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.