Correction of Lateralization of the Perioral Insertion of Gracilis Muscle in Facial Reanimation in Children: A Report of Two Cases.

Facial palsy in pediatric patients can lead to severe functional impairments and psychosocial challenges. Free gracilis muscle transfer (FGMT) is to date the gold standard for dynamic facial reanimation, but suboptimal aesthetic outcomes (SAO), due to malpositioning of the nasolabial fold, still represent a challenge to the surgeons. Especially, craniolateral displacement of the medial insertion of the gracilis muscle at the nasolabial fold represents a true challenge. The purpose of these two case reports is to propose a novel technique for the medialization of the perioral insertion of the gracilis muscle using fascia lata slings in pediatric patients, which might be useful to the reconstructive surgeon in dealing with this challenging complication. We present the cases of two male pediatric patients with complete unilateral facial palsy; a 7-year-old affected by congenital, complete, right-sided and an 11-year-old post-oncological complete right-sided facial palsy. Both patients underwent FGMT and suffered from craniolateral displacement of the nasolabial fold postoperatively after different time spans. (3- and 5-years post FGMT). To correct this SAO, we performed our herein proposed technique for secondary repositioning of the gracilis muscle to correct the malpositioned nasolabial fold. Pre- and postoperative outcomes were evaluated using photography, videography, and the Terzis Functional and Aesthetic Grading System by seven independent investigators. These independent investigators found that the overall Terzis score increased from poor to moderate through FGMT and sustained another relevant increase from moderate to good through our proposed medialization technique. Moreover, within our follow-up period of 17 months, we observed no major or minor complications. The take home message of this report is that our technique of medialization of the gracilis muscle insertion using fascia lata slings represents an effective and low-risk approach for correcting a lateralized nasolabial fold. In these challenging cases, this novel technique can offer a surgical alternative which can improve both functional and aesthetic outcomes in pediatric facial reanimation. However, further investigation with larger cohorts is necessary to validate our surgical approach.