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J. T. Gu et al.
Great Auricular Nerve (GAN)
Conley rst described the concept of cable grafting in 1955, using the GAN as the
donor nerve [31]. The GAN has the advantage less morbidity, as it does not typically
require an additional donor site. The GAN is also of a similar caliber to the facial
nerve and provides an excellent size match, and up to 10cm of length may be harvested (Fig.26.1a). The GAN can be located by drawing a line from the angle of the
jaw to the mastoid tip. The nerve will bisect this line as it passes parallel and posterior
to the external jugular vein and over the sternocleidomastoid muscle (SCM). The
nerve should be dissected free and can be followed proximally around the SCM to
obtain extra length. The spinal accessory nerve is close by when performing proximal
dissection near Erb’s point and should be preserved. Patients should be counseled to
expect numbness of the ear lobe and postauricular skin if the GAN is harvested [23].
Acellular Nerve Allografts
Acellular nerve allografts such as the Avance nerve graft by AxoGen, Inc. (Alachua,
FL) can be used in place of a nerve autograft to minimize donor site morbidity, or in
cases where donor nerve options are limited, although autografts remain the gold
standard. AxoGen nerve grafts are made from cadaveric human tissue that has been
decellularized in order to render it nonimmunogenic. It is available in various diameters and lengths and provides an infrastructure to support nerve regeneration and
allow for tension-free repair [32, 33]. Additional synthetic materials may be used as
articial conduits for interposition grafting, such as caprolactone (Polyganics BC,
Groningen, Netherlands), polyglycolic acid (Synovis Micro Companies), and collagen type 1 (Integra LifeSciences Co., Plainsboro, NJ and Collagen Matrix, Inc.,
Franklin, TN) [34]. Outcomes of acellular allografts have been demonstrated in
peripheral nerve repair and have been shown to be successful in restoring nerve
function; however, there are little data regarding outcomes in facial nerve repair [35,
36]. There have been no human trials evaluating the efcacy of acellular allografts
in facial nerve reanimation. Further investigation is needed to understand the role
these materials may play in facial nerve reinnervation procedures, as the current
data on peripheral nerve repair propose potential limitations dependent on the nerve
grafted and when acellular nerve grafts longer than 15mm in length are required [37].
Nerve Transfer
When the proximal end of the facial nerve is not available for reanastomosis, but
distal nerve branches and facial muscles are viable, nerve transfer is indicated.
Many donor sources have been described, including spinal accessory nerve, phrenic
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nerve, contralateral facial nerve, hypoglossal nerve, and the masseteric motor
branch of the trigeminal nerve [38]. The most commonly used nerve substitutions
for treatment of facial paralysis include the masseteric and hypoglossal nerves.
Ideally, nerve transfer should be performed within 1year of facial nerve injury, as
this has been shown to have the most predictable results [39]. If the facial nerve is
known to be transected or resected, then nerve transfer should be considered as soon
as possible. Patients who are 6–18months out from onset of facial paralysis without
electrical evidence of nerve recovery may also be considered. Successful reinnervation in patients over 24months out from initial injury is rare [40].
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Masseteric Nerve Transfer
Masseteric nerve transfer for facial reanimation was rst described by Spira in
1978in order to address lower facial paralysis [41]. The masseteric nerve has many
advantages including its close proximity to recipient facial nerve branches, low
morbidity to chewing function, large number of motor axons, and rapid reinnervation times [42]. Limitations of masseteric nerve transfer include lack of satisfactory
facial resting tone, and inability to produce a spontaneous emotive smile, although
more recent literature have shown that a spontaneous smile may be present in 23%
of patients [43].
The masseteric nerve is a motor branch of the anterior division of the trigeminal
nerve. It exits from the cranial cavity through the foramen ovale and passes over the
lateral pterygoid muscle and through the sigmoid notch to enter the posterior surface of the masseter muscle near its origin. It can be reliably exposed by dissecting
the area between the inferior border of the zygomatic arch and the mandibular arch.
This area has been described as the “subzygomatic triangle,” which is bounded by
the inferior border of the zygomatic arch superiorly, the vertical border of the temporomandibular joint posteriorly, and the frontal branch of the facial nerve inferiorly and anteriorly. The masseteric nerve can be found within the subzygomatic
triangle by following a line bisecting the angle formed by the temporomandibular
joint and the zygomatic arch as it crosses the midpoint of the triangle base formed
by the frontal branch of the facial nerve. The location of the masseteric nerve has
also been described as 3cm anterior to the tragus and 1cm inferior to the zygomatic
arch [40, 44]. A nerve stimulator can be used to conrm the identity of the masseteric nerve by visualizing contraction throughout the entire masseter muscle. The
nerve is then traced out distally until there is enough length to perform a tensionfree anastomosis to the buccal branch of the facial nerve. The masseteric nerve is
then transected distally and neurorrhaphy to the cut end of the facial nerve is performed with two to three stitches through the epineurium (Fig.26.3a).
Outcomes for masseteric nerve transfer for facial reanimation have traditionally
been reported in terms of the HB grading scale. However, since the masseteric nerve
transfer technique is only intended to improve specic areas of facial dysfunction,
and the HB lacks specicity and reliability, newer outcome measures such as the
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J. T. Gu et al.
ab
Fig. 26.3 Nerve transfer procedures. (a) Masseteric nerve transfer. Blue arrow depicts neurorrhaphy between masseteric nerve and facial nerve. (b) Hypoglossal nerve transfer. Purple segment
depicts cable graft connecting main trunk of facial nerve to hypoglossal nerve (illustrations courtesy of Natalie A.Krane, MD)
facial asymmetry index (FAI) and Sunnybrook facial nerve grading scale (SFGS)
have become more widely adopted. Several studies in the literature have sought to
report more specic outcomes examining improvement in oral commissure symmetry and length of time from reanimation to facial movement [40, 45]. A recent
meta-analysis of 71 studies reported improvement in oral commissure symmetry by
3.62±2.7mm, with time to rst movement of 4.6±2.6months. Patients undergoing direct masseteric nerve transfer had earlier time to rst movement than patients
with an interposition graft (3.9±2.6months vs. 6.6±3.9months) [38]. A recent
study examined using FAI to measure the difference in distance between the medial
canthus and oral commissure in healthy and paralyzed sides of the face and found
that preoperative FAI was a signicant predictive factor of improvement in commissure symmetry at rest. For each 1.0mm of worse preoperative oral commissure
asymmetry, the resulting postoperative improvement was 0.6mm; therefore, masseteric to facial nerve transfer may yield a 60% correction in oral commissure asymmetry [46]. Complications from masseteric nerve transfer are typically rare but
most commonly include masseter atrophy (1.9%) and sialocele (0.5%) [38, 46].
Hypoglossal Nerve Transfer
Hypoglossal nerve transfer was rst performed in 1904 by Korte and later was popularized by Conley and Baker. The hypoglossal nerve provides motor innervation to
all extrinsic and intrinsic muscles of the tongue, excluding the palatoglossus. It
emerges beneath the posterior belly of the digastric muscle and, at the level of the
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digastric muscle tendon, turns anteriorly toward the tongue. Hypoglossal nerve
transfer can restore resting tone; however, the appearance of the smile may not be as
natural as is seen with masseteric nerve transfer or cross-facial nerve grafting, as the
patient must subtly move the tongue to contract the zygomaticus major muscle [47].
The location of the hypoglossal nerve prevents direct coaptation to the facial
nerve without a cable graft or splitting and transposing the hypoglossal nerve
(Fig.26.3b). Early techniques for hypoglossal nerve transfer proposed complete
sectioning of the nerve with subsequent anastomosis to the main trunk of the facial
nerve, which resulted in recovery of facial tone and some recovery of volitional
movement [48]. However, complete sectioning of the nerve lead to signicant morbidity to speech and swallowing due to hemiatrophy and dysfunction of the tongue.
Partial neurotomy techniques of the hypoglossal nerve became popularized in an
effort to minimize donor site morbidity. Techniques to split the hypoglossal nerve
along its length and transposing a split segment for end-to-end coaptation to the
facial nerve, or use of an end-to-side interpositional graft between a partially sectioned hypoglossal nerve and the main facial nerve trunk, have been shown to be
successful with reduced rates of hemiglossal atrophy [49]. Additional techniques
have proposed mobilization of the intratemporal segment of the facial nerve to provide additional length for direct end-to-end coaptation of the hypoglossal to the
facial nerve [48].
Similar to outcomes reporting for masseteric nerve transfer, specic measures
such as oral commissure excursion, oral commissure symmetry at maximum smile
and at rest, and the Sunnybrook Facial Nerve Grading Scale (SFGS) have been
used, in addition to the HB grading scale. In a recent meta-analysis of 71 studies,
oral commissure symmetry at maximum smile and at rest after hypoglossal nerve
transfer was noted to be 3.09±3.2mm and 2.22±1.6mm, respectively. Time to
rst movement with hypoglossal nerve transfer was 6.3±1.3months, with the subset who received an interposition graft taking longer to achieve movement at
6.9±3.2months [38]. A retrospective cohort study examining face-specic QOL
outcomes noted improved postoperative Facial Clinimetric Evaluation (FaCE) and
Facial Disability Index scores following hypoglossal nerve transfer [50]. Another
retrospective cohort study examined objective outcomes using FACE-gram and
Emotrics software to measure oral commissure excursion, symmetry of excursion
and angle, with notable postoperative improvements after nerve transfer procedures
[51]. The most common complication reported is dysphagia/dysarthria (4.1%), followed by tongue numbness, hypogeusia, infection, and graft separation (less than
0.5%) [38].
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Cross-Facial Nerve Graft (CFNG)
The cross-facial nerve graft (CFNG) was rst introduced by Scaramella [52] and
involves the use of the main peripheral branches of the contralateral functioning
facial nerve to innervate corresponding branches and muscle groups on the
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J. T. Gu et al.
paralyzed side of the face, thereby allowing for the potential of a spontaneous smile.
An interposition nerve graft, most commonly the sural nerve given its length, is tunneled across the face. A buccal branch of the contralateral facial nerve is used as the
donor nerve because of the redundant innervation to this area of the face, thereby
reducing the risk of facial weakness on the donor side of the face. Multiple segmental branches can be used to power several distal paralyzed branches [53]. The CFNG
can be used in patients within 2years of facial nerve injury, prior to muscle atrophy
and brosis of the motor end plates [54].
CFNG can be performed as either a single-stage or a two-stage procedure. The
single-stage operation coapts the donor facial nerve branch to the paralyzed side
at the same operation through the CFNG.Advantages of the single-stage procedure are primarily that it avoids a second procedure. In the two-stage procedure,
the nerve graft is sutured to the contralateral facial nerve, tunneled to the paralyzed side, and left there until the graft shows evidence of nerve regeneration.
Tinel’s sign, which can be elicited as a tingling sensation by percussing along the
path of the CFNG, can be used to follow axonal ingrowth, which occurs at a rate
of about 1mm per day. The second stage is usually performed 6–12months later,
and the CFNG is sutured to the distal branches of the facial nerve on the paralyzed
side. The two- stage approach allows for the surgeon to ensure that axonal load
grows exclusively from the healthy side to the affected side and may have the
advantage of a more predictable result [55]. When considering repair after
6months from initial facial nerve injury, a “babysitter” procedure with a partial
hypoglossal to facial nerve transfer, along with a CFNG, can be considered. The
babysitter procedure is typically performed as a two-stage procedure, wherein a
hypoglossal to facial nerve transfer is rst performed to prevent muscle atrophy
and loss of motor end plates while allowing axonal growth through the CFNG.Six
months later, the CFNG is then connected to distal facial nerve branches on the
paralyzed side [54].
The main disadvantages of the CFNG include an additional site of morbidity
from sural nerve harvest, and potential for suboptimal reinnervation. In either the
single- or two-stage approach, there is potential for atrophy and brosis of the
denervated recipient muscles prior to reinnervation through the CFNG. As the
axons grow through the CFNG, they must pass through two sites of coaptation, and
growth through the CFNG may be slow and unpredictable. The two-stage approach
has the disadvantage of requiring an additional procedure [43, 56].
Outcomes of the CFNG have been promising in terms or producing a spontaneous emotive smile; however, results may take up to 9months for axons to cross the
long interposition graft, and up to only half of the axons may ultimately reach the
distal nerve branches [57]. A study comparing CFNG with masseteric nerve transfer
found that facial motor recovery was less symmetric, commissural displacement
and contraction velocity were lower, and spontaneity was higher in CFNG compared to masseteric nerve transfer [43]. Complications from CFNG include facial
weakness on the donor side, nerve graft harvest donor site morbidity, and graft separation [53, 58].
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Free Gracilis Muscle Transfer (FGMT)
The free gracilis muscle transfer (FGMT) was introduced in 1976 by Harii [59] and
has become the gold standard for dynamic facial reanimation in cases of prolonged
FP (Fig.26.4a). Regional muscle transpositions (e.g., digastric, masseter, or temporalis) often do not provide sufcient oral commissure excursion and may result in
an unnatural smile vector [54, 60]. The nerve transfers discussed earlier in this chapter may provide excellent results, however, depend on the presence of viable mimetic
muscles and motor end plates, and, therefore, are no longer suitable options after
2years of facial paralysis.
The gracilis muscle is one of the most supercially located thigh adductors
(Fig.26.4b, c). It arises from the medial margin of the lower half of the body of the
pubic symphysis and from the upper half of the pubic arch. It runs vertically
ab
c d
Fig. 26.4 Free gracilis muscle transfer. (a) Graphical depiction of FGMT with dual innervation
from a CFNG and masseteric nerve transfer. (b) Graphical depiction of the gracilis muscle donor
site. (c) Intraoperative gracilis muscle harvest and dissection of pedicle. (d) The gracilis muscle is
narrowed and thinned until its weight is between 15 and 25g prior to inset. * Obturator nerve
(illustrations courtesy of Natalie A.Krane, MD; Images courtesy of Mark K.Wax, MD)
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downward and forms a round tendon, which passes beneath the tendon of the sartorius to insert into the medial surface of the upper end of the tibia. The main vascular
supply and venous outow from the gracilis muscle emerge directly from the profunda femoris vessels and then pass between the adductor longus and adductor brevis muscles to enter the gracilis from the lateral side. The main motor innervation of
the gracilis is from the obturator nerve, which emerges from the obturator foramen
and divides into anterior and posterior branches under the pectineus muscle. The
anterior branch descends between the adductor brevis and adductor longus muscles,
providing motor branches to these muscles prior to entering the lower part of the
upper third of the gracilis.
FGMT may be performed in one or two stages. The single-stage procedure
involves utilizing the masseteric nerve to innervate the free muscle ap. The twostage approach utilizes a CFNG, which is performed 6–12 months prior to free
muscle transfer. The likelihood of obtaining a nearly normal spontaneous smile
approaches 85% if the patient is <50years of age and a cross-facial nerve graft is
used [61]. Functionally, the two-stage approach allows for a more emotive smile
due to the use of the contralateral facial nerve to control the gracilis muscle ap,
whereas in the single-stage approach, the patient controls the gracilis ap using the
masseteric nerve to voluntarily initiate a smile [61]. More recently, dual innervation
using a CFNG and masseteric nerve to power the FGMT has been used to produce
a spontaneous and reliable smile (Fig.26.4a) [62, 63].
J. T. Gu et al.
Single-Stage FGMT
The single-stage FGMT utilizes the masseteric nerve to power the gracilis ap and
generate a bite-driven voluntary smile. The procedure begins with a modied Blair
incision on the paralyzed side of the face, followed by dissection down to the level
of the parotidomasseteric fascia proceeding medially until the anterior border of the
parotid is exposed. The FGMT may be neurotized with the masseteric nerve or
through a CFNG.If using the masseteric nerve, the masseteric nerve is identied on
the deep surface of the masseter muscle (as previously discussed), and, once isolated, transection of the masseteric nerve is performed as distally as possible for
eventual coaptation with the obturator nerve. Alternatively, a single-stage CFNG
can be performed to coapt the donor facial nerve branch to the obturator nerve at the
same operation through the CFNG [62].
The gracilis donor site landmarks are the medial condyle of the tibia inferiorly
and the insertion of the adductor tendons onto the superior pubic ramus and symphysis superiorly. A line is drawn between these points, and an incision is made
parallel to it about 1–2cm medially. Dissection proceeds through subcutaneous fat
toward the muscle belly, taking care to avoid the great saphenous vein. The best way
to identify the gracilis muscle is to identify the vascular pedicle. The gracilis branch
of the adductor artery travels between the adductor longus anteriorly and adductor
magnus posteriorly before entering the gracilis at a right angle. The gracilis artery
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is accompanied by two venae comitantes and the pedicle enters the anterior aspect
of the deep surface of the gracilis, roughly 8cm below the pubic tubercle. The anterior branch of the obturator nerve supplies the gracilis and enters it 1–2cm superior
to the point where the vascular pedicle enters. Dissection of the gracilis itself begins
inferior to the pedicle, followed by developing a plane between the adductor magnus and longus muscles. The total length of harvested gracilis should exceed the
distance between the tragus and the corner of the mouth by 2cm. About 40–50% of
the anteroposterior width of the muscle is divided. To provide the longest possible
neural pedicle, the obturator nerve is dissected proximally until other branches are
encountered, after which it is divided. The pedicle is then dissected and methodically ligated. Before the gracilis ap is inset, it must be narrowed and thinned until
its weight is between 15 and 25 g, commensurate with the body habitus of the
patient (Fig.26.4d). The muscle is oriented with the neurovascular pedicle emerging on the inferior edge, and its cut edges are sutured to the orbicularis oris inferiorly. The vessels are then anastomosed under the operating microscope. The lateral
inset of the muscle is performed by suspending the muscle to the temporalis fascia,
taking care to lateralize the oral commissure by approximately 50% of the anticipated smile excursion [61].
Single-stage FGMT powered by the masseteric nerve has been shown to have
excellent reliability with up to 95% of patients producing a smile after surgery.
However, although these patients have a voluntary smile, there is a relatively lower
success rate at producing a spontaneous smile [64]. In a retrospective cohort study
comparing single- and two-stage FGMT, patients who underwent single-stage
FGMT powered by the masseteric nerve had a greater smile excursion than in twostage FGMT powered by a cross-face nerve graft [65]. The most common complications of FGMT are hematoma, infection, vascular compromise, lateralization of the
nasolabial fold, and excessive bulk of the gracilis ap. Hematomas should be treated
aggressively to prevent accumulation of blood and subsequent pressure and inammation, leading to possible ap compromise. Wound infections are uncommon,
especially with perioperative antibiotic prophylaxis [61]. Vascular compromise is
most commonly due to venous obstruction and can be detected when severe induration develops in the muscle over a short period of time [61].
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Two-Stage FGMT
O’Brien expanded upon the initial technique proposed by Harii to include a CFNG
to power the FGMT.In the rst stage, a sural nerve is harvested to be used as a
CFNG and then coapted to the distal buccal branches of the unaffected facial nerve.
After 6–9months of axonal regrowth, the second stage is performed to harvest and
inset the FGMT and perform a neurorrhaphy between the CFNG to the obturator
nerve of the FGMT.Compared with other donor sources, the CFNG in combination with a FGMT provides the greatest degree of spontaneity in facial expression [66].
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Outcomes from two-stage FGMT have been successful in restoring spontaneous
mimetic smile. Bhama and colleagues examined a cohort of 154 FGMT over
10years, noting smile length symmetry, as well as spontaneity, to be greater in
patients who received a two-stage FGMT with CFNG.Onset of movement was
noted to occur within 6–9months, with smile outcomes optimized with facial nerve
physical therapy [67]. QOL following FGMT was also noted to be signicantly
improved [65, 68]. However, a more recent meta-analysis of FGMT powered by
CFNG compared to masseteric nerve demonstrated improved oral commissure
excursion in FGMT powered by the masseteric nerve [69]. The most common complications after two-stage FGMT are similar to those of single-stage FGMT and
include hematoma, vascular compromise, infection, lateralization of the nasolabial
fold, and excessive bulk of the gracilis ap.
J. T. Gu et al.
Facial Nerve Rehabilitation
Although signicant advances in surgical technique to restore facial animation have
been made, optimal outcomes still depend on diligent facial rehabilitation postoperatively. Physical therapy exercises, such as active assistive movement exercises,
may help strengthen facial muscles. Patients with the ability to initiate slight movement may benet from soft tissue mobilization with massage and neuromuscular
retraining by performing slow, controlled graded facial expressions with visual
feedback in front of a mirror [70]. The facial grading scale (FGS) has been used to
quantify facial function after facial nerve injury and has been shown to improve
signicantly after treatment with facial rehabilitation exercises. In a study of 76
patients with chronic facial paralysis (>12months from onset) of varying etiologies,
all patients had improvement in FGS scores with facial rehabilitation. Signicant
improvement in FGS was associated with number of therapy sessions and lower
starting FGS score [71]. Signicant improvements have been shown with postoperative rehabilitation to promote motor relearning of facial expression after hypoglossal to facial nerve transfer [72].
Conclusion
Surgical techniques and management of facial palsy have come a long way in
advancing and improving outcomes in facial reanimation. Motor nerve reconstruction of the facial nerve may be achieved through primary repair of the transected
nerve, cable graft repair of the resected nerve, as well as nerve transfer, cross-facial
nerve grafts, and free gracilis muscle transfer. Surgeons and patients should consider and balance expected outcomes with functional donor site morbidity when
deciding on the reconstructive approach. Additionally, postoperative facial rehabilitation is an essential aspect of recovery to achieve optimal outcomes.
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