Cross Facial Nerve Grafting for Smile Restoration: Thoughts on Improving Graft Inset

Abstract

Summary: Cross facial nerve grafts (CFNGs) are one of the most ubiquitous and time-honored surgical tools used in facial reanimation. They may be used for targeting different mimetic muscles in the subacute setting as well as to innervate newly placed muscle flaps in varied facial subunits. In our experience, when used specifically for smile reanimation in two-stage strategies with either traditional “babysitting” approaches in nerve transfers or free functional muscle transfers, the second stage may present some challenges in CFNG identification as well as injury to the previously banked nerve graft. We present some technical modifications in the first-stage CFNG inset that can make the second stage easier and safer. These modifications include: (1) marking the course of the nerve graft with surgical metal clips and inserting loose circumferential sutures throughout the distal course of the nerve in the recipient area to avoid displacement; (2) transferring the nerve graft through the nasal sills rather than lips, protecting it from damage during insertion of free functional muscle transfer; and (3) routing the nerve from the lateral nose to the preauricular area over the zygomatic arch, allowing easier dissection and banking of adequate graft length to provide tension-free coaptation with the flexibility of nerve coaptation in variable positions.

Oral Health-Related Quality of Life in Rare Disorders of Congenital Facial Weakness

“…The surgical reanimation surgery of choice for bilateral facial weakness is neurovascular free muscle transfer using the gracilis and pectoralis minor muscles [33]; for unilateral facial weakness, cross-facial nerve grafting is also performed [34]. An alternative is "sling surgery," which provides muscle reattachment to the perioral muscles to prevent lower lip procumbence and drooling by suspending and supporting the lower lip [35].…”

Histomorphometry of the Sural Nerve for Use as a CFNG in Facial Reanimation Procedures

“…It is employed as either an augmentative procedure for reinnervating weakened facial muscles in early cases of FP or linked to a second stage muscle free flap in late cases of FP, where the mimic muscles have atrophied [6][7][8][9][10][11]. Most frequently, the gracilis muscle is used and its associated obturator nerve branch will be coapted to the CFNG [12,13]. For further treatment, especially second stage muscle free flap following CFNG, knowledge about the different stages of nerve regeneration is crucial for optimal timing and outcomes [14,15].…”

“…obturator nerve branch will be coapted to the CFNG [12,13]. For further treatment, especially second stage muscle free flap following CFNG, knowledge about the different stages of nerve regeneration is crucial for optimal timing and outcomes [14,15].…”