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

Background: Using functioning free muscle transplantation (FFMT) for facial paralysis and postparalysis facial synkinesis reconstruction is our preferred technique. Graciliswas the first choice ofmuscle. Threemotor 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 questionnaire, 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 singlestage 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 reconstruction which can achieve 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 Mobius syndrome, older patients (age, > 70 years), or patients with malignant disease.