181. Novel Method Of Double Innervated Free Gracilis Muscle Functional Transfer For Facial Reanimation

Abstract

PURPOSE: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported, with the goal of providing both spontaneity from the CFNG and strong neural input from the masseteric nerve. We report a series of patients who underwent a novel modification to the existing nerve coaptation configurations. METHODS: Eight patients (Image 1 below) received free gracilis muscle transfer using the new double innervation method between September 2014 and December 2017. The CFNG, which was performed nine months prior, was sutured in an end-to-end fashion to the obturator nerve. A nerve graft was coapted to the ipsilateral masseteric nerve and then sutured in an end-to-side fashion to the CFNG proximal to the end-to-end obturator coaptation (Image 2 below). RESULT: All patients recovered smile function with teeth clenching (average 7.5 months, range 3-12). Seven of eight patients recovered a strong spontaneous smile by an average of 8.9 months (range 7-12), with one patient having weak spontaneous function after 12 months of follow-up. Average follow-up time was 31.52 months. All patients achieved improvements in their smile excursion based on the FACE-Gram software. Smile with or without biting achieved similar excursion on average (7.91mm vs.8.04mm, p=0.93). CONCLUSION: Our novel method of a double-innervated free gracilis muscle transfer represents a viable technique that does not risk denervation of the gracilis muscle and provides a symmetric, spontaneous, emotional smile.