Facial reanimation in Moebius syndrome - 25-Year experience in treating bilateral facial paralysis.

Introduction
Moebius syndrome is a rare congenital neurological disorder characterised by bilateral facial (VII) and abducens (VI) nerve palsies, resulting in facial paralysis and impaired ocular abduction. Additional cranial nerve involvement and anomalies, such as limb deformities and neurodevelopmental abnormalities, complicate its presentation. Facial reanimation using a free functional muscle transfer is the gold standard for restoring movement and improving psychosocial outcomes. This study presents over 25 years of surgical experience in facial reanimation for Moebius syndrome management.Patients And Methods
A retrospective analysis of patients with Moebius syndrome who underwent bilateral facial reanimation between 1998 and 2023 was conducted. Outcomes were assessed using a surgeon's score, independent panel scoring with the Hay's rating scale and evaluation of spontaneous smile. We describe our surgical technique, key aspects of post-operative therapy and potential pitfalls.Results
Overall, 56 patients (30 women and 26 men) underwent facial reanimation. Among them, 49 had complete Moebius syndrome. Partial latissimus dorsi muscle flaps were used in 93% of the cases, with the masseteric nerve as the neural input (91%). Facial symmetry and function were rated as excellent (n=43) or good (n=11) in 96% of the patients. A spontaneous smile was achieved in 59% of the cases, with the best outcomes in masseteric-innervated latissimus dorsi transfers.Conclusion
Bilateral free functional muscle transfers are the gold standard for facial reanimation in Moebius syndrome management, yielding significant functional and aesthetic improvements, especially in children. We recommend performing bilateral facial reanimation as a single-stage procedure due to its physical and psychological benefits for this patient population.