Tessa A Hadlock and Mack L Cheney

The management of longstanding facial paralysis presents a unique surgical challenge. It has been established that during the first several years after facial nerve sacrifice or injury, techniques that reestablish neural input to the native facial musculature yield the most satisfactory clinical results.1 In the case of primary or cable graft repair of the facial nerve, the restoration of neural input from the facial motor nucleus directly to existing facial musculature offers the only chance for return of natural, emotive expression. In cases in which the proximal facial nerve is not available for grafting, reinnervation techniques with alternative proximal neural sources provide direct innervation of facial muscles. This type of repair may yield satisfactory resting tone and function during voluntary smiling, but lacks spontaneous emotive function.

Perhaps the most challenging clinical situation is one in which reinnervation of the facial muscles themselves is not possible. This occurs when the distal facial nerve stump is either absent or severely fibrotic or when the facial musculature is atrophic beyond contractile capability. Efforts to restore facial symmetry and tone then involve static and dynamic tissue transfer techniques. These methods routinely provide less satisfactory functional and aesthetic results, and controversy surrounds which procedures are best employed in different clinical situations. There are numerous static and dynamic approaches to facial reanimation, and various techniques have proved to be well matched to particular clinical situations.

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