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Single-stage Cross-facial Neurotized Free Gracilis Muscle Transfer for Smile Reanimation.
John P. Flynn, M.D.1; Tessa A. Hadlock, M.D.2; Nate Jowett, MD, PhD3
1Harvard Medical School / Massachusetts Eye and Ear Infirmary, Boston, MA; 2Facial Nerve Center - Dept. of Otolaryngology - Head and Neck Surgery, Harvard Medical School / Massachusetts Eye and Ear Infirmary, Boston, MA; 3Facial Nerve Center - Dept. of Otolaryngology, Harvard Medical School / Massachusetts Eye and Ear, Boston, MA

Introduction: Free gracilis muscle transfer is widely employed for smile reanimation in facial palsy. Neurotization options include ipsilateral trigeminal motor or contralateral facial nerve branches. Trigeminal motor neurotization is performed at time of muscle transfer in a single procedure and yields bite-activated smile with high reliability. Despite a higher risk of failure, evidence suggests most patients prefer a cross-facial neurotization strategy to restore smile spontaneity. Cross-facial neurotization is typically performed in two stages by preliminary nerve grafting owing to the relative short length of the nerve-to-gracilis muscle. Herein we describe a novel technique and one-year outcomes of free gracilis muscle transfer with contralateral facial neurotization performed as a single-stage procedure.
Materials and Methods: A new method of gracilis harvest and inset was implemented to position the nerve-to-gracilis close to the facial midline to enable direct coaptation with a contralateral facial nerve branch. From February 2019 to March 2021, patients who underwent single-stage gracilis transfer with cross-facial neurotization for whom photographic and videographic data was available at least one-year following the procedure were retrospectively analyzed. Pre- and postoperative smile was assessed using clinician-graded (eFACE) and software-based (Emotrics) tools.
Results: Thirteen patients who underwent single-stage GFMT with contralateral facial neurotization met inclusion criteria. Meaningful improvement in pre-to-postoperative smile excursion was achieved in 11 of 13 patients (84.6%), with significant improvement in eFACE smile scores (67 vs. 75; p=0.012), and several Emotrics measures. Pre- to postoperative oral commissure excursion improved from 2.6 mm vs 3.8 mm (p=0.10), with improvement in nasolabial fold vector symmetry (17.8 vs. 9.8; p=0.038), and upper lip slope symmetry (17.4 vs. 10.2, p=0.014).
Conclusions: This study suggests single-stage cross-facial neurotization of free gracilis muscle transfer may be a viable option for patients needing small improvements in affected-side smile excursion. Future work will compare results in age-matched controls against two-stage approaches.
Figure 1. Single-stage cross-facial neurotized free gracilis muscle transfer for smile reanimation. (A) Pre-operative smile effort in a 30M patient with left post-paralytic facial palsy demonstrates restriction of left-oral commissure excursion. (B) Gracilis muscle flap prior to inset demonstrating positioning of nerve near the midline of the face; vascular pedicle is rotated deep to the muscle for anastomosis with facial vessels. (C) Post-operative smile effort at 1.5 years demonstrates meaningful improvement in smile excursion and upper dentition show.


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