Gracilis Muscle Transplantation Research Articles

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.

Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury.

Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction. A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed. Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05). FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades. III.

Staged Phrenic Nerve Elongation and Free Functional Gracilis Muscle Transplantation–A Possible Option for Late Reconstruction in Chronic Brachial Plexus Injury

In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios. A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis). Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4. A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves. Therapeutic V.

Combined delivery of VEGF and IGF-1 promotes functional innervation in mice and improves muscle transplantation in rabbits

Microvascular muscle transfer is the gold standard for reanimation following chronic facial nerve paralysis, however, despite the regenerative capacity of peripheral motor axons, poor reinnervation often results in sub-optimal function. We hypothesized that injection of alginate hydrogels releasing growth factors directly into donor tissue would promote reinnervation, muscle regeneration, and function. A murine model of sciatic nerve ligation and neurorrhaphy was first used to assess the ability of gel delivery of vascular endothelial growth factor (VEGF) and insulin-like growth factor-1 (IGF-1) to promote functional reinnervation. VEGF + IGF-1 gel delivery to aged mice resulted in prolonged ability to control toe movement, increased toe spreading, and improved static sciatic index score, indicative of improved sciatic nerve and neuromuscular junction function. Further, a 26% increase in muscle fiber area, and 2.8 and 3.0-fold increases in muscle contraction force and velocity, respectively, were found compared to blank alginate in the murine model. This strategy was subsequently tested in a rabbit model of craniofacial gracilis muscle transplantation. Electromyography demonstrated a 71% increase in compound muscle action potential 9 weeks after transplantation following treatment with VEGF + IGF-1 alginate, compared to blank alginate in the rabbit model. Improving functional innervation in transplanted muscle via a hydrogel source of growth factors may enhance the therapeutic outcomes of facial palsy treatments and, more broadly, muscle transplantations.

A preliminary study on B -mode ultrasonic evaluation of muscle recovery after functional gracilis muscle transplantation

Objective To investigate the value of the B-mode ultrasound method for muscle recovery after transplantation. Methods From January, 2009 to January, 2014, 35 patients of functioning free gracilis muscle transplantation for brachial plexus injury were involved. Using B-mode ultrasound to determine the cross-sectional area (CSA) of transplanted gracilismuscle at rest and contraction state. The contraction ratio (CR) and the muscle bulk ratio (MBR) was calculated based on the CSA. Then the CR and MBR were analysised statistically with manual muscle strength and joint range of motion (ROM) to investigate the correlation. Results The followed-up time was 8-24 months, averaged of 22.4 months. The CR of the transplated muscle was (1.23±0.15), which was significantly correlated with muscle strength and joint ROM (P 0.05). There was no statistically significant difference in muscle strength and ROM between patients with MBR greater than 1 and those with MBR less than 1 (P= 0.054, P=0.284, respectively). Conclusion The transplanted muscle recovery can be quantitatively reflected by the CR. CR enlargement of the transplanted gracilis muscle indicated a better recovery of muscle contraction function. MBR is not suitable for evaluating function recovery of transplanted muscles. Key words: Gracilis; Functional muscle transplantation; B-mode ultrasound; Muscle contraction; Muscle strength

Segmental Gracilis Muscle Transplantation for Midfacial Animation in Möbius Syndrome: A 29-Year Experience.

Möbius syndrome is a complex congenital disorder of unclear cause involving multiple cranial nerves and typically presenting with bilateral facial and abducens nerves palsies. At The Hospital for Sick Children, Toronto, Ontario, Canada, microneurovascular transfer of free-muscle transplant is the procedure of choice for midfacial animation. The primary aim of this study was to investigate surgical outcomes of the procedure in terms of complications, secondary revisions, and smile excursion gains. A retrospective 29-year review was performed using patient records from a single tertiary care center. The authors included children with Möbius syndrome who had undergone facial animation surgery with a free segmental gracilis muscle transfer and microneurovascular repair between January 1, 1985, and August 31, 2014. Smile excursion measures were obtained using the Facial Assessment by Computer Evaluation-Gram on a subset of the included patients. A total of 107 patients undergoing 197 reconstructive procedures met inclusion criteria. Most reconstructions relied on the motor nerve branch to the masseter for innervation [n = 174 (88 percent)]. Thirteen complications were reported, of which six required surgical interventions. Three revision procedures were performed: scar revision, muscle repositioning, and removal of infected permanent suture material. The use of the motor nerve branch to the masseter resulted in good commissure excursion gains (average, 4.61 mm for bilateral cases and 9.34 mm for unilateral reconstructions). Midfacial animation with segmental gracilis muscle transfer for patients with Möbius syndrome provides gains in the amplitude and symmetry of oral commissure excursion and carries a reasonably low complication rate. Therapeutic, IV.

Construction of Chinese peripheral nerve society and progress in repair and reconstruction of peripheral nerve injury

The peripheral nerve group of the reparative and reconstructive surgery committee (branch of Chinese association of rehabilitation medicine) was established in 1995. Major research progress has been made in the repair, regeneration, and reconstruction of peripheral nerve injury. Professor GU Yudong initiated the contralateral cervical7 root (CC7) transfer for the treatment of total brachial plexus root injury in 1986. Now this method has been applied safely and effectively for 30 years with profound progress and refinement. In addition, the repair and reconstruction of peripheral nerve injury had achieved great development such as the treatment of spastic paralysis of upper limb, CC7 transfer using a modified prespinal route, the reconstruction of bladder function after spinal cord injury, the development of acellular allograft nerve, the small gap suture technique, the functioning free gracilis muscle transplantation, and contralateral S 1 transfer which have been widely used in clinical application with good outcomes. With the progress of the biological manufacturing of peripheral nerve bio-materials and the remodeling of central nervous system after brachial plexus injury, a novel peripheral neuroscience research field was growing up. It is still a challenge for surgeons and scholars in this field to insist on the popularization and improvement of peripheral nerve repair and reconstruction by microsurgical technique, and to make efforts to transform the results of peripheral nerve research into clinical practice.

Contralateral medial pectoral nerve transfer with free gracilis muscle transfer in old brachial plexus palsy

BackgroundThere is a very small chance of success for nerve reconstruction in patients with old total brachial plexus palsy who visit after 2 y or suffer from flail upper extremity after the failure of previous operations. Materials and methodsFor these individuals, the surgeon has to find a recipient motor nerve to perform free gracilis muscle transplantation. In this study, contralateral medial pectoral nerve from the intact side was transferred to the damaged side as a recipient nerve. Then, in the second operation, approximately 15 mo later, the free gracilis muscle transfer was performed. The gracilis muscle was removed and transferred to provide elbow and finger flexion. ResultsIn a retrospective study (over 10 y), we reviewed 68 patients for whom this method had been performed. After 1 y, the results were investigated using the Medical Research Council grading system. Five patients did not participate in the study, and the muscle underwent necrosis in two patients. M3 and M4 muscle power was regained in 26 (42.6%) and 21 (34.4%) patients, respectively. ConclusionsContralateral pectoral nerve transfer followed by free muscle transplantation can be a good option for patients with old total brachial plexus palsy.

Long-Term Outcomes of Smile Reconstruction in Möbius Syndrome.

Gracilis muscle transplant is the standard of care for smile reconstruction in children with Möbius syndrome. The authors describe the long-term clinical efficacy, durability, and psychosocial impact of this approach at a mean follow-up of 20 years. Patients with Möbius syndrome who underwent gracilis muscle transfer between 1985 and 2005 were included in the study. The authors assessed midfacial movements using photographs and Scaled Measurement of Improvement in Lip Excursion measure, administered the patient-reported Facial Clinimetric Evaluation Scale, and used semistructured interviews. The mean age at surgery was 13.2 ±10.6 years and the mean follow-up was 20.4 ± 4.4 years postoperatively. Twenty-two gracilis muscle transplants were performed, all innervated by the motor nerve to the masseter. Photographic analysis using Scaled Measurement of Improvement in Lip Excursion software demonstrated that movement of the muscle was unchanged 20 years after surgery. Smile symmetry was stable long term. The overall mean Facial Clinimetric Evaluation score of the cohort was 62.3 ± 12.0. Facial comfort (86.4 ± 21.2) and social function (69.9 ± 18.5) subdomains were the highest. Although the facial movement subdomain score was 35.6 ± 12.4, the score related to smiling alone was 84.1 ± 20.2, indicating satisfaction with the midfacial reconstruction. Interview responses indicated high satisfaction with surgery; fulfilled expectations of social acceptance; improved communication; enhanced self-confidence; and a sense of increased facial symmetry, spontaneity, and smile excursion. Segmental gracilis muscle transplantation provides long-lasting, durable improvements in objective and patient-reported measures of facial function.

Masseteric nerve for gracilis muscle re-innervation in unilateral facial palsy: Impact on quality of life

BackgroundUnilateral established or congenital facial palsies are usually treated with neuromuscular transplantation to reanimate the impaired side of the face. One of the most debated points is the motor nerve to choose for the reinnervation of the transplant. Contra-lateral healthy facial nerve is usually preferred, but in selected cases motor nerve to masseter is considered a valuable option. However only a few clinical studies focused on quality of life in this subset of patients are available in literature. MethodsTwenty patients treated for established or congenital unilateral facial palsy reanimated with gracilis muscle transplant reinnervated with masseteric nerve were retrospectively analyzed. The FDI questionnaire on quality of life was administered before and after surgery and statistical analysis of results was conducted to score changes. ResultsOverall results of the questionnaire resulted in a statistically significant improvement after surgery, with a p value of 0.05. ConclusionFacial animation with gracilis muscle transplant re-innervated with masseteric nerve is a safe and reliable procedure in selected unilateral facial palsy patients. Results reported here confirm that surgery mainly improves the functional aspects of a patient's daily life quality, while the impact on social interactions and self-perception is less significant. The comparison of these results with those obtained in patients treated with gracilis muscle transplant re-innervated via contralateral facial nerve suggests that spontaneity is probably highly relevant to improve social aspects of QOL in this subset of patients.

The Spinal Accessory Nerve for Functional Muscle Innervation in Facial Reanimation Surgery: An Anatomical and Histomorphometric Study.

Facial reanimation surgery is performed in severe cases of facial palsy to restore facial function. In a 1-stage procedure, the spinal accessory nerve can be used as a donor nerve to power a free gracilis muscle transplant for the reanimation of the mouth. The aim of this study was to describe the surgical anatomy of the spinal accessory nerve, provide a guide for reliable donor nerve dissection, and analyze the available donor axon counts. Dissections were performed on 10 nonembalmed cadavers (measurements of 20 nerves). Surgical anatomy of the spinal accessory nerve was described and distances to important landmarks were measured. Nerve biopsies were obtained of the main nerve trunk distal to the skull base, caudoposterior to the sternocleidomastoid muscle, proximal to the trapezius muscle and at the level of donor nerve harvest to analyze the myelinated axon count throughout the course of the spinal accessory nerve. The donor nerve length and available donor nerve axon count were the primary outcome parameters in this study. The mean donor nerve length was 11.6 cm. The spinal accessory nerve was transferred to the mandibular angle without tension for ideal coaptation to the free muscle transplant. After retraction of the trapezius muscle, a small distal nerve branch that leaves the main nerve trunk at a 90-degree angle medially was used as a landmark to indicate the level of donor nerve transection. On average, 1400 myelinated donor axons were available for innervation of the gracilis muscle transplant. This study gives a practical guide for spinal accessory nerve dissection for its application in facial reanimation as a motor source for the innervation of a free muscle transplant.

Facial animation with gracilis muscle transplant reinnervated via cross-face graft: Does it change patients' quality of life?

Gracilis muscle reinnervated by the contralateral facial nerve via cross-graft technique is nowadays considered to be a first-line procedure for facial animation in unilateral palsies. Despite the wide number of papers published analyzing technical aspects, refinements, functional results, and cosmetic outcomes, only a few authors have focused their publications on the patient's perspective and impact on QOL of these procedures. Changes in quality of life in 42 patients treated with gracilis muscle transplant reinnervated via cross-face graft were analyzed through a comparison of preoperative and postoperative items on the Facial Disability Index questionnaire. Statistical evaluation with a paired t-test was performed concerning overall results and specific items modifications. Overall improvement of QOL was found to be highly significant (p=0.001). Mouth and eye functions were the most improved (p=0.001), whereas isolation (p=0.004) and feeling calm and peaceful (p=0.001) were the most improved among the social functions. Facial animation with gracilis neuromuscular transplantation reinnervated with contralateral healthy facial nerve via a cross-graft procedure has been demonstrated to be a safe and reliable procedure in the treatment of congenital or established facial palsies. Our results on quality of life impact support that these operations are not only reliable and safe but also of primary relevance to patients' everyday lives.

Facial paralysis and the role of free muscle transplantation

Facial paralysis can have significant functional, psychological and aesthetic concerns that alter the lives of our patients. These effects can be functional, affecting the eye, nose and mouth, or aesthetic, affecting the symmetry of the face and particularly the mimetic function of smile. Several reanimation procedures have been described to address this. In this chapter, we will outline our technique for reanimation utilizing segmental gracilis muscle transplants to the face. These are innervated either by the contralateral normal 7thnerve via a cross face nerve graft, or a different ipsilateral motor where no 7thnerve is available or would not produce the required result. The other ipsilateral motor that we have found extremely effective is the motor nerve to masseter. This can power a segmental gracilis muscle transplant and lead to excursion that is near normal. These techniques will be described in detail.

Facial synkinesia before and after surgical reanimation of the paralyzed face.

Facial synkinesia is a common sequela of facial palsy, affecting 15 to 20 percent of patients. The rate of postoperative synkinesia after facial reanimation is not clearly established. The severity and type of synkinesia determine the degree of clinical relevance. One hundred sixty-seven patients with facial palsy were included in this retrospective cohort study. Three-dimensional video analysis of facial movements was performed preoperatively and 18 months after facial reanimation. The severity of synkinesia was rated subjectively on a four-degree severity scale. Objective three-dimensional analysis of synkinesia was performed on patients with 18-month follow-up times. Preoperatively, 84.4 percent of patients were not affected by synkinesia, 9 percent presented with mild synkinesia, 4.2 percent presented with moderate synkinesia, and 2.4 percent presented with severe synkinesia. Postoperatively, 51 percent of all patients presented with facial synkinesia (41.8 percent mild, 17.3 percent moderate, and 1 percent severe synkinesia; some patients had more than one type). Patients treated with territorially differentiated gracilis muscle transplantation were most frequently affected (69.8 percent), followed by patients treated with gracilis muscle transplantation in combination with temporalis muscle transposition to the eye (51.8 percent). Oculo-oral synkinesia was the most frequent form of synkinesia. After surgical reanimation of the paralyzed face, half of the patients presented with synkinesia. The majority of patients developed mild or moderate forms of synkinesia; therefore, the clinical relevance of synkinesia has to be seen in the context of total facial function. Because of the high prevalence of synkinesia, it should be documented and addressed in patients undergoing facial reanimation. Therapeutic, IV.

Successful salvage surgery after treatment failures with cross graft and free muscle transplant in facial reanimation

Background The microneurovascular transfer of a free-muscle transplant is the procedure of choice for facial animation, It is characterized by low morbidity in both adult and paediatric patients. In spite of the improvements in microsurgical techniques, failures due to absent revascularization or reinnervation of the transplanted muscle or infections causing flap necrosis are observed. We propose a second surgical procedure based on the gracilis muscle transplant reinnervated by the masseteric nerve as a solution for these cases. Methods We analyzed and report on two patients treated in our department after the failure of a previous cross-facial nerve graft and free muscle transplant. They were treated with a new facial reanimation using the contralateral gracilis muscle and the masseteric nerve as the donor nerve. Results and discussion We did not observe any postoperative complications, and all of the flaps survived. Reinnervation and contraction of the muscle appeared 3–4 months postoperatively, with good functional and aesthetic results. Conclusions This technique is a one-step procedure characterized by reliable flap harvesting, low donor site morbidity and good activity of the masseteric nerve. We consider it as a good option for treatment of facial animation failures.

Facial reanimation with gracilis muscle transplantation and obturator nerve coaptation to the motor nerve of masseter muscle as a salvage procedure in an unreliable cross‐face nerve graft

Facial reanimation with gracilis muscle transplantation and obturator nerve coaptation to the motor nerve of masseter muscle as a salvage procedure in an unreliable cross‐face nerve graft

Assessing Outcomes in Facial Reanimation: Evaluation and Validation of the SMILE System for Measuring Lip Excursion During Smiling

Assessing Outcomes in Facial Reanimation: Evaluation and Validation of the SMILE System for Measuring Lip Excursion During Smiling

Facial Animation With Free-Muscle Transfer Innervated by the Masseter Motor Nerve in Unilateral Facial Paralysis

Facial paralysis is a congenital or acquired disorder of varying severity leading to an asymmetric or absent facial expression. It represents an important debilitation from both esthetic and functional points of view. In this article we report our experience with patients treated with gracilis muscle transplantation innervated by the motor nerve to the masseter muscle. We discuss the surgical technique and the functional and esthetic results and evaluate the effectiveness of this donor nerve in providing adequate innervation to the muscle transfer for lower facial reanimation. Fifteen patients with unilateral facial paralysis were seen and surgically treated at the Department of Maxillofacial Surgery, University of Parma, Parma, Italy, between 2003 and 2007. In this study we report on 8 cases treated with gracilis muscle transfer reinnervated by the motor nerve to the masseter muscle. In this series all free-muscle transplantations survived transfer, and no flap was lost. Facial symmetry at rest and while smiling was excellent or good in all patients, and we observed a significant improvement in speech and oral competence. With practice, the majority of patients developed the ability to smile spontaneously and without jaw movement. We consider the masseter motor nerve a powerful and reliable donor nerve, allowing us to obtain a commissure and upper lip movement similar to those of the normal site for amount and direction. This is why we think that there may be a larger role for the masseter motor nerve for innervation of patients with unilateral facial paralysis who would otherwise have been considered candidates for cross-facial nerve graft innervation of the muscle transfer.

Physikalische Therapiemaßnahmen bei peripherer Fazialisparese: Indikationen, Zeitpunkte und praktische Anwendungen

Facial paralysis may be treated by physical therapies with different therapeutic strategies and devices. Exercise therapy, electrotherapy, massage, lymph-drainage, biofeedback therapy are applied. Therapeutic strategies are based on the course of disease. It may be assumed that paralysis in moderate and moderate to severe courses of disease in acute lesions, moreover in chronic partial lesions and after gracilis muscle transplantation will benefit best from physical therapies. Course of disease depends on the degree of lesion, low-grade lesion will improve earlier and prognosis of motor recovery is good. To predict the course of disease in idiopathic facial paralysis nerve conduction studies can render valuable information by measuring the amplitude of the motor evoked potential in side to side comparison. In regard to scientific studies there is limited evidence that exercise therapy and biofeedback therapy improve the course of disease, motor performance recovers earlier and motor synkinesis are decreased. There is no evidence for electrotherapy to improve the course of disease nor to have any adverse effects. There is no relevant literature for massage and lymph-drainage in regard to facial paralysis. Every patient with facial paralysis--regardless to the degree of lesion--should receive a brochure with mimic exercises and instructions to support facial symmetry as basic intervention.

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.