Gracilis Free Muscle Transfer Surgery

The innervated gracilis free muscle transfer is a versatile reconstructive surgery that can be used to treat facial paralysis. It is commonly used in smile restoration because the gracilis muscle flap can be harvested with its nerve, allowing for dynamic movement.

The procedure is intended to restore dynamic smile function in people with flaccid paralysis or synkinesis who are outside the normal treatment window or otherwise not ideal candidates for nerve transfers. It offers surgeons the ability to restore facial symmetry and voluntary movement, as well as a natural-looking smile.

What Is the Innervated Gracilis Free Muscle Transfer?

In gracilis free muscle transfer, a small slip of the gracilis muscle is taken from the inner thigh and transplanted into the face in the same orientation as the major smile muscles.

For this muscle transplant to survive, it must be hooked up to an artery, a vein, and a nerve in the face. To obtain movement of this muscle, the transplanted gracilis may be hooked up to a cross-facial nerve graft, the masseteric (chewing) nerve, or a small branch of the functioning facial nerve. Your surgeon will decide which nerve connection would be best for your particular condition.

Conditions we treat with the gracilis free muscle transfer

There are many conditions that cause facial nerve dysfunction and paralysis, including:

• Viral reactivations:
  • Bell’s palsy.
  • Pregnancy-related Bell’s palsy.
  • Ramsay Hunt syndrome.
• Infections:
  • Acute otitis media (inner ear infection).
  • HIV.
  • Lyme disease.
  • Syphilis.
• Tumors
  • Facial nerve schwannoma.
  • Geniculate ganglion hemangioma.
  • Parotid malignancy.
  • Skin cancer.
• Inflammatory conditions:
  • IgG4-related disease.
  • Miller Fisher syndrome.
  • Multiple sclerosis.
  • Sarcoidosis.
  • Systemic lupus erythematosus.
  • Granulomatosis with polyangiitis.
• Trauma
  • Forceps delivery.
  • Penetrating facial trauma.
  • Temporal bone fracture.
• Complications from other surgeries:
  • Middle ear surgery.
  • Facelift.
  • Skull base tumor removal surgery.
  • TMJ surgery.
• Congenital (inborn)
  • CHARGE syndrome.
  • Goldenhar syndrome.
  • Mobius syndrome.

Why Would I Need a Gracilis Free Muscle Transfer?

Your doctor might recommend the gracilis free muscle transfer surgery if you have flaccid facial paralysis or synkinesis that limits your ability to use facial expressions to convey your emotions — especially if this condition causes you distress.

Facial paralysis is shown to have a significant emotional and social impact:

• Around 60% of patients meet clinical measures for depression or anxiety.
• Misreading facial expressions during everyday interactions can lead to confusion and discomfort for both the person and those around them.
• Research shows that others often view people with facial paralysis as more upset, less reliable, and less capable.

Treating facial paralysis is important not only to restore facial function, but also to restore your self-esteem and sense of well-being.

Who’s a candidate for the gracilis free muscle transfer?

You may be a good candidate for a gracilis free muscle transfer if you:

• Are in good enough overall health to tolerate a long operation.
• Have a functioning masseteric (chewing) nerve.
• Have had facial paralysis for longer than two years.
• Have not achieved improvement with medications or physical therapy.
• Have realistic expectations for the partial restoration of your smile.

What Are the Risks and Complications of the Gracilis Free Muscle Transfer?

As with any surgery, gracilis free muscle transfer surgery is not without complications.

The most common are:

• Bleeding or hematoma.
• Flap failure.
• Inadequate muscle movement.

What Should I Expect From the Gracilis Free Muscle Transfer Surgery?

Before surgery

The gracilis free muscle transfer is performed as an inpatient surgery under general anesthesia in the operating room. On the day of surgery, you will have a chance to meet with your surgeon and anesthesiologist to ask any questions and sign the necessary paperwork. The surgery may last six to eight hours, depending on the number of procedures being performed.

During surgery

In this surgery, two surgical teams work at the same time. One prepares the face, while the other removes the gracilis muscle from the thigh.

Once removed from the thigh, the slip of gracilis muscle is connected to blood vessels (usually the facial artery and vein) and nerves (often the masseter nerve, which helps with chewing, or a cross-facial nerve graft). The gracilis muscle is then shaped and placed to mimic the natural smile muscles. It’s anchored at key points around the mouth to recreate the smile line.

Surgeons use special tools to make sure the nerves are active before connecting them.

After surgery

You will typically spend one to two nights in the hospital following a gracilis free muscle transfer to monitor the health of the transplanted muscle.

• You may be discharged with small surgical drains in your face and thigh that may be removed three to five days later in the clinic.
• You will receive instructions on how to care for these drains before leaving the hospital.
• You will need somebody to drive you to and from the hospital.
• Once home, you will be asked to keep your leg wrapped as much as possible for two weeks.
• After 72 hours, these dressings may be temporarily removed, and you can shower as normal.
• You will be provided with an antibiotic ointment to apply to the sutures.
• It is not uncommon to experience significant facial swelling or bruising for up to a month after surgery. Sleep with your head propped up on several pillows to minimize swelling.
• All sutures will be absorbable and may take 10 to 14 days to fully dissolve.
• Avoid any exercise, heavy lifting, or strenuous physical activity for two weeks after surgery, or until you are cleared at your postoperative visit.

What is recovery like after a gracilis free muscle transfer?

The recovery timeline is usually the following:

• Days one through seven — Facial swelling is most noticeable around days three to four.  Discomfort at the site in the thigh where the muscle was removed is usually mild. Most people can walk normally within one to two days.
• Weeks two through six — Swelling decreases significantly. Many people can return to desk jobs within two to three weeks.
• Months three to six — Early signs of muscle movement may be observed within three to four months after surgery, depending on the nerve that was used.  After movement is noted, you can expect to see steady improvement in your smile for several months afterwards.
• After six months — Major functional gains become visible, with continued progress and refinement possible for up to two years.

When will I see results?

Results are not seen immediately after surgery, as it takes time for the nerves to grow into the transplanted muscle. Final results may be seen between three months and one year following gracilis free muscle transfer, depending on the source of nerve input.

What's the success rate of a gracilis free muscle transfer?

Success rates depend on many factors. Your surgeon will discuss the range of potential outcomes for your specific case at your surgical consultation.

---

By UPMC Editorial Staff. Last reviewed on 2026-03-01.