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What is a gracilis flap?Left facial paralysis before and after picture

Patients who have had long-term facial paralysis (generally longer than 2 years) often have facial muscles that are no longer functional as they have not had nerve innervation for a prolonged period of time. In these patients, Dr. Miller can borrow a small piece of the gracilis muscle from the inner thigh and transfer it to the face to recreate the smile muscles. This transplanted muscle is connected to blood vessels to keep the muscle healthy, and to a nerve that restores smiles movement. There are no negative effects from harvesting a small piece of gracilis muscle. Patients can still run, jump, and do all activities they were doing prior to surgery.

What to expect during the gracilis free flap surgery:

The gracilis free flap (aka gracilis free tissue transfer) is performed under general anesthesia. During the procedure, Dr. Miller makes a modified facelift incision to prepare an area for the gracilis muscle to sit so that it is in the proper plane and vector to maximize smile symmetry. He also identifies blood vessels in the face which will nourish the gracilis muscle once it is transferred to the face. While Dr. Miller is preparing the face for the gracilis muscle, another surgeon who specializes in harvesting muscle, will make a small incision along your upper inner thigh and harvest the small piece of gracilis muscle along with its blood vessels and nerve.

Having two surgeons work together at the same time minimizes the amount of time you are under general anesthesia, minimizing risks of surgery and speeding up recovery. Once the gracilis muscle is harvested and transferred to the face, we stitch the muscle into position to recreate the natural smile muscles.

Why choose Dr. Miller for gracilis free flap surgery?

Dr. Miller and the patient will decide together the best nerve to power the gracilis muscle based on patient factors as well as a patient’s goals. Your treatment plan will be personalized. Theoptions include a nerve graft connected to a smile nerve branch on a patient’s healthy side (aka cross-face nerve graft, this does NOT affect your healthy side smile) and/or a branch of the masseteric nerve, one of the chewing nerves. While using a nerve graft connected to the healthy facial nerve allows for greater chance of a spontaneous smile, it is not as reliable as the massetericnerve. While using the masseteric nerve is more reliable, patients typically have to think about biting down when smiling. However, patients work with Heather Davis Cuevas, the UNC Facial Nerve Center therapist, and often get to the point when they can smile without thinking about biting.

ML Website Smile

After a gracilis free tissue transfer procedure, patients usually stay in the hospital for two or three days. While patients have some soreness in their leg and face after surgery, patients can walk the day after surgery. Depending on the nerve which is used to power the gracilis muscle, patients start to see a smile 6-12 months after surgery. The smile continues to improve as patients work with Heather Davis Cuevas, and as the muscle gains more and more strength.


If you would like to make an appointment to discuss the gracilis free flap with Dr. Miller, please call 984-974-2255 to schedule.