I read the second article below first. I was struck by the opening paragraphs of Daniel Alam, MD’s commentary which note the importance of smiling in human communication and how it is often taken for granted EXCEPT by those who have lost the ability to smile.
This is far from the case for patients who have lost the ability to smile. Patients who have endured facial paralyses (even in the transient cases that occur in certain idiopathic facial nerve palsies, ie, Bell palsy) understand the true psychological effects of this disability. …...
… Although this report is another well-designed clinical series of a well-established surgical technique, the true significance of this work extends far beyond the patients presented. ….This group, more than any other in facial plastic surgery, has made a concerted effort to quantify (to measure and validate) the outcomes they report. …
While myriad muscles have been transferred into the face to restore the smile, most large series describe the use of the gracilis muscle, the latissimus dorsi muscle, or the pectorals minor. Of these, the gracilis muscle is the most widely used, based on predictable pedicle anatomy, an acceptable donor deficit and scar, and favorable muscle microarchitectural features resulting in fast and robust excursion when activated.
There was only one muscle failure in the series. It resulted from an arterial thrombosis.The mean commissure excursion improvement was 8.8 mm ± 5 mm (Figure 4), commensurate with the findings in other facial reanimation series. When subdivided into those driven by a cross-face nerve graft vs those driven by the masseteric branch of the trigeminal nerve, the latter provided more excursion on average, as expected.
In conclusion, free gracilis transfer for smile reanimation in children carries an acceptable failure rate, significantly improves smiling, and seems to improve QOL with respect to facial function. It should be a cornerstone intervention in the appropriately counseled patient and family. Because it carries a lower failure rate than a similar cohort of adult patients, there is no need to wait until patients reach adulthood to offer dynamic reanimation. Early facial reanimation provides the advantage of permitting children to express themselves nonverbally through smiling and may in fact lead to fewer negative social consequences as they interact with peers.