Functioning Free Muscle Transplantation Research Articles

The Role of Length of Nerve Grafts in Combination with Free Functional Muscle Transplantation for Brachial Plexus Injury: A Single-Center Experience.

Extensive lesions of the brachial plexus, or late cases, require free functional muscle grafts because the expected recovery time exceeds the critical threshold of 1.5 years, beyond which irreversible damage may be expected in the distal nerve stump and in the muscle. The reconstructive concept consists of a two-stage procedure where, in the first step, a nerve transfer is performed (from ipsi- or contralateral donor nerves). In the second step, after successful axonal regeneration within the graft has been confirmed, a free muscle transfer is performed. These grafts often exceed 40 cm in length, particularly for contralateral transfers. The purpose of this study was to assess whether robust motor recovery could be supported by such long nerve grafts. From April 2004 to April 2023, a total of 327 free functional muscle transfers were performed, the nerve graft length ranging from 0 cm (direct coaptation) to 90 cm (serial grafts). Motor recovery was evaluated 1.5 years after surgery according to the MRC scale. A total of 208 patients were available for follow up. Direct coaptation yielded the best results, with 83% of patients reaching an M3 or M4 level of muscle strength. With the application of long (30-60 cm) grafts, 73% of the patients were classified as M3 or M4. The application of serial nerve grafts, however, only resulted in 18% of patients achieving a motor recovery rating of M3. These findings demonstrate that robust motor regeneration is supported by long (30-60 cm) nerve grafts, whereas serial nerve grafting results in a marked reduction in the quality of regeneration.

Resolving Co-Contraction of the Elbow in Patient with Sequelae of Obstetric Brachial Plexus Palsy: A Cohort Study.

Obstetric brachial plexus palsy can cause deformities of the upper extremity in up to 92% of patients. Elbow reconstruction is difficult because co-contraction of the elbow flexor (EF) and elbow extensor (EE) muscles makes the traditional treatment strategy ineffective. The authors propose a novel strategy to minimize the effect of co-contraction, comprising transfer of an EF to the triceps and a staged gracilis muscle transplantation [functioning free muscle transplantation (FFMT)] to augment EF. The authors hypothesize this will lead to improved elbow flexion and extension, as well as decreased elbow flexion contracture. A single-center retrospective review of patients who received a gracilis FFMT for EF after EF-to-EE transfer was performed. EF/EE strength and range of motion data were collected from the last clinical visit. Patients were excluded if they had fewer than 1.5 years of follow-up. A control group with sequelae of obstetric brachial plexus palsy and nonsurgical treatment was used for comparison. Twenty-one patients were included. Average age at muscle transfer was 7.6 ± 5.5 years (range, 3 to 22 years) and at gracilis FFMT was 10.4 ± 6.0 years (range, 5 to 26 years). Average follow-up was 7.3 ± 6.5 years (range, 1.5 to 14.8 years). After EF-to-EE transfer, EE strength increased significantly from Medical Research Council grade 2.2 ± 0.4 to 3.4 ± 0.5 ( P < 0.0001) and EF decreased from 3.2 ± 1.1 to 1.1 ± 1.1 ( P < 0.0001) and recovered to grade 3.3 ± 0.7 after gracilis FFMT. EF contracture was significantly lower compared with that in the nonsurgical cohort ( P = 0.029). Patients who undergo EF-to-EE transfer followed by gracilis FFMT have equivalent EF strength with significantly improved EE and improved elbow flexion contracture. Therapeutic, IV.

Erratum: Effect of Degree of Arterial Inflow on a Functioning Free Muscle Transplantation in a Rat Gracilis Model.

BACKGROUND Various surgical effects have previously been studied in an attempt to improve the functional outcome of the functioning free muscle transplantation (FFMT). However, the effect of the recipient arterial inflow on the FFMT has remained uninvestigated. This study was to investigate whether or not high flow versus low flow will affect the functional outcome of FFMT. METHODS Rat's left gracilis FFMT model was devised and the nutrient arterial inflow was modified. Twenty-four Lewis rats were divided evenly into relatively high (0.071 mL/min) and relatively low (0.031 mL/min) blood flow groups (p < 0.001). The unoperated right sides served as the controls. Cases resulting in poor function were additionally grouped as functional failure group for comparison. Regular swimming exercise was implemented at 1 month postoperatively for 3 months. Gracilis muscle functions were then evaluated. RESULTS Compared groups were: control (n = 13), low blood flow (n = 10), high blood flow (n = 8), and functional failure (n = 5). The control group showed superior functional results over the experimental groups (p < 0.0001). In the experimental group, successful group showed superior over the poor function group (p < 0.01). However, there was no significant difference between the high- and low-flow groups. CONCLUSION This is the first study to evaluate the effect of arterial inflow on the FFMT. The rate of blood flow (relatively high vs. low) has little effect on the functional outcome of transferred muscle. Survival of FFMT is the major concern while performing FFMT surgery. Arterial inflow while choosing the recipient artery is not the factor for consideration.

Functioning Free Muscle Transfer for Brachial Plexus Injury: A Systematic Review and Pooled Analysis Comparing Functional Outcomes of Intercostal Nerve and Spinal Accessory Nerve Grafts.

The aim of this study was to compare postoperative elbow flexion outcomes in patients receiving functioning free muscle transplantation (FFMT) innervated by either intercostal nerve (ICN) or spinal accessory nerve (SAN) grafts. A comprehensive systematic review on FFMT for brachial plexus reconstruction was conducted utilizing Medline/PubMed database. Analysis was designed to compare functional outcomes between (1) nerve graft type (ICN vs. SAN) and (2) different free muscle graft types to biceps tendon (gracilis vs. rectus femoris vs. latissimus dorsi). A total of 312 FFMTs innervated by ICNs (169) or the SAN (143) are featured in 10 case series. The mean patient age was 28 years. Patients had a mean injury to surgery time of 31.5 months and an average follow-up time of 39.1 months with 18 patients lost to follow-up. Muscles utilized included the gracilis (275), rectus femoris (28), and latissimus dorsi (8). After excluding those lost to follow-up or failures due to vascular compromise, the mean success rates of FFMTs innervated by ICNs and SAN were 64.1 and 65.4%, respectively. This analysis did not identify any difference in outcomes between FFMTs via ICN grafts and those innervated by SAN grafts in restoring elbow flexion in traumatic brachial plexus injury patients.

Effect of Degree of Arterial Inflow on a Functioning Free Muscle Transplantation in a Rat Gracilis Model.

Various surgical effects have previously been studied in an attempt to improve the functional outcome of the functioning free muscle transplantation (FFMT). However, the effect of the recipient arterial inflow on the FFMT has remained uninvestigated. This study was to investigate whether or not high flow versus low flow will affect the functional outcome of FFMT. Rat's left gracilis FFMT model was devised and the nutrient arterial inflow was modified. Twenty-four Lewis rats were divided evenly into relatively high (0.071 mL/min) and relatively low (0.031 mL/min) blood flow groups (p < 0.001). The unoperated right sides served as the controls. Cases resulting in poor function were additionally grouped as functional failure group for comparison. Regular swimming exercise was implemented at 1 month postoperatively for 3 months. Gracilis muscle functions were then evaluated. Compared groups were: control (n = 13), low blood flow (n = 10), high blood flow (n = 8), and functional failure (n = 5). The control group showed superior functional results over the experimental groups (p < 0.0001). In the experimental group, successful group showed superior over the poor function group (p < 0.01). However, there was no significant difference between the high- and low-flow groups. This is the first study to evaluate the effect of arterial inflow on the FFMT. The rate of blood flow (relatively high vs. low) has little effect on the functional outcome of transferred muscle. Survival of FFMT is the major concern while performing FFMT surgery. Arterial inflow while choosing the recipient artery is not the factor for consideration.

Impact of increasing age on functioning free muscle transplantation for facial palsy reconstruction.

Management of facial paralysis in older patients is controversial. The purpose of this study is to evaluate the impact of increasing age on functioning free muscle transplantation (FFMT). Twenty-nine facial paralysis patients over 50 years old received FFMT. A separate group of patients aged 41-50 years old were included as control. Outcome assessments included use of the SMILE evaluation system for excursion, a cortical adaptation scoring system for brain plasticity, and a subjective satisfaction assessment score. Meta-analysis of literature over the past 50 years was also performed to examine the impact of older age. The mean change in excursion movement was 13.39 ± 5.49 mm. Weakest excursion was found in the oldest age group (11.74 ± 4.84 mm, p = .097), in concordance with the meta-analysis. There was significant difference between the three different neurotizers (p = .036). Excursion and satisfaction score were significantly worse in the older cohort with the cross face-nerve graft FFMT. FFMT is a viable option in the elderly patient group but performs weaker in excursion. The choice of neurotizer is dependent on the patient's goals and the suitable age at which the benefits outweigh the risks.

Restoration of finger and thumb movement using one-stage free muscle transplantation

Objective: Functional reconstruction following severe traumatic muscle loss may cause problems for reconstructive surgeons. In such situations, functioning free muscle transplantation (FFMT) represents an important alternative treatment option.Methods: The clinico-demographic characteristics of 11 patients receiving modified FFMT between 2005–2013 were retrospectively reviewed. The muscle strength, range of joint motion (ROM), total active motion (TAM) of the fingers, and Disability of Arm Shoulder and Hand (DASH) score were adopted to assess the functional results.Results: All FFMTs were performed in the secondary stage. The authors found that the mean ROM, TAM, ratio of TAM compared with the contralateral side, and DASH score were 112 degrees, 150 degrees, 62%, and 22.8, respectively; and eight and nine patients achieved greatly improved grip function and M4 muscle strength, respectively.Conclusion: Using one-stage free muscle transplantation to restore finger and thumb movement simultaneously is an effective method for functional restoration following traumatic multi-muscle loss.

Facial Paralysis Grading System

Various facial paralysis grading systems have been introduced to evaluate the results of both spontaneous recovery and facial palsy reconstruction. The aim of the present study was to introduce and evaluate an objective new and quick Smile Excursion Score system which is readily applicable and easy to follow. It has been applied over the past 25 years for preoperative and postoperative result evaluation of smile reconstruction at Chang Gung Memorial Hospital. A standardized evaluation method was described for the assessment of the upper lip movement preoperatively and postoperatively with at least 1 year follow-up after functioning muscle transplantation. The evaluation was scored by the number of maxillary teeth exposed when smiling with teeth showing. Reliability of this technique was assessed by using 3 independent examiners who each evaluated the smiles of 34 unilateral facial paralysis patients 4 times, creating 408 sets of measurements. The intraclass correlation coefficients for interrater and intrarater reliability exceeded 0.94, which is considered as excellent and reliable. Chuang's Smile Excursion Score system is simple, quick, and accurate in evaluating smile after reanimation of paralyzed face effecting free functional muscle transplantation with no additional tools.

Free functional muscle transplantation of an anomalous femoral adductor with a very large muscle belly: a case report

We report the case of a 34-year-old man with a total brachial plexus injury that was treated by free functional muscle transplantation to restore simultaneously elbow flexion and finger extension. The muscle had a very large muscle belly (12 cm width), which was considered anatomically to be a fusion of the gracilis and the adductor longus muscles. Although the muscle possessed two major vascular pedicles with almost equal diameters, only the proximal vascular pedicle was anastomosed to the recipient vessels during the transplantation surgery, resulting in partial necrosis of the muscle. Several authors have reported on the successful simultaneous transplantation of the gracilis and adductor longus muscles, because they are supplied generally by a single common vascular pedicle. However, the present study suggests that when a surgeon encounters an aberrant femoral adductor with a very large muscle belly that can be considered to be a fusion of these muscles, the surgeon should assess intraoperatively the vascularity of the muscle using Doppler sonography, indocyanine green fluorescence injection, or other techniques.

Cortical adaptation staging system: a new and simple staging for result evaluation of functioning free-muscle transplantation for facial reanimation.

Movement-associated cortical reorganization occurs in patients after functioning free-muscle transplantation (FFMT), which is reinnervated by different neurotizers. Aiming to evaluate the process of recovery of the reinnervated muscle, we defined the cortical reorganization into 5 stages. This staging system has been applied during the past 25 years at our center with great convenience and accessibility. A standardized evaluation method for assessing the recovery after FFMT to reanimate the paralyzed face with at least a 1-year follow-up was applied. The evaluation included the following 5 stages: no movement, dependent movement, independent movement, and spontaneous movement with and without involuntary movement. Reliability of this technique was assessed by 3 examiners, who each evaluated the smiles of 30 unilateral facial paralysis patients 4 times, creating 360 sets of measurements. The intraclass correlation coefficients for interrater and intrarater reliability exceeded 0.929, which is considered excellent and reliable. Chuang's Cortical Adaptation Staging System is simple, quick,and accurate in evaluating patients after FFMT reanimation of the paralyzed face with no additional tools.

Prinzipien und Möglichkeiten der Defektedeckung im distalen Unterschenkeldrittel und Sprunggelenkbereich

The lower leg is the most often severely injured part of the lower extremity. Despite improved operative techniques, soft tissue defects alone or in combination with bone defects that cannot be closed by secondary suture still present a complex diagnostic and therapeutic problem. Modern treatment of severe trauma to the distal lower leg requires a global defect management which is based on: 1) profound basic knowledge, 2) multidisciplinary treatment team using a “common language” concerning diagnosis, classification and treatment, and 4) an integrated treatment concept. Adequate primary defect reconstruction is the basis of any successful treatment. For function improvement a variety of secondary operations like muscle/tendon transfer, tenodesis, capsulodesis, arthrodesis or ultimatively free functional muscle transplantation alone or in combination are available. Moreover adjuvant procedures such as orthesis, orthopaedic shoes, etc. may be useful at any time of treatment.

The Possibility and Potential Feasibility of Putting an Extra Functioning Free Muscle Transplant onto a Normal Limb

Functioning free muscle transplantation is currently and popularly used clinically to restore motor deficit caused by traumatic muscle loss or chronic muscle denervation. However, no one uses functioning free muscle transplantation in a normal subject who has no motor deficit. This study was designed to investigate the possible and potential feasibility of transferring an extra free muscle transplant onto a normal limb. A chimeric flap including biceps muscle with its neurovascular pedicles and a skin perforator flap was designed, harvested, and transferred from a Lewis inbred rat to the other rat overlying the original biceps following neurovascular repair where the ulnar nerve was chosen as the neurotizer. Sixteen rats were operated on and evaluated 6 months after surgery. Outcome measurements included arm circumferences, electrophysiologic studies, elbow flexion force, and muscle mass. The contralateral normal biceps was used as the control. All outcome measurements revealed that the extra muscle transfer resulted in significant increases in size and function of the operative limb without interfering with the original biceps function. The authors' study demonstrates the possible and potential application of using extra free muscle transplantation for functional and aesthetic augmentation purposes in a normal subject.

Bewährte und innovative operative Techniken zur Reanimation des gelähmten Gesichtes

This overview on the currently most effective reconstructive techniques for reanimation of the unilaterally or bilaterally paralysed face includes all important techniques of neuromuscular reconstruction as well as of supplementary static procedures, which contribute significantly to the efficiency and quality of the functional overall result. Attention is paid to the best indications at the best time since onset of the facial palsy, depending on the age of the patient, the cause of the lesion, and the compliance of the patient for a long-lasting and complex rehabilitation programme. Immediate neuromuscular reconstruction of mimic function is favourable by nerve suture or nerve grafting of the facial nerve, or by using the contralateral healthy facial nerve via cross-face nerve grafting as long as the time since onset of the irreversible palsy is short enough that the paralysed mimic muscles can still be reinnervated. For the most frequent indication, the unilateral irreversible and complete palsy, a three-stage concept is described including cross-face nerve grafting, free functional gracilis muscle transplantation, and several supplementary procedures. In patients with limited life expectancy, transposition of the masseteric muscles is favoured. Bilateral facial palsy is treated by bilateral free gracilis muscle transplantation with the masseteric nerve branches for motor reinnervation. Functional upgrading in incomplete lesions is achieved by cross-face nerve grafting with distal end-to-side neurorrhaphy or by functional muscle transplantation with ipsilateral facial nerve supply.

Free Functional Gracilis Muscle Transplantation for Reconstruction of Active Elbow Flexion in Posttraumatic Brachial Plexus Lesions

Reconstruction of powerful active elbow flexion. Reconstruction of missing muscle unit by neurovascular pedicled functional muscle transplantation. Treatment of last choice for --secondary reconstruction of active elbow flexion in case of complete lesion of the brachial plexus or musculocutaneous nerve (M0 muscle function = replacement indication), partial but incomplete lesion of the brachial plexus or musculocutaneous nerve (M1-(3) muscle function = augmentation indication); --replacement of the elbow flexor muscles in case of primary muscle loss (tumor, trauma). Concomitant lesions of the axillary artery. No adequate donor nerve. Relative: no sensibility at all at the forearm and hand. Free functional biarticular myocutaneous transplantation of gracilis muscle. A myocutaneous gracilis flap is raised at the thigh. At the upper arm the flap is fixed proximally to the coracoid process or the lateral clavicle. The distal insertion is sutured to the distal biceps tendon. Vascular anastomoses are carried out in end-to-side fashion with the brachial artery and vein. Nerval coaptation is done in end-to-end technique using the muculocutaneous nerve. Complete immobilization for 6 weeks. Dorsal upper arm splint until sufficient muscle power (M(4)). Progressive increase of active range of motion for another 6 weeks. Continuation of physiotherapy for 12-18 months. Postoperative standardized compression therapy, combined with scar therapy (silicone sheet). Functionally useful results can be expected in 60-75% of patients, especially if there is some residual function (M1 or M2) left ("augmentation indication"). Early free functional muscle transplantation shows best results in patients with direct muscle defect, because all vascular and neuronal structures are still available, and no secondary changes such as fibrosis or joint stiffness are present yet. There are inconsistent results for patients with neurologic insufficiency (i.e., total brachial plexus palsy) or mixed neuromuscular insufficiency, such as compartment syndrome. Especially in complete brachial plexus lesion, free functional muscle transfer is often the only treatment option. Provided there is a good patient selection, satisfactory results can be achieved for elbow flexion. Whether a higher number of axons, as provided by the contralateral C7 transfer, will lead to better results is the topic of an ongoing study.

Three-Dimensional Video Analysis of the Paralyzed Face Reanimated by Cross-Face Nerve Grafting and Free Gracilis Muscle Transplantation: Quantification of the Functional Outcome

Surgeons have found it difficult to quantify facial paralysis and its improvement by reconstructive surgery. This article presents the results achieved by free functional muscle transplantation for reconstruction of the paralyzed face, registered by three-dimensional video analysis of facial movements. Of patients treated consecutively between 1997 and 2006, two groups were constituted: group 1 comprised 22 patients with reinnervation completed after a single cross-face nerve graft and a free gracilis muscle graft for reconstruction of the smile; group 2 comprised nine patients treated with two cross-face nerve grafts followed by a territorially differentiated gracilis muscle transplant for reconstruction of the smile and eye closure. Smiling with showing teeth, maximal showing of teeth, and closing the eyes as in sleep were analyzed in detail. In group 1, static asymmetry was reduced from 12.19 +/- 8.73 mm preoperatively to -1.84 +/- 7.67 mm at 18 months postoperatively. Smile amplitude increased from 9 to 60 percent of that on the healthy side in 10 incomplete facial palsies of this group, and from 0 to 62 percent in eight functionally successful muscle grafts among 11 patients with complete lesions. In group 2, static asymmetry improved from 7.24 +/- 12.64 mm to -5.36 +/- 9.07 mm; the overcorrection was intentional. Movement was improved in eight cases. Smile amplitude reached 68 +/- 43 percent of that on the normal side. Lagophthalmus improved from 7.21 +/- 3.59 mm to 1.38 +/- 2.49 mm. All improvements were statistically significant (p <or= 0.05). Three-dimensional video analysis provided an exact quantitative documentation of the degree of facial palsy preoperatively and the reconstructed movements. The value of free functional gracilis muscle transplantation was demonstrated for both variations of the technique.

Free Tissue Transfer for the Treatment of Facial Paralysis

Long-standing facial paralysis requires the introduction of viable, innervated dynamic muscle to restore facial movement. The options include regional muscle transfer and microvascular free tissue transfer. There are advantages and disadvantages of each. Briefly, the regional muscle transfer procedures are reliable and provide immediate return of movement. However, the movement is not of a spontaneous mimetic nature. Free tissue transfer, in contrast, offers the possibility of synchronous, mimetic movement. It does, however, require a prolonged healing time in comparison with that of regional muscle transfer. The choice is made by physician and patient together, taking into account their preferences and biases. Muscle-alone free tissue transfer is our preferred option for reanimation of uncomplicated facial paralysis without skin or soft tissue deficits. Combined muscle and other tissue (most are skin flap) is another preferred option for more challenging complex facial paralysis with skin or soft tissue deficits after tumor excision. Gracilis flap is the author's first choice of muscle transplantation for both reconstructions. From 1986 to 2006, gracilis functioning free muscle transplantation (FFMT) was performed at Chang Gung Memorial Hospital for facial reanimation in 249 cases of facial paralysis. The main etiology is postoperative complication and Bell's palsy. The innervating nerve comes mostly from contralateral facial nerve branches, few from ipsilateral facial nerve due to tumor ablation, and from ipsilateral motor branch to masseter or spinal accessory nerve due to Möbius syndrome. We have evolutionally used a short nerve graft (10 to 15 cm) to cross the face in the first stage; after a 6- to 9-month waiting period, gracilis FFMT was performed for the second stage of the reconstruction. The technique of evolution has shown encouraging results to achieve the goal of rapid restoration and fewer scars on the donor leg.

Free functional muscle transplantation for facial reanimation: experimental comparison between the one- and two-stage approach

To investigate functional results of either one- or two-staged free muscle transplantation the scutuloauricularis model in the New Zealand white rabbit was used. Thirty rabbits were allocated to two groups with 15 animals each. In Group 1 (one-stage approach) peroneus brevis (PB) was harvested as a free muscle graft with a 7cm long motor branch. The graft was positioned instead of right scutuloauricularis (SCUT) and its vascular supply microsurgically re-established. The motor branch was transferred to the contralateral side and its proximal end coapted to the cut facial motor branch to left SCUT. Before nerve coaptation biopsies were harvested from the cut motor branch for morphological analysis. In Group 2 (two-stage approach) a 7cm long saphenous nerve graft was taken and coapted to the cut motor branch of SCUT and crossed over to the contralateral side. Nerve specimens from the cut motor branch were taken. Eight months later the free transplantation of PB was performed and its motor branch coapted to the distal end of the cross-over nerve graft. After a total time period of 13 months the final experiments were carried out in each group. Maximal tetanic tensions in reinnervated PB were measured and biopsies of muscle grafts together with nerve biopsies from the distal part of the motor branch were harvested for morphological analysis. Muscle grafts of Group 1 revealed tetanic tension values of 12.5N (SD 3.1) in comparison to 10.6N (SD 3.5) obtained in Group 2. This difference was not statistically significant (p=0.303). In Group 1, the amount of regenerated nerve fibers counted at the distal motor branch site (mean: 2798, SD 1242) was significantly higher (p=0.008) than in Group 2 (mean: 1138, SD 1004). Muscle graft morphology revealed significantly less Type I fibers (p=0.016) and more Type IIb/d fibers (p=0.011) in Group 1 compared to Group 2. However, the overall amount of perimysial connective tissue showed no significant difference in both groups (p=0.478). Free muscle transplantation in a one-stage approach offers similar functional results in comparison to the two-stage approach. Although muscle grafts of the one-stage transplantation underwent a longer period of denervation similar contents of perimysial connective tissue could be observed.

Traumatic Major Muscle Loss in the Upper Extremity: Reconstruction Using Functioning Free Muscle Transplantation

Traumatic Major Muscle Loss in the Upper Extremity: Reconstruction Using Functioning Free Muscle Transplantation

Microneurovascular anatomy of the peroneus brevis muscle in the NZW-rabbit: A new model for free functional muscle transplantation

This study introduces the peroneus brevis muscle of the NZW-rabbit as a new model for free functional muscle transplantation. The muscle originates from the lateral aspect of the knee joint and inserts on the 5th metatarsal with a circumscript tendon. It can be harvested with a 7 cm long motor nerve branch. In a series of 22 animals divided in two groups with a body weight of 3.19 +/- 0.30 kg and 4.81 +/- 0.38 kg respectively, vessel diameter of the supplying artery was found to be 0.3-0.35 mm in group one and 0.40-0.45 mm in group two, the two concomitant veins were 1.1-1.4 mm in diameter in the first group and 1.2-1.6 mm in the second group. Histomorphometric analysis stained with NADH showed 3.67 +/- 3.21% type I fibers, 25.41 +/- 7.87% type IIa fibers, and 70.93 +/- 9.12% type IIb/d fibers.

Dynamic reconstruction of eye closure by muscle transposition or functional muscle transplantation in facial palsy.

For patients with facial palsy, lagophthalmus is often a more serious problem than the inability to smile. Dynamic reconstruction of eye closure by muscle transposition or by free functional muscle transplantation offers a good solution for regaining near-normal eye protection without the need for implants. This is the first quantitative study of three-dimensional preoperative and postoperative lid movements in patients treated for facial paralysis. Between February of 1998 and April of 2002, 44 patients were treated for facial palsy, including reconstruction of eye closure. Temporalis muscle transposition to the eye was used in 34 cases, and a regionally differentiated part of a free gracilis muscle transplant after double cross-face nerve grafting was used in 10 cases. Patients' facial movements were documented by a three-dimensional video analysis system preoperatively and 6, 12, 18, and 24 months postoperatively. For this comparative study, only the data of patients with preoperative and 12-month postoperative measurements were included. In the 27 patients with a final result after temporalis muscle transposition for eye closure, the distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced from 10.33 +/- 2.43 mm (mean +/- SD) preoperatively to 5.84 +/- 4.34 mm postoperatively on the paralyzed side, compared with 0.0 +/- 0.0 mm preoperatively and postoperatively on the contralateral healthy side. In the resting position, preoperative values for the paralyzed side changed from 15.11 +/- 1.92 mm preoperatively to 13.46 +/- 1.94 mm postoperatively, compared with 12.17 +/- 2.02 mm preoperatively and 12.05 +/- 1.95 mm postoperatively on the healthy side. In the nine patients with a final result after surgery using a part of the free gracilis muscle transplant reinnervated by a zygomatic branch of the contralateral healthy side through a cross-face nerve graft, eyelid closure changed from 10.21 +/- 2.72 mm to 1.68 +/- 1.35 mm, compared with 13.70 +/- 1.56 mm to 6.63 +/- 1.51 mm preoperatively. The average closure for the healthy side was from 11.20 +/- 3.11 mm to 0.0 +/- 0.0 mm preoperatively and from 12.70 +/- 1.95 mm to 0.0 +/- 0.0 mm postoperatively. In three cases, the resting tonus of the part of the gracilis muscle transplant around the eye had increased to an extent that muscle weakening became necessary. Temporalis muscle transposition and free functional muscle transplantation for reanimation of the eye and mouth at the same time are reliable methods for reconstructing eye closure, with clinically adequate results. Detailed analysis of the resulting facial movements led to an important improvement of the authors' operative techniques within the last few years. Thus, the number of secondary operative corrections could be significantly reduced. These qualitative and quantitative studies of the reconstructed lid movements by three-dimensional video analysis support the authors' clinical concept of temporalis muscle transposition being the first-choice method in adult patients with facial palsy. In children, free muscle transplantation is preferred for eye closure, so as not to interfere with the growth of the face by transposition of a masticatory muscle. In addition, a higher degree of central plasticity in children might be expected.