Incomplete Facial Palsy Research Articles

An analysis of clinical efficacy of microvascular decompression for 21 inpatients suffering from primary hemifacial spasm

Objective:To assess the effectiveness of microvascular decompression（MVD） in treating inpatients suffering from primary hemifacial spasm（HFS）. Methods:A total of 21 inpatients with HFS underwent MVD. The clinical effect was follow up evaluated according to the clinical symptoms until post operative 6 months. Results:The effective rate of MVD for 1 day, 14 days, 1 month, 3 months and 6 months post-operation was 95.2%, 100%, 100%, 100% and 100%, respectively.one patient had transient tinnitus and the symptom disappeared within 6 days postoperatively.one patient developed postoperative incomplete facial paralysis（HB grade IV facial nerve function, grade Ⅱ） and recovered 6 days after surgery; There was no cerebrospinal fluid leakage, intracranial infection, death or disability occurred during follow-up. Conclusion:Microvascular decompression is a safe and effective method for the treatment of primary hemifacial spasm, which is worthy of clinical promotion.

Facial Paralysis Treatment Using Selective Neurectomy: A Comprehensive Review.

Facial paralysis can affect patients undergoing full mouth rehabilitation, regardless of what caused their paralysis. A procedure known as modified selective neurectomy of the facial nerve can enhance the movement of facial muscles in individuals with facial synkinesis safely and effectively. This approach is proposed as an alternative to more invasive surgical options when used independently as a treatment for incomplete facial palsy. Selective neurectomy offers a promising surgical option for managing nonflaccid facial paralysis and synkinesis, enhancing patients' quality of life. However, treatment plans should be individually tailored considering the complexity of facial paralysis and the unique needs of each patient, taking into account the timing and type of treatment. The objective of this review is to explore the use of selective neurectomy as a treatment for facial paralysis based on previously published papers.

Facial Palsy Secondary to Cholesteatoma: A Case-Series of 14 Patients

To evaluate patients with middle ear cholesteatoma presenting with facial palsy (FP). A total of 14 subjects (10 males and 4 females), with a mean age of 42.5 years, were included in our study. The majority of patients presented with incomplete FP (House-Brackmann HB II-IV, 11 cases) and the remaining 3 patients had complete facial paralysis (HB V-VI). A canal wall down mastoidectomy was performed in all the patients, followed by partial facial nerve decompression. At the one-year follow-up, eleven (78.5%) patients demonstrated satisfactory recovery to HB I-II. Facial function recovered to HB grade I-II in 9 (100%) patients who were surgically treated within one month, and in 2 (40%) patients who underwent surgery after one month. The tympanic segment of facial nerve was the most common site of involvement (8 patients). The multiple regression analysis showed that a higher preoperative HB grade combined with a gradual than sudden onset of FP more likely resulted in worse postoperative HB grade. Early surgical removal of cholesteatoma associated with FP is more likely to result in good facial nerve recovery (78.5% of cases), when it is performed within one month from the onset of FP. According to the literature, the tympanic segment of the facial nerve was more frequently damaged (77.7%), followed by the mastoid segment (22.9%), labyrinthine segment (11.1%), and geniculate ganglion (11.1%). Labyrinthine fistula, mainly of the lateral semicircular canal, can be expected in cases of facial nerve dehiscence. The canal wall down mastoidectomy combined with partial decompression surgery was the most preferred surgical treatment for the FP secondary to cholesteatoma.

Complete and incomplete lower motor neuron facial palsy in post-COVID-19 mucormycosis

Purpose:To study facial nerve palsy (FNP) in post-COVID-19-mucormycosis patients and its ocular complications, report different presentations of FNP in such patients, and propose its etiopathogenesis based on presentation and clinico-radiologic localization.Methods:A prospective cohort study was carried out in patients of post-COVID-19-mucormycosis who presented at our tertiary center, over a period of 3 months. Motor and sensory examination of the facial nerve was done to diagnose FNP and localize the lesion clinically. Slit-lamp examination was done for grading corneal involvement. MRI brain, orbit, and paranasal sinuses (PNS) with contrast were studied to find involvement along the facial nerve. It was assessed whether this site of lesion corresponded with clinical localization. Data were analyzed using the percentage of total cases and Fisher’s test.Results:A total of 300 patients with post-COVID-19 mucormycosis were examined, of which 30 (10%) patients were found to have FNP. All were lower motor neuron (LMN) type and were associated with corneal complications. The most common site clinically was distal to the chorda tympani (66.66%) and radiologically was infratemporal (IT) fossa (63.4%). The clinical localization significantly correlated with the radiological findings (P = 0.012). Twenty percent of patients showed incomplete involvement of facial musclesConclusion:FNP was found to be of LMN type. The most common site of insult was IT fossa. There was a good clinico-radiological correspondence of lesions. Isolated lesions were also found along the peripheral nerve course, presenting as incomplete facial palsy. Recognition of FNP in post-COVID-19 mucormycosis, in all its variable forms, is important to manage corneal complications.

Masseteric nerve transference with sling tendon for symmetry in the restoration of facial paralysis: An effective combination of dynamic and static correction

Masseteric nerve transposition has shown to be an effective technique for the treatment of facial paralysis. Due to its low morbidity at the donor site, its consistent anatomy, and one-stage operation, it constitutes a reliable option for both complete and incomplete facial paralysis. Masseteric nerve transference has proven to achieve good commissural excursion and dynamic symmetry. However, some patients with heavy faces and complete facial paralysis recover incompletely after surgery characterized by an asymmetrical smile with asymmetry at rest, affecting the cosmetic appearance. For these patients, we propose a novel combination of masseteric nerve transposition for the dynamic rehabilitation of the smile with a tendon sling suspension to create symmetry at rest. A detailed description of the surgical technique is given and results after using it with eight patients show good functional and aesthetic satisfaction. A combination of both dynamic and static techniques for complete facial paralysis rehabilitation may provide adequate symmetry with the contralateral healthy side both at rest and when smiling.

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

Over the last two decades, the senior author (B.H.) has had an extensive experience with facial paralysis reconstruction. During this period, the techniques have evolved substantially based on the experience and after observing and analyzing the surgical outcomes. The purpose of this article is to relay the lessons learned from the 20 years' experience and suggest an algorithm. In this retrospective study, we have included 343 cases of facial paralysis cases. Complete facial paralysis cases were 285 and 58 were incomplete facial paralyses, both requiring surgical procedures. Complete facial paralyses were divided in to short term (n = 83) and long term (n = 202). In total, 58% of the patients were women and 42% were men. The age range was 6 to 82 years. The techniques employed were 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 to achieve the best symmetry after reanimation of unilateral, bilateral, complete, and incomplete facial paralysis. The type of paralysis, objective measurements, the personal patient's smile, and the gender are key concepts to be considered before scheduling a dynamic facial paralysis reconstruction. For unilateral facial paralysis, the time of onset, the type of paralysis, the patient's comorbidities, and the healthy side status are some of the determining factors when selecting the correct technique. The preferred techniques for unilateral facial paralysis are direct repair, CFNG, masseteric-to-facial transposition, and free gracilis transfer. For incomplete facial paralysis, the masseteric-to-facial nerve transference is preferred. In bilateral facial paralysis, bilateral free gracilis transfer is performed in two stages using the nerve of the masseter muscle as the source of innervation. The authors provide an algorithm which simplifies facial paralysis reconstruction to achieve the greatest facial symmetry while thinking about the potential comorbidities and developing spontaneity smile according to the gender of the patient.

The Experience of a Facial Nerve Unit in the Treatment of Patients With Facial Paralysis Following Skull Base Surgery.

: The management of facial paralysis following skull base surgery is complex and requires multidisciplinary intervention. This review shows the experience of a facial nerve (FN) unit in a tertiary university referral center. A multidisciplinary approach has led to the breaking of some old treatment paradigms. An overview of five FN scenarios is presented. For each setting a contemporary approach is proposed in contrast to the established approach. 1) For patients with an anatomically preserved FN with no electrical response at the end of surgery for vestibular schwannoma, watchful waiting is usually advocated. In these cases, reinforcement with an interposed nerve graft is recommended. 2) In cases of epineural FN repair, with or without grafting, and a poor expected prognosis, an additional masseter-to-facial transfer is recommended. 3) FN transfer, mainly hypoglossal-to-facial and masseter-to facial, are usually chosen based on the surgeons' preference. The choice should be based on clinical factors. A combination of techniques improves the outcome in selected patients. 4) FN reconstruction following malignant tumors requires a combination of parotid and temporal bone surgery, involving different specialists. This collaboration is not always consistent. Exposure of the mastoid FN is recommended for lesions involving the stylomastoid foramen, as well as intraoperative FN reconstruction. 5) In patients with incomplete facial paralysis and a skull base tumor requiring additional surgery, consider an alternative reinnervation procedure, "take the FN out of the equation" before tumor resection. In summary, to achieve the best results in complex cases of facial paralysis, a multidisciplinary approach is recommended.

Combining an end to side nerve to masseter transfer with cross face nerve graft for functional upgrade in partial facial paralysis–an observational cohort study

Results of a single stage technique combining cross facial nerve graft(s) (CFNG) with an ipsilateral end to side nerve to masseter transfer (NTM) in incomplete facial paralysis are assessed in a retrospective cohort study. The hypothesis is that the technique can safely improve the quality of smile in these patients. End to side coaptations for the recipient facial nerve minimise the risk of iatrogenic function loss, contrasting with the end to end neurorrhaphies used in conventional babysitting procedures. A series of 27 patients was studied through case note review and standardised assessments. Surgical technique involves extensive exposure of the facial nerve and the NTM on the affected side and access is by bilateral preauricular incisions. End to end coaptations are made to the facial nerve on the donor side and on the recipient a standard CFNG is combined with an end to side NTM coaptation. Follow up was a minimum of 9 months from surgery. Overall improvement in the Sunnybrook scale averaged 33, from a pre-operative score of 40 (p < 0.05). Average upgrade of 4.7 mm of increased movement at the modiolus was achieved (p < 0.05), 43% improvement compared to the normal side. An improved resting symmetry of 3.8 mm was achieved in relevant cases. Where eye closure was strengthened the average improvement was 5 mm of increased lid closure. The smile achieved was spontaneous in 22 of 27 cases. The study confirms the hypothesis that CFNG with NTM transfer offers a physiological upgrade of facial movement in partial facial paralysis, applicable in both early and longstanding cases.

Effects of the Remaining and/or Spontaneously Regenerated Facial Axons After Hypoglossal-Facial Nerve Neurorrhaphy for Facial Paralysis.

Background: The incidence of incomplete facial paralysis is now relatively higher in clinical practice, and surgical intervention is still desirable for patients with significant facial paralysis. However, the importance and usefulness of the remaining and/or spontaneously regenerated facial axons for regaining facial function when using hypoglossal–facial nerve (HN-FN) neurorrhaphy or other nerve-transferring methods to treat facial paralysis remain controversial.Objective: We designed a rat FN injury model with preservation of the anatomical structure followed by HN-FN side-to-side neurorrhaphy to investigate the effects of the remaining and/or spontaneously regenerated FN axons on restoration of facial function.Methods: After the evident return of facial function in 3 months following FN injury and HN-FN side-to-side neurorrhaphy, the FN was cross-sectioned again according to different ratios (0, 30, 70, and 100%) at the site rostral to the initial FN injury to retain, partially abolish, or completely abolish the spontaneously regenerated FN axons that had successfully reinnervated the paralyzed facial muscles. Then, FN function was assessed using clinical evaluation methods and electrophysiological examinations, as well as retrograde labeling and axonal counting assessments of the reconstructed nerve pathways.Results: The evaluations show that the remaining facial axons not only influenced the extent of regained function, such as facial symmetry, eye blinking activity, and vibrissae motion, but also had an impact on regeneration and innervation of hypoglossal motoneurons.Conclusion: Participation of remaining or spontaneously regenerated facial axons plays an important role in innervating paralyzed facial muscles by both facial and hypoglossal motoneurons, thus, reestablishing facial function.

Analysis of Preoperative Factors Influencing Hypoglossal-facial ‘Side’-to-side Neurorrhaphy for Facial Paralysis after Excision of Acoustic Neuroma

ObjectiveHypoglossal nerve-facial nerve ‘side’-to-side neurorrhaphy is a new method for the treatment of potential incomplete facial paralysis after acoustic neuroma. However, there are differences in postoperative outcomes among patients. This study analysed preoperative factors that may influence the treatment outcomes of neurorrhaphy. MethodsWe performed a retrospective study of 53 patients who were treated by neurorrhaphy for facial paralysis after acoustic neuroma resection. After a one-year follow-up period, the patients were divided into two groups according to facial functional outcome: better recovery or ordinary recovery. We analysed the following factors: gender, age, tumour size, and characteristics, tumour adhesion to the facial nerve, the duration of facial paralysis (DFP) and F wave appearance prior to neurorrhaphy (F wave). ResultsUnivariate analysis showed significant differences between the two groups in DFP (P = 0.0002), tumour adhesion to the facial nerve (P = 0.0079) and F waves (P = 0.0048). Logistic regression analysis of these factors also showed statistical significance with P values of 0.042 for the DFP, 0.043 for F waves, and 0.031 for tumour adhesion to the facial nerve. ConclusionsTumour adhesion to the facial nerve, F waves appearance and DFP prior to neurorrhaphy are the predominant factors that influence treatment outcomes.

A Simple, Objective, and Mathematical Grading Scale for the Assessment of Facial Nerve Palsy.

It is imperative to acquire a simple, objective, and mathematical method for the assessment of facial nerve palsy which can be universally accepted and implemented. A grading scale which is convenient, continuous and economical was attempted for the first time for global and region-specific assessment of facial nerve palsy. Hospital-based observational study. Medical college hospital. Ten normal subjects and 51 patients with facial paralysis. Patients with facial nerve palsy were graded according to the revised version of House-Brackmann grading system (HBGS-2) and a newly proposed grading system. The results of the present study were compared with the HBGS-2. Data were analyzed using SPSS-17 (IBM Corporation, New York) for descriptive statistics, normality test, Wilcoxon signed-rank test, and Mann-Whitney U test. The mean time spent on recording measurements was 288 seconds. For the new method and HBGS-2, the modes were graded 3 and 4, corresponding to incomplete facial paralysis. The Kolmogorov-Smirnov normality and Wilcoxon signed rank tests were found significant. In Mann-Whitney U test, probability value indicated that grades of new scale were similar to grades of HBGS-2. The proposed simple, objective and mathematical (SOM) method of grading facial nerve palsy is convenient and provides global and regional continuous percentage that can monitor the progress and classify the patients with facial paralysis into six-point grades based on severity. This system was having substantial compatibility with HBGS-2 grading. For further validity, multi-center study with a larger sample of patients would be required.

Surgery for post-traumatic facial paralysis: are we overdoing it?

Early facial nerve decompression is recommended for cases of post-traumatic facial palsy on the basis of ENoG with degeneration > 95%. There is still a dispute in the literature concerning the role and timing of surgery versus conservative treatment in such cases. This study has been planned to evaluate the outcome of conservative management in traumatic facial paralysis with regard to type of trauma, onset, and electrodiagnostic tests. A prospective cohort study included 39 patients with post-traumatic facial palsy. All patients underwent ENoG, nerve stimulation test, HRCT temporal bone and Schirmer's test. The patients received intravenous methylprednisolone 1gm/day for 5 days or oral prednisolone 1mg/kg in tapering doses for 3 weeks. Follow-up was done at 4, 12 and 24 weeks after the treatment. Surgical exploration was limited to patients showing no improvement after 12 weeks. Facial nerve function was evaluated by the HBFNS and FEMA grading systems. Among the 39 patients in the study [5 women and 34 men; mean (SD) age, 33.5 (11.37) years], facial nerve recovery with conservative treatment alone was noted in 31 patients. The first signs of clinical recovery were noted in 27 patients by 4 weeks, in 31 patients by 12weeks. Seven patients required surgical exploration. At 24 weeks, 31 patients recovered to House-Brackmann grade I/III and 1 patient to grade IV. 19 of 26 patients with longitudinal fractures had grade I/III recovery, whereas all 6 patients with transverse fracture recovered on conservative treatment. Patients with incomplete facial palsy are candidates for conservative management. It is justified to try conservative management in patients with complete facial paralysis for up to 3months even in cases where ENoG and NET suggest poor prognosis. The presence of sensorineural hearing loss or transverse fracture at presentation does not suggest a poor prognosis for improvement.

An Experimental Study on the Optimal Timing for the Repair of Incomplete Facial Paralysis by Hypoglossal-facial ‘Side’-to-side Neurorrhaphy in Rats

ObjectiveTo investigate the optimal timing for the repair of persistent incomplete facial paralysis by hypoglossal-facial ‘side’-to-side neurorrhaphy in rats. MethodsA total of 30 adult rats with crushed and bulldog-clamped facial nerve injury were randomly divided into 5 groups (n = 6 each) that were subjected to injury without nerve repair or with immediate repair, 2-week-delayed repair, 4-week-delayed repair, or 8-week-delayed repair. Three months later, the effects of repair in each rat were evaluated by facial symmetry assessment, electrophysiological examination, retrograde labeling, and axon regeneration measurement. ResultsAt 3 months after injury, the alpha angle significantly increased in the group of rats with 4-week-delayed repair compared with the other four groups. Upon stimulation of the facial nerve or Pre degenerated nerve, the muscle action potentials MAPs were recorded in the whisker pad muscle, and the MAP amplitude and area under the curve in the 4-week-delayed repair group were significantly augmented at 3 months post-injury. Similarly, the number of retrograde-labeled motor neurons in the facial and hypoglossal nuclei was quantified to be significantly greater in the 4-week-delayed repair group than in the other groups, and a large number of regenerated axons was also observed. ConclusionThe results of this study demonstrated that hemiHN-FN neurorrhaphy performed 4 weeks after facial nerve injury was most effective in terms of the functional recovery of axonal regeneration and activation of facial muscles.

Hypoglossal-facial nerve "side-to-side" neurorrhaphy for facial paralysis resulting from closed temporal bone fractures.

Closed temporal bone fractures due to cranial trauma often result in facial nerve injury, frequently inducing incomplete facial paralysis. Conventional hypoglossal-facial nerve end-to-end neurorrhaphy may not be suitable for these injuries because sacrifice of the lesioned facial nerve for neurorrhaphy destroys the remnant axons and/or potential spontaneous innervation. we modified the classical method by hypoglossal-facial nerve "side-to-side" neurorrhaphy using an interpositional predegenerated nerve graft to treat these injuries. Five patients who experienced facial paralysis resulting from closed temporal bone fractures due to cranial trauma were treated with the "side-to-side" neurorrhaphy. An additional 4 patients did not receive the neurorrhaphy and served as controls. Before treatment, all patients had suffered House-Brackmann (H-B) grade V or VI facial paralysis for a mean of 5 months. During the 12-30 months of follow-up period, no further detectable deficits were observed, but an improvement in facial nerve function was evidenced over time in the 5 neurorrhaphy-treated patients. At the end of follow-up, the improved facial function reached H-B grade II in 3, grade III in 1 and grade IV in 1 of the 5 patients, consistent with the electrophysiological examinations. In the control group, two patients showed slightly spontaneous innervation with facial function improved from H-B grade VI to V, and the other patients remained unchanged at H-B grade V or VI. We concluded that the hypoglossal-facial nerve "side-to-side" neurorrhaphy can preserve the injured facial nerve and is suitable for treating significant incomplete facial paralysis resulting from closed temporal bone fractures, providing an evident beneficial effect. Moreover, this treatment may be performed earlier after the onset of facial paralysis in order to reduce the unfavorable changes to the injured facial nerve and atrophy of its target muscles due to long-term denervation and allow axonal regrowth in a rich supportive environment.

Incomplete Facial Paralysis: The Use of the Ipsilateral Residual Facial Nerve as a Donor Nerve for Facial Reanimation.

The reconstructive approach for incomplete facial paralysis is not yet determined. In this article, the authors present a new surgical approach for patients with incomplete facial paralysis in which residual, ineffective movement is detected preoperatively in the ipsilateral buccozygomatic territory of the paretic facial nerve. Sixteen patients with incomplete facial paralysis were found eligible for the procedure and underwent one-stage facial reanimation performed by the senior author (E.G.). Reanimation was performed using free gracilis muscle transfer with neural coaptation to an active facial nerve branch(es) responsible for the predetected buccozygomatic residual movement. Patients were reviewed in a systematic fashion using a combined still photographic and video scoring scale for symmetry at rest and at dynamic states. Following surgery, improved symmetry was observed in the majority of observations of the mouth region at rest and while smiling and of the nasolabial fold region while smiling. There was no significant change in symmetry in the majority of observations of the eye region at rest and while smiling and the nasolabial fold region at rest. Video assessment of dynamic facial symmetry while smiling demonstrated improved symmetry in 91 percent of the observations (n = 191 observations). Comparison of mean scores for dynamic smile symmetry produced a statistically significant improvement of 1.68 points following surgery (p < 0.001). Based on this series, the authors recommend that use of the ipsilateral facial nerve buccozygomatic residual branch be considered as a donor nerve for facial reanimation using a free gracilis muscle transfer in patients with incomplete facial paralysis with residual preoperative movement in the midface. Therapeutic, IV.

Discussion: Incomplete Facial Paralysis: The Use of the Ipsilateral Residual Facial Nerve as a Donor Nerve for Facial Reanimation.

Discussion: Incomplete Facial Paralysis: The Use of the Ipsilateral Residual Facial Nerve as a Donor Nerve for Facial Reanimation.

Masseteric Nerve as “Baby Sitter” Procedure in Incomplete Facial Paralysis

Supplemental Digital Content is available in the text.

Masseteric-facial nerve transposition for reanimation of the smile in incomplete facial paralysis

Incomplete facial paralysis occurs in about a third of patients with Bell's palsy. Although their faces are symmetrical at rest, when they smile they have varying degrees of disfigurement. Currently, cross-face nerve grafting is one of the most useful techniques for reanimation. Transfer of the masseteric nerve, although widely used for complete paralysis, has not to our knowledge been reported for incomplete palsy. Between December 2008 and November 2013, we reanimated the faces of 9 patients (2 men and 7 women) with incomplete unilateral facial paralysis with transposition of the masseteric nerve. Sex, age at operation, cause of paralysis, duration of denervation, recipient nerves used, and duration of follow-up were recorded. Commissural excursion, velocity, and patients’ satisfaction were evaluated with the FACIAL CLIMA and a questionnaire, respectively. The mean (SD) age at operation was 39 (±6) years and the duration of denervation was 29 (±19) months. There were no complications that required further intervention. Duration of follow-up ranged from 6-26 months. FACIAL CLIMA showed improvement in both commissural excursion and velocity of more than two thirds in 6 patients, more than one half in 2 patients and less than one half in one. Qualitative evaluation showed a slight or pronounced improvement in 7/9 patients. The masseteric nerve is a reliable alternative for reanimation of the smile in patients with incomplete facial paralysis. Its main advantages include its consistent anatomy, a one-stage operation, and low morbidity at the donor site.

Dynamic change of myogenin in denervated rat mimetic muscle.

We previously reported double innervation of rat mimetic muscles with labeling of facial nuclei. However, whether denervated mimetic muscles are affected after such nerve repair is not known. Rats were divided into five groups: Group A, controls; Group B, complete facial palsy; Group C, complete facial palsy with repair using end-to-end neurorrhaphy; Group D, incomplete facial palsy; and Group E, incomplete facial palsy with repair using end-to-side neurorrhaphy. Preoperatively and postoperatively, facial palsy and myogenin (Myog) expression in mimetic muscles were evaluated. Expression peaked on day 7 in Group B but was lower in Groups C and D. Expression in Groups D and E was comparable on day 28, and each model's score showed characteristic changes. Myog expression in facial mimetic muscles increases with denervation and decreases with nerve repair. Determining Myog expression levels in mimetic muscles just after nerve repair may help surgeons predict postoperative prognosis in facial palsy.

Mini-Temporalis Transposition

Facial paralysis is a common craniofacial deformity that is responsible for significant psychological and functional impairment. Free muscle transfer in 2 stages and latissimus dorsi transfer in one stage may be the most effective surgical procedure for achieving a symmetrical spontaneous smile for a patient with complete facial paralysis. However, these 2 procedures are unsuitable for many incomplete patients. The authors introduce a less invasive procedure, termed mini-temporalis transposition that is able to achieve a symmetrical spontaneous smile in incomplete patients. Through a zigzag incision into the temporal region, the middle third of the temporalis is transferred and elongated with the palmaris longus tendon or combined with the deep temporal fascia. The strips are anchored to key points at the modiolus and the middle of the ipsilateral orbicularis oris muscle through a small intraoral incision and subcutaneous tunnel. The key points are marked during preoperative smile analysis. This procedure was applied to 15 patients with long-standing incomplete facial paralysis. All patients obtained improvements in smile symmetry after the operation, and patients' satisfaction was high. In addition, no damage to residual facial nerve functions or development of procedure-induced complications (such as a facial contour defect, lip eversion or puckering, or skin tethering) was observed in any of the patients. Nevertheless, slight temporal hollowing was observed in 4 patients, and mild bulkiness over the zygomatic arch was a common observation. In summary, the mini-temporalis transfer technique is a safe and effective method of smile restoration for long-standing incomplete facial paralysis.