Surgical Treatment of Congenital Facial Palsy: A Retrospective Analysis of More than 20 Years’ Experience in Smile Surgery

Background and Objectives: Congenital facial palsy, either isolated or associated with syndromic conditions such as Moebius syndrome, is a rare disorder that poses significant functional and psychological challenges for patients, families, and healthcare teams. Dedicated care pathways and a multidisciplinary approach are essential for optimal management. This study presents our experience of more than 20 years in smile surgery, highlighting clinical outcomes with an objective analysis of facial symmetry and movement as well as a review of our progressive improvements of surgical techniques and patient management over time. Materials and Methods: Patients diagnosed with congenital facial palsy who were referred to our institution for rehabilitative treatment and surgical management between January 2003 and December 2025 were retrospectively reviewed. In those with standardized preoperative and postoperative photographs, commissure excursion (CE) and commissure excursion deviation (CEdev) were measured with Emotrics and compared before and after surgery within three groups defined by the laterality of the palsy and of the reanimation. Results: Ninety-six patients were included, of whom 56.2% had a syndromic pattern. Facial reanimation was achieved by gracilis muscle transfer innervated by cross-facial nerve grafting (CFNG), supercharged CFNG, or masseteric nerve innervation, and only two major complications occurred. Objective analysis was possible in 61 patients (64%). In unilateral palsy, CEdev during smiling decreased from a median of 14.7 to 2.4 mm, with improvement in all 28 patients (p < 0.0001). Across the whole cohort, CE of the operated side increased by a median of 11.6 mm (95% CI 10.2–13.1) and dynamic excursion by 5.6 mm (4.5–7.0). Conclusions: Gracilis muscle transfer produced a large, objectively measurable gain in facial symmetry and movement. These outcomes reflect the progressive specialization of our institution and the refinement of surgical timing, flap inset and innervation source, together with structured facial rehabilitation, which should ideally begin before surgery and continue postoperatively.