CRANIOFACIAL

Integrated Approaches for Reconstruction

of Facial Paralysis
Shihheng Chen, MD, PhD,a Hung-Chi Chen, MD, PhD, FACS,b and Yueh-Bih Tang, MD, PhDc,d
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other factors including patients' socioeconomic conditions and comor-

Background: Facial paralysis can affect periorbital muscles, oral competence,
and facial expressions with significant facial deformities, which could occur in
either children or adults with variable severity, duration, and degree of recovery.
Objective: The present study was aimed to delineate treatment plans for facial pa-
ralysis with different clinical scenarios and to report the results of these patients.
Methods: Patients were grouped according to different presentations as follows:
(1) facial paralysis with incomplete recovery; (2) young patients of facial paraly-
sis without recovery; (3) senile patients of facial palsy without recovery; (4) com-
bined facial palsy with mandibular deficiency, vascularized bone reconstruction
for mandible with (a) subsequent muscle transfer or (b) simultaneous sling oper-
ation or (c) simultaneous facial nerve exploration and cross nerve grafting; (5)
palsy of frontal branch of facial nerve; (6) palsy of zygomatic-buccal branch of
facial nerve; (7) palsy of marginal mandibular branch of facial nerve; (8) partial
recovery with dyskinesia; and (9) facial paralysis with dynamic asymmetry and
muscle atrophy. According to clinical scenarios, different treatment plans were
provided, and clinical outcomes were evaluated and presented.
Results: All patient groups achieved fair or satisfactory outcomes. Revisions using
sling procedures, botulinum toxin injection, and filler or fat graft as supplement fur-
ther refined the ultimate outcomes.
Conclusions: For reconstruction of facial paralysis, individualized integrated treat-
ment plans are mandatory according to the presentation and condition of the pa-
tient. Comprehensive considerations and strategic solutions for the existing disabil-
ities have been appreciated by the patients. The least numbers of operations with
considerate correction of asymmetry were the major concerns of the patients.
Key Words: facial paralysis, reconstruction, integrated, multimodal approaches
(Ann Plast Surg 2023;90: S165–S171)
F acial paralysis is caused by denervation of the facial muscles, includ-
ing periorbital and perioral muscles, resulting in deformation of fa-
cial expressions and weakness or complete loss of oral competence,
brow lifting, and eye closure. Facial paralysis could occur in childhood
or in adulthood with variable severity, duration, degree of recovery, and
areas of involvement. Treatments should be individualized because no
single method is sufficient for the treatment of all patients with facial
palsy. Multimodal approaches to reconstruction for facial paralysis
should include consideration of etiology, manifestation, timing, accept-
able treatment modality, and expectation of the patient. Lengthy sched-
ule of operations with multiple stages should be retained until the prob-
lems cannot be solved otherwise. The term “multimodal integrated” ap-
proach means that multiple procedures may be required to achieve
optimal results, but the planning should also take into consideration
Received December 5, 2022, and accepted for publication, after revision December 5,
2022.
From the aDepartment of Plastic and Reconstructive Surgery, Chang Gung Memorial
Hospital at Linkou, Chang Gung University and College of Medicine, Taoyuan,
Taiwan; bChina Medical University Hospital, Taichung, Taiwan; cFar-Eastern
Memorial Hospital at Banquio, New Taipei City, Taiwan; and dNational Taiwan
University Hospital, Taipei, Taiwan.
Conflicts of interest and sources of funding: none declared.
Reprints: Yueh-Bih Tang, MD, PhD, Far-Eastern Memorial Hospital at Banquio, New
Taipei City, Taiwan. E-mail: phoebetang0103@gmail.com.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/23/9002–S165
DOI: 10.1097/SAP.0000000000003427
bidities, and so on.
Facial nerve exits from the stylomastoid foramen of the cranium,
it runs vertically for 1.5 cm, branching radially with 5 branches, and
penetrates through the superficial and deep lobes of the parotid gland.
When the 5 branches of facial nerve leave the parotid, they stay above
the muscle fascia. In the cheek, these branches run across the masseter
muscle, whereas the buccal branch lies beside the Stensen's duct at buc-
cal fat pad. The marginal mandibular branch lies beneath the mandibu-
lar angle. In 1979, Millesi had started nerve suture and grafting to re-
store the extratemporal facial nerve.
Facial palsy could result from brain tumor, acoustic neuroma,
neurofibromatosis, osteosarcoma, malignant parotid tumor, osteoradionecrosis,
Bell’s palsy, trauma (eg, temporal bone or facial bone fractures, sever-
ance of nerve branches), idiopathic, congenital, or iatrogenic causes.
Manifestations of facial paralysis encompass different severity of
static/dynamic facial asymmetry or apathetic face in congenital Mobius
syndrome. The common manifestations include the following:
1. Forehead: flat forehead without wrinkle and inability to raise eyebrow;
2. Periorbital: lagophthalmos (inability to close upper eyelid), Bell's
phenomenon, lower eyelid laxity and sagging, asymmetric or down-
ward displacement of arcus marginalis, disappearance of corrugator
wrinkles and procerus transverse line with apparent asymmetry, ocu-
lar symptoms including conjunctivitis and exposure keratopathy,
tearing (which may also bother the patients);
3. Unilateral unopposed lifting of upper, midface, mouth angle, and de-
pression of lower lip on the sound side;
4. Failure of purse-stringing of orbicularis oris muscle of the affected
side, resulting in drooling, oral incompetence, and disturbance in
speech intelligibility;
5. Sagging down of soft tissue of the paralytic side and the patient
might accidentally bite buccal mucosa of the affected side off and on;
6. Atrophy of soft tissue and paralyzed muscles with subsequent fibro-
sis and remarkable asymmetry; and
7. Secondary deformity of the underlying facial skeleton if facial palsy
is left untreated for a long time.
The history of reconstruction for facial paralysis can be dated
back to 1946, when Adams1 started to perform regional muscle transfer
to reanimate a paralyzed face, which was popularized by Breidahl et al2
and Rubin.3 In 1976, Harii et al4 started to use free-functioning gracilis
muscle transfer, which was followed by O’Brien et al.5 Thereafter,
Dellon and Mackinnon6 used segmental latissimus dorsi for facial rean-
imation, whereas Harrison7,8 and Terzis9 advocated to use pectoralis
minor. In 1998, Harii et al10 started conducting 1-stage transfer of the
latissimus dorsi muscle for reanimation of a paralyzed face. Zuker
and Manktelow11,12 successfully created a smile for Moebius syndrome
in children with bilateral facial palsy using segmental free gracilis mus-
cle transfer. Subsequently, Chuang et al13 advocated 1-stage procedure
using spinal accessory nerve (XI)–innervated free muscle for facial pa-
ralysis reconstruction. Ueda et al14 used muscle transplantation for the
treatment of facial paralysis with free neurovascular muscle transplanta-
tion for the treatment of facial paralysis utilizing the hypoglossal nerve
as a motor source on the recipient site. Chen and Tang15 described
myectomy and botulinum toxin for the treatment of paralysis of the mar-
ginal mandibular branch of the facial nerve. Studies to improve the

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 Chen et al Annals of Plastic Surgery • Volume 90, Supplement 2, May 2023

TABLE 1. Important Surgical Tips for Successful Facial Paralysis Surgery

Presentations Solutions
Upper face Eyebrow symmetry Contralateral medial frontalis-periosteal flap transfer
Corrugator and procerus wrinkles Myotomy for the affected side or Botox injection
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Orbicularis oculi incompetence Partial temporal fascial flap sling

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Lagophthalmos Palmaris longus sling

Middle face Lower eyelid incompetence, marked Lateral canthoplasty
lower lid bags
Asymmetric arcus marginalis Soft tissue filling at medial cheek and arcus marginalis
(with fat graft, fascia or tendon graft, hyaluronic acid filling)
Sagging of nasal ala Palmaris longus operation
Incompetence in upper lip, mouth angle lifting Dynamic sling: temporal muscle-fascial flap
Masseter muscle-periosteal flap (anterior 1/3)
Free neurovascular functional muscle transfer
Sagging of nasal ala Palmaris longus sling operation
Lower face Lower lip depressor incompetence Myectomy of contralateral depressor anguli
Oris and depressor labii inferiois, mentalis
Complementary procedures Weakening of contralateral overly acting muscles with Botox

outcome of facial palsy reconstruction have been conducted over the The following are our general principles to plan the treatment for
years.16–25 Several investigations also addressed eyelid problems with facial paralysis patients:
cartilage grafting, which was subsequently refined by botulinum toxin 1. Facial nerve injury should be repaired or nerve grafted immediately
A and hyaluronic acid injections.26–31 if it is timely recognized. Inadvertent injury should be treated as soon
The present study was aimed to delineate treatment plans for fa- as possible.32,33 If remained untreated, the facial muscles end up with
cial paralysis with different clinical scenarios and to report the results of atrophy and undergo fatty metamorphosis gradually.
these patients. 2. For facial palsy with infectious origin, younger patients might show
various degrees of neurotization from the contralateral facial nerve or
underlying masticatory muscle, and the deformity might not be as se-
PATIENTS AND METHODS vere. However, spontaneous neurotization is usually not observed in
Having been working at the tertiary referral medical center, the elderly patients so that deformity and asymmetry in appearance
authors have been dealing with treatments for a variety presentations would be more prominent. Early neurotization with cross-facial
of facial palsies, amounting 362 patients during 40 years (Table 1 and nerve grafting is beneficial to elderly patients as well as young pa-
Table 2). However, some data had been lost. Now only the data of tients with partial recovery.
179 cases with follow-up for more than 3 years are available. The data 3. Because the presentation of facial palsy is diverse, treatment strategy
are presented in the tables. should be multimodal, including both surgical and nonsurgical ap-
proaches. Surgical modalities include cross-facial nerve graft, free
TABLE 2. Evaluation of Results After Reconstruction muscle transfer, local muscle transfers, sling procedures using fascial
or tendon grafts, and fat grafting. Nonsurgical treatments, including
A. Functional
botulinum toxin and filler injection, are usually applied as touch-ups
to refine the symmetry after surgical management or for patients
No drooling from mouth angle
who are unable or unwilling to undergo surgeries.
Speech intelligibility 4. Facial paralysis affects not only the appearance of the patient but also
Can close the eye completely creates tremendous psychosocial stress, especially social withdrawal,
Can lift eyebrow and severe depression. The affected individuals usually wish to re-
B. Aesthetic cover in no time with limited surgeries and costs. Therefore, detailed
Eyebrow symmetry explanation and achievable goals should be clarified and explicitly
No lower eyelid laxity explained to the patients before obtaining the consents.
Symmetry of bilateral nasal ala
Lower lip symmetry on expression
Symmetry of face, static TABLE 3. Data of Group 1: Facial Palsy With Incomplete Recovery,
Symmetry while smiling Treated With Cross-Facial Nerve Grafting and Partial Weakening of
C. Social Contralateral Overacting Muscles
Can assume a job
Case Average Result
Does not need to wear mask Number Age Sex Radiation/Trauma (Symmetry of Face)
Total points 12
10 points: excellent 24 34.2 y M/F = 10/14 2/24 had RT* before Good in 22 cases
8 points: good 1/24 due to trauma Fair in 2 cases
(radiated)
6 points: fair (acceptable)
4 points: poor *RT indicates radiation therapy for nasopharyngeal cancer.

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 Annals of Plastic Surgery • Volume 90, Supplement 2, May 2023
TABLE 4. Group 2: Young Patients of Facial Palsy Without
Recovery, Treated With Cross-Facial Nerve Graft Followed by
Free-Functioning Muscle Transfer
Result (Facial
Case Number Average Age Sex Radiation Symmetry)*
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28 25.6 y M/F = 3/25 1/27 Good in 17 cases
Acceptable in 11 cases
*All had auxiliary procedures for eyelids, fat grafts, and weakening for contra-
lateral depressor anguli oris and depressor inferioris, and so on.
In our series, patients with facial palsy were categorized based on
the following clinical scenarios:
1. Group 1, facial paralysis with incomplete recovery: cross-facial
nerve grafting with spreading of branches to innervate facial expres-
sion muscles and partial weakening of overacting muscles on the
contralateral side;
2. Group 2, young patients of facial paralysis without recovery:
cross-facial nerve graft with subsequent free muscle transfers;
3. Group 3, senile facial palsy without recovery: local muscle transfers
and sling procedures, including temporal muscle, masseter muscle
transfers, medial frontalis transfers, circumferential sling operation
with lateral canthopexy for tightening of eyelids, plantaris or
palmaris tendon sling to lift up nasal alar cartilage with fixation at
lateral aspect of orbital floor to form a natural nasolabial fold, in con-
junction with temporal muscle for dynamic action;
4. Group 4, combined facial palsy with mandibular deficiency:
vascularized osteocutaneous flap transfer was required for reconstruc-
tion of mandible, and facial palsy was addressed with (a) subsequent
muscle transfer or (b) simultaneous sling operation or (c) simultaneous
facial nerve exploration and cross nerve grafting, which might be used
for patients without atrophy of facial expression muscles (otherwise
regional functional muscle transfers or static sling operation with sub-
tle weakening of contralateral facial expression muscles might help
balance the contour and symmetricity of the face);
5. Group 5, palsy of individual branch of facial nerve (a) for palsy of
frontal branch of facial nerve: contralateral medial frontalis strip
muscle-periosteal sling transfer, (b) for palsy of zygomatic branch
of facial nerve: lateral canthopexy for lower eyelid laxity and tendon
sling to lift nasal ala with fixation to lateral inferior orbital rim, (c) for
palsy of buccal branch, spontaneous recovery was usually expected
if the neighboring branches were functional, (d ) for palsy of mar-
ginal mandibular branch, partial myectomy of the contralateral de-
pressor anguli oris and depressor labii inferioris through intraoral in-
ferior vestibular approach;
6. Group 6, patients with partial recovery and dyskinesia and did not
have major reconstructive surgery: botulinum toxin injection at the
overacting muscles with weakening of the contralateral muscles
TABLE 5. Group 3: Senile Patients of Facial Palsy Without Recovery,
Treated With Local Muscle Transfers and Sling Procedures, and so on
(See Text)
Case Result (Facial
Number Average Age Sex Radiation Symmetry)
46 47.3 M/F = 4/46 3/46 Good in 15
Smile not natural in 31
But static symmetry
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Multimodal Reconstruction for Facial Paralysis
was attempted to obtain facial balance, and upper and lower blepha-
roplasties with strip myectomy of orbicularis oculi muscles might
significantly mitigate the severity of periocular twitching; and
7. Group 7, facial paralysis with dynamic asymmetry and soft tissue/
muscle atrophy in patients who did not want major reconstructive
surgery: subtle weakening of contralateral side levator labii superioris
muscle and zygomaticus minor muscle with botulinum toxin injection,
palmaris longus sling for nasal ala, lateral canthopexy, followed by filler
or fat injection for soft tissue augmentation to improve facial symmetry.
Photographs with focal obscuring permit had been obtained
from all the presented patients.
RESULTS
Group 1 patients achieved satisfactory results. Those in group 2
could achieve fair results, but several revisions were often required to
achieve good results. Group 3 patients can effectively lift the affected
side of face. Partial weakening of contralateral facial expression mus-
cles might help to balance the facial expression. In group 4, significant
improvement of facial contour and facial symmetry could be obtained.
In group 5, for palsy of frontal branch of facial nerve, strip frontalis
muscle-periosteal sling operation could provide good results. For palsy
of zygomatic branch of facial nerve, recovery could be reasonably ex-
pected in 12 months. For palsy of marginal mandibular branch of facial
nerve, partial myectomy of contralateral side depressor anguli oris and
depressor labii inferioris could provide long-term results regarding
symmetry of the lower lip. In group 6, for patients with partial recovery
and dyskinesia, chemical myectomy with Botox injection, followed by
partial myectomy of orbicularis oculi muscle with lateral canthopexy,
palmaris longus tendon sling operation showed good outcomes. In group
7, facial paresis with dynamic asymmetry and soft tissue/muscle atrophy,
subtle weakening of contralateral levator labii superioris and zygomaticus
minor with botulinum toxin injection, in addition to palmaris longus ala
sling operation and lateral canthopexy, followed by filler injection for soft
tissue augmentation could obtain a fair balancing effect (Table 3, Table 4,
Table 5, Table 6, Table 7, Table 8, and Table 9) (Chen’s classification;
case presentations, Fig. 1, Fig. 2, Fig. 3, Fig. 4, and Fig. 5).
DISCUSSION
Facial paralysis is clinically challenging. This condition causes
not only facial deformity but also psychosocial embarrassment. Most
patients are unilateral, owing to infection, trauma, brain tumor surgery,
parotid tumor operations, or radiation necrosis. Mobius syndrome with
bilateral facial palsy has never been encountered in our group.
For patients with facial paralysis with incomplete recovery or
young patients without recovery, cross-facial nerve grafting is the primary
treatment, and subsequent free muscle transfer could be performed if
TABLE 6. Group 4: Facial Palsy Combined With Mandible Defect
(Treatment: See Text)
Case Avg Radiation,
Number Age Sex Chemotherapy Result
A. Functioning 3 46 M/F = 3 Good in 1 case;
muscle transfer 1/2 acceptable in
2 cases
B. Sling for 5 5 Good in 1 case;
mandible acceptable in
4 cases
C. Facial nerve 1 1 Acceptable in 1
grafting case
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 Chen et al Annals of Plastic Surgery • Volume 90, Supplement 2, May 2023

TABLE 7. Group 5: Palsy of Individual Branch of Facial Nerve (Treatment: See Text)

Case Number Avg Age Sex Radiation/Trauma Result (Symmetry)

Frontal branch 2 27.5 M/F = 2/0 Trauma in 2 cases Good in 2 cases
Zygomatic branch 3 29.6 M/F = 3/0 Trauma in 3 cases Good in 3 cases
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Buccal branch 4 23.4 M/F = 4/0 Trauma in 4 cases Good in 4 cases

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Marginal mandibular branch 7 31.6 M/F = 7/0 Trauma in 7 cases Good in 7 cases

TABLE 8. Group 6: Patients With Partial Recovery and Dyskinesia (Treatment: See Text)

Case Number Average Age Sex Radiation Result*

35 39.8 y M/F = 6/29 3/35 Good in 24 patients
Fair in 11 patients
*Requiring repeated use of Botox injection.

TABLE 9. Group 7: Facial Palsy With Dynamic Asymmetry and Soft Tissue/Muscle Atrophy (Treatment: See Text)

Case Number Avg Age Sex Radiation Result (Facial Symmetry)

21 47.4 y M/F = 11/10 6/21 Good in 14 cases*
Acceptable in 7 cases (including 6 radiated cases)*
*Needed repeated injection of Botox or fillers.

FIGURE 1. A and B, Image showed cross-facial nerve grafting with subsequent free gracilis muscle transfer. This 28-year-old female
patient had experienced complete left facial palsy since childhood, which did not recover. In the first stage, a cross-facial nerve graft
was done and Tinel sign was followed. Ten months later, a functioning muscle transfer was performed, and lateral canthopexy of left
lower eyelid was done. The patient showed good recovery with symmetry of face on smiling at 2 years of follow-up.

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 Annals of Plastic Surgery • Volume 90, Supplement 2, May 2023 Multimodal Reconstruction for Facial Paralysis
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FIGURE 2. This is a 48-year-old female patient of Ramsey-Hunt syndrome with involvement of multiple cranial nerves. For older facial
palsy patients without recovery, regional muscle transfer using temporalis muscle could be performed to restore the dynamic
symmetry of the face. Circumferential sling operation using palmaris tendon graft and lateral canthopexy was performed to tighten the
eyelids. Plantaris tendon sling was applied to lift left nasal alar cartilage for creation of left nasolabial fold for static symmetry, which
worked well with the transferred temporal muscle dynamic action (left upper photo: preoperative presentation; right upper and left
lower photos: during surgery, the temporalis muscle was elevate; left lower photo also showed the tendon sling facilitated
circumferential eyelid closure; right lower photo: good symmetry of face).

there is no return of local muscle function. Partial weakening of contralat-
eral muscles using botulinum toxin could refine the results.
For old patients experiencing facial palsy without recovery, re-
gional muscle transfer including temporalis muscle, masseter muscle,
and medial frontalis muscles are helpful to restore dynamic motion
and symmetricity, whereas circumferential sling operations and lateral
canthopexy are a useful approach for eyelid tightening to avoid dry
eyes. Additional tendon sling operation could be used to restore static
symmetry of the nasal ala and nasolabial fold, which could refine the
results of regional muscle transfer.
For combined facial palsy with mandibular deficiency, recon-
struction with vascularized bone flap is inevitable to restore the contour
and stability of mandible as well as soft tissue insufficiency. Simulta-
neously, cross-facial nerve grafting may be used for patients without
atrophy of facial expression muscles, which could be confirmed by
obtaining the compound muscle action potential of the affected side.
Otherwise, regional functional muscle transfers or static sling operation
with subtle weakening of contralateral facial muscles may facilitate the
balance of bilateral facial muscles and achieve facial symmetricity.
Regarding defect of the mandible, for minor mandibular defi-
ciency as in some cases with Goldenhar syndrome, in patients with
good occlusion, they chose not to do bone surgery such as sagittal split-
ting or sliding genioplasty; instead, the patient preferred to receive
Medpor mandibular implant onlay placement to correct hemifacial
microsomia and also turned out to be successful. For major mandibular
deficiency, vascularized bone mandibular reconstruction is necessary.
Regarding eyelid weights, placement of custom-made eyelid
gold weight had been tried in the past. Our experience was that it may

FIGURE 3. This 28-year-old patient had osteosarcoma treated with ablative surgery and radiation therapy, resulting in combined facial
palsy with mandible defect. She was treated with iliac osteocutaneous flap and temporalis muscle transfer. There was good symmetry
of face at 2 years of follow-up.

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 Chen et al Annals of Plastic Surgery • Volume 90, Supplement 2, May 2023
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FIGURE 4. This 18-year-old female patient experienced palsy of right frontal branch of facial nerve. For palsy of individual branch of
facial nerve such as frontal branch palsy, contralateral (left) medial frontalis strip muscle-periosteal sling transfer was done. There was
good recovery resulting in symmetry of upper face.

cause eye discomfort, looked unnatural, and may cause thinning of skin
and possibility of extrusion. Nowadays, the ophthalmologist may use
injection of hyaluronic acid as a source of adding weight to the upper
eyelid. However, it seemed that the effect of correction was minimal.
In old patients, nerve procedures could bring about variable de-
gree of improvement, then other auxiliary procedure were performed
for further correction as mentioned in Table 1.
CONCLUSIONS
Paralysis of the face has been a challenging and complicated
theme regarding how to alleviate the trauma caused by face cripple. The pa-
tient may face the problem of time and energy spent for correction of facial
deformities. For reconstruction of facial paralysis, multimodal integrated
approaches are mandatory, depending on the condition of the clinical

FIGURE 5. This 26-year-old woman had trauma in childhood resulting in palsy of marginal mandibular branch palsy. Myotomy of
depressor labii inferiois muscle was performed. There was good symmetry of lower face at 1 year of follow-up.

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 Annals of Plastic Surgery • Volume 90, Supplement 2, May 2023
presentation of each individual patient. Lengthy operations with
multiple stages should be retained until the problems cannot be
solved otherwise.
ACKNOWLEDGMENTS
The authors would like to thank Mr Ming-Chieh Li for his assistance
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in editing this manuscript. This work was presented at the World Associ-
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ation of Plastic Surgery of Chinese Descendent, Paris, November 2021.
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Multimodal Reconstruction for Facial Paralysis
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