We have now dissected out the zygomatic arch, and we are going to anchor double arms on the arch for the proximal anchor of the muscle. You can see that we have three oticron suture double armed, and we're going deep onto the periosteum so that the anchor is not mobile. We will place three to four such sutures coming along the length of the arch. We test each suture to be sure that it is immobile. And now we have the sutures placed, we're testing them, and we can see that there's little give so we have nicely anchored to the periosteum of the zygomatic arch. We are now going to prepare the sutures at the motiolus, and we have placed those around the motiolus starting from the lower lip to motiolus on into the upper lip to simulate the nasolabial fold. We have looked at the fold prior to the patient being asleep on the contralateral side, and we wish to simulate this. And based on our vector of pull, we can control the vector of the smile. We now can take our muscle and according to the template design, place the vessels and nerves where we had planned them to be. We stimulate the nerve to the obturator and the muscle is viable. The muscle is laying in its position, note that the proximal end of the muscle will go towards the zygomatic arch, the mid-portion of the muscle will go towards the motiolus. That is the obturator nerve, and below that you saw the vessels. We will now prepare the muscle to be parachuted down towards the motiolus, recall that we had placed approximately four double-armed sutures around the motiolus, we are now passing those double-armed sutures at the distal aspect of the muscle, or the mid-portion of the muscle or the fleshy portion. Note that this is the fleshy portion of the muscle and we don't want the double-armed sutures to tear through the fibers of the muscle, so we've had the team place horizontal mattress vicral sutures earlier, so that as we parachute the muscle down, should those double-armed sutures cheese wire through the fibers of the muscle, they will have a break at the point of the double-armed vicral sutures. We can therefore tuck the muscle in, tucking it nicely to the nasolabial fold, before we tie the double-armed sutures in sequence. It's important to ensure that there are no gaps between the muscle and the motiolus, so that the muscle activates the motiolus without loss of excursion. Here we're lifting the muscle, we've inset it to the motiolus, and we're going to now orient it for our further anastomosis. We're starting with our nerve anastomosis, which is the nerve to the masseter. We do this before the vascular anastomosis because we need to be able to lift the muscle up so we can work underneath it. Here we're doing an end-to-end anastomosis, nerve to masseter, coming to the obtrator nerve of the muscle. There's the muscle. We now have completed the nerve anastomosis and we can inset it to our proximal sutures at the zygomatic arch. Note that we cannot get back to the nerve to the masseter, which is why we did that anastomosis first. We now turn our attention to the vessels, and we can see that we have double-arm clamps on the vein and artery, and we are going to now pair that with the vein and artery to the gracilis muscle. We now, under microscope, we're doing the arterial anastomosis, bringing the branch of the circumflex femoral to the gracilis, to the facial vessels as the recipient vessels. We've completed the venous anastomosis using the coupler. Here we are with our tension set, so we have a baseline nasolabial fold.

facial reconstruction

zygomatic arch

nerve anastomosis

nasolabial fold

muscle function