1. Microneurovascular transplant of the seventh, eighth, and ninth slips of the ipsilateral serratus muscle.

2. Insertion of the split ninth slip into the upper and lower eyelid.

3. Insertion of the eighth and seventh slips into the outer third of the upper lip and the angle of the mouth.

4. Microneural anastomosis of the crossfacial nerve graft to the nerves of the lower three serratus slips.

5. Innervation of the digastric anterior belly with a fascicle of the crossfacial nerve graft.

6. Neurotization of the serratus muscle directly with excess crossfacial nerve fascicles, if present.

FIRST OPERATION

Preoperative photographs and videotapes are taken of the patient's face at rest, grimacing, with a normal smile, and closing the eyes. These are important from a documentary standpoint but also must be studied carefully to analyze the direction and range of movement in the patient's smile and to determine placement of the nasolabial fold on the paralyzed side to perfectly mimic the normal fold. The nasolabial fold position is marked preoperatively and scored in the skin once the patient is asleep so that it is not lost during the preparation. The patient is positioned supine with the endonasal tube coming out superiorly over the forehead, leaving the entire face and submental area exposed. The prep includes the entire face and neck as for a full face lift plus the leg on the unparalyzed side, prepped to the level of a thigh tourniquet placed as high as possible. Two teams operate simultaneously, one to harvest donor nerve from the leg and one on the face. The lower torso can be rotated with a large sandbag under the hip to facilitate the sural nerve dissection from the back of the leg.

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