Spinal accessory nerve-innervated gracilis (XI-Gracilis) for facial reanimation: Chang Gung experience

Background: Truly facial paralysis and postparalysis facial synkinesis both cause severe functional and aesthetic deficits. Gracilis functioning free muscle transplantation (FFMT) is our preferred muscle for facial reanimation. Three motor neurotizers: cross-face nerve graft (CFNG), spinal accessory (XI), and masseteric nerves (V3) are our preferred motor neurotizers for different indications. This chapter will focus on XI-gracilis. Methods: Between 2000 and 2017, 60 patients (out of 392; 17%) with 68 FFMT were treated by XI-gracilis as one-stage procedure for facial reanimation. Indications included bilateral or unilateral Möbius syndrome, chronic facial paralysis, severe type of postparalysis facial synkinesis, redo cases with failed primary CFNG-gracilis, and patient preference. Postoperative smile training was required to achieve spontaneity. Smile excursion score, cortical adaptation recovery stage, patient's questionnaire, Hadlock's lip excursion scale, and Terzis's evaluation systems were utilized for outcome comparison. Results: For XI-gracilis for facial reanimation, mean smile excursion score improved from 0.3 preoperatively to 3.8 in the last follow-up (≥3 years) postoperatively. Eighty-three percent of patients were able to perform at least stage III (independent) movement, and near half achieved stage IV or V spontaneous smile. Ninety percent of patients had a mean satisfaction score ≥3 out of 5. Hadlock's SMILE scale was located between results of CFNG- and V3-gracilis groups. Terzis's Functional and Aesthetic Grading showed the best in results. Conclusions: The classic two-stage CFNG-gracilis is still our first choice for facial reanimation. However, comparing the benefits and pitfalls, the XI-gracilis as a one-stage procedure has proven to be a good alternative.