If you have permanent paralysis of the muscles that allow you to smile, you may be offered a procedure to recreate the smile. The gracilis muscle is one of the muscles that can be used to do this.
This webpage explains more about the procedure and what to expect, including the benefits, risks, any alternatives and what you can expect when you come to hospital.
If you have any further questions, please speak to the doctor or nurse looking after you.
What is a gracilis muscle re-animation?
In order to restore smile to the face we need to replace the nerve that is not functioning and provide muscles to create movement.
One of the nerves that can be used is the facial nerve from the opposite side (we have two facial nerves, one on each side of the face). The working nerve is used to communicate with the affected side via a cross facial nerve graft, this is a surgical procedure which essentially acts like an extension lead.
Another nerve that can be used is a motor nerve on the affected side of the face. A motor nerve transmits instructions to muscles when we make a voluntary movement, such as chewing. Commonly used are the facial nerve and masseteric nerve which are joined together. The masseteric nerve is normally used to activate the chewing muscles but can be used to provide a nerve supply to the paralysed facial nerve and thereby help to restore the smile.
When patients have experienced facial paralysis for more than two years, the native facial muscles will often have become non-functional, this is because there has been insufficient nerve supply to the muscle to create movement. The free gracilis transfer uses a muscle from the thigh to act as a replacement motor, which will create movement when connected to the nerve to activate it.
It takes a minimum of 3 months from the operation to start to see movement in the muscle as small twitches, which continues to improve for up to two years.
Who is a suitable candidate?
This procedure relies on the growth of nerve fibres to re-innervate a muscle, as such the ideal candidates are younger patients who have better nerve growth potential, but there is no specific age cut off. It is used for those patients who specifically lack a smile and have an established facial palsy of longer than two years by which point any muscles in the face are likely to have wasted away to the point that new muscle needs to be introduced.
What are the risks?
In general the risks of any operation relate both to the anaesthetic and to the operation itself. The operation is performed under general anaesthetic, which means that you are asleep throughout. Your anaesthetist will go through the risks relating to the general anaesthetic with you before the operation.
Before suggesting the operation, your surgeon will have considered that the benefits of the procedure outweigh any disadvantages. However, in order to make an informed decision and give your consent, you need to know and be aware of the possible side effects, risks and complications. These common issues include:
Wound healing problems: Sometimes the skin near the edge of the scar can be a bit “battered and bruised” and may not heal as well as usual. Sometimes blisters or deep red colouration can occur; In spite of appearances, it will heal but takes a little longer than usual.
Asymmetry: No matter what, the reconstructed smile will not be exactly the same as the other side. This is because one muscle is being used to perform the function of a number of tiny muscles in the face. A great deal of time before and during surgery is used to make the reconstruction match the smile of the other side as best as possible, but it is important that you are aware that it will not be exactly the same as the other side.
Bulkiness: Because we are placing the muscle in the face, the extra volume can make the face look a little fuller on that side. Every effort is made to minimise this but it can add to the impression of asymmetry.
Things that can happen:
Bleeding and Haematoma: After the operation in a small number of cases, some bleeding can occur, this may cause a pool of blood under the skin called a haematoma. In many cases, small amounts of bleeding can stop with pressure, but a large collection of blood or significant bleeding will need a return to theatre to stop the bleeding. Importantly, pressure from bleeding can build up around the area of microsurgery and cause problems that may damage the muscle so surgeons are very careful to watch for this problem.
Infection: the risk of infection is low and is generally less than 2-5%. In the vast majority of cases, infection will be resolved by a course of oral antibiotics. Occasionally, admission into hospital may be required and antibiotics will be given through a drip.
Muscle Transfer Failure: For whatever reason, the blood vessels may stop working, cutting the blood supply off to the muscle. This is estimated to occur in 2-5% of cases (1 in 50 to a 1 in 20 chance). Should this occur due to bleeding the patient will be immediately returned to theatre to deal with the problem. If this is more insidious, we may not know it has happened until we find that the muscle does not work as it should more than three months after surgery. In this instance, we will have a discussion on how to proceed. You may wish for another muscle transplant to be performed.
Occasionally, some of the stitches break and the muscle loses its attachment and therefore doesn’t have an anchor to pull against. This will be manifest as an abnormal smile and may occur a while after the operation. If this happens, a smaller operation may be needed to reposition and re-secure the muscle.
Salivary leak: Near where we operate lies a salivary gland (the parotid gland) and the duct that carries its saliva into the mouth. As this is near where we operate there is the theoretical risk that this may be damaged and cause a leak of saliva under the skin of the cheek. This can be troublesome and even require a further surgery to deal with. Thankfully, damage here is very rare.
Are there any alternatives?
This is not a life-saving procedure and, therefore, the main alternative is to have no surgery at all. If you have decided that you would like surgery to improve your appearance and the function of your face, other alternatives do exist. Broadly speaking these can split into those that improve the symmetry of your face at rest but do not produce any movement (static procedures) and those that improve the position at rest and can produce movement of the face to express emotions (dynamic procedures). The gracilis muscle transfer is a dynamic procedure. The main advantages of static procedures are the shorter length of surgery and hospital stay, the ability to perform the surgery in one operation and the reduced risk of failure. Many options exist in both categories and your surgeon can discuss these with you.
How can I prepare for a gracilis muscle flap operation?
You will need to take time off work for the surgery. To begin with, you will be in hospital for around five days. After this, we would recommend that you take a further two weeks off work to recover. If your job involves heavy exertion, you should take a total of one month off work.
Any sports should be avoiding for 4-6 weeks and you should try to stop or cut down any smoking in the lead up to the operation and for the six weeks following surgery. Smoking will increase the risk of the muscle not working and the wound not healing.
With this being an operation performed under general anaesthetic, you will need to avoid any food in the six hours before surgery. You may drink water up until two hours before surgery.
Prior to coming in for surgery you will most likely be seen in a pre-assessment clinic. In this clinic they will go through any other medical problems that you have and list any medications that you take. Advice will be given on which medications to stop before surgery.
What does the surgery involve?
This operation involves the transfer of the gracilis muscle from the upper inner thigh to the affected side of the face; this is then connected to blood vessels using microsurgery to keep the muscle alive and the nerve in order to activate the muscle upon smiling. The incision is around 7-8cm long on the upper inner thigh, which allows the surgeon to remove part of the gracilis muscle together with the controlling nerve and the blood vessels that supply it. Removing part of the muscle does not appear to affect any functions of the leg during regular activities.
In order to place the muscle on the affected side, an incision is made to gain access to the corner of the mouth and the blood vessels that will be used to keep the muscle alive. It begins in the temple hidden in the hair and runs downwards, immediately in front of the ear, then curves behind the ear and then down onto the neck. This is similar to a facelift incision and is mostly well hidden once healed.
Once the muscle is ready, it is stitched to the corner of the mouth from the inside so that when it contracts it pulls the mouth into a smile. The blood vessels and nerve of the muscle are connected to those in the face using microsurgery. The operation requires a general anaesthetic and takes around 6-8 hours with a post-operative hospital stay of one week. The patient will typically be admitted on the day of surgery having had a pre-assessment appointment previously. A number of drawings will be made on the face and a careful assessment of the direction of smile is performed to get the best match of smile to the unaffected side. After the operation, the patient is likely to stay in hospital for around a week for monitoring and until they are comfortable enough to go home.
Will I feel any pain or discomfort?
After the surgery it is likely that you will feel some pain, although you will be given a number of different painkillers to reduce and ideally remove this pain. The pain is normally around the wounds themselves and should begin to subside in the first 72 hours after surgery. By the time you go home your pain should be low enough to be controlled by paracetamol alone.
What happens after the surgery?
After the operation, the patient will be closely monitored and there will usually be a small plastic tube (drain) behind the ear to allow any fluid build up to drain away. The face will swell up on the operated side and may have some bruising as if they have been bumped in the face. This is normal and will get worse over the first 48 hours after surgery and then reduce over the following week. The small amount of residual swelling on that side of the face will subsequently resolve over the next few months. Initially the swelling may make it a little difficult to eat and speak, much like after a visit to the dentist. Sleeping propped up on a number of pillows at night will help the swelling subside more quickly and in turn reduce any pain caused by swelling. In terms of pain, upon discharge the patient should require little more than some paracetamol regularly for a week.
A soft diet is used for a week post-operatively. If an incision inside the mouth has been used a bottle of mouthwash will often be provided and the patient asked to rinse their mouth out with water after each meal to stop food collecting around the incision.
The patient will have a scar on the affected side of the face where we make the incision to insert the muscle. The scars will remain red for over a year (up to two years) and may go through a phase of being rather lumpy. A period of scar massage once the wound has healed may be required. In rare instances, a thickened keloid scar can form and this is a difficult problem to treat that may require some non-surgical therapies. Thankfully, it is very rare. The scar on the inside of the thigh typically heals very well but may also be red for some time.
It will take three months or so for the muscle to begin to show evidence of working. Once it does, a course of physiotherapy will be instituted to “exercise” the muscle. Exercises will often be performed in the mirror to get the patient to see the movement when smiling and to coordinate the activity.
Will I have a follow-up appointment?
Your surgeon will make arrangements to see you around 1 week after leaving hospital to check that all is well with the wounds. They will also arrange an appointment to see you in their outpatient clinic at which point you will be given guidance on the exercises you should begin to practice to help the muscle start to work in the correct way. This will be done with the help of a physiotherapist experienced in managing patients with your condition.
What should I do if I have any concerns?
If, following the surgery, you have any concerns you should contact your surgical team or the ward that you were admitted to during your stay. They will then be able to give you further advice on what to do and whether they need to see you back at the hospital or not.
Last reviewed: 13-08-2019 || Next review due: 13-08-2022