Reanimation of the paralyzed face.

The challenge of reconstruction in the paralyzed face is to provide symmetry both at rest and in active expression. Although functional considerations must take precedence, the patient with unilateral facial palsy faces social stigmata that are exceptionally difficult. The best reconstructions in late paralyses fall far short of natural facial expression. Conley, one of the pioneers in facial nerve rehabilitation, reflected the frustration of dealing with limited techniques: It has been assumed by many surgeons that involuntary emotional communication is through the facial nerve, but this has never been substantiated. Indeed, emotional expression may be beyond our concept of a mere physical tract. It certainly has never been totally restored by any surgical technique that attempts to rehabilitate the face. When injury to the facial nerve is established, early nerve grafting on the ipsilateral side is the best treatment. In acoustic neuroma and other intracranial operations, the only real opportunity for grafting or repair is at the time of the procedure. If the nature of the injury is uncertain, a period of 12 months is allowed to elapse before consideration of intervention, which should be started if there is no return of function at that point. Electromyography may be of assistance in assessing minimal early return; if any early return is noted, further waiting is indicated. If there is no return at 1 year, cranial nerve XII to VII crossover will preserve facial muscle tone and permit a more measured decision-making approach. Patients with multiple cranial nerves involved may be candidates for a partial hypoglossal transfer using a nerve graft, to attempt to preserve swallowing. In selected cases, cross-facial nerve grafting to the preserved facial muscles will give excellent results and obviate the need for local or distant muscle transfers. When treating established paralysis of long duration, cross-facial nerve grafting with microneurovascular muscle transfer is the best option for symmetrical movement of the face. Temporalis and masseter muscle transfers should be reserved for the patient with intercurrent medical disease or the patient who refuses additional operations or operative sites. Static slings and other related procedures should be considered adjunctive but not primary treatment in the vast majority of cases. Although there are limitations in each of the procedures described, close cooperation between the otolaryngologist, the neurosurgeon, and the plastic surgeon can provide many patients with satisfactory rehabilitation from facial paralysis.