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Spinal Accessory Nerve-Innervated Gracilis (XI-Gracilis) for Facial Reanimation: Chang Gung Experience

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Facial Palsy

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Abstract

Background: Truly facial paralysis and postparalysis facial synkinesis both cause severe functional and aesthetic deficits. Gracilis functioning free muscle transplantation (FFMT) is our preferred muscle for facial reanimation. Three motor neurotizers: cross-face nerve graft (CFNG), spinal accessory (XI), and masseteric nerves (V3) are our preferred motor neurotizers for different indications. This chapter will focus on XI-gracilis.

Methods: Between 2000 and 2017, 60 patients (out of 392; 17%) with 68 FFMT were treated by XI-gracilis as one-stage procedure for facial reanimation. Indications included bilateral or unilateral Möbius syndrome, chronic facial paralysis, severe type of postparalysis facial synkinesis, redo cases with failed primary CFNG-gracilis, and patient preference. Postoperative smile training was required to achieve spontaneity. Smile excursion score, cortical adaptation recovery stage, patient’s questionnaire, Hadlock’s lip excursion scale, and Terzis’s evaluation systems were utilized for outcome comparison.

Results: For XI-gracilis for facial reanimation, mean smile excursion score improved from 0.3 preoperatively to 3.8 in the last follow-up (≥3 years) postoperatively. Eighty-three percent of patients were able to perform at least stage III (independent) movement, and near half achieved stage IV or V spontaneous smile. Ninety percent of patients had a mean satisfaction score ≥3 out of 5. Hadlock’s SMILE scale was located between results of CFNG- and V3-gracilis groups. Terzis’s Functional and Aesthetic Grading showed the best in results.

Conclusions: The classic two-stage CFNG-gracilis is still our first choice for facial reanimation. However, comparing the benefits and pitfalls, the XI-gracilis as a one-stage procedure has proven to be a good alternative.

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Authors and Affiliations

  1. The Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei-Linkou, Taiwan

    David Chwei-Chin Chuang

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  1. David Chwei-Chin Chuang
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Editor information

Editors and Affiliations

  1. Plastic and Reconstructive Surgery, Hospital of Divine Savior (Krankenhaus Goettlicher Heiland), Sigmund Freud University, TZOU MEDICAL, Vienna, Austria

    Chieh-Han John Tzou

  2. Department of Plastic and Maxillofacial Surgery and Department of Surgical Sciences, Uppsala University Hospital, Uppsala University, Uppsala, Sweden

    Andrés Rodríguez-Lorenzo

1 Electronic Supplementary Materials

A 20Y/O young male had right complete Bell’s palsy for 4 years. One year after XI-gracilis for facial reanimation, he shows “Smile Excursion score” from 0 to 4, “Cortical staging” from I to V, and Satisfaction score: 5; Lip excursion strength: Cornea: 15.4, Paralyzed X: 47, Paralyzed Y: 31.9, Paralyzed Z: 56.80, Standardized Pre-op Z: 25.22, Standardized Postop Z: 42.05, Difference: 16.83 mm; and Terzis score is excellent (WMV 34915 kb)

A 25Y/O young male had right postparalysis facial synkinesis type III due to Bell’s palsy for 5 years (WMV 10834 kb)

The patient in Video 15.2 received extensive myectomy and neurectomy and reconstructed by XI-gracilis. The video showed excellent results of 2.5 years after reconstruction: “Smile Excursion score” from 0 to 4; “Cortical staging” from I to IV; Satisfaction score: 5; Hadlock’s lip excursion score: Cornea: 18.1, Paralyzed X: 57, Paralyzed Y: 36.1, Paralyzed Z: 67.47, Standardized Pre-op Z: 42.49, Standardized Postop Z: 32.21, Difference: 11.28 mm; and Terzis score is excellent (WMV 6894 kb)

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Chuang, D.CC. (2021). Spinal Accessory Nerve-Innervated Gracilis (XI-Gracilis) for Facial Reanimation: Chang Gung Experience. In: Tzou, CH.J., Rodríguez-Lorenzo, A. (eds) Facial Palsy. Springer, Cham. https://doi.org/10.1007/978-3-030-50784-8_15

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  • DOI: https://doi.org/10.1007/978-3-030-50784-8_15

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-50783-1

  • Online ISBN: 978-3-030-50784-8

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