Functioning free gracilis myocutaneous flap transfer provides a reliable single-stage facial reconstruction and reanimation following tumor ablation.

BACKGROUND: Ablative orofacial defects incorporating mimetic facial musculature/nerve cause hemifacial expressive dysfunction and considerable morbidity but are rarely reanimated immediately using free functioning gracilis myocutaneous flaps.

METHODS: Disrupted buccal branches provided a recipient facial nerve for 24 gracilis reinnervations. An additional 15 free flaps were used for extensive composite defects. Smile outcome was graded according to Terzis' criteria after 2 years of recurrence-free follow-up. The effects of postoperative radiotherapy, integrity of the oral commissure, and double free flaps were compared.

RESULTS: Eighteen patients completed 2 years' recurrence-free follow-up; average smile outcome was Terzis grade 4 (mean, 3.8). Resection/reconstruction of the modiolus (five of 18 patients) tended to diminish outcome (Terzis grade 3, mean, 3.0; median, 3; versus Terzis grade 4, mean, 4.1; median, 5) compared with two free flaps performed simultaneously(mean, 3.56 versus 4.14; median, 3 versus 5). Postoperative radiotherapy (eight of 18 patients) had a more modest effect on outcome (Terzis grade 3, mean, 3.3; Terzis grade 4, mean, 4.1; median, 3 versus 5).

CONCLUSION: Reconstruction of oncologic defects including expressive facial musculature/nerve with gracilis free functioning muscle transfer can restore oral continence and facial expression primarily.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.