus
abdominis muscle. The intramuscular dissection proceeds
to the point that the perforator or inferior epigastric
vessel becomes submuscular (Fig. 16.8). At that point, the
Figure 16.5  Arteries of anterior abdominal wall. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Axillary artery
Lateral thoracic artery
Subscapular artery
Thoracodorsal artery
Anterior
intercostal arteries
Intercostal
muscles
External
Internal
Innermost
Anastomoses with lower
intercostal, subcostal,
and lumbar arteries
External,
Internal
oblique
muscles
Transversus abdominis muscle
Ascending branch of
deep circumflex iliac artery
Superficial
circumflex iliac artery
Superficial
epigastric artery (cut)
Femoral artery
Cremasteric and testicular
arteries and artery to ductus
deferens in spermatic cord
Subclavian artery
Internal thoracic arteries
Pericardiaco-
phrenic
artery with
phrenic nerve
Transversus thoracis
muscle
Branch to falciform
ligament of liver
Musculophrenic
arteries
Superior epigastric
arteries
Diaphragm
Transversus abdominis
muscle and aponeurosis
Rectus abdominis
muscles
Internal
oblique muscle
External
oblique muscle
Posterior layer of
rectus sheath
Arcuate line
Inferior epigastric
artery
Superficial epigastric
artery
Femoral artery
Superficial external
pudendal artery
Deep external
pudendal artery
Dorsal arteries of
penis (deep to
Buck’s fascia)

CHAPTER 16 — Breast Reconstruction
189
Figure 16.10 illustrates a patient following bilateral DIEP
flap reconstruction.
The primary recipient vessels for the DIEP and all free
flaps used for breast reconstruction include the internal
mammary artery and vein and the thoracodorsal artery and
vein (Fig. 16.5).26–28 The internal mammary vessels are
preferred by most surgeons because they are relatively easy
to expose, provide excellent flow characteristics, and are
usually of a more favorable caliber. The internal mammary
vessels are usually used for the most immediate and delayed
reconstructive procedures. The vessels are exposed at either
the third or fourth interspace by excising the cartilaginous
segment. At this level the diameter of the internal mammary
vein is usually 2.5–3.5 mm and the internal mammary artery
is 2.5–3 mm. The thoracodorsal artery and vein can also be
considered; however, given the prevalence of sentinel lymph
node biopsy and the rarity of axillary dissection, these vessels
This technique may minimize trauma to the rectus abdomi­
nis muscle and improve function. Dissection of multiple
perforators can potentially compromise function of the
rectus abdominis muscle if the myotomies are several in
number as well as diagonal or transverse in orientation.
Throughout the dissection of a DIEP flap, it is recom­
mended to assess the perfusion from the peripheral edges
of the flap. This is often achieved by direct visualization
for arterial and venous bleeding as well as by using a hand­
held Doppler probe to listen for the arterial and venous
signals. Fluorescent angiography using indocyanine green
can also be considered because it can identify cutaneous
perforator location and determine the limits of perfusion
within the adipocutaneous territory of the flap.15 When
several perforators are isolated but only one or two are
needed, the extra perforators are preserved until the pedicle
is completely isolated. The extra perforators can be used in
the event that a selected perforator is injured during the
dissection. When in doubt about the quality of the perfora­
tors, a muscle-sparing free TRAM flap can be considered.
Figure 16.6  A column of perforators following elevation of an
abdominal perforator flap.
Figure 16.7  A large perforator as it penetrates the anterior rectus
sheath.
Figure 16.8  A perforator has been dissected through the rectus
abdominis muscle into the retro-rectus space.
Figure 16.9  A three perforator DIEP flap.

190
PART 3 — RECONSTRUCTION
are used less often. However, in the setting of a modified
radical mastectomy where the thoracodorsal vessels have
been exposed, they are routinely preferred.
FREE TRAM FLAP (see Ch. 37)
The decision regarding whether to perform an MS-2 free
transverse rectus abdominis musculocutaneous (TRAM)
flap or DIEP flap is ultimately based on the presence and
quality of the abdominal wall perforating vessels.18–20 Knowl­
edge of these perforators can be assessed either pre- or
intraoperatively as previously described. When a suitable
perforator from the deep inferior vascular system is not
visualized, one can consider performing an SIEA flap or a
muscle-sparing free TRAM. The MS-2 muscle-sparing free
TRAM is the author’s preferred flap in this situation. With
this flap, a small central segment of the rectus abdominis
muscle and anterior rectus sheath (2–4 cm) is harvested
incorporating several small (<1.5 mm) vessels (Fig. 16.11).
An algorithm for the selection of a DIEP or muscle-sparing
free TRAM is depicted (Table 16.3). Figure 16.12 demon­
strates a woman following a left breast reconstruction with
a muscle sparing (MS-2) free TRAM flap.
A free TRAM flap is generally considered when the quality
of perforators is poor (<1.5 mm in diameter), when flap
volume requirements exceed 800 g, or in patients with a
Figure 16.10  (A) Preoperative photograph of a patient scheduled for bilateral nipple sparing mastectomy and immediate reconstruction. (B)
Intraoperative photograph of the rectus abdominis muscle and anterior rectus sheath following bilateral DIEP flap harvest. (C) Intraoperative
photograph demonstrating a single perforator DIEP flap. (D) Postoperative photograph following bilateral nipple sparing mastectomy and
immediate reconstruction with bilateral DIEP flaps.
A
B
C
D
Figure 16.11  A muscle-sparing free TRAM flap (MS-2) is depicted.
moderate to large abdominal pannus. The advantage of the
muscle sparing free TRAM is that multiple perforators can
be included in the flap that may minimize the incidence of
fat and skin necrosis and improve perfusion within the flap.
An MS-1 free TRAM is performed when the perforating

CHAPTER 16 — Breast Reconstruction
191
the DIEP flap dissection, the anterior rectus sheath is usually
elevated off the rectus abdominis muscle laterally in order
to continuously palpate the course of the inferior epigastric
artery. The muscle is then undermined and the submuscu­
lar portion of the inferior epigastric vessels is dissected
toward its origin.
There are several methods by which the free TRAM flap
is harvested. The rectus abdominis muscle is usually split
longitudinally using a fine tip mosquito clamp and a low
setting electrocautery device. Some surgeons prefer mono­
polar and others prefer bipolar electrocautery. The course
of the inferior epigastric vessels is variable and there may be
multiple branches that require ligation. It is important to
preserve the lateral intercostal motor innervation to main­
tain function of the rectus abdominis muscle. Following
harvest of the MS-2 free TRAM flap, the medial and lateral
muscle segments are reapproximated using absorbable
sutures. This will allow for neurotization of the medial
muscle segment. An example of a woman following a bilat­
eral MS-2 free TRAM flap is demonstrated in Figure 16.13.
SIEA FLAP (see Ch. 57)
The superficial inferior epigastric artery (SIEA) flap is an
alternative option that has the advantage of complete pres­
ervation of the rectus abdominis muscle and anterior rectus
sheath (Fig. 16.14).29–32 It is sometimes considered in women
that are of moderate body habitus, in which the superficial
inferior epigastric artery (SIEA) and vein (SIEV) are of suit­
able caliber. In general, the SIEA flap can be performed in
approximately 30% of women because of variations in
caliber and absence; thus, it is recommended to first visual­
ize these vessels before committing to the flap.
vessels are primarily located along the medial or lateral
segment of the rectus abdominis muscle. An MS-2 free
TRAM is performed when the perforating vessels are located
in the central segment of the rectus abdominis muscle.
Once a network of perforators is visualized, an outline along
the anterior sheath is delineated and incised. In contrast to
Figure 16.12  (A) Preoperative photograph of a patient scheduled for left skin-sparing mastectomy and immediate reconstruction. (B) Intra­
operative photograph of the rectus abdominis following MS-2 flap harvest. (C) Intraoperative photograph following fascial closure. (D) Postop­
erative photograph following left breast reconstruction with a MS-2 free TRAM flap.
A
C
B
D
Table 16.3  Individual algorithm for free TRAM,
DIEP, and SIEA flap
Factor
Free TRAM
DIEP
SIEA
Breast volume requirements
<800 g
+
+ +
+
>800 g
+ +
+
No
Abdominal fat
Mild to moderate
+
+ +
+
Severe
+ +
+
No
Perforators >1.5 mm
0
+
No
>1
+
+ +
Bilateral
+
+ +
+
TRAM, transverse rectus abdominis musculocutaneous; DIEP,
deep inferior epigastric perforator; SIEA, superficial inferior
epigastric artery.

192
PART 3 — RECONSTRUCTION
the primary blood supply, the vein can be preserved in the
event that a secondary anastomosis is needed to augment
venous flow. A potential limitation of the SIEA flap is that
the angiosome is usually confined to the ipsilateral flap;
therefore, inclusion of Zone 3 will sometimes result in some
degree of fat necrosis. Thus, the SIEA flap is ideal for women
having unilateral or bilateral breast reconstruction in which
only a hemi flap is used.
An important consideration is that the diameter of the
SIEA be 1.5 mm as it enters the edge of the flap. Lesser
diameters are associated with a higher failure rate. The
Patients are marked in a similar fashion to the free TRAM
and DIEP flaps. A recommended approach is to begin dis­
section with the contralateral SIEA and SIEV. The SIEA flap
is technically easier to harvest than either the DIEP or
muscle-sparing free TRAM flap because it is essentially an
adipocutaneous flap that is perfused by a direct perforator.
The SIEA and vein cross the inguinal ligament at about
one-third the distance from the pubic bone to the ASIS. If
the vessels are of suitable caliber with a palpable pulse, then
the vessels are dissected to their origins and the SIEA flap
is planned. Should the SIEA/V be deemed not useable as
Figure 16.13  (A) Preoperative photograph of a patient scheduled for bilateral mastectomy and abdominal flap reconstruction. (B) Intraopera­
tive abdominal photograph following bilateral MS-2 free TRAM flap harvest. (C) Intraoperative photograph demonstrating closure of the anterior
rectus sheath defect with porcine acellular dermal matrix. (D) Postoperative photograph of the bilateral MS-2 free TRAM flaps. (E) Postoperative
photograph following revision and burying of the flaps to reduce ptosis and improve contour.
A
B
C
E
D
A

CHAPTER 16 — Breast Reconstruction
193
vascular system. The adipocutaneous portion of the pedicle
TRAM flap is identical to that of the free TRAM and DIEP
flaps.
The elevation of a pedicle TRAM requires the full length
and a variable width of rectus abdominis muscle. The
primary purpose of the rectus abdominis muscle is that of
a carrier for the superior and inferior epigastric artery and
vein that provides the blood supply to the adipocutaneous
component. Many surgeons use the entire width of the
muscle (MS-0), whereas others will perform it as an MS-1 or
MS-2 (Fig. 16.15). The adipocutaneous component of the
flap is based on a similar system of perforators to the free
TRAM flap. The island of perforators is circumferentially
outlined along the anterior rectus sheath and is then
extended to the costal margin. The anterior sheath is incised
and the inferior edge of the rectus abdominis muscle below
the perforators is divided. The flap is elevated in a cephalic
direction. Once at the level of the costal margin, the lateral
aspect of the muscle is released while protecting the vascular
pedicle that is coursing under the costal margin in the retro-
rectus plane. Once complete, the pedicle TRAM is tunneled
into the breast pocket as an ipsilateral or contralateral flap.
Perhaps the most critical aspect of the pedicle TRAM flap
is proper closure of the donor site to prevent a bulge or
hernia. Usually this includes the use of a prosthetic mesh
either as in inlay between the fascial edges or as an onlay
over the reapproximated fascial edges (Fig. 16.16). Exten­
sive plication of the anterior abdominal wall is often neces­
sary to prevent contour abnormalities.
The advantages of the pedicle TRAM are that it is techni­
cally easier to perform, can be performed without an assis­
tant, and does not require the use of an operating
microscope. The operation is usually completed in 3–4 h
and that includes flap elevation, insetting, and closure. Dis­
advantages of the pedicle TRAM include partial flap loss, fat
necrosis, abdominal weakness, and contour abnormalities.
Flap-related morbidities are usually related to the reduced
vascularity of the superior system compared with the infe­
rior system. Donor site morbidities are usually related to the
sacrifice of the rectus abdominis muscle and anterior rectus
sheath. Flap-related morbidities such as fat or skin necrosis
length of the SIEA/V pedicle ranges from 5–8 cm. If the
contralateral vessels are of suboptimal caliber without a pal­
pable pulse, then the ipsilateral SIEA/V are explored. If
those vessels are not suitable, then the deep system of per­
forators are explored. The contralateral and ipsilateral
medial and lateral row of perforators are visualized and
preferentially selected. The recipient vessels for the SIEA
flap are usually the internal mammary artery and vein.
Insetting the SIEA flap requires special considerations
when compared with the free TRAM or DIEP flaps because
the vascular pedicle enters the flap at its edge rather than
the undersurface.32 Standard insetting will create a sharp
180° fold in the pedicle that can compromise flow. Insetting
the SIEA flap is best achieved by de-epithelizing the inferior
2–3 cm of the flap and by releasing the dermis at the new
epidermal edge. The flap is positioned with the pedicle
oriented in the inferomedial direction. This allows the
pedicle to rotate superiorly without kinking.
Despite the gains in abdominal wall function and the fact
that some surgeons are enthusiastic about the SIEA flap,
some remain skeptical because of the smaller caliber vessels,
the limited angiosomal territories, the increased incidence
of fat necrosis, and the higher rate of redo-arterial and
venous anastomoses. It is generally accepted that small-
caliber vessels are often associated with an anastomotic mis­
match and can predispose to flap failure.
PEDICLE TRAM FLAP (see Ch. 37)
The pedicle TRAM flap was introduced in 1981 and remains
a commonly performed method of autologous breast recon­
struction.33,34 This flap utilizes skin, fat, and variable amounts
of the rectus abdominis muscle from the lower abdomen to
reconstruct the breast. In contrast to the abdominal free
flaps, the pedicle TRAM receives its blood supply from the
superior epigastric artery and vein. The superior epigastric
system originates from the internal mammary artery and
vein. This vessel traverses through the rectus abdominis
muscle and is in continuity with the inferior epigastric
Figure 16.14  Intraoperative photograph of a hemi SIEA flap harvest.
Figure 16.15  Intraoperative photograph of a bilateral MS-1 pedicle
TRAM flap.

194
PART 3 — RECONSTRUCTION
the shoulder. The muscle is innervated by the thoracodorsal
nerve. This flap can be used for total or partial breast recon­
struction and can be transferred as a pedicle flap for the
ipsilateral breast as well as a free tissue transfer for the
contralateral breast under certain circumstances.35,36
The latissimus dorsi muscle is a highly predictable and
reliable flap. When used for immediate reconstruction
following total mastectomy, it is often combined with a pros­
thetic device. When used for delayed reconstruction follow­
ing radiation, it is often used without a prosthetic device in
order to improve the quality of the surrounding soft tissues.
When used for partial breast reconstruction either immedi­
ately following lumpectomy or on a delayed basis, it is also
used without prosthetic devices.
The latissimus dorsi muscle can be transferred as a muscle
only flap or as a musculocutaneous flap and usually depends
on the quality or quantity of breast skin (Fig. 16.18). The
muscle only variety is considered when additional soft tissue
coverage without the need for skin is needed in the setting
of prosthetic reconstruction. This is usually the case in
women with thin skin flaps and nipple- or skin-sparing
mastectomy. The muscle is often harvested endoscopically
through the anterior/lateral incision. A posterior incision
can usually be avoided. Musculocutaneous flaps are consid­
ered when there is a cutaneous deficit on the breast that
requires replacement. The cutaneous territory can vary in
size from a small 5 × 5 cm circle to a 20 × 8 cm ellipse depend­
ing on body habitus. The orientation of the skin paddle can
vary and is usually aligned in the direction of the resting
skin tension lines. The flap can be successfully harvested
with the patient in the lateral decubitus position for unilat­
eral cases or in the prone position for bilateral cases. During
elevation, the thoracodorsal nerve can be divided or pre­
served. In most cases the nerve is preserved in order to
minimize the amount of muscle atrophy. The insertion of
the latissimus dorsi muscle can be preserved or released
based on the amount of excursion needed. The flap is
usually transferred as a pedicle to the ipsilateral breast but
can also be transferred as a free tissue transfer to the contra­
lateral breast. Figure 16.19 demonstrates a patient that had
bilateral breast reconstruction with pedicle latissimus dorsi
musculocutaneous flaps and implants.
can be minimized by surgical ligation of the deep inferior
artery and vein (delay procedure) 2–3 weeks prior to per­
forming a pedicle TRAM. Figure 16.17 demonstrates a
woman following bilateral breast reconstruction with MS-1
pedicle TRAM flaps.
POSTERIOR THORAX
The latissimus dorsi musculocutaneous flap for autologous
breast reconstruction has been used since the 1970s with
excellent success. In the early 2000s, perforator-based flaps,
including the thoracodorsal artery perforator flap and
the lateral thoracic perforator flap were introduced to pre­
serve the latissimus dorsi muscle and minimize donor site
morbidities.
LATISSIMUS DORSI FLAP (see Ch. 41)
The latissimus dorsi flap is a type 5 muscle flap with a domi­
nant perforator and smaller segmental perforating vessels.
Its function is to abduct and internally rotate and extend
Figure 16.17  (A) Preoperative photograph of a patient prior to bilateral skin-sparing mastectomy. (B) Intraoperative photograph of a bilateral
MS-1 pedicle TRAM flap tunneled into the ipsilateral mastectomy pocket. (C) Postoperative photograph demonstrating well-healed and viable
pedicle TRAM flaps.
A
B
C
Figure 16.16  Intraoperative photograph demonstrating reinforce­
ment of the fascial closure with a synthetic mesh.

CHAPTER 16 — Breast Reconstruction
195
Figure 16.18  A latissimus dorsi musculocutaneous flap on its
pedicle is depicted.
is usually considered in patients that require partial breast
reconstruction. It can also be used for total breast recon­
struction but usually requires careful placement of a pros­
thetic device as to not compromise the vascular pedicle.
Following isolation of the cutaneous perforator, a myotomy
is created and the perforator is dissected along the course
of the primary source vessel. The dissection progresses until
enough length is obtained to allow for adequate flap trans­
position without tension. The TDAP flap is then tunneled
under a cutaneous bridge into the breast defect. It is ideally
suited for laterally based defects.
GLUTEAL FLAPS (see Chs 44 and 58)
The gluteal flaps are arguably the most complex flaps in the
armamentarium of the microsurgeon. In general, these
flaps are considered when the abdomen is not a suitable
donor site and the patient is not interested in prosthetic
reconstruction. Gluteal flaps can be raised with or without
the gluteus maximus muscle. There are two perforator flaps
that are derived from this region that include the superior
(SGAP) and inferior (IGAP) gluteal artery perforator flaps.
The specific locations for each flap include the upper
buttock (above the piriformis muscle) for the SGAP (Fig.
16.20) and the lower buttock including the gluteal crease
region (below the piriformis muscle) for the IGAP. The
gluteal flaps are ideally suited for women that are thin to
moderate in body habitus. They are not typically recom­
mended for heavy to obese women.
THORACODORSAL ARTERY PERFORATOR FLAP (TDAP)
(see Ch. 58)
The TDAP flap is a perforator flap that is based on the
descending branch of the thoracodorsal artery and vein.37–39
One advantage of the TDAP, unlike most other perforator
flaps for breast reconstruction, is that it can be transferred
as a pedicle flap rather than a free tissue transfer. This flap
Figure 16.19  (A) Preoperative photograph of a patient following right mastectomy and radiation and left implant reconstruction. (B) Preopera­
tive marking for a bilateral latissimus dorsi flap. (C) Intraoperative photograph of the bilateral latissimus dorsi musculocutaneous flaps transposed
to the anterior chest. (D) Postoperative photograph following bilateral latissimus dorsi flaps and silicone gel implants.
A
C
B
D

196
PART 3 — RECONSTRUCTION
isolated, the dissection commences through the gluteus
maxi­mus muscle. In contrast to a DIEP flap, where the
length of the myotomy is minimized, with the SGAP, the
length of the myotomy is maximized. This is because the
perforator dissection progresses deep and perpendicular to
the cutaneous surface, whereas with the DIEP flap, the dis­
section is parallel with the cutaneous surface. The dissection
continues deep to the gluteus maximus and medius muscle
before penetrating the deep fibrous fascia. Once beyond
this point, there are multiple venous branches that must be
carefully dissected and divided before choosing the end-
point of the perforator. Figure 16.21 illustrates a woman that
had staged bilateral breast reconstruction with SGAP flaps.
The IGAP flap is raised with the same landmarks in mind.
The skin territory for this flap can be positioned to be “in
the crease.” In general, the adipocutaneous component of
this flap is slightly less than that of the SGAP. Other consid­
erations are that the sciatic nerve is often exposed during
this dissection and may result in postoperative discomfort.
Because the incision is located in the ischial region, sitting
may be restricted for several days following the operation
and dehiscence of the incision may be observed more often.
MEDIAL THIGH FLAPS (see Ch. 49)
The medial thigh donor site has demonstrated success for
breast reconstruction.44–46 Flaps such as the transverse upper
gracilis (TUG), diagonal upper gracilis (DUG), and trans­
verse musculocutaneous gracilis (TMG) have been
described. These flaps are usually considered in the event
that the abdomen is not a suitable donor site. A competing
donor site to the medial thigh is the gluteal region. The
medial thigh as an alternative is gaining momentum because
the vascular pedicle is more predictable based on length
and caliber. The caliber of the gracilis vascular pedicle
ranges from 1.5–2.5 mm. The volume of these medial thigh
flaps ranges from 150–550 cc.
Candidates for medial thigh flaps include women with
insufficient abdomen skin and fat, who prefer not to use the
abdomen, and who have a moderate amount of skin and fat
in the medial thigh. Other indications include bilateral
reconstructions in which the mastectomy volume approxi­
mates the volume of the medial thigh or meets the expecta­
tion of the patient. Potential adverse events associated with
the TUG flaps include postoperative lymphedema, complex
scarring, and thigh distortion.
Patients undergoing a TUG flap are initially evaluated in
the standing position (see also Cases 49.7 and 49.8). The
medial thigh tissues are pinched to determine the optimal
height of the flap. In general, this ranges from 8–10 cm and
may be up to 12 cm in patients following massive weight loss.
The anterior and posterior limits of the flap are based on the
dimensions of the mastectomy defect. The skin paddle can
be delineated transversely or in a fleur-de-lis pattern. In the
operating room, patients are placed in the lithotomy position
to facilitate exposure and dissection. Following the incision,
the dissection proceeds to the level of the muscle fascia.
Superficial nerves within the flap are usually transected. The
saphenous vein is included into the flap for additional venous
drainage if necessary. Typically the gracilis artery is associated
with a venae comitantes. The gracilis muscle is visualized and
divided at its origin and at its distal musculotendinous inser­
tion. The flap is transferred to the chest wall for the
SGAP/IGAP FLAPS (see Ch. 58)
The gluteal flaps are considered by many to be among the
more difficult flaps to harvest.40–43 An appreciation of the
anatomic landmarks is essential in raising these flaps. These
include the greater trochanter laterally, the posterior supe­
rior iliac crest superiorly, and the coccyx inferiorly. The
location of the perforators is best determined using preop­
erative CTA or MRA but can also be appreciated using a
handheld Doppler probe. This method is performed with
the patient in the prone position on the operating table.
There may be several Doppler signals appreciated that are
located both laterally and medially. Many surgeons prefer
lateral perforators that are near the periphery of the flap.
The reasons for this are that the laterally based perforators
will usually provide a pedicle length of 6–8 cm, whereas the
medially based perforators are usually 4–6 cm in length.
Peripheral perforators are preferred to facilitate the techni­
cal aspects of performing a microvascular anastomosis. With
a central perforator, some of the useable length is under the
flap rather than outside the flap edge. With the peripheral
perforator, the added length can be used to facilitate the
positioning of the flap during the anastomosis.
The operation is initiated by incising along the delineated
flaps. The dissection extends to the gluteal fascia. Flap eleva­
tion commences in the subfascial plane, which is in contrast
to the DIEP flap, where the initial elevation progresses along
the suprafascial plane. Once the gluteal perforator is
Figure 16.20  (A) Intraoperative photograph of the gluteal muscula­
ture following harvest of bilateral SGAP flaps. (B) Intraoperative pho­
tograph of bilateral SGAP flaps.
A
B

CHAPTER 16 — Breast Reconstruction
197
from the frontal and lateral sides. Skin markings for this
flap are based on the position of the adductor longus and
gracilis muscle. The apex of the anterior border of the
skin paddle is at the prominence of the adductor longus.
The markings are curved and extended posteriorly. The
posterior border is based on the pinch test and Langer’s
lines to create an elliptical pattern. The dissection com­
mences anteriorly, through the adductor longus fascia to
expose the gracilis pedicle.
microvascular anastomosis. Ideally, recipient vessels are
selected that will provide an optimal size match. The internal
mammary vessels or their perforating branches are typically
used.
The DUG flap is similar in concept to the TUG flap
except that the orientation of the flap is oblique and poste­
rior and parallel to Langer’s lines.47 The reason for this
modification is to minimize disruption to the superficial
lymphatic vessels and to conceal the incision when viewed
Figure 16.21  (A) Preoperative image of a woman following right mastectomy and left partial mastectomy. (B) A staged bilateral SGAP flap is
scheduled. The right SGAP flap is outlined. (C) The right SGAP flap is depicted as it is being harvested on its vascular pedicle. (D) Postopera­
tive photograph following staged bilateral SGAP flap breast reconstruction. (E) Postoperative photograph of the donor site following bilateral
SGAP flaps.
A
C
E
D
B