{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T23:06:14Z","timestamp":1779231974968,"version":"3.51.4"},"reference-count":29,"publisher":"Georg Thieme Verlag KG","issue":"05","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Reconstr Microsurg"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Facial nerve palsy in children leads to significant functional impairment and facial asymmetry. While free gracilis muscle transfer (FGMT) is a cornerstone technique for smile reanimation in both pediatric and adult patients, its evaluation has mainly focused on the single metric of commissure excursion. This study seeks to evaluate the effectiveness of FGMT in restoring dynamic smiles in pediatric patients with facial palsy using image analysis.<\/jats:p>\n                  <jats:p>A retrospective review was conducted in children who underwent FGMT for facial palsy at a major children's hospital between 2007 and 2020. Data collection included pre- and postoperative chart reviews and image analysis. Anthropometric measurements were obtained using a machine learning-based smile analysis software. Primary outcomes included commissure excursion, commissure angle, dental show, and smile symmetry. Statistical analysis was performed using the Wilcoxon signed-rank test.<\/jats:p>\n                  <jats:p>A total of 31 patients with an average age of 10 years underwent FGMT for smile reanimation during the study period. The most common diagnosis was Moebius syndrome (48%). Donor nerves for gracilis neurotization included 18 ipsilateral trigeminal nerves (58.1%) and 12 contralateral facial nerves via cross-face sural nerve grafts (38.7%). Overall, 84% of patients demonstrated active gracilis contraction within a mean of 2.5 years postoperative follow-up. Commissure excursion increased by 9.7\u2009mm at 1 year (p\u2009&lt;\u20090.05), and symmetry significantly improved for commissure height, commissure excursion, upper lip height, and smile angle. There were no significant improvements in dental show, commissure angle, symmetry of dental show, and lower lip height. Furthermore, only 16% of patients demonstrated clinically symmetric smiles within the follow-up period.<\/jats:p>\n                  <jats:p>While FGMT effectively restores commissure excursion in pediatric patients with facial palsy, achieving multidimensional smile reanimation remains a challenge. New techniques in multi-vector free tissue transfer may help optimize FGMT outcomes in pediatric patients.<\/jats:p>","DOI":"10.1055\/a-2671-9586","type":"journal-article","created":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T22:56:50Z","timestamp":1753916210000},"page":"418-426","source":"Crossref","is-referenced-by-count":0,"title":["Evaluating Dynamic Smile Outcomes of Free Gracilis Muscle Transfer in Pediatric Facial Palsy Using Image-Based Analysis"],"prefix":"10.1055","volume":"42","author":[{"given":"Melanie","family":"Bakovic","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"},{"name":"The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Asli","family":"Pekcan","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"},{"name":"Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Raina","family":"Patel","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"},{"name":"Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, Florida, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Valeria","family":"Mejia","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"},{"name":"Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sally","family":"Danto","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maya","family":"Lazar","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"William P.","family":"Magee III","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jessica","family":"Lee","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mark A.","family":"Urata","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"},{"name":"Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California, United States"},{"name":"Division of Oral and Maxillofacial Surgery, Keck School of Medicine, Los Angeles, California, United States"},{"name":"Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jeffrey","family":"Hammoudeh","sequence":"additional","affiliation":[{"name":"Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States"},{"name":"Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California, United States"},{"name":"Division of Oral and Maxillofacial Surgery, Keck School of Medicine, Los Angeles, California, United States"},{"name":"Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"194","published-online":{"date-parts":[[2025,9,1]]},"reference":[{"issue":"02","key":"ref1","first-page":"273","article-title":"Acute facial nerve palsy in children: gold standard management","volume":"9","author":"D Wohrer","year":"2022","journal-title":"Children (Basel)"},{"issue":"11","key":"ref2","doi-asserted-by":"crossref","first-page":"2168","DOI":"10.1016\/j.jpedsurg.2011.06.036","article-title":"Surgical management of facial nerve paralysis in the pediatric population","volume":"46","author":"J S Barr","year":"2011","journal-title":"J Pediatr Surg"},{"issue":"07","key":"ref3","doi-asserted-by":"crossref","first-page":"1423","DOI":"10.1016\/j.bjps.2021.01.007","article-title":"Workhorse free functional muscle transfer techniques for smile reanimation in children with congenital facial palsy: case report and systematic review of the literature","volume":"74","author":"K Gasteratos","year":"2021","journal-title":"J Plast Reconstr Aesthet Surg"},{"issue":"01","key":"ref4","doi-asserted-by":"crossref","first-page":"1","DOI":"10.7181\/acfs.2023.00528","article-title":"Facial palsy reconstruction","volume":"25","author":"S H Woo","year":"2024","journal-title":"Arch Craniofac Surg"},{"issue":"16","key":"ref5","doi-asserted-by":"crossref","first-page":"4955","DOI":"10.3390\/jcm13164955","article-title":"Dynamic repair surgery for late-stage facial paralysis: advances in restoring movement and function","volume":"13","author":"Q Sun","year":"2024","journal-title":"J Clin Med"},{"issue":"02","key":"ref6","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1177\/019459988509300202","article-title":"Facial nerve grading system","volume":"93","author":"J W House","year":"1985","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"04","key":"ref7","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1016\/j.bjps.2014.12.015","article-title":"Is there an ideal outcome scoring system for facial reanimation surgery? A review of current methods and suggestions for future publications","volume":"68","author":"R Niziol","year":"2015","journal-title":"J Plast Reconstr Aesthet Surg"},{"issue":"07","key":"ref8","doi-asserted-by":"crossref","first-page":"1135","DOI":"10.3390\/jpm13071135","article-title":"Reliability and validity of emotrics in the assessment of facial palsy","volume":"13","author":"M G Kim","year":"2023","journal-title":"J Pers Med"},{"issue":"04","key":"ref9","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1001\/jamafacial.2018.0030","article-title":"A machine learning approach for automated facial measurements in facial palsy","volume":"20","author":"D L Guarin","year":"2018","journal-title":"JAMA Facial Plast Surg"},{"key":"ref10","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1016\/j.jpeds.2018.06.043","article-title":"Long-term outcomes of free gracilis muscle transfer for smile reanimation in children","volume":"202","author":"J J Greene","year":"2018","journal-title":"J Pediatr"},{"issue":"07","key":"ref11","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1055\/a-2245-9795","article-title":"Dual-innervated gracilis free functional muscle transfers in facial palsy patients: comparing long-term outcomes between one- versus two-stage procedures","volume":"40","author":"Y E Wen","year":"2024","journal-title":"J Reconstr Microsurg"},{"issue":"01","key":"ref12","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1055\/s-0042-1744309","article-title":"Functional outcome comparison of free gracilis muscle anchoring methods in patients with facial paralysis: upper lip red line incision versus facelift incision approach","volume":"39","author":"H Park","year":"2023","journal-title":"J Reconstr Microsurg"},{"issue":"05","key":"ref13","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1089\/fpsam.2022.0283","article-title":"Gracilis muscle-free flap objective improvement of oral commissure excursion in 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