Segmental Gracilis Muscle Transfer for Smile in a Case of Möbius Syndrome

Disclosure: No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication.

Facial paralysis causes significant morbidity and dynamic reconstruction aims to address functional, aesthetic, and psychological aspects of the impairment. Segmental gracilis muscle transfer is a reconstructive strategy used to restore smile function in a chronic injury, where nerve grafting or nerve transfers are no longer an option due to prolonged muscle atrophy or congenital causes. In this case, the patient presented with a congenital neurological disorder called Möbius syndrome, which involved complete bilateral paralysis of CN6, CN7 and partial paralysis of CN12. The patient’s inability to smile was due to the absence of facial muscles. A bilateral segmental muscle transfer was elected to reconstruct smile using the gracilis muscle with neurotization with the masseteric nerve. Often, patients with Möbius syndrome do not have a facial vein, as in this patient, and the transverse facial vein and the facial artery were utilized for vascular anastomosis. This video portrays the approach and technical details for performing a segmental gracilis muscle transfer using the donor masseteric nerve.

Standard

Extended

POSITION

Supine.

INCISION

Pre-auricular incision.

REFERENCES

1. Dorafshar AH, Borsuk DE, Bojovic B, Brown EN, Manktelow RT, Zuker RM, Rodriguez ED, Redett RJ. Surface anatomy of the middle division of the facial nerve: Zuker’s point.Plast Reconstr Surg. 2013 Feb;131(2):253-7. PMID: 23357986.
2. Borschel GH, Kawamura DH, Kasukurthi R, Hunter DA, Zuker RM, Woo AS. The motor nerve to the masseter muscle: an anatomic and histomorphometric study to facilitate its use in facial reanimation. J Plast Reconstr Aesthet Surg. 2012 Mar;65(3):363-6. PMID: 21992936.
3. Fattah A, Borschel GH, Manktelow RT, Bezuhly M, Zuker RM. Facial palsy and reconstruction. Plast Reconstr Surg. 2012 Feb;129(2):340e-352e. PMID: 22286449.
4. Fattah A, Borschel GH, Zuker RM. Reconstruction of facial nerve injuries in children. J Craniofac Surg. 2011 May;22(3):782-8. Review. PMID: 21558887.
5. Manktelow RT, Zuker RM, Tomat LR. Facial paralysis measurement with a handheld ruler. Plast Reconstr Surg. 2008 Feb;121(2):435-42. PMID: 18300969.
6. Manktelow RT, Tomat LR, Zuker RM, 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 15;118(4):885-99. PMID: 16980848.
7. Bae YC, Zuker RM, Manktelow RT, 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(7):2407-13. PMID: 16772949.
8. Ames WA, Shichor TM, Speakman M, Zuker RM, McCaul C. Anesthetic management of children with Moebius sequence. Can J Anaesth. 2005 Oct;52(8):837-44. PMID: 16189336.
9. Singham J, Manktelow R, Zuker RM. Möbius syndrome. Semin Plast Surg. 2004 Feb;18(1):39-46. doi: 10.1055/s-2004-823122. PMID: 20574469.
10. Goldberg C, DeLorie R, Zuker RM, Manktelow RT. The effects of gracilis muscle transplantation on speech in children with Moebius syndrome. J Craniofac Surg. 2003 Sep;14(5):687-90. PMID: 14501329.
11. Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant. Plast Reconstr Surg. 2000 Jul;106(1):1-8; discussion 9. PMID: 10883605.
12. Zuker RM, Posnick JC. The role of microsurgery in pediatric craniofacial reconstruction. Clin Plast Surg. 1992 Oct;19(4):833-9. Review. PMID: 1339639.
13. Zuker RM. Facial paralysis in children. Clin Plast Surg. 1990 Jan;17(1):95-9. PMID: 2302922.
14. Zuker RM, Manktelow RT. A smile for the Möbius’ syndrome patient. Ann Plast Surg. 1989 Mar;22(3):188-94. PMID: 2735718.
15.