Smile reconstruction using the gracilis muscle

Abstract

Because of its convincing advantages, gracilis muscle transplantation became the most frequently used technique for reconstruction of a smile in the long-standing, irreversible facial palsy. In the unilateral palsy, it is most often combined with cross-facial nerve grafting. In the majority of cases, reconstruction by free-gracilis-muscle transplantation is concentrated on the smile function, whereas closure of the eye is achieved by transposing a part of the temporalis muscle to the upper and lower eye lid. If the latter possibility is no longer available, the gracilis muscle is transplanted by its two functional territories to the eye and the mouth. We are using this technique as a principle in children. If a proximal stump of the ipsilateral facial nerve is available, the gracilis muscle graft is reinnervated by the ipsilateral facial nerve. In Moebius syndrome, a part of the ipsilateral hypoglossal nerve is used for reinnervation. During harvesting of the gracilis muscle, drugs for relaxation should not be used. The design of the muscle transplant is transferred to the gracilis muscle after preparing the vessels and nerves in the recipient area. By preferring the superficial temporal vessels to the facial vessels, the skin incisions can be limited. Usually two thirds of the muscle width is taken for transplantation. Three fingers are prepared in different lengths with the gracilis muscle still in situ. Before cutting the muscle, the resting tension has to be documented. Insertion of the muscle graft is performed to the remnants of the paralytic orbicularis oris muscle. The origin is fixed to the deep fascia around the zygomatic arch. After the neurovascular anastomoses, tissue O 2 is monitored. Exercises of the facial movements in front of a mirror start 3 weeks postoperatively and electric stimulation 6 weeks postoperatively. After a functional plateau has been reached, the effectiveness and natural appearance can be improved significantly by a revision of the muscle graft and by additional static measures in the majority of patients.