Facial Reanimation Using Free Functional Muscle Transfer: Lessons Learnt From a Long Term Experience Comparing Innervation With Cross Facial Nerve Graft and Masseter Nerve

Background: Facial palsy is a complex problem and goal of reanimation is to achieve symmetric face at rest and spontaneous smile. in our study the authors performed facial reanimation in long standing cases of facial palsy (more than 1 year), gracilis muscle was used as a free functioning muscle transfer. Two motor donor nerves were used: cross-face nerve graft and masseter nerve. Materials and Methods: A total of 205 cases of unilateral facial reanimation with free functional muscle transfer (FFMT) were performed between 1998 and 2019. Out of 205 patients, 184 patients were operated by cross facial nerve graft-gracilis, and 21 by masseter nerve-gracilis. Quantitative assessment for outcome was done by measuring the excursion on follow up. Oral competence outcome and satisfaction score calculation was done by questionnaire. Results of spontaneous smile were divided into positive and negative groups. Results: A 2 stage cross facial nerve graft-gracilis FFMT achieved most natural and spontaneous smile when longer observation period (>= 2 years) was followed. Masseter nerve-gracilis provided satisfactory results in the shortest rehabilitation period, had more excursion but never obtained spontaneous smile. Conclusions: The cross facial nerve graft-gracilis FFMT can achieve natural and spontaneous smile and remains our first choice for facial reanimation. Masseter nerve-gracilis can be used if cross facial nerve graft-gracilis fails, patient desires a single stage surgery and in some specific conditions, such as bilateral mobius syndrome.