About the Procedure
Gracilis free tissue transfer is a microsurgical smile reanimation procedure used for facial paralysis when the face's own muscles can no longer be reactivated, often in long-standing, complete, or congenital paralysis. A small segment of the gracilis muscle from the inner thigh is transferred to the cheek, where its blood vessels and nerve are connected to vessels and a nerve in the face under a microscope.
Once the transferred muscle becomes reinnervated over several months, its contraction produces movement at the corner of the mouth, restoring a dynamic smile. The muscle may be powered by the nerve to the chewing muscle (the masseteric nerve), by a cross-face nerve graft from the opposite side, or by a combination.
At Norelle Health, smile reanimation is planned individually based on the cause and duration of paralysis, which nerves and muscles are available, and the patient's goals. It is one option within a broader range of facial reanimation techniques.
Who may be a candidate
This procedure is generally considered for facial paralysis that is long-standing, complete, or present from birth, where the original facial muscles are no longer able to respond to nerve input.
Candidacy depends on the duration and cause of paralysis, the availability of a suitable donor nerve, and a patient's overall health and ability to undergo microsurgery. People with more recent paralysis or recoverable nerve function may be better suited to nerve transfers or other techniques.
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How the muscle is powered
The transferred muscle needs a nerve to drive its movement. Options include:
- The masseteric nerve (to the chewing muscle), which gives a strong contraction activated initially by clenching
- A cross-face nerve graft, which borrows signal from the healthy opposite side and can allow a more spontaneous smile
- A combination of both in selected cases
The choice depends on the patient's anatomy and goals.
How it is performed
Through an incision in the cheek and a small incision on the inner thigh, a segment of the gracilis muscle is removed with its artery, vein, and nerve. The muscle is shaped and secured between the cheek and the corner of the mouth.
Under a microscope, the muscle's blood vessels are connected to vessels in the face, and its nerve is connected to the chosen donor nerve. Careful tensioning aims to position the resting and moving smile symmetrically.
Recovery and aftercare
An initial hospital stay allows the team to monitor the transferred muscle's blood supply, which is most critical in the first days. Activity is limited early to protect the repair.
Movement does not appear immediately. As the nerve grows into the muscle over several months, contraction gradually develops, and facial physical therapy helps the patient learn to activate and strengthen the new smile over the following year.
Risks and alternatives
Possible risks include partial or complete loss of the transferred muscle if its blood supply fails, infection, bleeding, asymmetry, incomplete movement, and scarring at the cheek and thigh. Some patients need adjustment procedures later.
Alternatives include nerve transfers when the native muscles are still viable, regional muscle transfers such as a temporalis tendon transfer, static suspension to improve resting symmetry, and supportive measures.
Results and follow-up
When successful, the procedure restores a dynamic smile and improves facial symmetry, though the smile may differ from the natural one and continues to develop with therapy. Results vary between individuals.
Long-term follow-up tracks movement, supports rehabilitation, and addresses any need for refinement over time.
Medical review
This page is a patient-education resource reviewed by the responsible Norelle Health clinician before publication. It does not replace an in-person evaluation. If symptoms are severe or rapidly worsening, seek immediate medical care.
Specialists who perform gracilis free tissue transfer
Dr. Rakhna Araslanova
MD, FRCSC, FACS
Fellowship-Trained Facial Plastic & Reconstructive Surgeon — Facial Paralysis and Reanimation
Dr. Rakhna Araslanova is a fellowship-trained facial plastic and reconstructive surgeon who leads facial paralysis and reanimation at Norelle Health, with additional expertise in craniofacial reconstruction and aesthetic facial plastic surgery.
- Facial paralysis rehabilitation and surgical reanimation
- Craniofacial reconstruction
- Aesthetic facial plastic surgery
- Rhinoplasty
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(212) 444-8006Frequently Asked Questions
It is a microsurgical procedure that moves a small segment of thigh muscle to the cheek and reconnects its blood supply and nerve, so the muscle can eventually contract and restore a smile in facial paralysis.
It is generally used when the face's own muscles can no longer be reactivated, such as in long-standing or congenital paralysis. Nerve transfers are options when the native facial muscles are still viable.
It is connected to a donor nerve—often the masseteric nerve or a cross-face nerve graft. Once the nerve grows into the muscle, it can contract; with the masseteric nerve, patients often start by gently clenching.
Movement usually does not appear until the nerve reinnervates the muscle, often around several months after surgery, and it continues to strengthen over roughly a year with facial physical therapy.
Many patients regain meaningful, symmetric movement, though the smile may feel or look somewhat different from the original. Therapy helps make it stronger and, in some cases, more spontaneous over time.
The thigh donor site usually heals with limited long-term effect on leg function because only a portion of the gracilis muscle is taken. Soreness and a scar at the donor site are expected.
Sometimes. A cross-face nerve graft may be staged before the muscle transfer, and some patients have later adjustments to refine symmetry or movement.
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