Triple nerve transfers for the management of early unilateral facial palsy


  • Jose E. Telich-Tarriba Plastic and Reconstructive Surgery Division, Hospital General ‘Dr. Manuel Gea Gonzalez’, Mexico City, Mexico; Plastic Surgery Department, Hospital Angeles Pedregal, Mexico City, Mexico
  • David F. Navarro-Barquin Plastic and Reconstructive Surgery Division, Hospital General ‘Dr. Manuel Gea Gonzalez’, Mexico City, Mexico
  • Genesis Pineda-Aldana Plastic and Reconstructive Surgery Division, Hospital General ‘Dr. Manuel Gea Gonzalez’, Mexico City, Mexico
  • Alexander Cardenas-Mejia Plastic and Reconstructive Surgery Division, Hospital General ‘Dr. Manuel Gea Gonzalez’, Mexico City, Mexico



Facial paralysis, nerve transfer, peripheral nerves, nerve-to-masseter, cross-face nerve graft, hypoglossal nerve, facial reanimation


Background: Early onset facial paralysis is usually managed with cross-face nerve grafts, however the low number of axons that reach the target muscle may result in weakness or failure. Multiple-source innervation, or ‘supercharging’, seeks to combine the advantages of different donor nerves while minimizing their weaknesses. We propose a combination of cross-face nerve grafts with local extra-facial nerve transfers to achieve earlier facial reanimation in our patients.
Methods: A retrospective cohort including all patients with early unilateral facial palsy (<12 months evolution) who underwent triple nerve transfer between 2019 and 2021 was conducted. We performed single-stage procedure including zygomatic-to-zygomatic and buccal-to-buccal cross-face grafts, a nerve-to-masseter to bucozygomatic trunk transfer, and a mini-hypoglossal to marginal branch transfer. Results were evaluated using the clinician-graded facial function scale (eFACE).
Results: Fifteen patients were included (eight females, seven males), mean age at the time of surgery was 48.9 ± 13.3 years. Palsy was right-sided in eight cases. The mean time from palsy onset to surgery was 5.5 ± 2.8 months. Patients showed improvement in static (70.8 ± 21.9 vs. 84.15 ± 6.68, p = 0.002) and dynamic scores (20 ± 16.32 vs. 74.23 ± 7.46, p < 0.001), as well as periocular (57.33 ± 15.23 vs. 74 ± 7.18, p = 0.007), smile (54.73 ± 11.93 vs. 85.62 ± 3.86, p < 0.001), mid-face (46.33 ± 18.04 vs. 95 ± 7.21, p < 0.001) and lower face scores (67.4 ± 1.55 vs. 90.31 ± 7.54, p < 0.001).
Conclusion: The triple nerve transfer technique using cross-face nerve grafts, the nerve-to-masseter, and the hypoglossal nerve, is an effective and reproducible technique to obtain middle and lower face reanimation in cases of early facial palsy.


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Chávez-Serna E, Telich-Tarriba JE, Altamirano-Arcos C, Nahas-Combina L, Cárdenas-Mejía A. Facial paralysis, etiology and surgical treatment in a tertiary care center in plastic and reconstructive surgery in Mexico. Cir Cir. 2021;89(6):718–727. DOI:

Kim IA, Maxim T, Echanique K. Modern cross-facial nerve grafting in facial paralysis. Op Tech Otol Head Neck Surg. 2022;33(1):20–28. DOI:

Garcia RM, Hadlock TA, Klebuc MJ, Simpson RL, Zenn MR, Marcus JR. Contemporary solutions for the treatment of facial nerve paralysis. Plast Reconstr Surg. 2015;135(6):1025e–1046e. DOI:

Jandali D, Revenaugh PC. Facial reanimation: an update on nerve transfers in facial paralysis. Curr Opin Otolaryngol Head Neck Surg. 2019;27(4):231–236. DOI:

Klebuc M, Shenaq SM. Donor nerve selection in facial reanimation surgery. Semin Plast Surg. 2004;18(1):53–60. DOI:

Terzis JK, Konofaos P. Nerve transfers in facial palsy. Facial Plast Surg. 2008;24(2):177–193. DOI:

Yoshioka N. Differential reanimation of the midface and lower face using the masseteric and hypoglossal nerves for facial paralysis. Oper Neurosurg (Hagerstown). 2018;15(2):174–178. DOI:

Owusu JA, Truong L, Kim JC. Facial nerve reconstruction with concurrent masseteric nerve transfer and cable grafting. JAMA Facial Plast Surg. 2016;18(5):335–339. DOI:

Yoshioka N, Tominaga S. Masseteric nerve transfer for short-term facial paralysis following skull base surgery. J Plast Reconstr Aesthet Surg. 2015;68(6):764–770. DOI:

Lee YS, Ahn JH, Park HJ, et al. Dual coaptation of facial nerve using masseteric branch of trigeminal nerve for iatrogenic facial palsy: preliminary reports. Ann Otol Rhinol Laryngol. 2020;129(5):505–511. DOI:

Biglioli F, Allevi F, Rabbiosi D, et al. Triple innervation for re-animation of recent facial paralysis. J Craniomaxillofac Surg. 2018;46(5):851–857. DOI:

Chong LSH, Eviston TJ, Low TH, Hasmat S, Coulson SE, Clark JR. Validation of the clinician-graded electronic facial paralysis assessment. Plast Reconstr Surg. 2017;140:159–167. DOI:

Terzis JK, Tzafetta K. The ‘babysitter’ procedure: minihypoglossal to facial nerve transfer and cross-facial nerve grafting. Plast Reconstr Surg. 2009;123(3):865–876. DOI:

Mabvuure NT, Pinto-Lopes R, Bolton L, Tzafetta K. Lower lip depressor reanimation using anterior belly of digastric muscle transfer improves psychological wellbeing in facial palsy patients. Br J Oral Maxillofac Surg. 2022;60(3):299–307. DOI:

Bassilios Habre S, Googe BJ, Depew JB, Wallace RD, Konofaos P. Depressor reanimation after facial nerve paralysis. Ann Plast Surg. 2019 May;82(5):582–590. DOI:

Vejbrink Kildal V, Tee R, Reissig L, Weninger WJ, Tzou CJ, Rodriguez-Lorenzo A. Selective ansa cervicalis nerve transfer to the marginal mandibular nerve for lower lip reanimation: An anatomical study in cadavers and a case report. Microsurgery. 2023; 43(2): 142–150. DOI:

Biglioli F, Guerra MB, Rabbiosi D, Ciardiello C, Allevi F. Comparison of results utilizing one-step and two-step triple innervation techniques. J Craniomaxillofac Surg. 2021;49(7):628–634. DOI:

Admass BA, Ego BY, Tawye HY, Ahmed SA. Preoperative investigations for elective surgical patients in a resource limited setting: systematic review. Ann Med Surg (Lond). 2022 23;82:104777. DOI:

Telich-Tarriba JE, Velazquez E, Theurel-Cuevas A, et al. Upper extremity patterns of injury and management at a plastic and reconstructive surgery referral center in Mexico City. Ann Plast Surg. 2018;80(1):23–26. DOI:

Varelas AN. Use of three or more concomitant nerve transfers for facial nerve reanimation. In: 14th international facial nerve symposium. Seoul, Korea, April 28–30, 2022. The Charles Bell Society, Soul, Korea.

Dauwe PB, Hembd A, De La Concha-Blankenagel E, et al. The deep temporal nerve transfer: an anatomical feasibility study and implications for upper facial reanimation. Plast Reconstr Surg. 2016;138(3):498e–505e. DOI:

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How to Cite

Telich-Tarriba, J. E., Navarro-Barquin, D. F., Pineda-Aldana, G., & Cardenas-Mejia, A. (2023). Triple nerve transfers for the management of early unilateral facial palsy. Journal of Plastic Surgery and Hand Surgery, 58, 62–66.



Original Research Articles