Segmental Gracilis Muscle Transfer for Smile in a Case of Möbius Syndrome 1 Zuker RM1 Borschel GH1 Wong KW1, Snyder-Warwick AK2 Yee A2 July 28, 2014Disclosure: 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.Keywords: transverse facial veinneurotizationfacial vein and arterymasseteric nervesegmental free functional muscle transferfacial paralysisstaged muscle transferMobius syndrome Standard Edition Table of Contents- Slow down- Frustration00:00:00 - Introduction00:00:25 - Incision and Developing a Facial Pocket with Unipolar Cautery00:02:35 - Developing a Facial Pocket with Scissor Dissection00:02:56 - Exposing the Facial Artery00:03:27 - Further Developing a Facial Pocket and Identifying the Transverse Facial Vein00:04:57 - Debulking the Buccal Fat Pad00:06:07 - Dividing the Facial Artery00:07:43 - Dissection to the Labial Commissure00:08:15 - Suture Anchoring of the Labial Commissure and Creation of New Nasolabial Fold00:10:39 - Exposure and Division of the Donor Masseteric Nerve00:12:48 - Gracilis Muscle Harvest with Dominant Pedicle00:14:59 - Placement of Reinforcing Sutures into the Gracilis Insertion00:17:31 - Suture Technique for Inserting the Gracilis to the Commissure Using the Anchors00:22:58 - Anastomoses of Donor/Recipient Vessels and Coaptation of Donor/Recipient Nerve00:23:47 - Suturing the Gracilis Origin to the Temporal Fascia00:25:52 - Inspecting the Vascular Anastomoses and Nerve Coaptation Extended Edition Table of Contents- Slow down- Frustration00:00:00 - Introduction00:00:30 - Pre-operative Discussion with Case History and Surgical Planning (Zuker)00:02:40 - Incision Placement and Facial Dissection Discussion (Borschel)00:06:29 - Gracilis Muscle Harvest Discussion (Wong)00:07:48 - Incision and Developing a Facial Pocket with Unipolar Cautery00:12:59 - eveloping a Facial Pocket with Scissor Dissection00:13:35 - Exposing the Facial Artery00:14:37 - Further Developing a Facial Pocket and Identifying the Transverse Facial Vein00:17:53 - Debulking the Buccal Fat Pad00:19:51 - Dividing the Facial Artery00:22:11 - Dissection to the Labial Commissure00:23:30 - Suture Anchoring of the Labial Commissure and Creation of New Nasolabial Fold00:27:30 - Exposure and Division of the Donor Masseteric Nerve00:31:21 - Gracilis Muscle Harvest with Dominant Pedicle00:34:54 - Placement of Reinforcing Sutures into the Gracilis Insertion00:37:44 - Suture Technique for Inserting the Gracilis to the Commissure Using the Anchors00:44:29 - nastomoses of Donor/Recipient Vessels and Coaptation of Donor/Recipient Nerve00:45:42 - Suturing the Gracilis Origin to the Temporal Fascia00:50:30 - nspecting the Vascular Anastomoses and Nerve Coaptation00:51:32 - Post-operative Discussion POSITION Supine. 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