One-Stage Facial Reanimation with Bilateral Free Gracilis Muscle Transfer in Patients with Möbius Syndrome
Erika De La Concha, MD; Alexandro Aguilera-Salgado, MD; Alexander Cardenas-Mejia, MD
Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico
Möbius syndrome is a congenital disorder that affects facial and abducens cranial nerves, resulting in unilateral or bilateral facial palsy and strabismus. The treatment for Möbius syndrome is facial reanimation with free functional muscle transfer, the most commonly donor muscle used is the gracilis to its length, force and excursion. Typically, facial reanimation has been realized in two or more stages with controversial issues such as the amount of time between the two surgical stages and which is the ideal donor nerve (masseter, spinal accessory, hypoglossal). Lu and Chuang in 2013 reported a one-stage bilateral reconstruction with bilateral spinal accessory (XI) nerves to innervate 2 free functional muscle transfers. They report 6 cases with this treatment, achieving a complete smile in 6 months for children and 12 months for adults.
We included 4 Möbius syndrome patients with bilateral facial palsy (2 female, 2 male, and with an age range from 4 to 22 years). A total of 8 gracilis were transferred, 4 free flaps were innervated using bilateral masseter nerves and 4 free flaps were innervated using bilateral spinal accessory nerves. Mean operative time was 7 hours. Postoperative follow-up averaged 11 months. Results were evaluated using Terzis Functional and Aesthetic grading system for smile excursion. An average score of 3.5 for patients innervated with the masseter and an average score of 4 for patients innervated with the spinal (XI) nerve. Using Chuang’s Smile Excursion score patients innervated with the masseter achieved an average score of 2.5 and patients innervated with the spinal (XI) nerve achieved an average score of 3, without synkinesis or contractures. No complications or free flap failures presented in the study.We conclude that a one-stage bilateral free muscle transfer for facial reanimation is a safe and feasible procedure with low morbidity. We also concluded that the best results were seen using the spinal (XI) nerve as the donor nerve for innervation of the gracilis muscle. Careful patient selection and postoperative rehabilitation for smile training are important factors in achieving optimal outcomes.
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