A Novel Method of Spinal Accessory Nerve Banking Using Silicone Catheter for Functioning Free Muscle Transfer.

In secondary brachial plexus reconstruction, exploring an area that has already been operated on is challenging and time-consuming for a surgeon, especially in centers with a single-team approach. Due to their inertness and lack of adverse effects, silicone Foley catheters were used successfully during the reconstruction of flexor tendons. Based on the concept, we have achieved an acceptable functional outcome by banking the spinal accessory nerve in a silicon catheter for gracilis reanimation, which permits smooth dissection, maintains the length, and shortens the operating time for subsequent reconstruction. Level of Evidence: Level V.

Long-term outcomes of dual innervation in functional muscle transfers for facial palsy.

BACKGROUND: This study describes a different approach with a 2-stage facial reanimation in patients with long-standing unilateral facial paralysis using free gracilis muscle transfer, innervated by both cross-facial nerve graft and masseteric nerve. The authors present their rationale, surgical technique, and long-term outcomes. METHODS: Between August 2012 and March 2016, 11 patients (6 female and 5 male patients) underwent a 2-staged dually innervated gracilis muscle transfer. Patients were evaluated with physical examination and needle electromyography. A standardized assessment of preoperative and postoperative photographs and videos was performed using Terzis' smile functional grading system at 48 months following surgery and the Emotrics software to assess improvement in symmetry over a 36-month postoperative period. RESULTS: Voluntary contraction of the gracilis muscle was observed in all patients at a mean of 4 months and 4 days following muscle transfer. A spontaneous smile produced without teeth clenching was developed in all patients by 18 months postoperatively. Six patients achieved excellent and 5 good results. The difference between the averaged pre- and postoperative scores was statistically significant. With Emotrics, there were significant improvements in the smile angle, upper lip elevation, commissural excursion, and commissural height, with continuous improvement over 36 months. The postoperative electromyography (EMG) confirmed dual innervation of the gracilis muscle by the facial and masseteric donor motor neural sources. We present our results at minimum 48 months postoperatively. CONCLUSIONS: Dual innervated two-stage gracilis transfer is an effective method for reanimation in long-standing unilateral facial paralysis, providing both rapid reinnervation of the transferred muscle, together with a powerful, synchronous smile.

Dual innervation of free gracilis muscle for facial reanimation: What we know so far.

BACKGROUND: In the last decade, some institutions have begun combining the CFNG and masseteric nerve to provide dual innervation to the gracilis muscle for dynamic facial reanimation in facial paralysis patients. We reviewed the various ways that these two nerves have been coapted to provide dual innervation, and summarized the functional outcome for these methods. METHODS: A search of the Ovid EMBASE, MEDLINE, Cochrane, and Scopus databases was performed from 1946 to May 2019 for dual innervation of gracilis muscle using CFNG plus masseteric nerve for facial reanimation. RESULTS: A total of 184 articles were identified in the initial search, of which seven met our inclusion criteria. Three additional abstracts with 43 patients were identified but the level of details was not sufficient to include the results in the analysis. A total of 57 patients were reviewed (mean age of 42.1 years (6-79 years)). The majority of dual innervation procedures were performed using the ipsilateral masseteric nerve sutured end-to-end to the obturator nerve, and an additional CFNG connected end-to-side to the obturator nerve. In the 26 patients with Terzis scores available, there were no differences between masseteric nerve coapted end-to-end and CFNG as end-to-side to the obturator, or the reverse coaptation. All but two patients achieved function of the gracilis activated by the masseteric nerve within 2-5 months. CONCLUSIONS: This review shows that dual innervation of the gracilis is safe; and in some cases, does appear to provide early onset gracilis activation as well as an eventual spontaneous smile.

Biometría del músculo grácil: pedículos vasculares e inervación en un grupo de individuos brasileños / Biometric characteristics of the gracilis muscle: vascular pedicles and innervation in a group of Brazilian individuals

El músculo grácil (MG) está ubicado en la cara medial del muslo, medial y posterior al aductor largo en su parte proximal. Se origina a nivel del pubis y se inserta en la cara medial de la tibia, en su parte superior. Como colgajo libre funcional ha sido uno de los injertos más utilizados en reconstrucciones diversas, tales como pene, perineo, vagina, pierna, plexo braquial, parálisis facial, lesiones rectales, entre otras. Basado en lo anterior, el objetivo de este estudio fue complementar la anatomía del MG tanto en sus dimensiones como en sus pedículos vasculares e inervación, estableciendo las relaciones biométricas existentes, contribuyendo a la anatomía quirúrgica, en su uso como injerto. Para ello, se utilizaron 30 miembros inferiores de 20 cadáveres de individuos adultos, brasileños, de sexo masculino, 14 derechos y 16 izquierdos; 17 fijados en formol y 13 en glicerina. Se dividió al muslo en 4 cuartiles enumerados de proximal a distal como C1,C2,C3 y C4. Se contabilizó el número de pedículos y se nombraron como pedículo principal (PP), pedículo menor 1 (Pm1), pedículo menor 2 (Pm2) y pedículo menor 3 (Pm3). La longitud media del GM fue de 42,25 cm ± 2,35 cm y su ancho promedio de 32,90 ± 4,86 mm. Con respecto a los pedículos vasculares se encontró un pedículo en 10/30 casos (33,3 %); un pedículo principal y uno menor en 10/30 (33,3 %); un pedículo principal y dos menores en 8/30 (26,7 %) y un pedículo principal y tres menores en 2/30 (6,7 %). Su inervación siempre procedió del ramo anterior del nervio obturador (RaNO). El punto motor se encontró a una distancia promedio de 7,94 mm proximal al ingreso del pedículo principal en el MG. Los registros biométricos están expresados en tablas. Los resultados obtenidos aportarán al conocimiento anatómico, pudiendo ser utilizados como soporte morfológico a los procedimientos quirúrgicos que involucren al músculo grácil.

The gracilis muscle (GM) is located in the medial aspect of the thigh, medial and posterior to the long adductor in its proximal part. It originates at the pubic level and is inserted in the medial face of the tibia, in its upper part. As a functional free flap, it has been one of the most co mmonly used grafts in various reconstructions, such as penis, perineum, vagina, leg, brachial plexus, facial paralysis, rectal lesions, among others. Based on the above, the objective of this study was to complement the anatomy of the GM both in its dimensions and in its vascular pedicles and innervation, establishing the existing biometric relationships, contributing to the surgical anatomy, in its use as a graft. For this, 30 lower limbs of 20 bodies of adult, Brazilian, male, 14 right and 16 left individuals were used; 17 fixed in formaldehyde and 13 in glycerin. The thigh was divided into 4 quartiles listed from proximal to distal such as C1, C2, C3 and C4. The number of pedicles was counted and they were named as principal pedicle (PP), minor pedicle 1 (mP1), minor pedicle 2 (mP2) and minor pedicle 3 (mP3). The average length of the GM was 42.25 cm ± 2.35 cm and its average width was 32.90 ± 4.86 mm. With respect to vascular pedicles, a pedicle was found in 10/30 cases (33.3 %); one PP and one mP in 10/30 (33.3 %); one PP and two mP in 8/30 (26.7 %) and one PP and three mP in 2/30 (6.7 %). Its innervation always came from the anterior branch of the obturator nerve (aBON). The motor point was found at an average distance of 7.94 mm proximal to the entry of the PP in the GM. Biometric records are expressed in tables. The results obtained will contribute to anatomical knowledge, and can be used as morphological support for surgical procedures that involve the GM.

Powering the Gracilis for Facial Reanimation: A Systematic Review and Meta-analysis of Outcomes Based on Donor Nerve.

Importance: Free gracilis transfer for dynamic reanimation in chronic facial paralysis is the gold standard, but there remains a need to better understand outcomes with respect to the donor nerve. Objective: To characterize outcomes in adults undergoing primary gracilis transfer for facial paralysis stratified by donor nerve used for neurotization. Data Sources: Search strategies were used in Ovid MEDLINE (1946-2019), Embase (1947-2019), Scopus (1823-2019), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov (1997-2019). Study Selection: Inclusion and exclusion criteria were designed to capture studies in adults with unilateral chronic facial paralysis undergoing single-paddle free gracilis transfer. All study types were included except case reports. Abstracts and full texts were reviewed in duplicate. Of 130 unique citations, 10 studies including 295 patients were included after applying inclusion and exclusion criteria. Data were analyzed between November 2018 and December 2019. Data Extraction and Synthesis: PRISMA guidelines were followed. The Newcastle-Ottawa scale was used to assess study quality, and the Cochrane Risk of Bias tool was used to assess risk of bias. Independent extraction by 2 authors (P.M.V. and J.J.C.) was performed. Data were pooled using a random-effects model. Main Outcomes and Measures: Owing to heterogeneity in reporting of facial reanimation outcomes, we first performed a systematic review, and then compiled available outcomes for meta-analysis. Outcomes studied for meta-analysis were oral commissure excursion and facial symmetry. Results: Meta-analysis of masseteric nerve (MN) (n = 56) vs cross-facial nerve graft (CFNG) (n = 52) in 3 retrospective studies showed no statistical heterogeneity between these studies (I2 = 0%), and the standardized mean difference (SMD) was greater for MN (0.55; 95% CI, 0.17 to 0.94). Meta-analysis of angles of symmetry in 2 retrospective studies comparing MN (n = 51) to CFNG (n = 47) both at rest (-0.22; 95% CI, -0.63 to 0.18) and with smiling (-0.14; 95% CI, -0.73 to 0.46) were better with MN, though the difference was not statistically significant. Conclusions and Relevance: Owing to heterogeneity in reported outcomes from facial reanimation, we were unable to make definitive conclusions regarding the optimal donor nerve. Establishing a reporting standard at peer-reviewed journals to improve results reporting is one method to allow for improved collaboration in the future. Standardizing follow-up times, assessing spontaneity in an objective and reproducible fashion, and use of consistent outcome measures would allow for future meta-analyses and better understanding of options for facial reanimation.

Cadaveric Evaluation of Myelinated Nerve Fiber Count in the Nerve to the Gracilis Muscle in Relation to Use as a Free Functional Muscle Transfer for Elbow Flexion.

BACKGROUND: Optimizing axon count is essential for successful nerve transfer surgery, and a donor-to-recipient axon count ratio greater than 0.7:1 has been associated with improved outcomes. A gracilis free functioning muscle transfer (FFMT) is an option to restore elbow flexion, but its axon count has not been evaluated. Our aim was to quantify the axon count of the nerve to the gracilis muscle. METHODS: The nerve to the gracilis was dissected in 10 fresh frozen adult cadaveric hindquarter specimens (four females and six males). The length of the nerve to the gracilis was measured and a biopsy taken. A validated histologic preparation technique was utilized, and axons were counted. The mean length and axon counts were calculated. RESULTS: The average axon count in the nerve to the gracilis was 818 (range = 684-1,000, standard deviation [SD] = 116). The average length was 98 mm (range = 81-115 mm, SD = 13 mm). CONCLUSION: Our study found the average axon count in the nerve to the gracilis was 818. Prior literature suggests axon count ratio greater than 0.7:1 is associated with better clinical outcomes. Using data from prior studies, the spinal accessory, three intercostal, and two intercostal nerves are all sufficient for the transfer to the nerve to the gracilis with donor to recipient ratios of 1.7:1, 1.3:1, and 0.9:1, respectively.

Comparative Study of 2 Different Innervation Techniques in Facial Reanimation: Cross-face Nerve Graft-Innervated Versus Double-Innervated Free Gracilis Muscle Transfer.

Recently, 1-stage double innervation with the masseter nerve and the cross-face nerve graft (CFNG) has gained popularity owing to its outcomes of powerful and synchronous muscle contraction. In this study, we compared CFNG- and double-innervated free gracilis muscle transfer (FGMT) for facial palsy reconstruction.A total of 49 patients with facial palsy who underwent facial reanimation surgery from August 2013 to January 2017 were enrolled. The CFNG group (18 patients) underwent 2-stage CFNG innervation, whereas the double-innervated FGMT group (31 patients) underwent dual coaptation with end-to-end masseter nerve and end-to-side CFNG. The FACEgram software was used for evaluating smile excursion, symmetry index, spontaneous smile occurrence, Terzis' score including palsy pathogenesis, and clinical progress.In the CFNG group, the smile excursion at rest increased (P = 0.000); however, there was increased smile excursion both at rest and during smiling in the double-innervated FMGT group (rest P = 0.002, smile P = 0.028). Improvement of the symmetry index was observed only in the FMGT group (rest P = 0.001, smile P = 0.000). There was no significant difference in Terzis' scores. The average time to the first visible muscle contracture was statistically significantly shorter in the double-innervated FGMT group (P = 0.035). With respect to spontaneous smile achievement, the double-innervated FGMT group (25.8%) showed a satisfactory outcome.Cross-face nerve graft-innervated FGMT improved only smile excursion at rest, whereas double-innervated FGMT provided improvement in both the resting and smiling postures. Furthermore, the double-innervated FGMT group showed a higher symmetry index. However, the 2 operations did not show a significant difference in functional aspects.

The Inverted Free Functioning Gracilis Muscle Transfer For Restoration of Elbow Flexion Following Delayed Presentation or Failed Primary Nerve Reconstruction of Upper Trunk Injuries.

Free functional gracilis transfer is a well-established technique for restoring active elbow flexion in brachial plexus injuries following delayed presentation or failed nerve reconstruction procedures. In cases of delayed presentation or failed nerve reconstruction following upper trunk injuries, the lower trunk intraplexal median and ulnar nerves are spared, thereby making them available to reinnervate the transferred gracilis. Therefore, we have inverted the conventional free functional gracilis orientation so as to orient the flap's recipient nerve in closer proximity to donor median or ulnar nerve fascicles to enable a short, tension-free coaptation in the middle to distal arm. Herein is our descriptive surgical technique for performing an inverted free functional gracilis muscle transfer in order to restore elbow flexion in the setting of an upper trunk injury.

Spontaneity Assessment in Dually Innervated Gracilis Smile Reanimation Surgery.

IMPORTANCE: Surgeons have sought to optimize outcomes of smile reanimation surgery by combining inputs from nerve-to-masseter and cross-face nerve grafts. An objective assessment tool could help surgeons evaluate outcomes to determine the optimal neural sources for smile reanimation. OBJECTIVE: To evaluate the use of a novel video time-stamping method and standard outcome measurement tools to assess outcomes of facial reanimation surgery using various innervation strategies. DESIGN, SETTING, AND PARTICIPANTS: Cohort study assessing the outcomes of dually innervated gracilis free muscle transfers vs single-source innervated gracilis transfer performed at a tertiary care facial nerve center between 2007 and 2017 using a novel, video time-stamping spontaneity assessment method. The statistical analyses were performed in 2018. INTERVENTIONS: Dually innervated gracilis free muscle transfers or single-source innervated gracilis transfer. MAIN OUTCOMES AND MEASURES: Spontaneous smiling was assessed by clinicians and quantified using blinded time-stamped video recordings of smiling elicited while viewing humorous video clips. RESULTS: This retrospective cohort study included 25 patients (12 men and 13 women; median [range] age, 38.4 [29.3-46.0] years) treated with dually innervated gracilis free functional muscle graft for unilateral facial palsy between 2007 and 2017. Smile spontaneity assessment was performed in 17 patients and was compared with assessment performed in 24 patients treated with single-source innervated gracilis transfer (ie, nerve-to-masseter-driven or cross-face nerve graft-driven gracilis [n = 13]) (demographic data not available for NTM and CFNG cohorts). The use of time-stamped video assessment revealed that spontaneous synchronous oral commissure movement in a median percentage of smiles was 33% in patients with dually innervated gracilis (interquartile range [IQR], 0%-71%), 20% of smiles in patients with nerve-to-masseter-driven gracilis (IQR, 0%-50%), and 75% of smiles in patients with cross-face nerve graft-driven gracilis (IQR, 0%-100%). Clinicians graded smile spontaneity in dually innervated cases as absent in 40% (n = 6 of 15), trace in 33% (n = 5 of 15) and present in 27% (n = 4 of 15). No association was demonstrated between clinician-reported spontaneity and objectively measured synchronicity. CONCLUSIONS AND RELEVANCE: Dually innervated gracilis free muscle transfers may improve smile spontaneity compared with masseteric nerve-driven transfers but not to the level of cross-face nerve graft-driven gracilis transfers. Quantifying spontaneity is notoriously difficult, and most authors rely on clinical assessment. Our results suggest that clinicians may rate presence of spontaneity higher than objective measures, highlighting the importance of standardized assessment techniques. LEVEL OF EVIDENCE: 4.

Using the "Sugarcane Chewing" Concept as the Directionality of Motor Neurotizer Selection for Facial Paralysis Reconstruction: Chang Gung Experiences.

BACKGROUND: Facial paralysis and postparalysis facial synkinesis both cause severe functional and aesthetic deficits. Functioning free muscle transplantation is the authors' preferred method for reconstructing both deformities. METHODS: From 1985 to 2017, a total of 392 patients underwent 403 gracilis functioning free muscle transplantations for facial reanimation. Different motor neurotizers were used: cross-face nerve graft (74 percent), spinal accessory nerve (17 percent), and masseter nerve (8 percent). Smile excursion score, cortical adaptation stage, patient questionnaire, Hadlock lip excursion, and the Terzis evaluation systems were used to assess outcomes. RESULTS: For smile excursion score, the spinal accessory and masseter nerve groups showed higher scores than the cross-face nerve graft group in the first 2 years, but no difference by 3-year follow-up. For cortical adaptation stage, nearly all cross-face nerve graft patients achieved stage IV or V spontaneity, the spinal accessory nerve group achieved at least stage III (independent) movement, but individuals in the masseter nerve group achieved only stage III or less. The cross-face nerve graft group also achieved higher scores according to the Hadlock system and the Terzis evaluation system compared with the other two groups. CONCLUSIONS: The concept of "sugarcane chewing" where the sweetness is the least at the tail but the most at the head can be simply applied for surgeons and patients in weighing the benefits and drawbacks during the motor neurotizer selection. Cross-face nerve graft-innervated gracilis is analogous to chewing sugarcane from tail to head; despite lower outcome measures earlier, it yields the highest scores at 3 years postoperatively. Masseter-innervated gracilis is akin to chewing sugarcane from head to tail, with greater outcome scores initially but little improvement at longer follow-up. Spinal accessory-innervated gracilis results fall in between these two groups. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effectiveness and safety of the use of gracilis muscle for dynamic smile restoration in facial paralysis: A systematic review and meta-analysis.

BACKGROUND: Smiling is a fundamental component of social interactions. Significant challenges arise for patients with facial palsy. One of the key procedures for dynamic smile restoration is the microneurovascular transfer of a gracilis muscle. We aimed to assess the effectiveness and safety of dynamic smile reanimation surgery using the free gracilis muscle unit in patients with facial palsy. METHODS: We conducted a systematic review and meta-analysis of studies reporting surgical outcomes of dynamic smile restoration using free gracilis muscles identified from EMBASE, Medline, and Web of Science databases from their inception to March 15, 2018. Two-stage screening and data extraction were performed by two independent reviewers. Pooled proportions were calculated using random-effects models. RESULTS: Thirty-one studies including 1647 patients who underwent 1739 free gracilis flaps were included. Twelve (38.7%) studies measured perioperative smile excursion change using six different tools. Six of these studies were homogeneous and were used in meta-analyses of smile excursion improvement, which revealed a mean change of 7.5 mm (95% CI 6.0-9.0 mm, I2 86.7%) perioperatively. Twenty (64.5%) studies reported perioperative complications, and pooled proportions of flap failures were of 2.9% (95% CI 1.3-4.5%, I2 47.7%). CONCLUSIONS: Dynamic smile restoration using a free gracilis muscle may represent an effective procedure to regain oral commissure motion and is associated with an approximately 3% rate of flap failure. Masseteric nerve coaptations lead to larger improvements in perioperative smile excursion (10 mm) than cross-facial nerve grafts (6.8 mm). Future studies with homogeneous reporting of smile excursion and patient-reported outcome measures are needed.

Patient experience in nerve-to-masseter-driven smile reanimation.

INTRODUCTION: The nerve-to-masseter is one of the most frequently used neural sources in smile reanimation surgery. Very little information has been reported on patient experience with regard to reanimated smile usage and sequelae following transfer. The aim of this study was to quantify patient perception of nerve-to-masseter use in smile reanimation surgery. METHODS: An online questionnaire was developed based on the clinical expertise of our team, patient interviews, and existing questionnaires of facial palsy-related quality of life and temporomandibular joint dysfunction. All patients treated with nerve-to-masseter-driven smile reanimation surgery, both nerve transfers and muscle transplantations, between 2007 and 2016 with a valid email address were invited to participate. RESULTS: Of 171 operated patients, 122 with a valid email address were invited to participate. Seventy-one patients responded (63.4% female, mean age 51.1 years) after a median follow-up of 3.8 years. A voluntary smile while biting down at least "most of the time" was reported by 83.1% of patients; 46.5% reported ability to smile on the affected side without bite. A "normal" or "almost normal" spontaneous smile was reported in 23.9% of patients. A total of 18.3% of patients self-reported masseter muscle atrophy, and 1.4-14.1% reported temporomandibular joint dysfunction. Forty-one patients (57.7%) reported prandial movement of the face at least "most of the time," with 9 patients (12.7%) considering this bothersome. CONCLUSION: Patients report good voluntary smiling ability following nerve-to-masseter-driven smile reanimation surgery, with low rates of sequelae.

Comparison between donor nerves to motorize the free functional gracilis muscle transfer for elbow flexion: Retrospective study of 38 consecutive cases in traumatic adult brachial plexus injuries.

PURPOSE: Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed, or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice. In this report, the authors present the results of a comparison study on different donor nerves (spinal accessory and ulnar) in elbow flexion reconstruction with gracilis flap for traumatic adult brachial plexus injuries. METHODS: Retrospective analysis of patients with both total or partial traumatic brachial plexus injuries was carried out. Of the 38 patients enrolled, 37 were male (97.4%) with a mean age of 28.3 years. The mean follow-up period was 25 months. Postoperative function of the gracilis muscle flap was recorded and patients were divided into two groups according to donor nerve: spinal accessory nerve (SAN) (18 cases), and motor fascicles of the ulnar (ULNAR) (20 cases). RESULTS: Twenty-six cases obtained elbow flexion strength M3 or M4 (68.4%): 0 M0 (0.0%), 4 M1 (10.5%), 8 M2 (21.1%), 9 M3 (23.7%) and 17 M4 (44.7%). The mean interval to first recorded M3 muscular strength was 12.4 months. Functional elbow flexion strength (≥ M3) had the following distribution: SAN 83.3% (15/18) and ULNAR 55.0% (11/20) (p = .086). CONCLUSION: No statistical difference for final muscle strength was found between donor nerve groups.

Long-Term Outcomes of Free Gracilis Muscle Transfer for Smile Reanimation in Children.

OBJECTIVE: To evaluate long-term outcomes of free gracilis muscle transfer (FGMT) for smile reanimation on smile excursion, facial symmetry, and quality of life in a cohort of children with facial palsy. STUDY DESIGN: A retrospective analysis of 40 pediatric patients who underwent FGMT for facial palsy at the Massachusetts Eye and Ear Infirmary Facial Nerve Center was performed. Preoperative and postoperative photography and videography were used to quantify smile excursion and facial symmetry. Preoperative and postoperative quality of life was assessed with the Facial Clinimetric Evaluation (FaCE) survey, a validated, patient-based instrument for evaluating facial impairment and disability. RESULTS: Of the 40 patients who underwent FGMT for facial palsy, 38 patients had complete data including preoperative and postoperative photography and videography from 3 months to 10 years following surgery; 13 cases had >5 years of follow-up. FGMT resulted in significant improvements in smile excursion within several months, with continued improvements in smile excursion and symmetry demonstrated more than 5 years later. Fifteen patients completed preoperative and postoperative FaCE surveys, which demonstrated significant improvement in quality of life scores following FGMT. CONCLUSIONS: FGMT significantly improves smile, facial asymmetry, and quality of life for years after this surgery for facial palsy.

Surgical Refinement Following Free Gracilis Transfer for Smile Reanimation.

IMPORTANCE: Gracilis free muscle transfer is widely regarded as the gold standard functional smile reanimation in long-standing facial palsy. Although most patients achieve meaningful oral commissure movement, a subset has suboptimal aesthetic outcomes due to midfacial bulk or oral commissure malposition. Safe refinements that do not compromise excursion would be a welcome addition to the surgical armamentarium for this population. OBJECTIVES: The goal of this study was to describe surgical approaches to the 3 most common postoperative sequelae that detract from the final result after gracilis facial reanimation and to examine how these surgical refinements affect aesthetic outcome, smile excursion, and quality of life. DESIGN: This was a retrospective case series. SETTING: Tertiary care center (Massachusetts Eye and Ear Infirmary Facial Nerve Center). PARTICIPANTS: Of 260 gracilis transfers performed since 2003, meaningful excursion (>3 mm) but poor aesthetic outcome requiring additional surgery was noted in 21 patients and was related either to excess muscle bulk (9), resting inferior malposition of the oral commissure (9), or resting superior/lateral malposition of the oral commissure (3). INTERVENTION: Specific surgical interventions to address each of these negative sequelae were developed and refined, to preserve muscle functionality but eliminate the unsightly feature. MAIN OUTCOME: Aesthetic status, determined by midfacial symmetry; quantitative smile excursion; and quality of life (using the FaCE instrument) were measured before and after revision. RESULTS: Patients who underwent gracilis refinement directed at either muscle debulking, or gracilis tightening or loosening experienced significantly improved aesthetics/midfacial symmetry and improved quality of life with no significant decrease in smile excursion. CONCLUSIONS: Improved aesthetics and quality of life can be achieved through targeted revision of the gracilis free tissue transfer, without significant loss of smile excursion.

Incomplete Facial Paralysis: The Use of the Ipsilateral Residual Facial Nerve as a Donor Nerve for Facial Reanimation.

BACKGROUND: The reconstructive approach for incomplete facial paralysis is not yet determined. In this article, the authors present a new surgical approach for patients with incomplete facial paralysis in which residual, ineffective movement is detected preoperatively in the ipsilateral buccozygomatic territory of the paretic facial nerve. METHODS: Sixteen patients with incomplete facial paralysis were found eligible for the procedure and underwent one-stage facial reanimation performed by the senior author (E.G.). Reanimation was performed using free gracilis muscle transfer with neural coaptation to an active facial nerve branch(es) responsible for the predetected buccozygomatic residual movement. Patients were reviewed in a systematic fashion using a combined still photographic and video scoring scale for symmetry at rest and at dynamic states. RESULTS: Following surgery, improved symmetry was observed in the majority of observations of the mouth region at rest and while smiling and of the nasolabial fold region while smiling. There was no significant change in symmetry in the majority of observations of the eye region at rest and while smiling and the nasolabial fold region at rest. Video assessment of dynamic facial symmetry while smiling demonstrated improved symmetry in 91 percent of the observations (n = 191 observations). Comparison of mean scores for dynamic smile symmetry produced a statistically significant improvement of 1.68 points following surgery (p < 0.001). CONCLUSION: Based on this series, the authors recommend that use of the ipsilateral facial nerve buccozygomatic residual branch be considered as a donor nerve for facial reanimation using a free gracilis muscle transfer in patients with incomplete facial paralysis with residual preoperative movement in the midface. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of Functional Results After Cross-Face Nerve Graft-, Spinal Accessory Nerve-, and Masseter Nerve-Innervated Gracilis for Facial Paralysis Reconstruction: The Chang Gung Experience.

BACKGROUND: Using functioning free muscle transplantation (FFMT) for facial paralysis and postparalysis facial synkinesis reconstruction is our preferred technique. Gracilis was the first choice of muscle. Three motor neurotizers: cross-face nerve graft (CFNG), spinal accessory nerve (XI) and masseter nerve (V3) have been used as neurotizers for different indications. METHODS: A total of 362 cases of facial reanimation with FFMT were performed between 1986 and 2015. Of these, 350 patients with 361 FFMT were enrolled: 272 (78%) patients were treated by CFNG-gracilis, 56 (15%) by XI-gracilis, and 22 (6%) by V3-gracilis. Smile excursion score, cortical adaptation stage with tickle test for spontaneous smile, facial synkinesis, satisfaction score by questionnaire, and functional facial grading were used for outcome assessment. RESULTS: The CFNG-gracilis in a 2-stage procedure achieved most natural and spontaneous smile when longer observation (≥2 years) was followed. The single-stage procedure using the XI-gracilis has proven a good alternative. V3-gracilis provided high smile excursion score in the shortest rehabilitation period, but never obtained spontaneous smile. CONCLUSIONS: The CFNG-gracilis remains our first choice for facial paralysis reconstruction which can achieve natural and spontaneous smile. XI- or V3-gracilis can be selected as a save procedure when CFNG-gracilis fails. The V3-gracilis is indicated in some specific conditions, such as bilateral Möbius syndrome, older patients (age, >70 years), or patients with malignant disease.

The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation.

IMPORTANCE: A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis. OBJECTIVE: To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone. DESIGN, SETTING, AND PARTICIPANTS: Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital. INTERVENTIONS: The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation. MAIN OUTCOMES AND MEASURES: The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling. RESULTS: There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P < .001). The mean exposed maxillary gingival scaffold width improved from 31.5 mm to 43.7 mm (95% CI, 1.9 to 4.3; P < .001). There was no significant difference in interlabial exposure at midline (7.1 mm vs 7.7 mm; CI, -1.5 to 2.7; P = .56) but a 56.4% improvement at the level of the canines (3.9 vs 6.1; CI, 0.1 to 4.3; P = .04). The mean FAI when smiling was reduced from 9.1 mm to 4.5 mm (CI, -8.0 to -1.2; P = .01). Dynamic wrinkling of the periorbital area with smiling was noted in 4 patients. CONCLUSIONS AND RELEVANCE: The gracilis flap can be reliably designed as a functional double paddle muscle flap for a multivector facial reanimation. The multivector gracilis flap design is effective in improving all components of the smile display zone and has the potential for producing periorbital-wrinkling characteristic of a Duchenne smile. LEVEL OF EVIDENCE: 4.

Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children.

The purpose of this study was to evaluate long-term outcomes of the free functioning gracilis transfer in children with traumatic total brachial plexus palsy. We used the free functioning gracilis transfer to reconstruct elbow flexion and prehension in 17 children with a mean age of 13.4 years (range 3-17) who were followed-up over a mean period of 6 years (range 2-16). The transferred gracilis delivered a stable elbow flexion with a useful power, as well as reconstructed active finger motion. In 3-11-year-old patients we noted a tendency towards developing a progressive flexion contracture of the elbow. The limb length discrepancy observed in our patients was not different from the brachial plexus palsy patients treated without the free functioning gracilis transfer. In conclusion, the free functioning gracilis transfer is a reliable reconstructive technique for reanimating upper extremity in children of all ages capable of delivering stable function over a long period of time. LEVEL OF EVIDENCE: IV.

Facial reanimation surgery in Möbius syndrome: Experience from 76 cases from a tertiary referral hospital in Latin America.

INTRODUCTION: Möbius syndrome is defined as a combined congenital bilateral facial and abducens nerve palsies. The main goal of treatment is to provide facial reanimation by means of a dynamic surgical procedure. The microneurovascular transfer of a free muscle transplant is the procedure of choice for facial animation in a child with facial paralysis. OBSERVATION: Between January 2008 and January 2017, 124 patients with the syndrome have been approached at our institution. Distribution according to Möbius Syndrome classification presents as follows: Complete Möbius syndrome (n=88), Incomplete Möbius syndrome (n=28), Möbius-Like syndrome (n=8). Seventy-nine female and 45 male patients. Sixty-one percent have undergone a microsurgical procedure (n=76), in all of them, a free gracilis flap transfer was performed. DISCUSSION: Our proposed treatment protocol for complete Möbius syndrome is determined by the available donor nerves. We prefer to use the masseteric nerve as first choice, however, if this nerve is not available, then our second choice is the spinal accesory nerve. For this purpose, all patients have an electromyography performed preoperatively. Overall, dynamic facial reanimation obtained through the microvascular transfer of the gracilis muscle have proved to improve notoriously oral comissure excursion and speech intelligibility. CONCLUSION: The free gracilis flap transfer is a reproducible procedure for patients with Möbius syndrome. It is of utmost importance to select the best motor nerve possible, based on an individualized preoperative clinical and electromyographic evaluation. To our best knowledge, this is the largest series of patients with Möbius syndrome globally, treated at a single-institution.