Static reconstruction for facial paralysis is mainly used for improving acute symptoms around the eyelid and symmetry at rest. Many procedures have been reported for each facial region. Proper treatment options should be selected by evaluating multiple factors such as duration of paralysis, age of the patient, and severity of the symptoms.
　　Static reconstruction is the major procedure for eyelid reconstruction, and reconstruction around the eyelid requires not only functional recovery from paralytic lagophthalmos but also cosmetic improvement for paralysis.
　　For eyelid reconstruction in acute cases, we think lower eyelid reconstruction using minimally invasive procedures, such as the Kuhnt-Szymanowski procedure, should be considered first, followed by evaluation for upper eyelid surgery.
　　In chronic cases, lower eyelid reconstruction should also be considered first；however, the procedures should be more stable using grafts of fascia or cartilage. Then, eyebrow lift is performed, especially when upper eyelid ptosis is marked due to redundancy of upper eyelid skin. Finally, we consider surgery for the upper eyelid on a case-by-case basis.
　　In this study, we describe our systemic algorithm for each facial region using representative cases.

　　The etiologies, symptoms, and prognosis of facial palsy vary. For example, the facial nerve reconstruction for congenital paralysis is different from that for acquired disease.
　　Conditions of facial palsy include flaccid complete paralysis, incomplete paralysis, contracture, and mass movement.
　　The social status and general condition of the patients should also be considered during the management of facial palsy.
　　Surgical procedures for facial nerve reconstruction differ greatly, and there are numerous surgical options such as end-to-side neurorrhaphy, cross-facial nerve graft, hypoglossal or masseteric or accessory nerve cross-over, interpositional jump graft, babysitter procedure, cable graft and loop graft for defects in multiple branches of facial nerves, and neural signal augmentation in network type or cross-link surgeries.
　　Nerve reconstruction for the respective periorbital and perioral regions is a useful option for both new and established facial palsy.
　　Surgical procedures for facial nerve reconstruction are selected based on many factors.
　　We here present our surgical algorithm for nerve reconstruction for facial palsy.

　　The pathology of facial palsy is complicated because it includes both acute palsy and long-onset palsy with mimetic muscle atrophy, viral infection and surgical abrasion, and both complete and incomplete palsy. Our algorithm for surgical treatment for facial nerve palsy is presented in this article. We divided facial nerve palsy into three groups, 1）complete acute palsy, 2）incomplete palsy with ongoing denervation or re-innervation, and 3）long-onset palsy with mimetic muscle atrophy.
　　1）For complete acute palsy caused by trauma or tumor abrasion, we perform nerve reconstruction as soon as possible. However, if reconstruction is impossible at the damaged area, interpositional-jump grafting is carried out at the distal facial nerve trunk with axonal switching from the partial hypoglossal nerve.
　　2）For incomplete palsy with ongoing denervation or re-innervation, network like reconstruction with axonal supercharge from the hypoglossal nerve using an interpositional nerve graft with two end-to-side neurorrhaphies, is performed.
　　3）For long-onset palsy with mimetic muscle atrophy, static reconstruction or dynamic reconstruction using free muscle transfer is selected or combined, depending on the patient’s needs, age, and complications.

　　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.

　　Although facial synkinesis and contracture are distressing consequences of incomplete recovery form facial paralysis, there is no consensus regarding its preferred treatment. In this report, we present our therapeutic strategy and methods, including non-surgical and surgical treatments, for facial synkinesis and contracture.
　　Our non- surgical treatments include（1）facial neuromuscular retraining and（2）botulinum toxin type A（BTX-A）injections for selective chemodenervation of the affected muscle groups. Our surgical treatments include（1）myectomy and selective neuromyectomy to decrease muscle contraction,（2）blepharoplasty, nasolabialplasty and face-lift to repair the facial deformity caused by facial contracture, and（3）neurorrhaphy between the branches of the facial nerve and the hypoglossal nerve and/or the masseter nerve using a nerve graft to improve synkinesis and recovery from facial paralysis.
　　Non- surgical methods are less invasive and suitable for first-choice treatments. However, not all patients can continue non-surgical treatments, because the effects of BTX-A are temporary, and neuromuscular retraining generally takes a long time and a good outcome is not guaranteed. We think that combined BTX-A and surgical treatments in a patient-tailored graduated fashion based on facial neuromuscular retraining is necessary.

　　Neurovascular free muscle transfer for facial reanimation was first reported by Harii, et al in 1976. Although the restoration of strong and powerful contractions upon smiling was encouraging, these patients also exhibited involuntary muscle contractions with biting, most likely because the obturator nerve innervating the gracilis muscle was sutured to the ipsilateral deep temporal nerve that innervates the temporal muscle.
　　To overcome this problem, a two-stage operation combining the cross-facial nerve graft with the free-muscle transfer was developed. This method enables the use of the contralateral facial nerve, which results in a significant probability of achieving spontaneous synchronous animation. Surgeons therefore applied this method using different free-muscles, including the gracilis, pectoralis minor, rectus abdominis, and latissimus dorsi muscles. However, the long recovery period associated with this strategy may dissuade patients from choosing this treatment
　　One-stage reconstruction, in which the motor nerve is directly crossed through the face and sutured to the contralateral facial nerve branches, may shorten the duration until recovery of motor function. In 1981, Mayou described 10 cases of one-stage reconstruction using the extensor digitorum brevis muscle, followed by some new methods developed by other surgeons using the abductor halluces, gracilis, rectus abdominis, and latissimus dorsi muscles. However, its power as a motor source is sometimes weak because only some small branches of the facial nerve, not the whole trunk, can be used.
　　In 1993, Harii, et al. therefore developed the one-stage latissimus dorsi muscle transfer in which the thoracodorsal nerve was crossed across the face through the upper lip and hooked up to the branch of the contralateral facial nerve. This method allowed for strong contraction due to innervation by the contralateral facial nerve, which promised more natural facial movement. However, approximately 10% of cases had weak contraction despite innervation from the contralateral facial nerve branches.
　　To overcome the disadvantages with the contralateral facial nerve, the ipsilateral masseteric nerve was reconsidered as an alternative motor source approximately 10 years ago. Cortical adaptation between the nerve centers of the trigeminal and facial nerves was found to coordinate the motor activity of smiling. This hypothesis must be confirmed using functional MRI.
　　Recently, in order to gain the benefits of both nerves, dual innervation muscle transfer was developed. However, whether this method is superior to conventional methods is unknown. In this report, the history of neuro-vascularized free muscle transfer for treatment of established facial paralysis is described.

　　In the over 10-year follow-up of 57 cases of primary cranial expansion with distraction by our team, 2 cases have resulted in a bumpy calvarial deformity. These cases are reported in detail.
　　Case 1 was a 3-year-old patient diagnosed with oxycephaly who underwent calvarial expansion. The post-operative course was uneventful. Since puberty, the cranium began to gradually deform unevenly, requiring contouring surgery 15 years later. CT imaging revealed a wave-shaped outer cortex, and the bone marrow was fatty and yellowish in some areas.
　　Case 2 was mild trigonocephaly with increased intra-cranial pressure. Frontal advancement was successfully carried out by distraction when the patient was 2 years of age. After six years, a marked bumpy skull deformity in the front of the coronal suture was noted. Wavy cortical bone was also observed by X-ray.
　　The bumpy deformity on the distracted cranium may have been caused by overreaction during adolescence, mainly in the medulla of the frontal bone, where endochondral ossification occurs at the edge and film ossification occurs at the center. As such, the coronal ring area must be carefully followed-up for a long time after distraction surgery.