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Comparison of Functional Results After Cross-Face Nerve Graft-,
Spinal Accessory Nerve-, and Masseter Nerve-Innervated
Gracilis for Facial Paralysis Reconstruction
The Chang Gung Experience
David Chwei-Chin Chuang, MD, Johnny Chuieng-Yi Lu, MD,
Tommy Nai-Jen Chang, MD, and Vincent G. Laurence, MD
Background: Using functioning free muscle transplantation (FFMT) for facial
paralysis and postparalysis facial synkinesis reconstruction is our preferred tech-
nique. Gracilis wasthe f irst choice of muscle. Three motor neurotizers: cross-face
nerve graft (CFNG), spinal accessory nerve (XI) and masseter nerve (V3) have
been used as neurotizers for different indications.
Methods: A total of 362 cases of facial reanimation with FFMTwere performed
between 1986 and 2015. Of these, 350 patients with 361 FFMT were enrolled:
272 (78%) patients were treated by CFNG-gracilis, 56 (15%) by XI-gracilis,
and 22 (6%) by V3-gracilis. Smile excursion score, cortical adaptation stage with
tickle test for spontaneous smile, facial synkinesis, satisfaction score by question-
naire, and functional facial grading were used for outcome assessment.
Results: The CFNG-gracilis in a 2-stage procedure achieved most natural and
spontaneous smile when longer observation (≥2 years) was followed. The single-
stage procedure using the XI-gracilis has proven a good alternative. V3-gracilis
provided high smile excursion score in the shortest rehabilitation period, but
never obtained spontaneous smile.
Conclusions: The CFNG-gracilis remains our first choice for facial paralysis re-
construction which canachieve natural and spontaneous smile. XI- or V3-gracilis
can be selected as a save procedure when CFNG-gracilis fails. The V3-gracilis is
indicated in some specific conditions, such as bilateral Möbius syndrome, older
patients (age, >70 years), or patients with malignant disease.
Key Words: facial paralysis, CFNG-gracilis, XI-gracilis, V3-gracilis
(Ann Plast Surg 2018;00: 00–00)
The cranial facial nerve, originating from pons, contains 2 roots: the
facial root contains efferentfibers for facial expression, lacrimation
and salivation, and the nervus intermedius root contains afferent fibers
for tongue taste and external ear cutaneous sensibility.
1
Facial nerve is
composed of 6000 to 7000 myelinated motor fibers
2
that innervate 22
(19–24) mimic muscles for simultaneously and delicately controlling
synergistic and antagonistic muscles for complex facial expression.
There are 2 major dysfunctions of the facial nerve injury: facial palsy
(incomplete or complete) and postparalysis facial synkinesis.
3
Both will
cause serious affliction and devastation on the patient's quality of life.
Etiologies of facial paralysis include Bell's palsy (or idiopathic
facial palsy), infection (herpes simplex, herpes zoster, or suppurative
ostitis media), after tumor resection (cholesteatoma, vestibular
schwannoma, acoustic schwannoma, facial schwannoma, or parotic
gland tumor), trauma (animal bite, iatrogenic injury, penetrating injury,
birth trauma, temporal bone fracture), and congenital (Möbius
syndrome, hemifacial microsomia), and others.
4
For chronic facial palsy (more than 1 year), reconstruction requires
the use of alternative muscles for reanimation. Local muscle transfers in-
clude frontalis (for forehead rising), temporalis (for eye closure or smile),
masseter (for mouth angle smiling), or digastric (for lower lip pull-down)
muscle transfer.
5–8
Distal muscle transfers include nonvascularized
muscle graft and vascularized functioning free muscle transplantation
(FFMT). With advanced microsurgical technique, FFMT has become
the standard option for long-standing facial paralysis.
9–17
Gracilis is the preferred muscle for FFMT by most reconstruc-
tive surgeons. Cross-face nerve graft (CFNG), spinal accessory nerve
(XI), and masseter nerve (V3) are used most commonly as motor
neurotizers.
9–17
The purpose of this study was to comparatively evalu-
ate CFNG-, XI- and V3-gracilis for facial reanimation, their advantages
and disadvantages, from our series.
MATERIALS AND METHODS
Between 1986 and 2015, 362 patients were reconstructed with
FFMT for facial paralysis or postparalysis facial synkinesis at the
Linkou Chang Gung Memorial Hospital. They all were performed by
the same surgeon (DCC Chuang). Eight patients with bilateral facial
paralysis because of Möbius syndrome underwent bilateral gracilis
muscles for reconstruction simultaneously: 6 by bilateral XI and 2 by
bilateral V3 for muscle innervation. There were 4 failed gracilis (4/362,
1%) and 3 underwent successful second FFMT. Seven patients treated
by facial nerve repair (directly or indirectly) or local muscle transfer
were excluded. Functioning free muscle transplantation innervated by
ipsilateral facial nerve (8 patients), contralateral facial nerve in a 1-stage
procedure (4 patients) were also excluded. Totally, 350 patients with
361 FFMTs were enrolled in this study.
The etiology of the palsies was most commonly because of post-
operative complications, then Bell’s palsy, congenital, and trauma.
There were 272 patients (272/350, 78%) reconstructed by CFNG-
FFMT, 56 (56/350, 15%) by XI-FFMT, and 22 patients (22/350, 6%) by
V3-FFMT. Functioning free muscle transplantation came most from
gracilis (98%). The facial artery and vein were the preferred vessels
for anastomoses.
Surgical Techniques
(A) CFNG-gracilis: The classic 2-Stage Procedure
Stage 1, Short CFNG
Since November 2001, we have started to use a short leg sural
nerve (10–15 cm) for CFNG, which was placed subcutaneously from
the contralateral cheek of the healthy face to the nasolabial fold of the
paralyzed face (Fig. 1A–B), to decrease leg incision wounds and
shorten the waiting period (from 1 year to 6 months). The procedure
was done under general anesthesia with orotracheal intubation. A
preauricular incision about 10 cm in length was made on the healthy
Received April 24, 2017, and accepted for publication, after revision October 26, 2017.
From the Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang
Gung University, Taipei-Linkou, Taiwan.
Conflicts of interest and sources of funding: none declared.
Clinical question/level of evidence: therapeutic, IV.
Reprints: David Chwei-Chin Chuang, MD, Department of Plastic Surgery, Chang
Gung Memorial Hospital, 5, Fu-Hsing St, Kuei-Shan, Taoyuan 33305, Taiwan.
E-mail: d ccchuang@gmail.com; micro.c gmh@gmail.com.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-70 43/18/0000–0000
DOI: 10.1097/SAP.0000000000001327
PERIPHERAL NERVE SURGERY AND RESEARCH
Annals of Plastic Surgery •Volume 00, Number 00, Month 2018 www.annalsplasticsurgery.com 1
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
side. Subcutaneous dissection to lift the face between preauricular and
pupil lines was performed. The facial skin flap was elevated. In front
of the parotid gland, the zygomatic and buccal branches of the facial
nerve can be found through careful dissection with the help of a nerve
stimulator. One small branch of the zygomatic and the whole buccal
branch were cut and transferred. The sural nerve was placed in reverse
fashion subcutaneously with the help of a nerve passer. Another small
hole incision over the nasolabial fold of the paralyzed face was made.
The nerve passer was used to pass the sural nerve subcutaneously from
the elevated skin flap wound to the contralateral nasolabial fold wound.
The sural nerve graft was coapted to the transferred zygomatic and
buccal branches under the microscope (Fig. 2). The other end of the
sural nerve stump was sutured to the dermis of the nasolabial fold wound
on the paralyzed face. The total operative time was about 3 hours or less.
Stage 2: Gracilis FFMT
The second stage procedure was performed under general anes-
thesia with nasotracheal intubation, instead of orotracheal intubation, to
minimize the interference of the upper lip manipulation. The operation
consisted of simultaneous dissection of the donor (the contralateral
gracilis) and recipient (the paralytic face) sites by 2 teams. On the par-
alyzed side of the face, an incision about 2 cm in length on thewhite line
of the upper lip between philtrum-lip junction point and mouth angle
(but not including these 2 points) was made first. The previous stump
neuroma of the CFNG was identified and dissected proximally as long
as possible. The stump neuroma was cut from its fixed point and placed
deep inside the lip wound for protection.
Another preauricular incision extending to the mandibular body
was made on the paralyzed side of the face. Subcutaneous dissection
was performed from the infraorbital rim superiorly, the mandibular mar-
gin inferiorly and to the upper lip wound. Under the facelift skin flap, a
4-cm transverse incision was made along the inferior zygomatic arch
(behind the zygomatic body) down to the periosteum which was mildly
elevated. Anchoring 3-0 Vicryl stitches (usually 4 stitches) were placed
on the elevated periosteum for fixation of the transferred muscle. The
soft tissue from the infrazygomatic margin down to the upper lip was
removed to create a pocket for the muscle fill-in. The buccal fat pad
was also removed to make the surface of the pocket smooth. The
Stenson duct was identified and protected to avoid injury.
To determine the length and shape of the harvested gracilis, we
made an in-site face measurement. The distance between the most inner
stitch over the zygomatic arch and medial edge of the upper lip wound
(AA’, Fig. 3 A), and the distance between the most outer stitch over the
zygomatic arch and the lateral edge of the upper lip wound (BB’) were
measured. The measurement should be done loosely. From experience,
we have learned to add about 2 cm to the medial edge (AD) and 3 cm to
the lateral (BC) to avoid consequent lip contracture deformity. The
width of the gracilis was determined by the infrazygomatic stitches
FIGURE 1. A, Using 2 small incisions to harvest a leg sural nerve
graft. B, The graft is placed subcutaneously from the cheek of
the healthy face to the nasolabial fold of the paralyzed face.
Reproduced with permission from Facial Plastic Surgery 2008;
24(2):194–203, New York: Thieme.
FIGURE 2. The short CFNG is split into 2 parts to coapt the
transected facial nerve branches: a small zygomatic and a big
buccal branches.
Chuang et al Annals of Plastic Surgery •Volume 00, Number 00, Month 2018
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Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
placement superiorly (AB) and the length of the incision along the up-
per lip inferiorly (CD). The trapezoid shape of the potential implanted
muscle was drawn down (ABCD, Fig. 3A).
The contralateral gracilis was always used as donor to take ad-
vantage of pedicle orientation. A 10-cm incision along the medial thigh
posterior to the adductor longus was performed to expose the proximal
gracilis muscle with its aponeurosis at its origin, and its neurovascular
pedicle, which were mobilized from the surrounding tissues. The trap-
ezoid shape (ABCD) measured on the face was then transferred onto
the gracilis, but in an inverted fashion, anticlockwise 180° rotation
(Fig. 3B). The distal end of the gracilis (AB) should be marked 2 finger
widths beyond the neurovascular pedicle. The proximal aponeurosis
should be dissected as far as possible to its bony origin. Distance BC
(lateral edge on face) was on the pedicle side, and AD was on the
nonpedicle side. The proximal end of the gracilis (CD) was located at
the lower aponeurosis. The trapezoid shape of the gracilis was marked.
The muscle was then cut with cautery. The distal gracilis (AB) was
sutured with interrupted 3-0 nylon stitches, and the nonpedicle side
(AD) with running, locked 3-0 catgut sutures for hemostasis. The part
of the most proximal thin fascial aponeurosis, with 1-cm width of
continuity with the muscle, was harvested as the drawing shown
(Fi g. 3B), in a series of concentric right angles, to provide the longest
tail for eventual insertion on the lower lip.
The motor nerve (anterior branch of the obturator nerve) should
be dissected as long as possible, under and beyond the adductor longus
muscle, up to the obturator foramen where the posterior branch was
further separated from the anterior branch, and transected. The vessel
pedicles usually 1 artery and 2 accompanied veins were dissected up
to the bifurcation of the femoral profunda artery and vein. The pedicle
vessels were ligated and transected before the bifurcation.
The trimmed gracilis including the neurovascular bundles was
then transferred to the cheek flap in an inverted fashion. The distal
muscle edge was mattress-sutured to the infrazygomatic periosteum
(as the new origin) with the anchoring stitches set earlier. The proximal
cut edge of aponeurosis was anchored to the mucosa beneath the
orbicularis oris of the upper lip with 4-0 Vicryl (usually 4 stitches). A
third incision, approximately 2 cm in length over the white line of the
lower lip of the paralytic side was made. The created tail of the fascial
aponeurosis passed through the incision wound and sutured to the lower
lip orbicularis oris muscle as medially as possible under tension (Fig. 3C).
Once the muscle was well set, vessel anastomoses (1 artery and
1 vein) to the facial vessels were performed. Finally, the obturator
nerve of the gracilis muscle, passing under the muscle to the upper
lip wound, was coapted to the previous CFNG under operative micro-
scope in the small but adequate upper lip wound.
(B) XI-Gracilis, One Stage Procedure
For the second stage CFNG-gracilis, a 2-team approach was
used, with simultaneous dissection of the paralyzed face, neck, and
FIGURE 3. A, In the recipient site, the draw depicts the position of the inside face measurement, including vessel-opposite side (AA'),
vessel side (BB'), and 2 attachment sides: infrazygomatic arch (AB) and upper lip wound (A'B'). B, In the donor thigh (always
contralateral to the paralyzed face), infrazygomatic attached side (AB) will be placed on the caudal muscle, and upper lip attached side
(CD) on the lower margin of the aponeurosis (BC vessel side length = BB' + 3 cm; and AD vessel-opposite side length = AA'' + 2 cm).
The upper aponeurosis was harvested as long as possible; (C) the trimmed gracilis has been in place inside the face (reproduced with
permission from Facial Plastic Surgery 2008; 24(2):194-203, New York: Thieme).
Annals of Plastic Surgery •Volume 00, Number 00, Month 2018 Facial Palsy, Free Functioning Muscle
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Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
the contralateral gracilis. On the paralyzed face, facelift, trough crea-
tion, vessel preparation, in-side muscle measurement, and so on, the
preparations were all the same as the described above. An additional in-
cision on the neck was performed to identify the XI with help of the
nerve stimulator. The length of the XI dissection should be long enough
to reach the mandibular angle through a tunnel beneath the platysma
muscle, usually 10 cm at least. The gracilis dissection, shaping, attach-
ment at the new origin and insertion sites, and vessel anastomoses were
the same as described above. The XI nerve was coapted to the motor
nerve of the gracilis in the mandibular angle.
16
After wound closure and dressing, the neck was immobilized
with a prefixed neck splint to avoid interruption of the nerve coaptation.
(C) V3-Gracilis, One Stage Procedure
Incision, elevation of the cheek flap, and dissection of the facial
vesselswere as described above. The V3 nerve was roughly localized to
the intersection of lines: one finger-width inferior to the zygomatic arch
and one finger-width anterior to the condyle process of the mandible
(Fig. 4). The masseter muscle was incised at its origin and partially re-
moved until the V3 was identified with the aid of a nerve stimulator.
The V3 nervewas dissected distally to gain enough length, then divided
and reflected upward for nerve repair. Gracilis shaping, harvest, and in-
set were as above. The V3 nerve and gracilis motor nerve were coapted
with tension-free.
Postoperative Care and Rehabilitation Protocol
(A) CFNG-Gracilis
In the first stage, patient was usually hospitalized for 3 to 5 days.
There was no need for postoperative rehabilitation. In the second stage,
patient was usually hospitalized for a week. Patient would be extubated
after the operation and spend 3 to 5 days in the microsurgery intensive
care unit (ICU) for close monitoring. A simple system to check the
swelling was used. Palpation of the nasojugal region to check face
swelling was performed every hour in the ICU observation. There are
4 different degrees of swelling which can be compared with the varying
firmness of the thenar eminence with different (index to little) finger-to-
thumb opposition. If the face firmness is same as thumb-index opposi-
tion, it is soft and classified as 1° swelling (Fig. 5). If the firmness is
slightly firmer same as thumb-long finger opposition, it is 2° swelling.
As thumb-ring finger opposition, it is 3°; and thumb-little finger, 4°
swelling. A 1° to 2° swelling is acceptable, 3° swelling is concerning
and warrants closer observation. A 4° swelling is critical and requires
wound opening to assess the hematoma.
FIGURE 5. Varying firmness of the thenar eminence with
different (index to small) finger-to-thumb opposition, which
can be used as a reference for severity of facial swelling. The
firmness of thumb-index opposition is the 1° swelling.
FIGURE 4. The masseter nerve is found at the intersection of
1 finger width inferior to the zygomatic arch and 1 finger width
anterior to condyle process of the mandible. The origin of the
masseter muscle is transected, removed, and retracted. The
masseter nerve is found deep into the masseter muscle with aid
of a nerve stimulator.
TABLE 1. Chuang's Smile Excursion Score
Score Visible Teeth
0 None of minimal central incisor
1 Full or near-full central incisor
2 Full central incisor and part of lateral incisor
3 Full central incisor, lateral incisor, and canine
4 Full central incisor, lateral incisor, canine and premolar or more
TABLE 2. Chuang's Cortical Adaptation Stage After FFMT
Reconstruction
Stage Description
I Inability to smile (no movement of the muscle)
II Dependent smile (movement) with need of inducting movement to
initiate the FFMT; failed to pass tickle test
III Independent smile (movement) of the FFMT; failed to pass tickle test
IV Spontaneous smile without having to think about it, but still present
involuntary movement; tickle test (+) without latency
V Spontaneous smile with absent involuntary movement; tickle test (+)
without latency
Acceptable result, when stage ≥III postoperatively.
Chuang et al Annals of Plastic Surgery •Volume 00, Number 00, Month 2018
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Rehabilitation, including massage and muscle stimulation, would
begin 3 weeks after FFMT. Usually, the muscle may start moving (M1
strength) in 4 to 6 months postoperatively. Induction exercise
18
would
start. Patients were encouraged continuous induction exercise for at least
1 year. Surgical treatment of the residual deformity was usually
performed a year and half postoperatively.
(B) XI-Gracilis
After surgery, the neck was immobilized with a prefixed neck
splint for 3 weeks. The ICU care and postoperative rehabilitation were
all the same as the CFNG-gracilis described above. At approximately
4 months postoperatively, M1 muscle movement was found and
“induction exercise”was begum. Patient was taught to perform shoul-
der elevation against resistance, a trigger movement that “jumpstarts”
the movement of the transferred muscle. Once the upper lip movement
was noted (usually 6–12 months postoperatively) and the lateral incisor
was visible (M2 musclestrength), induction exercise should be reduced
and stopped. Smile training in front of mirror (mirror therapy) to
adjust and control the muscle movement, making symmetric smile
to the healthy side, was begun with a goal of achieving a natural smile.
(C) V3-Gracilis
After surgery, postoperative ICU care and rehabilitation was the
same as the CFNG-gracilis described above without neck immobiliza-
tion. Upper lip movement could be expected 3 to 4 months postopera-
tively, or even earlier. “Induction exercise”was begun with biting.
Once the transferred muscle achieved upper lip movement with lateral
incisor visible (usually 6–12 months postoperatively), induction exercise
should be reduced and stopped. Smile training in front of mirror was
particularly important for this group of patients.
Patient and Outcome Assessment
In general, the optimal results achieved at different timepoints for
each methods: CFNG-gracilis at the second to third year, XI-gracilis the
TABLE 3. Severity of Postoperative Facial Synkinesis
Degree Description
Mild Tension face, mild cheek twitching, noticed only on close inspection
Moderate Tension face, obvious eye-cheek synkinesis, dominant nasolabial
fold, chin skin dimples, platysma neck bands
Hypertrophy of corrugator
Severe Tension face, contracture with disfiguring : narrow eye,dominant
nasolabial fold, dominant platysma bands, dominant lower lip
retraction, dominant chin skin dimpling
TABLE 4. Satisfaction Score From Patients' Questionnaire
Questionnaire
For facial smile 1. Primary complaint
a. what are you most unsatisfied about the results
after the surgery?
b. is it a functionally or aesthetically based complaints?
2. Do you think you have a symmetric smile?
3. Do you use your smile in daily activities?
a. do you use your smile in front of family and friends?
b. do you use your smile in front of strangers
or public areas?
Score Description
1 Regrets the surgery
2 Not acceptable, but does not regret surgery
3 Acceptable, but needs major improvement
4 Satisfied, but needs only minor improvement
5 Completely satisfied
TABLE 5. Results and PValues
CFNG-FFMT XI-FFMT V3-FFMT
Preoperative
1y
Postoperative
>2 y
Postoperati ve Preoperative
1y
Postoperative
>2 y
Postoperative Preoperative
1y
Postoperative
>2 y
Post op era tive
Smile excursion
Score (average)
0.50 ± 0.80 2.74 ± 0.75 3.30 ± 0.70 0.50 ± 0.55 3.30 ± 0.88 3.45 ± 0.74 0.11 ± 0.28 2.59 ± 0.90 3.21 ± 0.77
Cortical adaptation Most stage
IV–V
Most (83%),
≥stage 3
(33%, stage IV;
12%, stage V)
Most stage II
None passes
thetickletest
Satisfaction score
(average score
out of 5)
N = 40 N = 30 N = 15 3.2
(67% pts ≥3)
3.42 3.40
(90% pts ≥3:
(83% pts
score ≥3:
score 3, 15
score 3, 12 score 4, 9
score 4, 18 score 5, 3
score 5, 3
Correction between
smile excursion
score and
satisfaction
score
+0.160
(P= 0.325)
Pts, patients.
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first to second year, and V3-gracilis 6 months to 1 year. Therefore, all
patients should be followed at least 2 years. All patients were filmed
and videoed routinely at different time points. Five independent ob-
servers (the senior author, 2 residents, and 2 research assistants) graded
the patients by viewing the photos and videos. Before viewing these
materials,all 5 observers met and established a consensus on how to as-
sess the results to maximize interobserver reliability.
For patient assessment preoperatively or postoperatively,
Chuang's Smile Excursion Score,
19
Chuang's Cortical Adaptation
Stage System,
20
synkinesis severity score,
3
patient satisfaction score
from questionnaire, and finally Functional Result Score were used.
Chuang's Smile Excursion Score is a score system from 0 to 4
19
to categorize patient’s smile based on the visibility of the teeth (Table 1).
A postoperative smile excursion score ≧2 is considered acceptable, ≧3
meant good, and ≥4 as excellent in result.
Chuang's Cortical Adaptation Stage System from I to V is a system
to evaluate the functional recovery of progress of the transplanted
muscle
20
(Table 2). When the patient can smile spontaneously at tickling
(tickle test), it is classified as spontaneous smile. A postoperative stage
reaching stage III is classified as acceptable, stage IV as good, stage V as
excellent in result.
Postoperatively facial synkinesis was also evaluated. There are
three degrees of facial synkinesis
3
: mild, moderate, and severe (Table 3).
Muscle excursion does not always correlate with the patient
satisfaction. Therefore, a patient questionnaire was devised, which in-
cluded 3 concerns: primary complaints, symmetric smile, and facial
smile in daily activities (Table 4). For patients younger than 10 years,
their representative guardians fill the questionnaire. The questionnaire
was performed via a phone interview and/or a written document
which is mailed to the participant’s home for any additional input. All
patients who participated in the interviews agreed to the questionnaire
and granted permission to use their answers. There were 5 scores: regrets
the surgery, not acceptable but does not regret surgery, acceptable but
needs major improvement, satisfied but needs minor improvement,
and completely satisfied (Table 4).
Functional Result Score is finally used to define the results
based on the above data. It has 5 categories: excellent, good, fair, poor,
and failed.
Statistical Analysis
Data were presented as percentages or means with ranges or
SDs. Wilcoxon signed-rank tests were used to compare preoperative
and postoperative facial nerve gradings. Fisher exact test was used to
compare the ability to smile (tooth visible), working latency, spontane-
ous movement, and patient's satisfaction. SPSS version 21.0 (SPSS,
Inc, Chigaco, Ill) was used for statistical analyses. Two-sided Pvalues
less than 0.05 were considered statistically significant. The Mann-Whitney
FIGURE 6. A–B, A 43-year-old lady with left Bell's palsy
completely since infancy. She received CFNG-innervated
gracilis for facial reanimation. C–D, Results of 2 years
postoperatively, her smile excursion score was from 0 up to 3.5,
cortical adaptation stage from stage 1 up to V, and satisfaction
score being 4.
FIGURE 7. A, A 21-year-old young male had right Bell's palsy completely for 6 years. He received XI-innervated gracilis for facial
reanimation. B–C, Results of 1 year postoperatively, his smile excursion score was from 0 up to 4, cortical adaptation stage was IV, and
satisfaction score was 5.
Chuang et al Annals of Plastic Surgery •Volume 00, Number 00, Month 2018
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test was used for 2 independent samples, and the Kruskal-Wallis test
was used for more than 2 independent groups.
RESULTS
For 4 failed gracilis, 3 were found at outpatient clinic weeks after
discharge. The necrotic muscles were removed at second hospitaliza-
tion. A second gracilis for further reconstruction 1 year later was per-
formed, and all were successful. The second gracilis was innervated:
one from CFNG changed to XI, one from CFNG to V3, and one using
the original XI nerve. One additional case who received XI-innervated
gracilis for primary reconstruction showed no muscle movement at all
after a 2-year follow-up. She did not want to redo reconstruction.
Smile Excursion Score
Photos and video analysis showed that the smile excursion score
was improved from mean 0.50 ± 0.80 (no or little medial incisor visible)
preoperatively up to mean 3.30 ± 0.70 (at least the canine tooth visible)
postoperatively in CFNG-FFMT (Table 5, Fig. 6A–D). In the XI-FFMT
group, it was from a mean of 0.50 ± 0.55 preoperatively improved to a
mean of 3.45 ± 0.74 postoperatively (Table 5, Fig. 7A–C); and from a
mean of 0.11 ± 0.28 preoperatively improved to a mean of 3.21 ± 0.77
postoperatively in V3-FFMT patients (Table 5, Fig. 8A–C). All Pvalue
were less than 0.001 and significant.
Cortical Adaptation Stage
All patients with CFNG-FFMTachieved at least stage IV (spon-
taneous smile with some involuntary movement), and many were in
stage V (spontaneous smile with no involuntary movement). They all
passed tickling test. In the XI-FFMT patients, 83% patients attained at
least stage III: 33% reached stage IV and 12% stage V. The XI-FFMT
group demonstrated a tendency to reach the stage IVor V gradually over
time with continued smile training. For the V3-FFMT, 100% reached
stage II (dependent movement), and none passed the tickle test, which
meant they often forget to smile and demonstrate a smile latency. All
V3-FFMT continued to have involuntary movement when biting.
Satisfaction Score
In the CFNG-gracilis group, the average satisfaction score was
3.42 from 33 patients who were randomly chosen for the study. Eighty-
two percent of the patients gave a score of 3 or higher (acceptable
or satisfied) out of 5, and many (14/33, 42%) gave a score of 4 (satis-
fied). In XI-gracilis group, the average score was 3.40 from 30 patients'
FIGURE 8. A, An 8-year-old boy had right facial palsy due to hemifacial microsomia completely since birth. He received
V3-innervated gracilis for facial reanimation. B–C, Results of 9 months postoperatively, his smile excursion score was from 0 up to 4,
cortical adaptation stage was III, and satisfaction score was 5.
FIGURE 9. These graphs illustrate the Functional Result Score (from 1 to 5) for CFNG-gracilis group (129 patients), XI-gracilis group
(43 patients) and V3-gracilis group (16 patients) preoperative and postoperative grading scores. Wilcoxon matched-pairs test,
P< 0.0001, compared with both the pre- and post-FFMT.
Annals of Plastic Surgery •Volume 00, Number 00, Month 2018 Facial Palsy, Free Functioning Muscle
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Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
survey. Ninety percent of the patients gave a score of 3 or higher, and
many (15/30, 50%) gave a score of 3. In V3-gracilis group, the average
score was 3.2 from 15 patients. Only 67% patients gave a satisfaction
score of 3 or higher (Table 5).
Functional Results Score
Three group patients obtained significantly higher scores after
FFMT for facial reanimation (P< 0.0001), compared with both the
pre- and post-FFMT (Fig. 9).
Second Surgery (Revision and/or Aesthetic Surgery)
Nearly half (49%) of the patients requested or required second
procedure for secondary deformity correction or aesthetic procedure
to enhance the results. The secondary deformities included contracture
of upper lip, lower lip or mouth angle, asymmetry of eyelids or lip width
(too widening or too thinning), notch of the upper lip, bulkiness or de-
pression on the reconstructed face, dropping eyebrow, and insuff icient
muscle mobility with inadequate tooth exposure, and asked for correc-
tion. Aesthetic procedures included blepharoplasty, rhinnoplasty, fat
grafting, botox injection, scar revision, and so on.
DISCUSSION
There is no 1 (or2) muscle(s) which can totally replace thewhole
facial animation. Our reconstruction focuses on the upper lip elevation
and lower lip suspension only, that is, a reconstruction for smile. The
main goal is to achieve a symmetric face at rest and a synchronous
(or spontaneous) smile with no latency and no involuntary movement.
Upper lip elevation is performed by FFMT, and lower lip suspension
on the paralyzed face with an elongated gracilis aponeurosis, or
altern atively with a tendon graft,or plantaris tendon graft for the lower
lip latero-upward pulling.
21
Forehead elevation and eye narrowing
are usually managed conservatively, such as botox injection or
lateral tarsorrhaphy.
Most surgeons use the middle third of gracilis belly in either full
or split for transfer. There are some disadvantages, including the looser
attachment, upper lip bulkiness, and not easy to perform second revi-
sion. Using upper third gracilis muscle including proximal attached
aponeurosis is the author’s preferred method.
16
When secondary revi-
sion is required, the aponeurosis has become thick and dense, which
is easily identified and revised.
A variety of facial nerve grading scales has been developed over
the years with the intended goals of objectively documenting facial
nerve function, tracking recovery, and facilitating communication
between practitioners.
19,20,22–26
Since 2010, a new evaluation system
was developed in this center, which included smile excursion score,
cortical adaption stage system, satisfaction score from patient's ques-
tionnaire, and finally functional results score for final conclusion of
the results.
We have performed CFNG-gracilis, a 2-stage procedure, for
facial reanimation since 1985. Though the CFNG neurotizer is theo-
logically the weakest in power, requiring longer rehabilitation before
achieving optimal recovery, it offers the greatest chance of restoring
a natural-looking spontaneous smile. XI-gracilis, a 1-stage procedure,
has been extensively used by the author since 2000.
16
The results, in
general, have exceeded expectation. Patients often take 6 to 12 months
to reach smile excursion score 3. We actually started V3-gracilis as a
one stage procedure at 1995, 5 years earlier than XI-gracilis. We stopped
using the procedure for nearly 2 decades because its severe involuntary
movement seen in many patients. After 2013, We reused the V3-FFMT
technique, because it can remarkably achieve a quick result. V3-FFMT
is a good indicative in some conditions, such as bilateral facial palsy,
failed primary CFNG- or XI-FFMT cases, aged patients (>70 years),
and malignant tumor resection patients.
The advantages and disadvantages of the different neurotizers
are shown in Table 6.
To a sugar cane, the sweetest part is at its head portion (at ground
part), and least sweet at its tail (in the air) part. The CFNG-FFMT for
facial reanimation is something like eating a sugar cane from tail to head,
getting more synchronous with time over. The best result of CFNG-
FFMT is usually seen in the second to third years postoperatively. On
the contrary, V3-FFMT is like eating a sugar cane from its head to tail.
The transferred muscle starts to move very early, 3 to 6 months postop-
eratively. The muscle is getting stronger, not natural. The advantages of
XI-FFMT are located between the CFNG- and V3-FFMT.
CONCLUSIONS
The CFNG-FFMT procedure remains our first choice for unilat-
eral facial paralysis reconstruction, especially for children and women
patients. However, the effectiveness of using XI-FFMT, a 1-stage
procedure, is proven a good alternative. There remain some specific
indication for V3-FFMT, such as bilateral facial palsy, failed primary
CFNG- or XI-FFMT cases, older patients (>70 years old) and malignant
tumor resection patients, but it is generally our third choice.
TABLE 6. Comparison of Functioning Muscle Transplantation With Different Neurotizers
CFNG-Gracilis XI-Gracilis V3-Gracilis
Stage requirement 2 1 1
Nerve graft requirement yes No No
Scars Face and leg Face and neck Face
Neurotizer power + ++ +++
Time to reach smile
excursion score 1 (mo)
6–12 6 2–6
Time to achieve smile
excursion score ≥2(mo)
12–24 <12 <6
Cortical adaptation stage Stage IV–VStageIII,IV,orV
(getting better by time)
Stage II–III
(most, stage II)
Tickle test Spontaneously,
no latency
Latency (+) Latency (++)
Smiling training requirement + ++ +++
Satisfaction score 4–53–43
Chuang et al Annals of Plastic Surgery •Volume 00, Number 00, Month 2018
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Annals of Plastic Surgery •Volume 00, Number 00, Month 2018 Facial Palsy, Free Functioning Muscle
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