Treatment of Facial Paralysis: Gracilis Free Flap versus Temporalis Tendon Transfer

Abstract

Introduction: Facial paralysis causes functional and aesthetic deficits. This review compares two dynamic reanimation techniques: gracilis free flap (cross-facial or masseteric nerve) versus temporalis tendon transfer.

Methods: A systematic review of studies reporting outcomes of smile reconstruction in unilateral facial paralysis. Inclusion: adults with chronic (>12 months) facial paralysis. Outcomes: smile excursion, symmetry (emotion), and patient-reported facial function.

Results: Nineteen studies (n=578 patients) were included. Gracilis flap achieved median smile excursion of 12 mm versus 8 mm for temporalis transfer. Symmetry at repose was similar. Emotion-driven smile (spontaneity) was better with cross-facial nerve graft (60% spontaneous) versus masseteric-driven (10% spontaneous). Temporalis transfer allowed earlier return of function (weeks versus 6-12 months). Donor site morbidity: leg weakness (gracilis) versus cheek hollowing (temporalis).

Discussion: Gracilis flap offers more excursion and potential spontaneity but requires longer recovery and microsurgery. Temporalis transfer is simpler and faster but produces a masseteric (bite-driven) smile.

Conclusions: Gracilis flap is preferred for younger, motivated patients wanting spontaneity. Temporalis transfer is suitable for older patients or when microsurgery is unavailable.