Double innervated free functional muscle transfer for facial reanimation

Background: The treatment of long-standing facial palsy represents a challenge for the reconstructive surgeon. Treatment is based on dynamic procedures such as functional muscle flaps. The benefit of added axonal load has recently been reported. This study describes a two stage technique involving dual innervation of a gracilis muscle flap with initial cross-facial nerve graft (CFNG) followed by free muscle transfer co-apted to both the CFNG and a masseter nerve for facial reanimation. Methods: A total of nine patients from August 2008 - July 2011 were operated on with the double innervated gracilis muscle flap. Pre- and postoperative electromyography was documented, and video analysis with the five-stage classification of reanimation outcomes was performed. Results: All patients recovered voluntary and spontaneous smile abilities, with an average of 70% motor unit recruitment. Based on the Terzis reanimation outcome classification, four patients had an excellent result, four good, and one moderate. Conclusions: The double innervated gracilis muscle flap is a viable technique for the treatment of long-standing facial palsy. It enables a fast recovery with fast muscle activity, and allows an emotional smile and aesthetic symmetry.