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Pediatric Free Gracilis Muscle Transfer: Functional and Aesthetic Outcomes in Smile Reanimation
Melanie Bakovic
*1, Asli Pekcan
2, Raina K. Patel
1, Valeria Mejia
2, Marvee Turk
2, Mark M. Urata
1, Jeffrey A. Hammoudeh
11Children's Hospital Los Angeles, Los Angeles, CA; 2University of Southern California, Los Angeles, CA
Background: Facial nerve palsy in children results in significant dysfunction and disfigurement. While free gracilis muscle transfer (FGMT) is a cornerstone technique for achieving smile reanimation in the adult population, its utility in children with facial palsy is poorly understood. This study evaluates the long term outcomes of FGMT in restoring smile among children with facial palsy.
Methods: A retrospective review was conducted in children who underwent FGMT for facial palsy at a major children's hospital between 2007 and 2020. Data collection consisted of pre- and post-operative photographs, on the basis of which quantitative smile analyses were performed by a single reviewer. Primary outcomes included commissure excursion, commissure angle, smile symmetry, and incisor show. Statistical analysis was performed using Wilcoxon sign-rank test.
Results: A total of 31 patients with an average age of 10 years underwent FGMT for smile reanimation during the study period. The most common diagnosis was Moebius Syndrome (48%). Donor nerves for gracilis neurotization included 19 ipsilateral masseteric nerves (61.3%) and 12 contralateral facial nerves via cross-face sural nerve grafts (38.7%). Overall, 84% of patients demonstrated active gracilis contraction within a mean of 3 years postoperative follow up. The average increase in commissure excursion was 9.7 mm at one year and 10.3 at two years (p<0.05). However, there were no significant improvements in commissure angle, smile symmetry, incisor show. Only 15% of patients demonstrated symmetric smiles within the follow up period.
Conclusion: While FGMT effectively restores commissure excursion in children with facial palsy, achieving multidimensional smile reanimation remains a challenge. Successful gracilis neurotization in a majority of patients did not translate to significant improvements in most measures of smile aesthetics. Further understanding of the unique physiology that distinguishes childhood facial palsy from its adult counterpart might help to optimize outcomes of FGMT within the pediatric context.
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