Quality-of-Life Improvement After Free Gracilis Muscle Transfer for Smile Restoration in Patients With Facial Paralysis

Abstract

IMPORTANCE Facial paralysis can contribute to disfigurement, psychological difficulties, and an inability to convey emotion via facial expression. In patients unable to perform a meaningful smile, free gracilis muscle transfer (FGMT) can often restore smile function. However, little is known about the impact on disease-specific quality of life.OBJECTIVE To determine quantitatively whether FGMT improves quality of life in patients with facial paralysis. DESIGN, SETTING, AND PARTICIPANTS Prospective evaluation of 154 FGMTs performed at a facial nerve center on 148 patients with facial paralysis. The Facial Clinimetric Evaluation (FaCE) survey and Facial Assessment by Computer Evaluation software (FACE-gram) were used to quantify quality-of-life improvement, oral commissure excursion, and symmetry with smile. INTERVENTION Free gracilis muscle transfer. MAIN OUTCOMES AND MEASURES Change in FaCE score, oral commissure excursion, and symmetry with smile. RESULTS There were 127 successful FGMTs on 124 patients and 14 failed procedures on 13 patients. Mean (SD) FaCE score increased significantly after successful FGMT (42.30 [15.9] vs 58.5 [17.60]; paired 2-tailed t test, P < .001). Mean (SD) FACE scores improved significantly in all subgroups (nonflaccid cohort, 37.8 [19.9] vs 52.9 [19.3]; P = .02; flaccid cohort, 43.1 [15.1] vs 59.6 [17.2]; P < .001; trigeminal innervation cohort, 38.9 [14.6] vs 55.2 [18.2]; P < .001; cross-face nerve graft cohort, 47.3 [16.6] vs 61.7 [16.9]; P < .001) except the failure cohort (36.5 [20.8] vs 33.5 [17.9]; Wilcoxon signed-rank test, P = .15). Analysis of 40 patients' photographs revealed a mean (SD) preoperative and postoperative excursion on the affected side of −0.88 (3.79) and 7.68 (3.38), respectively (P < .001); symmetry with smile improved from a mean (SD) of 13.8 (7.46) to 4.88 (3.47) (P < .001). CONCLUSIONS AND RELEVANCEFree gracilis muscle transfer has become a mainstay in the management armamentarium for patients with severe reduction in oral commissure movement after facial nerve insult and recovery. We found a quantitative improvement in quality of life after FGMT in patients who could not recover a meaningful smile after facial nerve insult. Quality-of-life improvement was not statistically different between donor nerve groups or facial paralysis types.LEVEL OF EVIDENCE 3.

Selective Stimulation of Facial Muscles Following Chronic Intraneural Electrode Array Implantation and Facial Nerve Injury in the Feline Model

“…Similar to data obtained from chronically-implanted electrodes, stimulation following FN injury resulted in significantly diminished EMG output and marked reduction in the degree of visible facial muscle contraction compared to the previously published acute FN experiments, 11 with maximal EMG responses reaching 400µV in acute stimulation of injured FN compared to a 4,000µV maximal response in uninjured FN experiments (p < 0.01).…”

“…The selectivity of muscle contraction and current-dependent EMG voltage responses reported here are similar to findings reported in our previous acute studies in the uninjured FN. 11 The primary distinction in the results reported presently and our previously reported results lies in the markedly reduced EMG voltage responses and reduction of visible muscle contraction following chronic MEA implantation.…”

“…11 EMG responses following chronic MEA implantation in normal, uninjured FN were significantly lower, with maximal EMG responses reaching only 800µV in chronic implants compared to responses of 4,000µV at maximum stimulation levels in acute experiments (p < 0.05).…”

“…While dynamic surgical interventions for patients with permanent unilateral facial paralysis, such as myoneurovascular gracilis transfer, can provide meaningful movement, these interventions focus on specific facial regions, can require multiple procedures and surgical sites, and carry a 10–15% failure rate. 910 Furthermore, while functional goals may be achieved and quality-of-life improved, 11 aesthetic outcomes are uncommonly fully satisfactory and infrequently restore normal facial form and function.…”

A Contemporary Approach to Facial Reanimation

“…[3][4][5][6][7][8] The time course of FFP dictates reconstructive options. Use of native facial musculature for dynamic reanimation is contraindicated when the time from injury to reinnervation exceeds 18 to 24 months, owing to fibrosis and loss of electrical activity in chronically denervated facial muscle.…”