Content uploaded by Tommy Nai-Jen Chang
Author content
All content in this area was uploaded by Tommy Nai-Jen Chang on Jan 15, 2019
Content may be subject to copyright.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
www.PRSJournal.com 1307
Functioning free muscle transplantation
has become the gold standard of the
reconstruction for smile reanimation in
facial paralysis patients.1–10 Functioning free
muscle transplantation involves the use of dif-
ferent motor donor nerves such as the cross-face
nerve graft (a two-stage procedure),1,7,9 contra-
lateral facial nerve branches (one-stage proce-
dure),4 ipsilateral facial nerve branch,2,5 spinal
accessory nerve,3 masseter nerve,6,8 hypoglossal
nerve,10 and others.11 The goals of facial reani-
mation are to achieve symmetry at rest, and sym-
metry during dynamic facial expressions without
latency and synkinesis. Most efforts at smile reani-
mation, however, have focused only on the upper
lip such as movement of the oral commissure12,13
Disclosure: The authors have no financial interest
to declare in relation to the content of this article. No
external funding was received.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004849
Jerry Tsung-Kai Lin, M.D.
Johnny Chuieng-Yi Lu, M.D.
Tommy Nai-Jen Chang,
M.D.
David Chwei-Chin Chuang,
M.D.
Taoyuan, Taiwan
Background: Functioning free muscle transplantation is currently the gold
standard for the reconstruction of facial paralysis, focusing more on the upper
lip reconstruction rather than on the lower lip. This study aimed to compare
different lower lip reconstructive methods when performing functioning free
muscle transplantation for facial reanimation.
Methods: A retrospective review of functioning free muscle transplantation for
facial reanimation from 2007 to 2015 was performed. Patients were divided
into three groups: in group 1 (n = 15), a free plantaris tendon graft anchored
to the gracilis muscle was passed into the lower lip to create a loop within; in
group 2 (n = 12), an aponeurosis tail of the gracilis muscle was attached to
the lower lip; and in group 3 (n = 18), no suspension of the lower lip was per-
formed. All patients had at least 2 years of follow-up. Outcomes were assessed
by photographs and videos, including subjective evaluation of midline devia-
tion and horizontal tilt and objective analysis of smile dimensions and area.
Results: A total of 45 patients were included. Results from the subjective eval-
uation demonstrate group 1 patients having the best improvement (overall
score: p = 0.004 and p = 0.005, Fisher’s exact test). The objective evaluation
showed group 1 and 2 patients with better results compared with group 3 (hor-
izontal component, p = 0.009; vertical component, p = 0.004; area distribution,
p < 0.001, Kruskal-Wallis test).
Conclusions: Both plantaris tendon graft and gracilis aponeurosis achieved
better improvement in subjective and objective evaluations than those who had
no reconstruction of the lower lip. In particular, the plantaris tendon graft can
achieve the most lower lip excursion with overall improved symmetry. (Plast.
Reconstr. Surg. 142: 1307, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
From the Division of Reconstructive Microsurgery, Depart-
ment of Plastic Surgery, Chang Gung Memorial Hospital,
Chang Gung University.
Received for publication July 5, 2017; accepted May 16,
2018.
The first two authors contributed equally to this article.
Presented at the American Society for Reconstructive
Microsurgery Annual Meeting 2017, in Waikoloa, Hawaii,
January 14 through 17, 2017; and the 9th Congress of the
World Society for Reconstructive Microsurgery, in Seoul,
Republic of Korea, June 15 through 17, 2017.
Simultaneous Reconstruction of the Lower
Lip with Gracilis Functioning Free Muscle
Transplantation for Facial Reanimation:
Comparison of Different Techniques
CODING PERSPECTIVE FOR THIS ARTICLE IS ON
PAGE XXX.
cpt
RECONSTRUCTIVE
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
1308
Plastic and Reconstructive Surgery • November 2018
and appearance of the upper lip, rather than on
restoring symmetry of the lower lip, leaving it as
a neglected area.14 This would be a cause for con-
cern in patients that seek to achieve better sym-
metry and function after surgery. The purpose of
this study was to present our patients who under-
went simultaneous reconstruction of the lower lip
and gracilis functioning free muscle transplanta-
tion for smile reanimation, and to analyze the
effects on symmetry and function.
PATIENTS AND METHODS
Between the years 1986 and 2015, a total
of 362 cases of gracilis functioning free muscle
transplantation were performed for facial reani-
mation. Patients were accrued retrospectively
from 2007 to 2015 for collection of more recent
and accurately documented data, and a total of
45 patients with chronic complete facial paralysis
were enrolled in this study. All functioning free
muscle transplantations used the gracilis muscle,
and all operations were performed by the same
senior surgeon (D.C.C.C.). Exclusion criteria
included patients with less than 2 years of follow-
up and patients who underwent reconstruction
for postparalytic facial synkinesis (17 percent
of our 362 cases). They were excluded to avoid
confounding factors such as incomplete facial
palsy with functional depressors.15 This study was
approved by the Institutional Review Board at
Chang Gung Memorial Hospital under the certi-
fication number 201701233B0. We have received
consent to use and publish the photographs and
videos from the enrolled patients.
Patients were divided into three groups based
on how the lower lip was addressed. In group 1
(15 patients), a plantaris tendon graft was har-
vested from the same leg from which the gracilis
muscle was harvested. Using a tendon stripper,
a plantaris tendon graft of approximately 15 cm
was harvested (Fig. 1, left). With the gracilis in
situ, one end of the tendon graft was sutured
onto the lower and medial (vessel-opposed side)
edge of the muscle (Fig. 1, right). After the graci-
lis muscle was transferred and inset into the
paralyzed face (insertion at the infrazygomatic
margin superiorly and the upper lip inferi-
orly1), the other end of the plantaris tendon was
threaded through the lower lip through a small
incision on the white line of the ipsilateral lower
lip. With the help of a nerve passer, the tendon
end was passed across the midline of the lower
lip to the opposite side through two small inci-
sions on the contralateral lower lip. The tendon
was then looped back and exited through the
same small incision on the ipsilateral paralyzed
lip. The end of the tendon end was sutured onto
itself under mild tension (Fig. 2).
In group 2 (12 patients), the proximal gracilis
fascial aponeurosis was dissected as high as pos-
sible to the origin at the pubic ramus. The whole
aponeurosis was tailored by creating a 1-cm-wide
tail that was still in continuity with the muscle
(Fig. 3). After the muscle was inset, the aponeuro-
sis tail was pulled out through a lower lip incision
on the white line of the lower lip vermillion and
anchored to the orbicularis oris muscle and sur-
rounding tissue with two or three stitches of 4-0
Vicryl (Ethicon, Inc., Somerville, N.J.). Because
of its limited length, this aponeurosis tail did not
cross the lower lip midline (Fig. 4). In group 3
(18 patients), there was no lower lip suspension
of any form, and the gracilis muscle was anchored
only to the upper lip in the same manner as in the
other groups (Fig. 5).
Samples of the preoperative and postopera-
tive photographs in the three groups are shown
in Figure 6. Patient demographics including age,
sex, cause of facial palsy, and donor nerve used
for functioning free muscle transplantation are
shown and analyzed (Table 1).
Outcome Evaluation
Standardized photographs and videos were
taken at each visit in the clinic before and after
surgery. Each photograph and video was taken 2
m away from the patient, and the camera lens was
set at the height of the nasal tip. Adjustments are
made to set the intercanthal line parallel to the
horizontal axis of the photograph. All patients in
our database were asked to take photographs at
“rest status,” “smile with ease” that mimics Rubin’s
classification of commissure smile, and “smile with
maximum effort” that tries to expose denture if
possible.16 They were asked to pronounce the |E|
sound as in “cheese” to facilitate performance of
the smile. Video documentation was used primar-
ily for confirmation of the measurements made
from the photographs.
Results were evaluated using subjective and
objective approaches. Subjective evaluation con-
sisted of scores given intuitively by reviewers as soon
as the photographs and videos were shown. Objec-
tive evaluation was measured on photographs in
detail based on a concept derived from the scaled
measurement of improvement in lip excursion
evaluation method reported by Bray et al.17
Subjective evaluation was performed by
three individuals for better interrater reliability.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 142, Number 5 • Lower Lip Reconstruction
1309
Outcomes evaluated were as follows. “Midline
deviation” was defined as the extent of lower lip
midline deviation away from the nasal columella.
A score from 1 to 5 was given based on the devia-
tion severity, where 1 was the most severe, with
lower lip midline deviation beyond the lateral
side of the contralateral nostril; 2 was severe,
with midline deviation within the lateral half of
the nostril; 3 was moderate, with midline devia-
tion within the medial half of the nostril; 4 was
mild, with midline deviation within the colu-
mella; and 5, with no deviation (Fig. 7). A score
of 1 to 5 was also used to assess the mouth angle
“horizontal tilt” using the following method. A
horizontal line, defined as the intercanthal line,
was compared to the line connecting the two
mouth angles, with the difference between these
two lines at the ipsilateral commissure recorded
and compared to the upper lip height, which is
used as the reference (Fig. 7). The most severe
was scored as 1, with tilt as defined by the distance
between these two lines at the ipsilateral commis-
sure being more than twice the upper lip height;
2 was severe, with the tilt being more than the
upper lip height; 3 was moderate, with the tilt less
than the upper lip height; 4 was simply a mild tilt;
and 5 was no tilt at al. Using these metrics, pho-
tographs taken at resting position (static) and
at maximum smile excursion (dynamic) before
and after surgery (2 years postoperatively) were
all evaluated. “Overall score” was defined as the
numeric sum of the scores of the above two sub-
jective items.
Objective evaluation was examined by smile
photographs only.18 Each photograph was stan-
dardized by adjusting the iris diameter value to
11.77 mm as established in previous literature.19 The
midline was defined as the perpendicular bisector
of the connection of the two canthi. The iris-scale-
corrected horizontal and vertical components of
the lower lip excursion before and after surgical
intervention were measured by Adobe Photoshop
(Adobe Systems, Inc., San Jose, Calif.). Data were
tabulated and calculated using Excel spreadsheet
software (version 2016; Microsoft Corp., Redmond,
Wash.). Besides horizontal and vertical lower lip
excursion, “area distribution” was also assessed, as
derived from the scaled measurement of improve-
ment in lip excursion evaluation; during full smile
excursion, the area of the paralyzed side of lower
lip was measured and then calculated as a percent-
age of the entire lower lip area20 (Fig. 8).
Fig. 1. (Left) The plantaris tendon is harvested using a tendon stripper. (Right) The plantaris tendon is sutured on the medial side
of the gracilis muscle.
Fig. 2. Simultaneous lower lip reconstruction with a looped-
plantaris tendon graft crossing the midline of the lower lip.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
1310
Plastic and Reconstructive Surgery • November 2018
Statistical Analysis
Statistical analysis was completed by using
IBM SPSS Version 22.0 (IBM Corp., Armonk,
N.Y.). For the subjective evaluation, the Fisher’s
exact test was used to compare the results among
the three groups. Differences among evaluators
were assessed using the two-way mixed model to
demonstrate whether the measurements changed
across patients.21 For the objective evaluation, the
Kruskal-Wallis test was used, because the sample
Fig. 4. The gracilis aponeurosis is sutured to the lower lip with-
out crossing the midline.
Fig. 3. (Left) The gracilis muscle and its aponeurosis tail. (Right) The aponeurosis tail is pulled out
through an incision wound of the lower lip. (Used with permission from Chuang DCC. Gracilis
ap. In: Wei FC, Mardini S, eds. Flaps and Reconstructive Surgery. Philadelphia: Saunders Elsevier;
2009:395–409.)
Fig. 5. In the third group of patients, the lower lip is not involved
in the reconstruction.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 142, Number 5 • Lower Lip Reconstruction
1311
size in each group was less than 30. The results of
the objective evaluation are expressed as medi-
ans and interquartile ranges. Post hoc analysis
was performed secondarily using the Dunn test,
specifically comparing one group to another if
there was a significant difference found among
the three groups.22 A value of p < 0.05 was con-
sidered statistically significant. A multivariate
analysis was not performed because the patient
number in each group was not large enough to
warrant such a study to derive any significant
conclusions.
RESULTS
Subjective Evaluation
The interrater reliability was estimated by an
average intraclass correlation coefficient of 0.936,
Fig. 6. A representative patient was selected from each group, and
their before-and-after functioning free muscle transplantation pho-
tographs are shown. (Above) Group 1, plantaris tendon. (Center)
Group 2, gracilis aponeurosis. (Below) Group 3, not repaired.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
1312
Plastic and Reconstructive Surgery • November 2018
which was considered acceptable. For static evalu-
ation, group 1 had the best improvement after sur-
gery in midline deviation, horizontal tilt analysis,
and the overall score, and these results were statis-
tically significant (p = 0.0005 and p = 0.036, respec-
tively) (Fig. 9, above). For the dynamic evaluation,
there was no difference in midline deviation or
horizontal tilt (p = 0.062 and 0.163, respectively),
but the overall score showed a significant differ-
ence among the three groups (p = 0.004) (Fig. 9.
below).
Objective Evaluation
A statistical analysis of the objective evalua-
tion verified that group 1 and group 2 had signifi-
cant differences in lower lip movement compared
with group 3 (Fig. 10 and Table 2). Comparing
the overall difference among all of the groups,
there were significant differences in the three
parameters (horizontal component, p = 0.009;
vertical component, p = 0.004; and area distri-
bution, p < 0.001). When comparing the groups
with each other, group 1 (median, 11.98 mm;
interquartile range, 9.67 to 16.92 mm) showed a
significant increase in the horizontal component
of the lower lip compared with group 3 (median,
7.00 mm; interquartile range, 3.15 to 10.67 mm;
p = 0.008). The vertical component demonstrated
improvement in both lower lip surgical interven-
tion groups, with group 1 (median, 6.65 mm;
interquartile range, 4.52 to 9.65 mm) and group
2 (median, 4.88 mm; interquartile range, 3.19 to
9.04 mm) both showing significant differences
versus group 3 (median, 2.39 mm; interquartile
range, 1.03 to 4.22 mm) (group 1 versus group
3, p = 0.001; group 2 versus group 3, p = 0.039).
Similarly, in the improvement of lower lip area
distribution, group 1 (median, 26.78 percent;
interquartile range, 21.04 to 29.21 percent) and
group 2 (median, 28.64 percent; interquartile
range, 15.83 to 33.47 percent) both demonstrated
improvements that were significantly better than
those in group 3 (median, 7.35 percent; inter-
quartile range, 0.19 to 15.78 percent) (group 1
versus group 3, p < 0.001; group 2 versus group
3, p = 0.001). However, no significant difference
was found between groups 1 and 2 in these three
parameters.
DISCUSSION
Lower lip depressor muscles include depres-
sor labii inferioris, depressor angularis, and pla-
tysma.14 The first two muscles evert the vermillion
and pull down the lower lip medially and laterally
on the mouth angle, helping to show the lower
teeth when excursion is strong during smiling.
The platysma has a minor influence on lower lip
movement, although it can influence the posi-
tion of the lower lip by means of its muscle resting
tone. These depressor muscles have little impact
on creating a “joyful” expression with zygomati-
cus smile (the Mona Lisa smile) and canine smile.
Instead, the depressor muscles may generate a
snarling expression at maximal contraction, thus
creating a “full denture” smile that often seems
fake. Most facial paralysis patients request a smile
to express pleasure or happiness, but not a full
dentured smile. Our goal in facial reanimation is
to aim for an attractive natural-appearing smile
that is symmetric and acceptable for both the
intended target audience and the patient.
Reconstruction of lower lip paralysis is still con-
sidered important when a person speaks, although
the reconstruction does remain an unsolved prob-
lem in facial reanimation. Terzis and Kalantar-
ian described the lower lip as a neglected area
of facial reanimation and attempted to address
these issues.14 In their study involving 74 patients,
they introduced selective approaches for dynamic
reanimation of the lower lip: transfer of the ante-
rior belly of the digastric muscle, transfer of the
platysma muscle, using a mini-hypoglossal nerve
Table 1. Patient Demographics*
Characteristic Group 1 Group 2 Group 3 p
Total no. of patients 15 12 18
Age, yr >0.05
Mean 35 37 27
Range 6–63 11–55 4–67
Sex >0.05
Male 4 4 11
Female 11 8 7
Side
Left 4 4 10
Right 11 8 8
Cause
Bell palsy 5 2 3
Tumor 10 9 3
Infection 0 1 3
Trauma 0 0 2
Congenital 0 0 6
Others 0 0 4
Donor motor nerves >0.05
CFNG 4 6 6
XI 9 5 8
V3 2 1 4
One-stage donor
nerves, % 73 50 67 >0.05
CFNG, cross-face nerve graft; XI, spinal accessory nerve; V3, nerve
to masseter muscle.
*Patient characteristics of the three group are listed and analyzed.
The distribution of age and gender ratio were analyzed with the
Kruskal-Wallis test, and the distribution of neurotizers was analyzed
with the χ2 test.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 142, Number 5 • Lower Lip Reconstruction
1313
Fig. 7. The subjective evaluation grading system. The evaluators were counseled to focus on the lower lip without
regard to the upper lip.
transfer to the cervicofacial branch, direct neu-
rotization of the depressor muscle, and facial-to-
facial nerve transfer.10 In response, Manktelow
criticized such overly complicated procedures.7
He recommended simpler procedures, either
local injection of long-acting anesthetic drug (for
a short requirement), or botulinum toxin (for
a longer requirement) into the depressor labii
Fig. 8. Objective evaluation. Modied SMILE evaluation (Bray, 2010). Horizontal component (left). Vertical component (center).
Area distribution (right).
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
1314
Plastic and Reconstructive Surgery • November 2018
inferioris muscle on the normal side, or a selective
myectomy of the normal lower lip, all of which are
easier procedures that can be accomplished safely
and effectively.
From the senior author’s experience on facial
paralysis patients who underwent functioning
free muscle transplantation for smile reanima-
tion, synchronous movement of the lower lip with
the upper lip can dramatically improve symme-
try. Simply denervating the depressor muscles on
the healthy side is insufficient for dynamic move-
ment. Reinnervating the paralyzed depressor
muscles (such as hypoglossal nerve or masseter
nerve transfer to the cervicofacial trunk or man-
dibular branch) may create a “snarling” appear-
ance that is inconsistent with a natural attractive
smile.23 Fixating the functioning free muscle
transplantation to the mouth angle has a risk
of creating a disfiguring dimpling to the mouth
angle during smile. Attempts to replace the lower
lip depressors with local muscle transfer are not
recommended, as they may increase the risk for
asymmetry at rest because of contracture.24 This
is why we performed simultaneous reconstruction
of the lower lip by means of either a plantaris ten-
don graft or the gracilis aponeurosis for lateral,
but not downward, pulling of the lower lip to help
achieve dynamic smile symmetry.
Our method for smile reanimation involves
harvesting a segment of the proximal gracilis
muscle, usually from the contralateral thigh. The
proximal portion of the muscle with its aponeu-
rosis is reversed and fixed into the upper lip, and
the distal end of the muscle is fixed to the peri-
osteum of the inferior margin of the zygomatic
arch.1,3 If the patient has a complete palsy of the
Fig. 9. (Above) Results of subjective evaluation; static status. (Below) Dynamic status. (Left) Midline deviation. (Center) Horizontal
tilt. (Right) Overall score. The results of subjective evaluation are expressed as percentages of that group. (Above) In the static sub-
jective evaluation, the distributions are classied as improved, no change, or regressed. (Below) In the dynamic subjective evalua-
tion, there was an obvious improvement in all cases after functioning free muscle transplantation; therefore, the distributions are
classied with regard to the degree of improvement.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 142, Number 5 • Lower Lip Reconstruction
1315
upper and lower lip, simultaneous reconstruction
of the lower lip will be performed while perform-
ing the standard gracilis inset for the upper lip
elevation. Given the sufficient length of the plan-
taris tendon, the graft can be passed beyond the
midline of the lower lip, giving more strength to
pull the entire lower lip. The gracilis with its apo-
neurosis tail can only reach the ipsilateral lower
lip because of its short length. This may explain
why the plantaris tendon group provided better
symmetry at dynamic status compared with the
gracilis aponeurosis group.
In retrospect, there were two patients in the
plantaris tendon group that required subsequent
revisions of the anchored tendons. They were
performed earlier in the series when we inad-
vertently created contour abnormalities. Both
patients complained of tightness of the mouth
angle and had compensatory tongue movement
constantly. Both underwent tenotomy finally. One
patient had a dominant dimpling deformity over
the lower lip caused by contracture. Release of the
contracture by two small incisions, full undermin-
ing of the underlying contracture, and placement
of a dermofat graft were given as the secondary
procedures. Therefore, the tension adjustment
should be neither too tight nor too loose. Too
much tension in setting the plantaris graft may
create a tight band in the commissure that can
restrict mouth opening. In addition, if it is put
too superficial, it will create a severe dimpling
deformity over the lower lip. To avoid these com-
plications, the tension should be adjusted by pull-
ing the tendon to see whether it could mobilize
the midline of the lower lip approximately 5 mm
toward the ipsilateral paralyzed side after tendon
repair. The tendon graft should be also placed
deeply inside the muscle, and not too superficial.
There were no apparent complications in the
group 2 patients. We made our incisions on the
vermillion border of the lip for disguise. Incision
Fig. 10. Statistical results of objective evaluation. The p value
between the groups (Dunn test) and the overall p value of the
Kruskal-Wallis (K-W) test are all shown above the graphs.
Table 2. Results of Objective Evaluation
Group 1 Group 2 Group 3 p
Horizontal
component
(mm)
13.13 11.64 6.38 p1&2 = 0.009†
p1&2 = 0.411
p2&3 = 0.155
p1&3 = 0.008†
Vertical
component,
mm
7.03 5.41 2.63 p1&2 = 0.004†
p1&2 = 0.348
p2&3 = 0.039†
p1&3 = 0.001†
Area
distribution,
%
26.78 25.53 7.57 p1&2 < 0.001†
p1&2 = 1.000
p2&3 = 0.001†
p1&3 < 0.001†
*Improvement of the paralyzed side of the lower lip after function-
ing free muscle transplantation. The results are expressed as mean in
this table. The p values are the results of Kruskal-Wallis tests.
†The results are expressed as means.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
1316
Plastic and Reconstructive Surgery • November 2018
scars over the lower (or upper) lip were not often
complained of by the patients.
Most of the patients that did not receive lower
lip intervention (group 3) were from our earlier
series of functioning free muscle transplantation,
the period when we focused only on the upper
lip. Indication and selection of which method is
used for lower lip reconstruction is made accord-
ing to the strength difference or prominence of
the contraction of the healthy side of the lower
lip depressors. Patients with bilateral Möbius syn-
drome are not required to undergo simultaneous
reconstruction of the lower lip.
Limitations
Although this study suggested that simultane-
ous lower lip reconstruction during functioning
free muscle transplantation has an important
role in restoring lower lip symmetry for facial
reanimation, the conclusions could be statisti-
cally more powered if there were more patients in
each group. The uneven distribution of the vari-
ous donor nerves used in each group was another
confounding factor, but the percentage of one-
stage donor nerves used in each group showed no
significant difference.
CONCLUSIONS
Simultaneous lower lip intervention during
functioning free muscle transplantation for facial
reanimation reestablishes lower lip movement
and improves overall symmetry in facial reanima-
tion. By applying subjective and objective evalu-
ations, both the plantaris tendon graft and the
gracilis aponeurosis present significant improve-
ment of symmetry and movement to the lower
lip. The plantaris tendon graft can achieve the
most lower lip excursion with overall improved
smile symmetry. Not suspending the lower lip
may have an unsatisfactory impact on the final
outcome.
David Chwei-Chin Chuang, M.D.
Department of Plastic Surgery
Chang Gung Memorial Hospital
5 Fu-Hsing Street
Kuei-Shan, Taoyuan 333, Taiwan
micro.cgmh@gmail.com
ACKNOWLEDGMENTS
The authors would like to thank Jessie Lin for artis-
tic contributions to the figures, and they would like to
acknowledge Hubert Shih, M.D., a native English speaker,
for providing grammatical corrections to the manuscript.
CODING PERSPECTIVE
Coding perspective provided by Dr.
Raymond Janevicius is intended to
provide coding guidance.
15842 Graft for facial nerve paralysis; free
muscle flap by microsurgical tech-
nique
20924 Tendon graft, from a distance (e.g.,
palmaris, toe extensor, plantaris)
• The free gracilis muscle flap is reported
with code 15842.
• The free muscle flap code, 15756, should
not be reported, as code 15842 is more
specific for facial paralysis.
• The free muscle flap code, 15842, does
not include tendon grafting. The plan-
taris tendon graft is reported with code
20924.
• Since the tendon graft is an additional
procedure, the multiple procedure
modifier, 51, is appended:
15842 Free gracilis muscle transfer for
facial paralysis
20924-51 Plantaris tendon graft.
CODING PRINCIPLE: Free flap codes are
global and include:
• Harvest of the free flap
• Dissection of donor vessels
• Straightforward closure of donor site
• Dissection and isolation of recipient vessels
• Microvascular anastomosis of one artery
and two veins
• Use of the operating microscope
• Inset of the flap
• Straightforward wound closure
• Monitoring of the flap intraoperatively
and postoperatively
Additional procedures, such as tendon
grafts, vein grafts, or skins grafts, are report-
ed in addition to the free flap codes.
Disclosure: Dr. Janevicius (janeviciusray@
comcast.net) is the president of JCC, a firm
specializing in coding consulting services
for surgeons, government agencies, attor-
neys, and other entities.
cpt
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 142, Number 5 • Lower Lip Reconstruction
1317
REFERENCES
1. Chuang DC. Technique evolution for facial paralysis recon-
struction using functioning free muscle transplantation:
Experience of Chang Gung Memorial Hospital. Clin Plast
Surg. 2002;29:449–459, v.
2. Chuang DC, Devaraj VS, Wei FC. Irreversible muscle con-
tracture after functioning free muscle transplantation using
the ipsilateral facial nerve for reinnervation. Br J Plast Surg.
1995;48:1–7.
3. Chuang DCC, Lu JCY, Anesti K. One-stage procedure using spi-
nal accessory nerve (XI)–innervated free muscle for facial paral-
ysis reconstruction. Plast Reconstr Surg. 2013;132:117e–129e.
4. Guelinckx PJ, Sinsel NK. Muscle transplantation for recon-
struction of a smile after facial paralysis past, present, and
future. Microsurgery 1996;17:391–401.
5. Gur E, Stahl S, Barnea Y, et al. Comprehensive approach in
surgical reconstruction of facial nerve paralysis: A 10-year
perspective. J Reconstr Microsurg. 2010;26:171–180.
6. Hontanilla B, Marre D, Cabello A. Facial reanimation with
gracilis muscle transfer neurotized to cross-facial nerve
graft versus masseteric nerve: A comparative study using
the FACIAL CLIMA evaluating system. Plast Reconstr Surg.
2013;131:1241–1252.
7. Manktelow RT. Free muscle transplantation for facial paraly-
sis. Clin Plast Surg. 1984;11:215–220.
8. Manktelow RT, Tomat LR, Zuker RM, Chang M. Smile recon-
struction in adults with free muscle transfer innervated by
the masseter motor nerve: Effectiveness and cerebral adapta-
tion. Plast Reconstr Surg. 2006;118:885–899.
9. Terzis JK, Noah ME. Analysis of 100 cases of free-muscle
transplantation for facial paralysis. Plast Reconstr Surg.
1997;99:1905–1921.
10. Ueda K, Harii K, Yamada A. Free neurovascular muscle
transplantation for the treatment of facial paralysis using the
hypoglossal nerve as a recipient motor source. Plast Reconstr
Surg. 1994;94:808–817.
11. Terzis JK, Konofaos P. Novel use of C7 spinal nerve for
Moebius. Plast Reconstr Surg. 2010;126:106–117.
12. Bae YC, Zuker RM, Manktelow RT, Wade S. A compari-
son of commissure excursion following gracilis muscle
transplantation for facial paralysis using a cross-face nerve
graft versus the motor nerve to the masseter nerve. Plast
Reconstr Surg. 2006;117:2407–2413.
13. Manktelow RT, Zuker RM, Tomat LR. Facial paralysis measure-
ment with a handheld ruler. Plast Reconstr Surg. 2008;121:435–442.
14. Terzis JK, Kalantarian B. Microsurgical strategies in 74
patients for restoration of dynamic depressor muscle mecha-
nism: A neglected target in facial reanimation. Plast Reconstr
Surg. 2000;105:1917–1931; discussion 1932–1934.
15. Chuang DC, Chang TN, Lu JC. Postparalysis facial synkine-
sis: Clinical classification and surgical strategies. Plast Reconstr
Surg Glob Open 2015;3:e320.
16. Rubin LR, Mishriki Y, Lee G. Anatomy of the nasolabial fold:
The keystone of the smiling mechanism. Plast Reconstr Surg.
1989;83:1–10.
17. Bray D, Henstrom DK, Cheney ML, Hadlock TA. Assessing
outcomes in facial reanimation: Evaluation and validation of
the SMILE system for measuring lip excursion during smil-
ing. Arch Facial Plast Surg. 2010;12:352–354.
18. Tzou CH, Chuang DC, Chen HH. Facial paralysis grading sys-
tem: A new and simple smile excursion score for evaluating
facial reanimation surgery. Ann Plast Surg. 2015;74:210–213.
19. Rüfer F, Schröder A, Erb C. White-to-white corneal diameter:
Normal values in healthy humans obtained with the Orbscan
II topography system. Cornea 2005;24:259–261.
20. Lindsay RW, Edwards C, Smitson C, Cheney ML, Hadlock
TA. A systematic algorithm for the management of lower lip
asymmetry. Am J Otolaryngol. 2011;32:1–7.
21. Barton B, Peat J. Intra-class correlation notation. In: Peat JK,
ed. Medical Statistics: A Guide to SPSS, Data Analysis and Critical
Appraisal. Hoboken, NJ: Wiley; 2014:322–325.
22. Pett MA. Assessing differences among several indepen-
dent groups. Nonparametric Statistics in Health Care Research:
Statistics for Small Samples and Unusual Distributions. Thousand
Oaks, Calif: SAGE; 1997:217–218.
23. Terzis JK, Tzafetta K. Outcomes of mini-hypoglossal nerve trans-
fer and direct muscle neurotization for restoration of lower lip
function in facial palsy. Plast Reconstr Surg. 2009;124:1891–1904.
24. Tulley P, Webb A, Chana JS, et al. Paralysis of the marginal
mandibular branch of the facial nerve: Treatment options.
Br J Plast Surg. 2000;53:378–385.
