Evaluating Dynamic Smile Outcomes of Free Gracilis Muscle Transfer in Pediatric Facial Palsy Using Image-Based Analysis.

Journal: Journal of reconstructive microsurgery
Published Date: Jul 30, 2025

Abstract

BACKGROUND: Facial nerve palsy in children leads to significant functional impairment and facial asymmetry. While free gracilis muscle transfer (FGMT) is a cornerstone technique for smile reanimation in both pediatric and adult patients, its evaluation has mainly focused on the single metric of commissure excursion. This study seeks to evaluate the effectiveness of FGMT in restoring dynamic smiles in pediatric patients with facial palsy using image analysis. METHODS: A retrospective review was conducted in children who underwent FGMT for facial palsy at a major children's hospital between 2007 and 2020. Data collection included pre- and postoperative chart reviews and image analysis. Anthropometric measurements were obtained using a machine learning-based smile analysis software. Primary outcomes included commissure excursion, commissure angle, dental show, and smile symmetry. Statistical analysis was performed using the Wilcoxon signed-rank test. RESULTS: A total of 31 patients with an average age of 10 years underwent FGMT for smile reanimation during the study period. The most common diagnosis was Moebius syndrome (48%). Donor nerves for gracilis neurotization included 18 ipsilateral trigeminal nerves (58.1%) and 12 contralateral facial nerves via cross-face sural nerve grafts (38.7%). Overall, 84% of patients demonstrated active gracilis contraction within a mean of 2.5 years postoperative follow-up. Commissure excursion increased by 9.7 mm at 1 year (p < 0.05), and symmetry significantly improved for commissure height, commissure excursion, upper lip height, and smile angle. There were no significant improvements in dental show, commissure angle, symmetry of dental show, and lower lip height. Furthermore, only 16% of patients demonstrated clinically symmetric smiles within the follow-up period. CONCLUSION: While FGMT effectively restores commissure excursion in pediatric patients with facial palsy, achieving multidimensional smile reanimation remains a challenge. New techniques in multi-vector free tissue transfer may help optimize FGMT outcomes in pediatric patients.

Authors

  • Melanie Bakovic
    Division of Plastic and Reconstructive Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • Asli Pekcan
    Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
  • Raina K Patel
    Division of Plastic & Reconstructive Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • Valeria Mejia
    Plastic and Reconstructive Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • Maya Lazar
    Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • Sally Danto
    Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • William Magee
    Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • Jessica A Lee
    Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • Mark M Urata
    Division of Plastic & Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States.
  • Jeffrey A Hammoudeh
    Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States.

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