Objectives: Loss of smile and inability of eye closure are coexisting features of complete facial paralysis. Both reconstructions are commonly performed separately. In this study, we present an option of using one gracilis functioning free muscle transplantation for the simultaneous and combined reconstruction of smile and lagophthalmos.

Methods: A retrospective review was performed from an institutional database for facial paralysis. The gracilis for functioning free muscle transplantation was split into three portions, namely the upper gracilis was used for smile, the lower gracilis was used for eye closure, and the central gracilis was used for maintenance of vasculature. Intramuscular dissection of the obturator nerve was performed to create two motor neurotizers. The design was to adopt one muscle with two functioning free muscle transplantations for two functions, i.e., smile and eye closure.

Results: A total of five patients with unilaterally complete facial palsy, which resulted from acoustic neuroma resection, were enrolled. All patients had a follow-up of at least 1 year. The smile score improved from 0 (no tooth visible) up to 3+ (at least three teeth visible). The eye closure improved from 9-11 mm to 0-6 mm in interpalpebral distance.

Conclusions: Based on the technique of intramuscular nerve dissection and division, one gracilis functioning free muscle transplantation can be split into upper and lower gracilis for two functioning free muscle transplantations with the preservation of the central part of the vasculature. The surgical strategy proves that it is theoretically and clinically applicable for simultaneous and combined reconstruction of smile and eye closure with only one nutrient vessel anastomosis.

Level of Evidence: IV