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Original Investigation
March 22, 2018

The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation

Author Affiliations
  • 1Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Mid Atlantic Permanente Medical Group, McLean, Virginia
  • 3University of California Los Angeles, Santa Monica
  • 4Ohio State University, Columbus
JAMA Facial Plast Surg. Published online March 22, 2018. doi:10.1001/jamafacial.2018.0048
Key Points

Question  Can a gracilis muscle flap be designed as a compound flap with multiple paddles for multivector reanimation after facial paralysis, and what effect does this design have on the smile display zone?

Findings  In this prospective cohort study of 12 patients who underwent facial reanimation for complete paralysis, the gracilis flap was reliably designed and transplanted as a functional double paddle muscle flap for a multivector facial reanimation. The multivector design resulted in statistically significant improvement in the dental display, smile width, and correction of paralytic labial drape.

Meaning  Designing the gracilis flap as a multivector gracilis flap with 2 or more paddles is an effective way of improving all components of the smile display zone and has the potential for restoring a Duchene-type smile in patients with facial paralysis.


Importance  A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis.

Objective  To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone.

Design, Setting, and Participants  Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital.

Interventions  The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation.

Main Outcomes and Measures  The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling.

Results  There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P < .001). The mean exposed maxillary gingival scaffold width improved from 31.5 mm to 43.7 mm (95% CI, 1.9 to 4.3; P < .001). There was no significant difference in interlabial exposure at midline (7.1 mm vs 7.7 mm; CI, −1.5 to 2.7; P = .56) but a 56.4% improvement at the level of the canines (3.9 vs 6.1; CI, 0.1 to 4.3; P = .04). The mean FAI when smiling was reduced from 9.1 mm to 4.5 mm (CI, −8.0 to −1.2; P = .01). Dynamic wrinkling of the periorbital area with smiling was noted in 4 patients.

Conclusions and Relevance  The gracilis flap can be reliably designed as a functional double paddle muscle flap for a multivector facial reanimation. The multivector gracilis flap design is effective in improving all components of the smile display zone and has the potential for producing periorbital-wrinkling characteristic of a Duchenne smile.