Maximizing the Smile Symmetry in Facial Paralysis Reconstruction: An Algorithm Based on Twenty Years' Experience

Area of Science:

• Plastic Surgery
• Reconstructive Surgery
• Facial Nerve Surgery

Background:

• Facial paralysis reconstruction techniques have evolved significantly over two decades.
• Analysis of surgical outcomes informs current best practices.
• A comprehensive understanding of patient factors is crucial for successful facial reanimation.

Purpose of the Study:

• To share lessons learned from 20 years of experience in facial paralysis reconstruction.
• To propose a novel algorithm for guiding surgical technique selection.
• To optimize facial symmetry and spontaneous smile in patients with facial paralysis.

Main Methods:

• Retrospective analysis of 343 facial paralysis cases (285 complete, 58 incomplete).
• Inclusion of diverse surgical techniques: direct suture, nerve grafts, cross-facial nerve grafts (CFNGs), masseteric-to-facial nerve transference, hypoglossal-to-facial nerve transference, free muscle transplants, and lengthening temporal myoplasty.
• Development of a decision-making algorithm based on paralysis type, onset, patient factors, and desired outcomes.

Main Results:

• Key factors influencing technique selection include paralysis type, onset duration, patient comorbidities, and gender.
• Preferred techniques for unilateral facial paralysis: direct repair, CFNG, masseteric-to-facial transposition, and free gracilis transfer.
• Masseteric-to-facial nerve transference is preferred for incomplete paralysis; bilateral free gracilis transfer in two stages for bilateral paralysis.

Conclusions:

• The proposed algorithm simplifies facial paralysis reconstruction, aiming for maximal facial symmetry.
• Personalized approach considering comorbidities and gender enhances spontaneous smile outcomes.
• Experience-based algorithm provides a structured framework for dynamic facial reanimation.