What is gracilis free flap surgery?
A gracilis free flap or gracilis free tissue transfer is a muscle transplant surgery, where a muscle from the inner thigh called the gracilis is used to correct paralyzed smile muscles. Using the gracilis muscle is desirable as it only leaves a small hidden scar in the inner thigh. Using the gracilis muscle does not affect leg function long term, because there are multiple muscles in the inner thigh responsible for a similar function. Therefore, gracilis is the most popular free flap choice for facial paralysis reanimation.
Once the gracilis muscle is taken from inner thigh, it is shaped to replicate your smile muscles prior to transplantation into the face. Because the gracilis muscle needs a good blood supply, the muscle is harvested with its own artery, vein and nerve.
Bringing the nerve that moves the gracilis muscle (obturator nerve) is very important to the success of the procedure. Connecting the obturator nerve to the nerves in the face lets patients use it as a smile muscle. It is usually connected to a cross-face nerve graft (CFNG) or a combination of CFNG and nerve to masseter performed 6-12 month prior. Similarly, the vessels between the gracilis free flap and the arteries and veins in the neck are connected under a microscope in order to establish blood flow to the transplant and therefore keep the muscle alive.
The gracilis muscle flap is monitored in the hospital for 7-14 days after surgery to make sure the reconnected blood vessels maintain blood flow. Patients regain movement in 8-12 months after gracilis free flap surgery, because that’s how long it takes for nerves to regrow. Our expert facial physiotherapist will help you train the gracilis transplant once it begins to move, therefore helping you strengthen the smile.
When do I need gracilis free flap surgery?
Patients with flaccid facial paralysis, for more than 2 years may no longer have functional facial muscles, because the muscles waste away if they are not used. In rare cases, smile muscles may be removed during cancer surgery. In those circumstances, patients need both a nerve transplant and a gracilis free flap in order to achieve the most natural movement on the paralyzed side.
Usually nerve transplant or cross-face graft surgery is performed first, allowing 6-12 months for the nerves to grow across the face. Your surgeon will test the readiness of the nerve for a muscle transplant by tapping on the skin in a location where it was placed, which is called the “Tinel sign”. Tapping the nerve will produce pins and needles sensation signaling that the nerve cells have grown to the tapped end.
As a second stage surgery, the gracilis free flap is brought from the inner thigh and shaped into a smile muscle (called double paddle gracilis) in order to simulate the most natural smile. A gracilis free flap essentially replaces wasted smile muscles due to long standing flaccid facial paralysis. A free flap means that the muscle is brought up with its own artery, vein and nerve like a transplant. It is then connected to the cross-face nerve graft performed 6-12 month prior and the arteries and veins in the neck under a microscope. The muscle transplant then slowly learns movement from the nerve transplant over additional 8-12 months
How do I prepare for gracilis free flap surgery?
Prior to gracilis free flap surgery, your surgeon may get an electromyography (EMG) study of your facial muscles to determine if you are a candidate for the gracilis free flap or if nerve transplant alone would be sufficient.
Your surgeon will discuss the procedure with you including risks, benefits and alternative treatments. They will review your medications including herbal and over-the-counter drugs and supplements. Many herbal products and pain relievers make it harder for you blood to clot and should be discontinued before surgery. You will sign informed consents and get your instructions for before and after surgery.
You will see your own personal physician for a medical clearance to make sure they feel it is safe for you to have surgery. Your physician may order laboratory blood tests, an EKG or a chest X-ray. You need to stop smoking as this delays healing. You should have nothing to eat or drink after midnight before your procedure. You will be told when to arrive at the surgery center before your surgery. You are signed in, change into a gown, given an IV, and talk to the nurse and anesthesiologist. You will then talk to your surgeon before you get any medication at the hospital so you can ask questions.
What happens during gracilis free flap surgery?
You are taken into the operating room, lie down on your back, and the anesthesiologist will put you to sleep with a breathing tube to make sure your airway is safe. The area to be operated on is sterilely prepared with a cleaning solution and drapes. Facial nerve monitoring systems are connected to carefully monitor the facial nerve during the procedure. This system is able to monitor the transplanted nerves and it can also help in obturator nerve identification in the inner thigh.
The incision is made in natural facial grooves, similar to a facelift incision, but it continues into the neck in a natural skin crease. Extension into the neck is necessary in gracilis free flap surgery because the muscle vessels are connected to neck vessels in order to ensure the transplanted muscle has blood supply. The face is prepared for muscle transplant and by lifting the skin to the corner of the mouth. Preoperative photos and videos are used in the operating room in as a guide for smile creation. Function of the normal side of the face determines how the surgeon insets the gracilis muscle. Sutures are placed in the corner of the mouth and customized to recreate a smile as close as possible to the preoperative photos and videos. The neck vessels are identified and prepared for the transplant under the microscope.
The leg is also sterilely prepared and an incision is made in the inner thigh similar to a thigh lift surgery. The gracilis muscle is identified along with its artery, vein and the obturator nerve. Two thirds of the muscle are usually taken for smile muscle creation. The muscle is shaped into two strips (double paddle) connected by arteries, veins and nerves. The two strips allow for the most natural smile creation. Each end of the cut muscle is carefully sutured to make a tendon so that it can be properly sutured in the face. The gracilis muscle is then disconnected from its blood supply in the leg and brought to the face. The thigh donor site is closed, a surgical drain placed, and a special wrap protects the thigh.
The gracilis is then inset into the corner of the mouth and upper face to recreate the muscles of the smile. Then, using a high-powered microscope the transplanted muscle’s artery is connected to a neck artery, and the vein is connected with a vein connector to a neck vein. The nerves are then reattached. Special nerve sheaths are placed on suture connections in order to improve and expedite nerve growth. The nerves do not function right away, but the surgery creates new pathways or conduits for nerves to grow and therefore allow for the creation of movement on the paralyzed side of the face. The face and neck incision are closed with surgical drains.
What is the follow-up for gracilis free flap surgery?
After gracilis free flap surgery you will be admitted to hospital for 7-14 days. This allows your surgeon to monitor the transplant closely, in order to make sure no problems arise with the blood flow. You will be started on aspirin during your hospital stay to help reduced the chance of the graft clotting. You will continue to take aspirin for 1 month after surgery. In the hospital, your transplant will be monitored with an ultrasound probe multiple times per day and to ensure that there is adequate blood flow through the blood vessels. If you have clotting in the vessels or graft during healing, an additional surgery may be required to re-establish blood flow to muscle.
You may receive either oral or intravenous pain medicine depending on your level of discomfort. Intravenous antibiotics are given to provide prophylaxis against infection. The donor thigh will be wrapped in special bandage to prevent bleeding under the skin. There will be surgical drains under the skin in the face hidden in your hairline as well as at the thigh donor location. Surgical drains will generally come out on day 3-7 after surgery, depending on the recovery process.
After discharge from the hospital, keeping your head and donor leg elevated will decrease pressure on the incisions. You should take it easy for at least two weeks and your doctor will let you know what level of activity you can resume. Call your doctor if you have increasing redness of the incision, fever, bleeding, pus, drainage, the incision opens or you have worsening pain. Also, let your doctor know if you have any other concerns. You will see your surgeon regularly after discharge from the hospital. You usually can be performing normal activities within two weeks of surgery.
What are the risks of gracilis free flap surgery?
The risk of any free tissue transplant surgery is free flap loss due to occlusion of blood vessels by a clot. The probability of complete loss of transplant is 0.5-1%. If there are signs of compromise of the blood flow during your hospital stay, you may need to return to the operating room for a procedure to re-establish blood flow.
The general risks of facial surgery include scarring, bleeding, bruising, infection, injury to the movement nerves on the donor sites, numbness, the need for additional surgery, chronic pain, numbness, temporary or permanent loss of facial movement on the functional side risks of general anesthesia. Preparing for surgery and following your doctor’s instructions are useful to help minimize risks.
The Surgeons of Norelle Health are highly trained and skilled in the diagnosis, management, and treatment of facial paralysis. Dr. Araslanova can provide the optimal treatment for facial paralysis in your situation. The field of facial paralysis is growing rapidly and our surgeons are at the forefront of research and most modern surgical treatment options. As out-of-network providers, we will check your benefits for you and let you know if there are costs are so there are no surprises. We use an individualized treatment plan for your concerns to provide a personalized holistic plan of care. If you would like assistance, please feel free to contact us.