Cross face nerve graft versus ipsilateral cranial nerve transfer to power free muscle transfer: what do you think?

Traditional donor nerves have included the contralateral facial nerve (CFNG), hypoglossal nerve, spinal accessory nerve and motor nerve to masseter. When the contralateral facial nerve is not functioning then the decision is made for you. But when deciding between transfer and CFNG and transfer what considerations do you take into account? Often it is pitched as a decision between spontaneous smile (CFNG) versus voluntary activation. But the motor nerve to masseter is regarded as providing a more powerful input to a transferred muscle1 and cerebral adaptation is said to occur.2 A number of papers have looked at the differences between innervation of CFNG and transfer, 3-5 and demonstrated that motor nerve to masseter delivers a greater number of axons and a clinically more powerful smile. Do you take into account the excursion of the contralateral smile into your decision-making? What is your anecdotal experience and how do you tailor your procedure depending on the source of innervation? Have you found patients with weaker bite after sacrificing the motor nerve to masseter. Do you prefer hypoglossal nerve? End to side? End to end? Jump graft? Why? Do you witness unwanted muscle flap activation during mastication and if so what therapy strategies do you have to mitigate this. Please contribute on this blog post: over 200 members are interested in your viewpoint!