Obturator Nerve Split for Gracilis Free-flap Double Reinnervation in Facial Paralysis

Chronic facial paralysis of congenital or iatrogenic origin lasting more than 12 months can be treated by revascularized and reinnervated free muscle flap transfer. The gracilis free muscle flap, first introduced by Harii et al1 in 1976, is often used for several reasons including predictable pedicle anatomy, acceptable donor site morbidity, and favorable muscle microarchitectural features resulting in fast and robust excursion when activated.2 This free flap can be innervated by either the contralateral facial nerve, masseteric nerve, or both, in a 1- or 2-stage procedure. Since its first description,3 the use of a double-powered free muscle transfer for facial reanimation has been reported by several authors,4,5 with different nerve suture techniques. A 1-stage double-powered free gracilis muscle flap transfer in a patient with long-standing facial paralysis is described herein by splitting the obturator nerve and anastomosing the 2 free ends to the facial nerve (through the sural graft) and to the masseteric nerve.