Double innervation (facial/masseter) on the gracilis flap, in the middle face reanimation in the management of facial paralysis: a new concept

Introduction: The facial paralysis is a non-rare condition that has very disabling functional, morphological and psychological repercussions. The current gold standard in facial reanimation is revascularized re-innervated muscle transfers. Materials and methods: In this paper, we report the results of a new method using the gracilis flap with a double innervation on the masseter motor nerve and the controlateral facial nerve via a sural graft in a single stage intervention, on a series of six patients. Results: No failure was observed. The average delay of a voluntary contraction was 3.8. months, and 7.2. months for a spontaneous one. Three of the six patients had "excellent" results according to the Terzis and Noah classification, two were classified as "good" and one "average" Discussion: A choice is to be made between a method advocating a natural and spontaneous dynamicity (controlateral facial nerve stimulus) and a method focusing on the quality and quantity of contractions (ipsilateral trijeminal stimulus). In this new technique, we combine the two methods: a free gracilis transfer with a dual innervation on the healthy controlateral facial nerve via a sural graft, on one hand, and a second anastomosis on the ipsilateral masseter nerve, on the other hand. Conclusion: This new proposed method seems to be, according to our results, a reliable technique rallying voluntary contraction and emotional smile.