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Physician Resource

UVA Surgeons Perform Their First Free Flap Innervated Muscle Transfer On a Child with Facial Palsy

There are many known causes of pediatric facial palsy, from brain tumors and trauma to congenital abnormalities and infections. Yet there are some children in which the facial nerve — the seventh cranial nerve — just isn’t functioning as it should.

This was the case for one 8-year-old boy, the first-ever pediatric patient at UVA to have a complex procedure called a free flap innervated muscle transfer.

“The left side of his face works normally, but the right side doesn’t work at all,” explains UVA craniofacial surgeon Jonathan Black, MD. “His chewing muscle and tongue work. So it’s the muscles of facial expression that are impaired.”

The boy’s parents pursued surgical options at other hospitals near their home, but they were turned away. “They came to me and asked if we could do something to help restore their son’s smile and I said, ‘yes, I think we can,’” says Black.

Black had participated in innervated muscle transfer procedures on adults, but had not done the surgery on a child. He agreed to try it because he knew his UVA team would rise to the occasion.

“We have an experienced team of three surgeons here at UVA and I was confident that, together, we could do this procedure successfully,” he says. “I’m a craniofacial surgeon trained in operating on the face and skull of children. We have a hand and peripheral nerve surgeon, Brent DeGeorge, with particular training in peripheral nerve injuries. And our microsurgeon, Chris Campbell, is trained in connecting tissue like blood vessels and nerves under a microscope. The combination of our three talents is what it took to make this happen.”

A Closer Look at Free Flap Innervated Muscle Transfer

“The seventh cranial nerve comes out just below the ear on both sides of the head,” explains Black. “One nerve ending controls one side of the face and one controls the other,” he says. “That’s why you can have a child that has one side of the face that is completely normal, while the other is paralyzed.”

To remedy the paralysis in this case required a dynamic surgical repair to restore movement, not just a static fix to improve facial positioning. The two-step repair process began with a facial nerve graft.

“In the first procedure, we borrowed a nerve from the leg and performed a cross-facial nerve graft,” says Black. “We connected the nerve from the working left side of the face, across the upper lip to the right side of the face.”

It takes approximately six to 12 months for the newly transplanted nerve to become fully functional. “That’s the frustrating part of this procedure,” says Black. “After the first procedure, you don’t see any improvement. You’re just getting that nerve to work.”

The next step in this two-part process is to bring muscle up from the leg to the face. “We waited until the following summer to connect the muscle to the transplanted nerve. Now we just have to wait for the muscle to turn on,” says Black. “The patient will work with a therapist to get the most power out of it. And in approximately six months, we should see a change. The worst-case scenario is that the muscle doesn’t do anything and the patient ends up in the same place he was. But I’m confident that we’re going to see an improvement – and the parents will be able to see their son smile.”

Contraindications for Free Flap Innervated Muscle Transfer

This procedure is not suitable for all children with facial paralysis. Patients not eligible include those who:

  • Are unable to participate in a lengthy surgery due to a medical condition or other reason
  • Are under age 6
  • Have a condition that inhibits them from participating in the physical therapy necessary for full recovery, such as autism or cerebral palsy.

To find out if your patient may be a candidate for free flap innervated muscle transfer, call 434.924.5078 or email

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