"Smile" reconstruction in facial paralysis.

Reanimation of the face following facial nerve paralysis, especially the socially important smile, presents a complex surgical challenge requiring an individualized approach. Both neural and non-neural operative procedures have been used in an attempt to achieve the goal of a symmetrical synchronous smiling expression. A retrospective review of the results of both neural and nonneural methods was made to determine the relative efficacy of various methods. Of the neural techniques, early direct nerve repair primarily consistently achieved the best functional recovery. Double nerve grafts were found to be superior to a single nerve graft in nerve severance with a nerve gap at the facial nerve trunk bifurcation in delayed cases. In long-standing cases, ipsilateral or cross-face nerve grafting followed by functioning muscle transfer gives the most acceptable synchronous smile. Although cross-face nerve graft only, hypoglossal facial transfer, or non-neural techniques such as temporal muscle transfer achieved restoration of the smile, their inconsistent results and asynchronous action still limited the patient's confidence in social interactions.