The sternohyoid muscle flap for new dynamic facial reanimation technique: Anatomical study and clinical results

Published:April 19, 2021DOI:



      Long-term facial nerve palsy has a highly negative impact on patients’ quality of life. In 2016, Alam reported one case of facial reanimation with the sternohyoid muscle after publishing a preclinical study in 2013. Despite the potentially ideal characteristics of this muscle for reanimation of facial palsy, this technique is still not widely used. The objective of our description of cases was to present the clinical results obtained with the surgical procedure and the study on cadavers to confirm the anatomical findings.


      This work describes the anatomical study of the vascular and nervous pedicle of the sternohyoid muscle compared with clinical results from a series of patients with long-term facial paralysis who underwent facial reanimation between June 2016 and September 2019, through the insertion of the sternohyoid muscle into the masseteric nerve.


      The anatomical study was conducted in eight human hemi-necks. In five cases (62%), the vascular pedicle was provided by the superior thyroid artery, and the entrance of the ansa cervicalis to the muscle was constant 1.8 cm from the distal insertion. This series included ten patients who underwent the surgery technique of facial reanimation using the sternohyoid muscle, with a 90% (n = 9) of reinnervation; 100% (n = 10) of flaps were viable, and none of the patients showed complications in the donor area.


      The sternohyoid muscle showed itself as a reliable muscle as a free flap in facial reanimation, and alternative to the gracilis flap. The surgical technique was safe, without any complications, with excellent excursion, recovery, and aesthetic results.


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        • Byrne P.J.
        Importance of facial expression in facial nerve rehabilitation. 12.
        Curr Opin Otolaryngol Head Neck Surg. 2004; (United States): 332-335
        • Coulson S.E.
        • O'Dwyer N.J.
        • Adams R.D.
        • Croxson G.R
        Expression of emotion and quality of life after facial nerve paralysis.
        Otol Neurotol. 2004; 25: 1014-1019
        • Bongers K.S.
        • Fox D.K.
        • Ebert S.M.
        • et al.
        Skeletal muscle denervation causes skeletal muscle atrophy through a pathway that involves both Gadd45a and HDAC4.
        Am J Physiol Endocrinol Metab. 2013; 305: E907-E915
        • Terzis J.K.
        • Olivares F.S.
        Long-term outcomes of free-muscle transfer for smile restoration in adults.
        Plast Reconstr Surg. 2009; 123: 877-888
        • 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; 57: 133-143
        • Garcia R.M.
        • Hadlock T.A.
        • Klebuc M.J.
        • Simpson R.L.
        • Zenn M.R.
        • Marcus J.R.
        Contemporary solutions for the treatment of facial nerve paralysis.
        Plast Reconstr Surg. 2015; 135: 1026e-1046e
        • Harrison D.H.
        The treatment of unilateral and bilateral facial palsy using free muscle transfers.
        Clin Plast Surg. 2002; 29 (United States): 539-549
        • Bos R.
        • Reddy S.G.
        • Mommaerts M.Y.
        Lengthening temporalis myoplasty versus free muscle transfer with the gracilis flap for long-standing facial paralysis: a systematic review of outcomes.
        J Cranio-Maxillofacial Surg. 2016; 44: 940-951
        • Bianchi B.
        • Ferri A.
        • Poddi V.
        • et al.
        Facial animation with gracilis muscle transplant reinnervated via cross-face graft: does it change patients’ quality of life?.
        J Craniomaxillofac Surg. 2016; 44: 934-939
        • Bhama P.K.
        • Weinberg J.S.
        • Lindsay R.W.
        • Hohman M.H.
        • Cheney M.L.
        • Hadlock T.A.
        Objective outcomes analysis following microvascular gracilis transfer for facial reanimation: a review of 10 years’ experience.
        JAMA Facial Plast Surg. 2014; 16: 85-92
        • 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; 118: 885-899
        • Boahene K.O.
        • Owusu J.
        • Ishii L.
        • et al.
        The multivector gracilis free functional muscle flap for facial reanimation.
        JAMA Facial Plast Surg. 2018; 20: 300-306
        • Frey M.
        • Michaelidou M.
        • Tzou C.H.J.
        • et al.
        Three-dimensional video analysis of the paralyzed face reanimated by cross-face nerve grafting and free gracilis muscle transplantation: quantification of the functional outcome.
        Plast Reconstr Surg. Dec 2008; 122: 1709-1722
        • Greene J.J.
        • Tavares J.
        • Guarin D.L.
        • Jowett N.
        • Hadlock T.
        Surgical Refinement Following Free Gracilis Transfer for Smile Reanimation.
        Ann Plast Surg. Sep 2018; 81: 329-334
        • Braig D.
        • Bannasch H.
        • Stark G.B.
        • Eisenhardt S.U.
        Analysis of the ideal muscle weight of gracilis muscle transplants for facial reanimation surgery with regard to the donor nerve and outcome.
        J Plast Reconstr Aesthetic Surg. Apr 2017; 70: 459-468
        • Alam D.S.
        The sternohyoid flap for facial reanimation.
        Facial Plast Surg Clin North Am. 2016; 24 (United States): 61-69
        • Alam D.S.
        • Haffey T.
        • Vakharia K.
        • et al.
        Sternohyoid flap for facial reanimation: a comprehensive preclinical evaluation of a novel technique.
        JAMA Facial Plast Surg. 2013; 15: 305-313
        • Mathes S.J.
        • Nahai F.
        Classification of the vascular anatomy of muscles: experimental and clinical correlation.
        Plast Reconstr Surg. 1981; 67: 177-187
        • Natghian H.
        • Fransén J.
        • Rozen S.M.
        • Rodriguez-Lorenzo A.
        Qualitative and quantitative analysis of smile excursion in facial reanimation: a systematic review and meta-analysis of 1-versus 2-stage procedures.
        Plast Reconstr Surg - Glob Open. 2017; 5: e1621
        • Wernick Robinson M.
        • Baiungo J.
        Facial rehabilitation: evaluation and treatment strategies for the patient with facial palsy.
        Otolaryngol Clin North Am. 2018; 51: 1151-1167
        • 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; 117 (United States): 2407-2413
        • Murphey A.W.
        • Clinkscales W.B.
        • Oyer S.L.
        Masseteric nerve transfer for facial nerve paralysis a systematic review and meta-analysis.
        JAMA Facial Plast Surg. 2018; 20: 104-110
        • Oh T.S.
        • Kim H.B.
        • Choi J.W.
        • Jeong W.S.
        Facial reanimation with masseter nerve–innervated free gracilis muscle transfer in established facial palsy patients.
        Arch Plast Surg. 2019; 46: 122-128
        • Hontanilla B.
        • Cabello A.
        Spontaneity of smile after facial paralysis rehabilitation when using a non-facial donor nerve.
        J Cranio-Maxillofacial Surg. 2016; 44: 1305-1309
        • 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; 54: 66-70
        • Okazaki M.
        • Kentaro T.
        • Noriko U.
        • et al.
        One-stage dual latissimus dorsi muscle flap transfer with a pair of vascular anastomoses and double nerve suturing for long-standing facial paralysis.
        J Plast Reconstr Aesthetic Surg. 2015; 68: e113-e119
        • Harrison D.H.
        • Grobbelaar A.O.
        Pectoralis minor muscle transfer for unilateral facial palsy reanimation: an experience of 35 years and 637 cases.
        J Plast Reconstr Aesthetic Surg. 2012; 65: 845-850
        • Whitney T.M.
        • Buncke H.J.
        • Alpert B.S.
        • Buncke G.M.
        • Lineaweaver W.C.
        The serratus anterior free-muscle flap: experience with 100 consecutive cases.
        Plast Reconstr Surg. 1990; 86: 481-490
        • Sajjadian A.
        • Song A.Y.
        • Khorsandi C.A.
        • Deleyiannis F.W.B.
        • VanSwearingen J.M.
        • Henkelmann T.C.
        • et al.
        One-stage reanimation of the paralyzed face using the rectus abdominis neurovascular free flap.
        Plast Reconstr Surg. 2006; 117: 1553-1559
        • Mayou B.J.
        • Watson J.S.
        • Harrison D.H.
        • Parry C.B.
        Free microvascular and microneural transfer of the extensor digitorum brevis muscle for the treatment of unilateral facial palsy.
        Br J Plast Surg. 1981; 34: 362-367
        • Hadlock T.A.
        • Malo J.S.
        • Cheney M.L.
        • Henstrom D.K.
        Free gracilis transfer for smile in children the Massachusetts eye and ear infirmary experience in excursion and quality-of-life changes.
        Arch Facial Plast Surg. 2011; 13: 190-194
        • Hiller A.
        • Davis J.
        • Schulz S.
        • Henderson J.
        • Wilhelmi B.J.
        Recipient Vessel Selection in Head and Neck Reconstruction.
        Eplasty. 2017; 17: e42
        • Banneheka S.
        Anatomy of the ansa cervicalis: nerve fiber analysis.
        Anat Sci Int. 2008; 83: 61-67
        • Li K.
        • Zhang Z.
        • Nicoli F.
        • et al.
        Application of indocyanine green in flap surgery: a systematic review.
        J Reconstr Microsurg. 2018; 34 (United States): 77-86