Research Article| Volume 65, ISSUE 10, P1343-1349, October 2012

Double innervation in free-flap surgery for long-standing facial paralysis



      One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patient's ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch.


      Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve.


      All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noah's five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes.


      In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Terzis J.K.
        Pectoralis minor: a unique muscle for correction of facial palsy.
        Plast Reconstr Surg. 1989 May; 83: 767-776
        • Harrison D.H.
        Surgical correction of unilateral and bilateral facial palsy.
        Postgrad Med J. 2005 Sep; 81: 562-567
        • Frey M.
        • Giovanoli P.
        The three-stage concept to optimize the results of microsurgical reanimation of the paralyzed face.
        Clin Plast Surg. 2002 Oct; 29: 461-482
        • Harii K.
        • Ohmori K.
        • Torii S.
        Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report.
        Plast Reconstr Surg. 1976 Feb; 57: 133-143
        • O'Brien B.M.
        • Franklin J.D.
        • Morrison W.A.
        Cross-facial nerve grafts and microneurovascular free muscle transfer for long established facial palsy.
        Br J Plast Surg. 1980 Apr; 3: 202-215
        • Vedung S.
        • Hakelius L.
        • Stålberg E.
        Cross-face nerve grafting followed by free muscle transplantation in young patients with long-standing facial paralysis. Reanimation of the cheek and the angle of the mouth.
        Scand J Plast Reconstr Surg. 1984; 18: 201-208
        • Koshima I.
        • Moriguchi T.
        • Soeda S.
        • Hamanaka T.
        • Tanaka H.
        • Ohta S.
        Free rectus femoris muscle transfer for one-stage reconstruction of established facial paralysis.
        Plast Reconstr Surg. 1994 Sep; 94: 421-430
        • Harii K.
        • Asato H.
        • Yoshimura K.
        • Sugawara Y.
        • Nakatsuka T.
        • Ueda K.
        One-stage transfer of the latissimus dorsi muscle for reanimation of a paralyzed face: a new alternative.
        Plast Reconstr Surg. 1998 Sep; 102: 941-951
        • Biglioli F.
        • Frigerio A.
        • Rabbiosi D.
        • Brusati R.
        Single-stage facial reanimation in the surgical treatment of unilateral established facial paralysis.
        Plast Reconstr Surg. 2009 Jul; 124: 124-133
        • Faria J.C.
        • Scopel G.P.
        • Busnardo F.F.
        • Ferreira M.C.
        Nerve sources for facial reanimation with muscle transplant in patients with unilateral facial palsy: clinical analysis of 3 techniques.
        Ann Plast Surg. 2007 Jul; 59: 87-91
        • Cuccia G.
        • Shelley O.
        • d'Alcontres F.S.
        • Soutar D.S.
        • Camilleri I.G.
        A comparison of temporalis transfer and free latissimus dorsi transfer in lower facial reanimation following unilateral longstanding facial palsy.
        Ann Plast Surg. 2005 Jan; 54: 66-70
        • Zuker R.M.
        • Goldberg C.S.
        • Manktelow R.T.
        Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant.
        Plast Reconstr Surg. 2000 Jul; 106: 1-8
        • Lifchez S.D.
        • Matloub H.S.
        • Gosain A.K.
        Cortical adaptation to restoration of smiling after free muscle transfer innervated by the nerve to the masseter.
        Plast Reconstr Surg. 2005 May; 115: 1472-1479
        • Bianchi B.
        • Copelli C.
        • Ferrari S.
        • Ferri A.
        • Bailleul C.
        • Sesenna E.
        Facial animation with free-muscle transfer innervated by the masseter motor nerve in unilateral facial paralysis.
        J Oral Maxillofac Surg. 2010 Jul; 68: 1524-1529
        • Manktelow R.T.
        • Tomat L.R.
        • Zuker R.M.
        • Chang M.
        Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation.
        Plast Reconstr Surg. 2006 Sep; 118: 885-899
        • Watanabe Y.
        • Akizuki T.
        • Ozawa T.
        • Yoshimura K.
        • Agawa K.
        • Ota T.
        Dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer for re-animation of established facial paralysis: simultaneous reinnervation of the ipsilateral masseter motor nerve and the contralateral facial nerve to improve the quality of smile and emotional facial expressions.
        J Plast Reconstr Aesthet Surg. 2009 Dec; 62: 1589-1597
        • Terzis J.K.
        • Noah M.E.
        Analysis of 100 cases of free-muscle transplantation for facial paralysis.
        Plast Reconstr Surg. 1997 Jun; 99: 1905-1921
        • Hadlock T.
        • Cheney M.L.
        Facial reanimation: an invited review and commentary.
        Arch Facial Plast Surg. 2008 Nov–Dec; 10: 413-417
        • Bae Y.C.
        • Zuker R.M.
        • Manktelow R.T.
        • Wade S.
        A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve.
        Plast Reconstr Surg. 2006 Jun; 117: 2407-2413
        • Chen R.
        • Anastakis D.J.
        • Haywood C.T.
        • Mikulis D.J.
        • Manktelow R.T.
        Plasticity of the human motor system following muscle reconstruction: a magnetic stimulation and functional magnetic resonance imaging study.
        Clin Neurophysiol. 2003 Dec; 114: 2434-2446
        • Yamamoto Y.
        • Sekido M.
        • Furukawa H.
        • Oyama A.
        • Tsutsumida A.
        • Sasaki S.
        Surgical rehabilitation of reversible facial palsy: facial-hypoglossal network system based on neural signal augmentation/neural supercharge concept.
        J Plast Reconstr Aesthet Surg. 2007; 60: 223-231
        • Viterbo F.
        • Amr A.H.
        • Stipp E.J.
        • Reis F.J.
        End-to-side neurorrhaphy: past, present, and future.
        Plast Reconstr Surg. 2009 Dec; 124: 351-358
        • Labbé D.
        • Hamel M.
        • Bénateau H.
        Lengthening temporalis myoplasty and transfacial nerve graft (VII-V). Technical note.
        Ann Chir Plast Esthet. 2003 Feb; 48: 31-35
        • Kumar P.A.
        Cross-face reanimation of the paralysed face, with a single stage microneurovascular gracilis transfer without nerve graft: a preliminary report.
        Br J Plast Surg. 1995 Mar; 48: 83-88
        • Jiang H.
        • Guo E.T.
        • Ji Z.L.
        • Zhang M.L.
        • Lu V.
        One-stage microneurovascular free abductor hallucis muscle transplantation for reanimation of facial paralysis.
        Plast Reconstr Surg. 1995 Jul; 96: 78-85
        • Koshima I.
        • Tsuda K.
        • Hamanaka T.
        • Moriguchi T.
        One-stage reconstruction of established facial paralysis using a rectus abdominis muscle transfer.
        Plast Reconstr Surg. 1997 Jan; 99: 234-238
        • Hayashi A.
        • Maruyama Y.
        Neurovascularized free short head of the biceps femoris muscle transfer for one-stage reanimation of facial paralysis.
        Plast Reconstr Surg. 2005 Feb; 115: 394-405
        • Kalantarian B.
        • Rice D.C.
        • Tiangco D.A.
        • Terzis J.K.
        Gains and losses of the XII-VII component of the ‘‘baby-sitter” procedure: a morphometric analysis.
        J Reconstr Microsurg. 1998 Oct; 14: 459-471