The split hypoglossal nerve to supply the free functional
muscle transfer in facial reanimation
Tarek Ahmed Amer
Received: 6 April 2012 / Accepted: 30 October 2012 / Published online: 15 November 2012
Springer-Verlag Berlin Heidelberg 2012
Background The introduction of the concept of free muscle
transfer ushered a new era in the management of facial
paralysis. Several nerves were used to supply the newly
introduced muscle. The current work studies the possibility
of using the split hypoglossal nerve in supplying the func-
tional muscle transfer.
Methods Twenty-five patients with long-standing facial
nerve paralysis were treated by the author using 26 free
muscle transfers and the split hypoglossal nerve. The dis-
tance and the angle of commissure excursion were measured
pre- and postoperatively, and results were statistically ana-
lyzed. Only results from 24 patients were analyzed after
exclusion of one patient with Mobius syndrome treated with
two free flaps.
Results The first contraction observed after muscle transfer
occurred 3 to 6 months postoperatively (mean 4.6 months).
Postoperatively, the gained excursion using the free latiss-
mus dorsi flap and split lypoglossal nerve ranged between 9
and 29 mm (mean 17.75±6.14) and the difference in angle
ranged between 0° and 19° (mean 6.88±5.83). None of our
patients complained of mastication or speech problems.
Conclusions Within the limitations of the present study, the
split hypoglossal nerve is probably a possible alternative
donor nerve to supply the free functional muscle transfer
in long-standing facial nerve paralysis.
Level of Evidence: Level IV, therapeutic study.
Keywords Facial nerve
Functional muscle transfer
Facial nerve paralysis is a devastating deformity seriously
affecting handicapped individuals both aesthetically and
functionally . The introduction of the concept of free
muscle transfer by Harii in 1976 ushered a new era in the
management of long-standing facial nerve paralysis .
Several nerves were then used to supply the newly intro-
duced muscle. The contralateral buccal branch of facial
nerve was one of the most commonly used nerves. The
masseteric nerve was used successfully by Zucker et al.
 in 1995 in the treatment of Mobius syndrome. Both
nerves proved successful in producing muscle contractions
but each method has its own drawbacks. The objective of
the current work is to study the possibility of using the split
hypoglossal nerve as a possible alternative donor nerve to
supply the free muscle flap.
Materials and methods
Twenty-five patients with long-standing complete facial
nerve paralysis treated by the author using 26 free muscle
transfers and the split hypoglossal nerve are included in the
study. The muscle of choice was the latissmus dorsi muscle
in all cases. Period of follow-up ranged from 15 to
32 months. All patients were available for follow-up.
The procedure consists of three steps. The first step is the
preparation of the facial pocket, recipient facial vessels, and
the donor nerve. The hypoglossal nerve is identified in the
neck by elevation and upward retraction of the submandib-
ular gland and digastric tendon. The nerve is dissected
T. A. Amer (*)
Department of Plastic Surgery, Faculty of Medicine,
Eur J Plast Surg (2013) 36:155–164