The Success of Free Gracilis Muscle Transfer to Restore Smile in Patients With Nonflaccid Facial Paralysis

Background: Development of synkinesis, hypertonicity, and poor smile excursion after facial nerve insult and recovery contribute to disfigurement, psychological difficulties, and an inability to convey emotion via facial expression. Despite treatment with physical therapy and chemodenervation, some patients who recover from transient flaccid facial paralysis never spontaneously regain the ability to perform a meaningful smile. Methods: Prospective evaluation was performed on 20 patients with nonflaccid facial paralysis who underwent free gracilis muscle transfer. Patients were evaluated using the quality-of-life (QOL) FaCE survey, Facial Nerve Grading Scale, and Facegram to quantify QOL improvement, smile excursion, and symmetry after muscle transfer. Results: A statistically significant increase in the FaCE score was seen after muscle transfer (paired 2-tailed t test, P < 0.039). In addition, there was a statistically significant improvement in the smile score on the Facial Nerve Grading Scale (P < 0.002), in the lower lip length at rest (P = 0.01) and with smile (P = 0.0001), and with smile symmetry (P = 0.0077) after surgery. Conclusions: Free gracilis muscle transfer has become a mainstay in the management armamentarium for patients who develop severe reduction in oral commissure movement after facial nerve insult and recovery. The operation achieves a high overall success rate, and innovations involving transplanting thinner segments of muscle avoid a cosmetic deformity secondary to excess bulk. This study demonstrates a quantitative improvement in QOL and facial function after free gracilis muscle transfer in patients who failed to achieve a meaningful smile after physical therapy.