Recipient Vessel Utilization in Gracilis Free Functional Muscle Transfer for Facial Reanimation: A 12‐Year Single‐Center Experience

Background Free functional muscle transfer (FFMT) using the gracilis muscle is a well‐established technique for smile restoration in long‐standing facial paralysis. However, recipient vessel selection remains poorly standardized, particularly when facial vessels are unavailable. This study evaluated recipient vessel utilization, associated clinical outcomes, and potential predictors of alternative vessel selection to propose a practical surgical algorithm. Methods A retrospective review of patients undergoing gracilis FFMT for facial reanimation between 2011 and 2022 was performed. Demographic, clinical, and operative characteristics were compared between facial and non‐facial recipient vessel groups using Fisher's exact test and Welch's t ‐test. Exploratory multivariable logistic regression analyses evaluated factors associated with alternative vessel utilization and complications. Results A total of 151 patients were included (mean age, 20.9 ± 18.6 years), predominantly with congenital facial paralysis (68.2.%). Facial vessels were used in 123 cases (81.5%), while alternative vessels were required in 28 (18.5%), most frequently the superficial temporal system. Vascular pedicle and gracilis muscle lengths were significantly longer in the non‐facial vessel group, while ischemia time was shorter. Overall complications occurred in 27.8% of patients, with a flap survival rate of 97.4%. No significant differences were observed between recipient vessel groups in overall complications (26.0% vs. 35.7%; p = 0.351), flap loss, or inadequate muscle activation. Surgical site infections were more frequent in the non‐facial vessel group ( p = 0.023). Exploratory subgroup analyses identified younger age in patients experiencing complete flap loss ( p = 0.017) or inadequate muscle activation ( p = 0.010). Conclusions Facial vessels remain the preferred recipients for gracilis FFMT, with the superficial temporal system providing a suitable alternative. Recipient vessel selection was not associated with significant differences in overall complications, flap survival, or muscle activation. A flexible, anatomy‐guided algorithm may facilitate surgical planning when facial vessels are absent or unsuitable.