for the gracilis muscle harvest, which is between the ischial tuberosity and the medial femoral condyle, identifying a point where the vessels are expected to enter approximately the junction of the middle and proximal thirds of the gracilis muscle. The gracilis can then be dissected, lifting the adductor longus up to identify the vessels which will enter the gracilis on its deep and anterior surface. We now can stimulate the obturator nerve, identifying the gracilis muscle. We now will devise a template that we can design the gracilis muscle to follow, starting at the zygomatic arch and working towards the motiolus. We have also identified where the facial vessels will cross the mandibular border. The facial vessels will cross and we will identify those vessels for the recipient vessels. There's the zygomatic arch outlined, which will be the top of our template. We can now draw the vector of the muscle coming from arch to the motiolus and extending to the upper lip and a few extensions down onto the lower lip. The nerve to the masseter is also identified, emerging from deep and inferior to the zygomatic arch. We mark approximately three centimeters anterior to the tragus and approximately one centimeter below the zygomatic arch for the point where we expect to identify the nerve to the masseter. Facial vessels are identified by Doppler and we will now design our template such that we accommodate the nerve to the masseter as well as the facial vessels where they enter the gracilis muscle. This template is then given to the team working on the gracilis harvest so they can harvest the gracilis to model after the template. The facial dissection can then be commenced and we tend to work in two teams one at the thigh one at the face and we enter a subcutaneous plane staying just superficial to the parotid fascia. We continue to extend that plane to the motiolus and the nasolabial fold and inferiorly to the jowl line. These are facelift scissors being used for the dissection. Going back to the thigh identifying the gracilis muscle, identifying the vascular pedicle and from superiorly identifying the obturator nerve entering it. The muscle can then be isolated and it's lifted off of the adductor magnus deep to it. And we now stimulate the nerve to identify its activity for the muscle. The muscle can now be trimmed to match the template. The muscle is now being prepared for transfer keeping it vascularized until the very end so we don't have an ischemic muscle time for any longer than need be. We now dissect the nerve to the masseter and we identify the nerve to the masseter with our nerve stimulator. Identifying it approximately three centimeters anterior to the tragus and one centimeter below the zygomatic arch. The nerve to the masseter is now divided and prepared for the transfer. We will now identify the vessels. We have the facial vein and the facial artery. Note that the vein is slightly posterior and superior to the artery.

gracilis muscle

surgical template

vessels and nerves

muscle transfer

simultaneous dissections