‘Super-Innervation’ of a Free Latissimus Dorsi Flap in Facial Reanimation: A Novel Strategy for Supplementing Muscle Innervation

The gold-standard for facial reanimation in facial palsy involves a first stage crossed facial nerve graft and a second stage free muscle flap transfer, with a single neurorrhaphy of the muscle flap nerve to the nerve graft. The timing of the second stage is usually 6 months after the first stage, which is undertaken once there is a positive Tinnel's sign. We present new technique for situations where there is either a significant delay between the first and second stages or if there is a question over the viability of a nerve graft. To maximise the chances of success a latissimus dorsi free flap was used, where the medial branch of the thoracodorsal nerve was joined to the cross facial nerve graft and the lateral branch was ‘super-innervated' by the nerve to masseter. Although both these techniques have been described, to our knowledge they have not been used previously in the same patient.