Repairing advanced facial palsy is indeed quite difficult: after whatever causes facial nerve damage, the facial expression muscles innervated by the facial nerve are also bound to undergo denervated atrophy and degeneration, eventually becoming fibrous tissue with no contractile function. As a result, the facial expression activity on the affected side is also completely lost. The repair of advanced facial palsy has always been a major problem in plastic surgery, and there is still no ideal method. The basic principle of plastic surgery tells us: the same thing —- means to repair the defect with similar tissues. Therefore, to repair the facial muscle defect and restore the facial expression activity in patients with advanced facial palsy, it is necessary to transplant the muscle to the affected side of the face to rebuild the function of the expression muscle on the affected side with the contraction function of the transplanted muscle. The facial muscle is composed of several muscle groups, and the facial nerve has multiple innervation of each muscle group, which is extremely complex and varies from person to person in terms of the strength of the contraction force of the facial muscle, the direction of muscle contraction, the strength of antagonism and synergy between each muscle group, and the coordination of various expression movements. Therefore, it is practically impossible to reestablish the complex and delicate expression function of multiple muscle groups on the affected side of a patient with facial palsy by transplanting only 1 or 2 muscles. However, it does not mean that plastic surgeons will be helpless and unable to do anything for the repair of advanced facial palsy. It is still possible to improve the symmetry of both sides of the face and to restore certain expressive movements (e.g. smiling) on the affected side through plastic surgery. In fact, patients with facial palsy often do not smile in order to conceal their crooked “smiling face”, which gives people the misconception that they are extremely serious, and this inevitably affects their interpersonal communication. If you can restore the natural smile to the face of a person with facial palsy, you can integrate the patient into society with a smile on your face. Smile —- This is essential not only for people with facial palsy, but even for everyone. To repair advanced facial palsy to transplant muscles to rebuild facial muscles: my experience in repairing facial palsy for 24 years tells me: because muscle contraction is active, flexible and elastic, replacing the paralyzed muscles of the face with muscle transfer is the same tissue to repair in order to get the most ideal results for patients with advanced facial palsy. It cannot be compared with other tissue grafts, either static or dynamic fascial suspension repair. The muscle transfer procedure can be divided into free muscle grafting with microsurgical techniques and local muscle transfer with non-microsurgical procedures. Since free muscle grafting must be performed with microvascular and nerve anastomosis, either muscle necrosis due to vascular crisis after vascular anastomosis, or nerve necrosis after nerve grafting, or nerve regeneration with wrong growth and wrong site, will cause facial palsy repair surgery failure. Microsurgery has many unknown uncertainties, so the outcome after surgery is highly variable. After microsurgery, patients with facial palsy have to recuperate for at least a year before the final result of the repair can be known. As far as I know, the percentage of surgical failures is not low. As long as there is a problem with any of the tissues of the blood vessels, nerves and muscles, the facial palsy repair will be a complete failure. For this reason, both the surgeon and the patient with facial palsy have to suffer great psychological stress and risk for the success or failure of the surgery. It is certain that no patient or surgeon would like to see or accept the result of failure, but who should bear the risk of microsurgery itself? In order to avoid this soft spot of microsurgery risk and to apply muscle transplantation to repair the facial muscle defect of advanced facial palsy, since 1999, based on the previous experience of repairing facial palsy, I have invented a new procedure of applying sternocleidomastoid muscle transfer to repair advanced facial palsy. The basic principle of this procedure is to surgically transfer the sternocleidomastoid muscle on the affected side to the corner of the mouth on the affected side, and to reconstruct the patient’s smile expression by contraction of the sternocleidomastoid muscle. Because of the positive effect, small trauma and quick recovery, this procedure has been performed for more than 200 patients over the past ten years and has been accepted and confirmed by patients. The features of sternocleidomastoid muscle transposition to repair advanced facial palsy: 1. The sternocleidomastoid muscle is located in the neck and is close to the face, so it is convenient to transfer the surgery nearby. 2, The muscle belly of the sternocleidomastoid muscle is long and can have a large transfer range, and the muscle is more than enough to transfer from the neck to the corner of the mouth. The blood supply of the sternocleidomastoid muscle is extremely rich, and although some of the blood vessels must be ligated during the surgery, it will not affect the survival of the muscle. The sternocleidomastoid muscle has its own blood vessels, so there is no need to anastomose the blood vessels again. Since the operation was carried out, no case of necrosis of the transplanted muscle has occurred. The sternocleidomastoid muscle has long innervated nerves, so as long as attention is paid to the protection of the paraneoplastic nerves during the operation, it will not cause muscle paralysis. Since the operation, no paralysis of the transplanted sternocleidomastoid muscle has occurred. 5. Since the sternocleidomastoid muscle is innervated, there is no need to anastomose the nerve, so it can contract and move immediately after the transfer. 6. The sternocleidomastoid muscle itself is an innervated muscle, so when it is transferred to the face and comes in contact with the paralyzed facial muscle, the nerve branches in the sternocleidomastoid muscle can grow into the original paralyzed facial muscle and make it regain innervation. 7. As long as the function of the sternocleidomastoid muscle is intact, muscle transposition can be performed to repair facial paralysis. Therefore, the indications for this surgery are very wide. Because the sternocleidomastoid muscle has the above characteristics, the use of local transfer of the sternocleidomastoid muscle avoids the risk of significant microvascular and nerve surgery. The sternocleidomastoid muscle is transferred with a nerve, which also avoids the problems that may occur when the nerve is regenerated. In addition, it is possible to reinnervate the paralyzed facial muscles and regain the contractile function, which can lead to an unexpected effect of repairing facial paralysis. Since I started to perform sternocleidomastoid muscle transposition to repair advanced facial palsy in 1999, I have accumulated more than 200 surgical cases, and so far I have not encountered a single case of complete failure after surgery. Of course, I cannot guarantee that no surgical failure will occur in the future, but the safety, reliability, and effectiveness of the procedure are still evident. Sternocleidomastoid transposition surgery steps and recovery process: Sternocleidomastoid transposition surgery is a plastic surgery procedure, and since it is a surgical procedure there must be a surgical incision. The incision for this surgery is made from the front of the ear on the side of the facial palsy down to the neck and ends at the front of the neck. The incision is hidden and the incision is mostly in the direction of the skin line, so the scar of the surgical incision is not obvious. Careful separation of the sternocleidomastoid muscle first during surgery can avoid damage to the sensory nerves in the neck and prevent postoperative neck numbness. The innervated nerves of the sternocleidomastoid muscle must be carefully separated to avoid damage to the collateral nerves and to prevent scapular mobility impairment due to injury to the trapezius muscle. The sternocleidomastoid muscle can elevate the affected orofacial angle immediately after transposition to the affected orofacial angle to achieve orofacial symmetry at rest. Patients can move their corners of the mouth after waking up from surgery, but since the muscle suture has not yet grown strong, functional movement training of the corners of the mouth can only be performed one month after surgery according to the surgeon’s instructions. One week after surgery, the stitches will be removed and the patient can go home to recuperate. After 6 months, the post-operative swelling on the affected side of the face will gradually subside and you will be able to smile more naturally. I always tell my patients that they should come back for a follow-up exam six months after surgery, and that if there are any unsatisfactory areas, some minor outpatient surgery can be done to further improve the symmetry of the face. The patient also needs to be instructed to train the corners of the mouth in smiling movements in order to make the smiling movements more natural and symmetrical, and the results of the surgery will become better. Actual results of sternocleidomastoid muscle repair for facial palsy: Typical case Female, 28 years old. In November 2005, a right sternocleidomastoid muscle transposition was performed under general anesthesia. After suturing the sternal and clavicular heads of the sternocleidomastoid muscle to the orbicularis oris muscle of the healthy upper and lower lip, the distorted orofacial deformity was corrected. The postoperative recovery was smooth and the orofacial movement was resumed after one month. At the one-year postoperative follow-up, the static symmetry was basic and the dynamic smile was natural. The sternocleidomastoid transposition has its own characteristics and there are also places for further improvement. The impact of sternocleidomastoid transposition on the appearance of the neck is mainly due to the incision scar. Occasionally, patients refuse to operate because of the fear of scarring. For this reason, minimally invasive endoscopic excision of the donor muscle has been considered, and the incisional suture can be closed with biological tissue adhesive to minimize incisional scarring. There is no significant effect on the appearance of the neck after sternocleidomastoid muscle transposition. Although this procedure transfers the sternocleidomastoid muscle on the affected side, the movement of the neck can be compensated by other cervical muscles. Therefore, none of the postoperative patients had any significant impairment of neck movement or significant cosmetic deformity. This is a normal manifestation of sternocleidomastoid muscle contraction after transposition, which can be explained to the patient before surgery. Other than this, no adverse consequences have been observed. However, in children, it is unclear whether the sternocleidomastoid muscle will affect their neck function and development after transposition, and it is recommended that this procedure should be carefully considered in pediatric cases. The main impact of the surgery on the appearance of the neck is the incisional scar. Occasionally, patients refuse surgery because of scar concerns. For this reason, minimally invasive donor muscle excision with endoscopy has been considered, and incisional sutures can be replaced with biologic tissue adhesive to minimize incisional scarring. After unilateral sternocleidomastoid muscle transposition, there is no major obstacle to the neck rotation function, but individual patients feel effort when raising their heads in supine in the early stage after surgery, and they can adapt to it after several months. 2. The importance of neural re-education of the sternocleidomastoid muscle after transposition: when the neck is rotated to the healthy side, the sternocleidomastoid muscle presents contraction, which is the basis of postoperative orofacial activity on the affected side. Since this is not known to the patient, the patient should be taught how to make the affected donor muscle contract flexibly before surgery, otherwise it will be much more difficult for the patient to learn to innervate the transposed donor muscle after surgery. In the early postoperative period, when the patient rotated his neck, he smiled with the corners of his mouth on the healthy side, which could show the effect of “smiling back” but always made people feel unnatural. The patient was instructed to train repeatedly in front of the mirror, not to rotate the neck only through the subjective intention of a slight head down can also make the muscle contraction, so that the facial smile is more natural, can give the patient an unexpected surprise, as long as adhere to the training, so that the smile action habit, the smile will be more natural. The author once treated a patient who was admitted to a middle school after surgery. When we met again many years later, the little patient had grown into a big girl. We can also see this. Some patients with facial palsy since childhood, because they have been hiding their facial expressions by not smiling since childhood, after the author successfully operated on them, although the transposed muscles were moving well, the patients were still not used to smiling, so they had to overcome the psychological barriers, actively train and dare to smile to get good surgical results. 3. Sternocleidomastoid muscle with neurovascular has the function of reinnervation of paralyzed perioral muscles: previous studies have confirmed that (the author’s NSF funded project completed in 1996 – experimental study on the reinnervation of denervated muscles by muscle bundles with neurovascular) when muscle bundles with neurovascular are implanted in paralyzed muscles, they can When the neurovascular muscle bundle was implanted into the paralyzed muscle, it restored innervation to the paralyzed muscle. In follow-up patients, electrophysiological examination revealed that the close contact between the muscle belly and the paralyzed periorbital muscle during sternocleidomastoid displacement gradually restored innervation to the paralyzed periorbital muscle. In the existing cases, patients with short disease duration can have better surgical results due to the reinnervation of multiple perioral muscles that can make the corners of the mouth more symmetrical, while patients with long disease duration and complete loss of perioral muscles have only a single transposed muscle contraction after surgery, and the surgical results and symmetry of the corners of the mouth are not as good as the former, which may be related to this. Especially in cases of facial palsy since childhood, due to the long-term influence of the affected side by the pull of the healthy side and unilateral chewing, there is a big difference in the development of facial bones on both sides, although the postoperative angle of the mouth has improved, but the overall symmetry of the face still needs to be repaired by local surgery after surgery. 4.Characteristics of sternocleidomastoid transposition: the application of microsurgical techniques for dynamic repair of advanced facial palsy is more complex and technically demanding. Therefore, the indications for surgery are quite strict, and not many patients are suitable for surgery due to the restrictions of age and physical condition. Because the results of the surgery cannot be confirmed, patients have many doubts about the results of the surgery and cannot be widely performed. Sternocleidomastoid transposition, which replaces the contractile function of the facial muscle by the contraction of the displaced sternocleidomastoid muscle, is also a dynamic repair, but the results are positive because the instability of nerve regeneration and the risk after vascular anastomosis are avoided. The recent results are satisfactory. We are still following up the patients and the final results are still to be judged by time, but in general, this procedure has a wide range of indications and is not complicated and can be mastered by any well-trained plastic surgeon. At the same time, it is easy to be accepted by patients because of its small damage to the patient, obvious and reliable effect, quick recovery, short hospitalization time and low cost, etc. It is believed that this procedure can play a role in the repair of advanced facial palsy. 5. The repair of advanced facial palsy is a systematic project: due to the paralysis of expression muscles, the loss of expression function in advanced facial palsy is followed by various deformities of the forehead, eyes and eyebrows, mouth and nose, cheeks and so on. Due to the different extent and degree of facial muscle paralysis, the facial deformities are also manifested in a variety of ways. A single local surgery can only correct this local deformity. Therefore, it is obviously impossible to expect that all deformities of advanced facial palsy can be repaired by applying a particular procedure. The authors propose: individualization of facial palsy treatment surgery and serialization of facial palsy deformity repair, the purpose of which is to select a suitable surgical procedure based on careful examination of the physical symptoms before surgery, and to gradually and serially repair multiple deformities of the affected face on the basis of repairing perioral deformities, so that the repair of advanced facial palsy can be done better.