Stage 1 – Cross-Facial Nerve Grafting for Smile 2 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. Cross-facial nerve grafting is a reconstructive strategy used to restore smile function and eye closure in both acute and chronic unilateral injury. In an acute injury, nerve grafting provides regenerating fibers from the donor nerve on the normal side to reinnervate across the face to the similar recipient nerve on the paralyzed side. In a chronic injury where the paralyzed muscle can no longer be reinnervated, the cross-facial nerve graft serves as the first stage to a segmental free functional muscle transfer to reconstruct smile. In this case, the patient presented 4-years-ago with a posterior fossa medulloblastoma, which was removed, and underwent a successful course of chemotherapy. However, the tumor involved partial CN12 and complete CN6 and CN7 nerve paralysis on the left side. Reconstruction included a 2-stage segmental gracilis muscle transfer to reconstruct smile with stage one providing the donor nerve source for the muscle. This video details the selection of the donor buccal branch of the contralateral facial nerve and coaptation of the sural nerve graft as the cross-facial nerve graft. The specifics of the sural nerve harvest are not included in this video.Keywords: cross-facial nerve graftingsural nervebuccal branch of facial nervesegmental free functional muscle transferfacial paralysiseye closurestaged muscle transferposterior fossa medulloblastomasmile function Standard Edition Table of Contents- Slow down- Frustration00:00:00 - Introduction00:00:25 - Incision and Developing a Facial Pocket with Unipolar Cautery00:01:35 - Developing a Facial Pocket with Scissor Dissection00:03:11 - Identifying and Exposing the Contralateral Buccal Branch of Facial Nerve00:04:30 - Mapping of Contralateral Facial Nerve through Electrical Stimulation00:05:33 - Incision and Exposure of Upper Gingival Buccal Sulcus to the Periosteum00:06:09 - Tunneling the Nerve Graft from the Upper Buccal Sulcus to the Buccal Nerve Branch00:06:58 - Dividing the Buccal Branch of Contralateral Facial Nerve00:07:32 - Coaptating the Buccal Branch to the Proximal End of Nerve Graft00:08:14 - Suturing the Distal End of Nerve Graft to the Periosteum00:09:28 - Closure Extended Edition Table of Contents- Slow down- Frustration00:00:00 - Introduction00:00:30 - Pre-operative Dissection with Case History and Surgical Planning (Zuker)00:02:29 - Incision Placement and Facial Dissection Discussion (Borschel)00:05:42 - Sural Nerve Graft Harvest Discussion (Wong)00:06:39 - Incision and Developing a Facial Pocket with Unipolar Cautery00:09:55 - Developing a Facial Pocket with Scissor Dissection00:12:48 - Identifying and Exposing the Contralateral Buccal Branch of Facial Nerve00:16:03 - Mapping of Contralateral Facial Nerve through Electrical Stimulation00:18:43 - Incision and Exposure of Upper Gingival Buccal Sulcus to the Periosteum00:19:43 - Tunneling the Nerve Graft from the Upper Buccal Sulcus to the Buccal Nerve Branch00:21:33 - Dividing the Buccal Branch of Contralateral Facial Nerve00:22:26 - Coaptating the Buccal Branch to the Proximal End of Nerve Graft00:23:50 - Suturing the Distal End of Nerve Graft to the Periosteum00:26:00 - Closure00:26:50 - Post-operative Discussion POSITION Supine. 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