Peripheral facial palsy: contemporary advances and unresolved debates in management from pathogenic mechanisms to tailored reconstruction

Background: Peripheral facial palsy (PFP) exhibits highly variable etiology and clinical course. While some patients recover spontaneously within weeks, others develop persistent sequelae including synkinesis and crocodile tears that substantially impair quality of life. Management strategies differ considerably across clinical centers worldwide, reflecting ongoing uncertainty regarding optimal therapeutic approaches. Methods: This narrative review examines PFP pathophysiology, pharmacotherapy, surgical interventions, PRF neuromodulation, and rehabilitation technologies (125). A literature search of PubMed, Embase, and Cochrane Library (inception to June 2026) was conducted using keywords including "Bell's palsy," "peripheral facial palsy," "facial nerve decompression," "pulsed radiofrequency," and "rehabilitation." RCTs and observational studies were evaluated, with emphasis on systematic reviews and meta-analyses. All pooled statistics are reproduced from cited meta-analyses rather than generated by this review. Results: Bell's palsy pathogenesis involves a triple-hit cascade comprising viral reactivation, immune-mediated inflammation, and ischemic edema within the rigid Fallopian canal. Corticosteroids remain the first-line pharmacological intervention; antiviral agents demonstrate incremental benefit only in severe presentations (number needed to treat [NNT] = 15; as reported in a meta-analysis by de Almeida et al.). Surgical decompression for idiopathic facial palsy lacks Level I randomized controlled trial (RCT) evidence. PRF neuromodulation, a minimally invasive interventional modality, occupies an intermediate therapeutic position between pharmacotherapy and open surgery, demonstrating anti-inflammatory and neuroprotective effects with 70-90% symptom relief in hemifacial spasm at 6-24 months. Functional electrical stimulation (FES), extended reality (XR), and artificial intelligence (AI)-enhanced rehabilitation technologies show theoretical promise but await rigorous clinical validation. Conclusion: PFP management is evolving toward precision medicine, incorporating biomarker-driven patient stratification, AI-assisted outcome prediction, and multinational collaborative trials to establish evidence-based therapeutic standards. Four critical evidence gaps are identified: corticosteroid-antiviral stratification, decompression RCTs, PRF standardization, and rehabilitation validation.