The free innervated muscle transfer is currently the most effective technique to restore motion of the lower face and the lip to create the dynamics of the smile. One of the problems associated with free muscle transfer is dehiscence of the muscle from its points of fixation with resultant compromise of the transferred muscle function. There are three techniques that have been developed to improve the muscle fixation: 1) use of the GIA stapler across the ends of the gracilis muscle 2) use of the Mitek suture anchor into the zygoma and 3) placement of an internal splint which is removable at six weeks postoperative. The use of the GIA stapler has provided a double row of staples across each end of the muscle. This provides a stable end of the muscle that sutures can be passed into and prevent "cheese wiring". This method also allows radiologic marking of the positions of the muscle ends and can allow verification of the intact fixation of the muscle near the lip. The use of the Mitek and its placement into the areas of the zygoma is reviewed. The placement of a pull out Prolene suture from the commissure to the parietal skin is used for a period of six weeks to protect the muscle while it heals into the points of fixation at the zygoma and commissure level.

These techniques have been used in six patients with facial palsy, one patient with Moebius syndrome and one patient with Volkmann's ischemic contracture.

A description of these techniques will be presented as well as pre and postop videos displaying successful function.