BACKGROUND: Facial reanimation in patients with facial palsy secondary to malignancy is among the most challenging. This study explores the diagnostic pitfalls, treatment challenges, and variable outcomes in this patient population. METHODS: Adult patients at a single institution with facial palsy due to head and neck cancer were analyzed for demographics, facial palsy history, tumor characteristics, tumor treatments, reanimation treatments, and outcomes. RESULTS: Seventy-three patients met the inclusion criteria between 2009 and 2024. Facial palsy was caused by tumor involvement of the facial nerve in 52% of patients and by tumor treatment in 48% of patients. 32% of patients were initially misdiagnosed. 29% of patients presented with multiple cranial nerve involvement. In 4% of patients, the unexpected discovery of cancer within nerves during surgery changed the course of surgery. At the university hospital, 84% of patients received concomitant reanimation during extirpation and 40% concomitant free flaps compared with 9% and 13% respectively at outside institutions. 36% of operated patients experienced recurrence or major progression postoperatively. Dynamic reanimation failed in 26% of initial attempts. 94% of patients who underwent dynamic reanimation received at least 1 subsequent operation. CONCLUSIONS: Facial paralysis due to cancer represents a high-risk population, yet most patients should be offered reanimation procedures. Preoperative evaluation is the single most important stage of treatment, especially considering the high rate of misdiagnosis. Unexpected intraoperative findings, progressive and recurrent disease, high risk of reanimation failure, and the need for additional reconstructions must be anticipated and discussed with all patients.