BACKGROUND The "babysitter" procedure combines cross-facial nerve grafting with segmental transfer of the hypoglossal to the affected facial nerve. Introduced by Terzis in 1984, the technique can produce satisfactory to excellent results. In long-lasting paralysis, nonetheless, the babysitter procedure may need to be combined with a muscle(s) flap(s) for outcome upgrading, which was the focus of the present study. METHODS Thirty-eight patients had the babysitter procedure over a 20-year period (1984 to 2003). Twenty patients had only the babysitter procedure, whereas 18 needed an additional muscle flap(s) (up to three) to enhance function and cosmesis. These muscles included nine free (gracilis, pectoralis minor) and 20 regional (frontalis, minitemporalis, platysma, digastric) muscles for distinct target needs: eye closure, smile restoration, and lower lip depression. The need for a muscle flap was determined at the initial consultation. All free muscles were transferred at the second-stage of the babysitter procedure, whereas regional muscles were also transposed later. Three independent observers graded the results at two time intervals, preoperatively and 2 years after all operations were completed. RESULTS The average postoperative grading scores were significantly higher compared with preoperative scores for eye closure, smile, lower lip depression, and overall aesthetic outcome (p < 0.0001, Wilcoxon signed ranks test). All patients had upgrading of overall aesthetics and smile, whereas four maintained similar scoring for eye closure and one maintained similar scoring for lip depression. All but two had secondary procedures to further enhance facial symmetry. CONCLUSION The babysitter procedure in conjunction with muscle transfers in selected patients with late presentation can provide highly satisfactory results when seeking uncompromising outcome.