Gracilis Free Muscle Transfer Surgery for Facial Paralysis

Stanford Facial Nerve Center


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Originally described in the 1970’s, the gracilis muscle of the thigh may be used for facial reanimation.1

In general, the Gracilis free muscle transfer is used when the duration of facial paralysis is longer than 2 years.  In these cases, the facial muscles can no longer receive new nerve input. Therefore, a new muscle must be inserted into the face in order to restore smile and facial tone (symmetry at rest).

In this procedure, the gracilis muscle is removed from the inner thigh through a skin incision, as shown in Figure 1.  Importantly, the nerve and blood vessels that supply the gracilis muscle are carefully removed along with the muscle.  These nerves and blood vessels will then be reconnected to nerves and vessels in the face and/or neck, as shown in Figure 2.  Commonly, the nerve to the gracilis is attached to the masseteric nerve, resulting in smile (gracilis contraction) when the patient bites down.  Retraining and rehabilitation are then required to practice the use of this new movement, which is called “bite to smile.”  A patient who underwent Gracilis free muscle transfer by Dr. Pepper is shown in Figure 3 and the Video. Alternatively, the Gracilis muscle can be connected to a nerve graft that is taken from the leg (the sural nerve).

[1] Harii KI, Ohmori KI, Torii SH. Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plastic and reconstructive surgery. 1976 Feb;57(2):133-43.


Figure 1: Surgical incisions and illustrated anatomy of the Gracilis free muscle transfer. The incision on the inner thigh and the removal of the gracilis muscle with its attached nerve and blood vessels is illustrated.

Figure 2: Illustration of Gracilis free muscle transfer once reattached in the face.  Note that the muscle must be attached under the skin to the muscles of the corner of the mouth and to the tissue in the temple region.  Note also that the muscle has a nerve and blood vessels that must be reattached to donor nerve and vessels in the face.

Figure 3: Gracilis free muscle transfer performed by Dr. Pepper.

Is This Procedure for Me?

The Gracilis free muscle transfer for facial paralysis can be used at any time after facial paralysis occurs.  Typically, patients who select a Gracilis free muscle transfer have a duration of facial paralysis that is two years or more.  This procedure can be used in both cases of facial paralysis (no movement) and in cases of facial paresis (partial movement).

Patients must also have a masseteric nerve that works normally.  In some cases of tumor or trauma, the masseteric nerve or the trigeminal nerve (this is the nerve that feeds into the masseteric nerve) may not work normally.

Patients usually stay in the hospital for 4-5 days following this procedure.  Swelling typically softens over the first several months after surgery.  Noticeable facial movement from this procedure usually takes about 6 months to show, and the movement will typically get stronger over the first year after surgery.  All patients must undergo rehabilitation exercises after surgery, as learning to “bite to smile” requires practice.  We are fortunate to have world-class facial rehabilitation treatment to assist with this at the Stanford Facial Nerve Center. Lastly, this surgery can cause some pain and discomfort in the leg during recovery from surgery.  This typically subsides several months after the procedure.