PRS Journal Club: Synkinesis Progression, Functional Gracilis Debulking, and Extended Sural Graft Harvesting

Contemporary management in facial reanimation emphasizes approaches that restore both power and spontaneity while addressing synkinesis. Management of synkinesis has advanced, with selective neurectomy/myectomy as a targeted surgical adjunct to neuromuscular retraining and botulinum toxin, with growing evidence of improved symmetry and patient-reported outcomes. Thus, an understanding of the progression of synkinesis allows for appropriate implementation of these techniques. Free gracilis transfer restores both power and spontaneity for facial reanimation, but commonly requires debulking procedures to improve facial contour and balance. Increasingly, these free gracilis transfers utilize dual innervation from the masseteric and a crossfacial nerve graft. The long course or use of multiple grafts of the sural nerve for crossfacial nerve grafting requires an extended length to create a nontensioned coaptation. In the January of 2026 edition of PRS Journal Club, we discuss these 3 topics relating to facial synkinesis and paralysis reconstruction. In the first article, “The Natural Progression of Synkinesis,” Rail et al.1 investigate the timeline and natural course of facial synkinesis, a condition marked by involuntary co-contraction and hypertonicity of facial muscles following facial nerve injury. In a retrospective cohort of 98 patients evaluated between 2010 and 2024, standardized photographs and videos were analyzed using the eFACE clinician-graded scale to assess changes in synkinesis severity over time. The study found that synkinesis symptoms were minimal within the first 100 days after facial palsy onset but progressively worsened thereafter, with the most significant progression occurring between 200 and 300 days. The last period of statistically significant worsening was observed between 400 and 500 days, after which symptoms plateaued, typically around 16 months. The onset of synkinesis varied widely, ranging from as early as 1 month to as late as 10 to 11 months after the onset of facial palsy. These findings provide an evidence-based framework for counseling patients about the expected progression of their symptoms, and have important implications for treatment timing. Recognizing the natural plateau of synkinesis around 16 months helps guide decisions regarding interventions, prevents premature surgical planning, and supports more accurate prognostication for patients recovering from facial nerve injury. In the second article, “The Efficacy of Flap Debulking after Facial Reanimation Surgery to Enhance Facial Symmetry,” by Weiss et al.,2 the authors examined the role of flap debulking after facial reanimation surgery to improve facial symmetry in patients with longstanding facial paralysis. The standard treatment, free functional gracilis transfer (FFGT), reliably restores smile function, but some patients experience excess muscle bulk that compromises aesthetic outcomes. To address this, the authors analyzed 54 patients who underwent flap debulking following unilateral smile reconstruction between 2014 and 2023. Using standardized photographs, they measured hemifacial surface area, commissure height deviation, and commissure excursion. Results showed that although FFGT initially increased facial bulk and caused asymmetry, flap debulking effectively restored balance, bringing hemifacial ratios closer to 1.0 and further reducing commissure deviation. The commissure excursion ratio also improved, reflecting enhanced smile symmetry. Only 1 patient experienced a postoperative infection, and no flap losses were reported. The authors conclude that flap debulking is a safe, effective secondary procedure that significantly enhances both static and dynamic facial symmetry following FFGT, highlighting its value as an important refinement in facial reanimation surgery. Finally, in the third article, “Extended Sural Nerve Harvest: A Technique to Gain Additional Graft Length,” Millesi et al.3 present a novel technique for extended sural nerve harvest to obtain longer nerve grafts for nerve reconstruction. Usually, the sural nerve provides up to 35 cm of graft length. Still, some clinical scenarios, such as multiple crossface nerve grafts, require longer grafts, often necessitating bilateral harvests and increased morbidity. The authors conducted both cadaveric dissections and a retrospective clinical review to evaluate the feasibility and safety of extending sural nerve harvest above the popliteal crease using interfascicular dissection. Anatomical studies on cadaver legs demonstrated that this method could yield an additional 14 cm of graft, achieving an average total length of nearly 50 cm without structural compromise. Histological analysis confirmed consistent fascicle and axon counts along the nerve. Clinically, the technique was applied in 7 adult and 2 pediatric patients, producing grafts up to 55 cm in length without intraoperative complications or long-term functional deficits. Minor transient postoperative sensory changes resolved within 6 weeks. The study concludes that extended sural nerve harvest is both anatomically feasible and clinically safe, providing significantly longer grafts without added donor-site morbidity and offering advantages in pediatric patients and complex reconstructions. Overall, these articles provide valuable additions to the literature on the prognosis and management of facial synkinesis and reanimation. The authors have taken important steps in advancing patient counseling on facial synkinesis, improving static and dynamic symmetry through gracilis flap debulking, and providing increased length of sural nerve graft for extended or multiple crossfacial nerve grafting. DISCLOSURE The authors have no relevant financial disclosures to report.