Multivector gracilis muscle transfer for smile reanimation in long-standing facial paralysis: Simultaneous upper and lower lip construction.

BACKGROUND

Traditional facial reanimation with gracilis muscle transfer effectively restores oral commissure excursion but often fails to correct lower lip asymmetry, resulting in compromised full-dental smiles and perioral dysfunction. This study evaluated a multivector gracilis transfer designed to simultaneously reanimate both the upper and lower lips.

METHODS

We retrospectively analyzed 29 patients with long-standing unilateral facial paralysis who underwent multivector gracilis free muscle transfer between 2020 and 2024. The gracilis was tailored into a forked configuration, with slips anchored to the oral commissure, upper lip, and lower lip. Objective outcomes were quantified using Emotrics software. Smile symmetry and muscle function were evaluated with the Terzis and Noah grading scale. Patient-reported quality of life was assessed using the Facial Clinimetric Evaluation (FaCE) scale.

RESULTS

The mean follow-up was 1.76 ± 0.95 years. All patients demonstrated significant improvements in perioral symmetry at rest and during both closed- and open-mouth smiling. The dental show asymmetry between affected and unaffected sides was significantly reduced. The mean Terzis and Noah score increased from 1.07 ± 0.26 to 3.83 ± 0.60, and overall FaCE scores improved from 41.7 (IQR 34.6-48.8) to 61.7 (IQR 57.5-70.4). Complications included one hematoma and three flap bulkiness

CONCLUSION

This multivector forked gracilis design enables one-stage reanimation of both the upper and lower lips, improving functional and aesthetic outcomes in dynamic smile restoration.