Free muscle transfer is the standard treatment for smile reconstruction, and a number of variations have been described, including one-stage procedures, two-stage cross-facial nerve grafting followed by free muscle transfer, and free muscle transfer innervated by the masseter motor nerve. Moreover, lengthening temporalis myoplasty has been reported as a beneficial single-stage option for smile reconstruction. At our facility, an algorithm for selecting the optimal surgical treatment for smile reconstruction was proposed. The following facial nerve palsy patients are suitable candidates for lengthening temporalis myoplasty：those who are at high risk, such as older patients with cardiovascular complications, for whom lengthy microsurgical procedures are unsuitable, those wanting extremely early muscular contraction after surgery, those who wish to avoid the risks of microsurgical procedures or scarring in the thoracodorsal and femoral regions where free flaps are harvested, those with bilateral facial palsy, or those who only exhibit poor movement of the oral commissure after free muscle transfer. A modified procedure involving an extended lazy-S incision can be performed for patients with the above conditions or preferences. In particular, we consider it suitable for patients who are young and/or female, those who do not wish to have facial scars, or those who have scars caused by parotidectomy for tumors of the parotid glands.
