Arteriovenous Loop‐Assisted Free Functional Gracilis Transfer in Vessel‐Compromised Patients: A Salvage Strategy for Facial Reanimation

BACKGROUND: Free functional gracilis transfer (FFGT) is the gold standard for dynamic facial reanimation in long-standing facial paralysis and its success depends on the availability of reliable recipient vessels. In patients with compromised vessels due to prior surgery, radiation, or trauma, arteriovenous (AV) loops are a well-established reconstructive strategy. However, their role in facial reanimation remains scarcely reported. METHODS: We retrospectively analyzed all patients with facial paralysis receiving facial reanimation with FFGT at our center between January 2010 and March 2025. All patients with absent or compromised standard recipient vessels, who underwent facial reanimation using FFGT in combination with an AV loop, were included. A sequential approach with preoperative Doppler examination, intraoperative flow assessment, AV loop construction, and continuous Cook-Schwartz Doppler monitoring was used before gracilis harvest. Each case was compared with an age-matched cohort of patients who underwent conventional FFGT without AV loops to contextualize operative and ischemia times. Primary outcomes were technical success and perioperative complications. RESULTS: Out of 196 patients who underwent facial reanimation, four patients (4/196, 2.0%) with compromised recipient vessels who received AV loop-assisted FFGT were identified (mean age 57 years (range: 40-65) years). The mean follow-up time was 19.3 months (13-30 months). No AV-loop thrombosis, flap loss, hematoma, wound complications, or donor-site morbidity occurred. Compared with age-matched controls, operative times were prolonged, whereas ischemia times remained comparable. Functional smile restoration was achieved in two of four patients within 12 months. CONCLUSIONS: AV loop-assisted FFGT is a technically feasible salvage approach for facial reanimation in patients with compromised recipient vessels, enabling restoration of vascular access and expanding reconstructive options. TRIAL REGISTRATION: FRKS (Freiburger Reister Klinischer Studien), No. FRK005908.