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

Melanie Bakovic; Asli Pekcan; Raina K. Patel; Valeria Mejia; Maya Lazar; Sally Danto; William Magee; Jessica A. Lee; Mark M. Urata; Jeffrey A. Hammoudeh

doi:10.1055/a-2671-9586

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg
DOI: 10.1055/a-2671-9586

Original Article

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

Melanie Bakovic

¹Division of Plastic and Reconstructive Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

²The George Washington University School of Medicine and Health Sciences, Washington, United States (Ringgold ID: RIN43989)

,

Asli Pekcan

³Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

⁴USC Keck School of Medicine, Los Angeles, United States (Ringgold ID: RIN12223)

,

Raina K. Patel

⁵Division of Plastic & Reconstructive Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

⁶Nova Southeastern University Dr Kiran C Patel College of Allopathic Medicine, Fort Lauderdale, United States (Ringgold ID: RIN503842)

,

Valeria Mejia

⁷Plastic and Reconstructive Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

⁸Plastic and Reconstructive Surgery, USC Keck School of Medicine, Los Angeles, United States (Ringgold ID: RIN12223)

,

Maya Lazar

⁹Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

,

Sally Danto

⁹Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

,

William Magee

⁹Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

,

Jessica A. Lee

⁹Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

,

Mark M. Urata

¹⁰Division of Plastic & Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

¹¹Division of Plastic and Reconstructive Surgery, USC Keck School of Medicine, Los Angeles, United States (Ringgold ID: RIN12223)

¹²Division of Oral and Maxillofacial Surgery, USC Keck School of Medicine, Los Angeles, United States (Ringgold ID: RIN12223)

¹³University of Southern California Herman Ostrow School of Dentistry, Los Angeles, United States (Ringgold ID: RIN43801)

,

Jeffrey A. Hammoudeh

⁹Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

¹Division of Plastic and Reconstructive Surgery, Children's Hospital Los Angeles, Los Angeles, United States (Ringgold ID: RIN5150)

¹²Division of Oral and Maxillofacial Surgery, USC Keck School of Medicine, Los Angeles, United States (Ringgold ID: RIN12223)

¹³University of Southern California Herman Ostrow School of Dentistry, Los Angeles, United States (Ringgold ID: RIN43801)

› Author Affiliations

Abstract

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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 post-operative 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 Wilcoxon sign-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 one 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, and 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.

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