Established Facial Paralysis Research Articles

Advances and future directions in the care of patients with facial paralysis

Advances and future directions in the care of patients with facial paralysis

Comparative Blink Analysis in Patients With Established Facial Paralysis Using High-Speed Video Analysis.

This study analyzed the blink characteristics of patients with incomplete and complete facial paralysis. The authors measured and compared the palpebral distance, eyelid movement distance, and the eye-closing ratio of blinks in 55 patients with Bell's palsy or Ramsay Hunt syndrome (Bell & Hunt group) and 14 with complete paralysis (Complete Paralysis group). in the Bell & Hunt group, the palpebral distance (7.94 mm) was smaller on the paralyzed side than on the non-paralyzed side (9.61 mm). The eyeclosing ratio and the upper eyelid movement were reduced on the paralyzed side (65.3% versus 93.7%, 4.61 versus 7.97 mm) and in the Complete Paralysis group (25.3% versus 94.7%, 2.10 versus 8.49 mm). In the Bell & Hunt group, movement of the upper eyelid on the paralyzed side was weakened despite palpebral contracture. The Complete Paralysis group exhibited highly reduced movement in both the upper and lower eyelids.

One-stage free transfer of latissimus dorsi-serratus anterior combined muscle flap with dual innervation for smile reanimation in established facial paralysis

Microneurovascular free muscle transfer is the gold-standard surgical procedure for the reanimation of established facial paralysis. However, the innervation of the transferred muscle by the contralateral facial nerve is usually insufficient to produce a stable smile. Besides, the corner of the mouth sometimes moves unnaturally as if it were being pulled up because of the single-direction movement. Thus, we propose one-stage facial reanimation using free latissimus dorsi (LD)-serratus anterior (SA) combined muscle flap transfer with dual innervation. The LD-SA combined muscle flap was harvested with the thoracodorsal artery and vein as common vessels to move the corner of the mouth bidirectionally for natural smiling. The LD muscle was located in the same direction as the zygomaticus major muscle and reinnervated by dual innervation. The contralateral facial nerve was coapted with the thoracodorsal nerve, and the ipsilateral masseter motor nerve was inserted into the LD muscle by intramuscular neurotization. The 6th or 7th SA muscle was located in the same direction as the risorius muscle and reinnervated by neurorrhaphy of the long thoracic nerve and the thin branch of the ipsilateral masseter motor nerve. Since 2015, seven patients have been treated with this method without complications. On average, SA muscle movement was detected in voluntary biting at 3.1 months, and spontaneous smiling occurred 7.7 months after surgery. All patients developed a spontaneous natural smile. This method for established facial paralysis has the potential to improve the quality of the reconstructed smile and the unstable results of conventional single-innervation-single-muscle transfer.

Facial reanimation with masseter nerve-innervated free gracilis muscle transfer in established facial palsy patients.

BackgroundThe masseter nerve is a useful donor nerve for reconstruction in patients with established facial palsy, with numerous advantages including low morbidity, a strong motor impulse, high reliability, and fast reinnervation. In this study, we assessed the results of masseter nerve–innervated free gracilis muscle transfer in established facial palsy patients.MethodsTen patients with facial palsy who received treatment from January 2015 to January 2017 were enrolled in this study. Three patients received masseter nerve–only free gracilis transfer, and seven received double-innervated free gracilis transfer (masseter nerve and a cross-face nerve graft). Patients were evaluated using the Facial Assessment by Computer Evaluation software (FACEgram) to quantify oral commissure excursion and symmetry at rest and when smiling after muscle transfer.ResultsThe mean time between surgery and initial movement was roughly 167.7 days. A statistically significant increase in excursion at rest and when smiling was seen after muscle transfer. There was a significant increase in the distance of oral commissure excursion at rest and when smiling. A statistically significant increase was observed in symmetry when smiling. Terzis’ functional and aesthetic grading scores showed significant improvements postoperatively.ConclusionsMasseter nerve innervation is a good option with many uses in in established facial palsy patients. For some conditions, it is the first-line treatment. Free gracilis muscle transfer using the masseter nerve has excellent results with good symmetry and an effective degree of recovery.

History of Neurovascular Free Muscle Transfer for Treatment of Established Facial Paralysis

History of Neurovascular Free Muscle Transfer for Treatment of Established Facial Paralysis

Altered axonal excitability properties in facial palsy.

Axonal excitability measures give insight into the biophysical properties of peripheral nerve axons. In this study we applied these techniques to the study of facial palsy. Thirty patients with established facial palsy due to unresolved Bell's palsy or herpes zoster (>6 months duration), tumor invasion of the facial nerve, or traumatic facial nerve injury were assessed using facial nerve excitability techniques. Full recordings were obtained in 23 patients (15 unrecovered Bell's palsy or herpes zoster, 5 trauma, 3 tumor-related). Compared with normal controls, the facial palsy group demonstrated changes in stimulus response properties, threshold electrotonus, refractoriness, superexcitability, and I/V slope. Depolarizing threshold electrotonus distinguished between viral and non-viral etiologies on subgroup analysis. In this cross-sectional study, established facial palsy demonstrated findings similar to those seen in studies of regenerated axons. The improved understanding of underlying axonal characteristics offered by the technique may guide future treatment. Muscle Nerve 57: 268-272, 2018.

Experience and anatomical study of modified lengthening temporalis myoplasty for established facial paralysis

Lengthening temporalis myoplasty, reported by Daniel Labbé in 1997, is a unique and definite facial reanimation procedure that involves moving the whole temporal muscle anteroinferiorly and inserting its tendon directly into the nasolabial fold. In the present article, we report our experience in the use of his modified method of the procedure, which preserves the zygomatic arch by transecting the coronoid process through the nasolabial fold incision. We also describe our cadaveric study that aimed to elucidate a secure approach for coronoid process transection. We performed this procedure in five patients with permanent facial paralysis. To improve facial symmetry, we also performed several additional static reconstructions such as T-shaped double-sleeve fascia grafts for lower lip deformities. We were successful in achieving considerable static improvement at rest, immediately after the surgery, and the recovery of facial movement was apparent approximately 3 months after the surgery. With regard to the cadaveric study, we noted that the entry to the buccal fat region, which is also the pathway of the temporal fascia, was a narrow space, and a short transection of the medial upper edge of the masseter fascia would make it easy to locate the coronoid process. Therefore, for a safe and secure access to the coronoid process from the nasolabial fold, we believe that we should first expose the cranial side and continue to dissect along the side and lower edge of the maxilla to locate the medial upper edge of the masseter fascia. By transecting along its edge, we could easily access the coronoid process, located immediately behind it, and widen the pathway of the temporal fascia. This modified method is less invasive and simpler compared to the original procedure, and understanding the detailed anatomy for dissection would help surgeons perform this procedure more confidently.

Postoperative Treatment of Neurovascular Free Muscle Transfer for Established Facial Paralysis

Postoperative Treatment of Neurovascular Free Muscle Transfer for Established Facial Paralysis

Free transfer of abductor hallucis combined with anastomosis of blood vessels and nerves for established facial paralysis:assessment of long term effectiveness

Objective:To evaluate the long-term effectiveness of free transfer of Abductor hallucis muscle plus anastomosis of blood vessels and nerves for dynamic reanimation of the established facial paralysis.Methods: Twenty-eight patients who received the above-mentioned treatment during March 1999 to November 2006 were followed up.The follow-up period was 1 to 16 years,with a median period of 4 years.The facial pictures of frontal view were analyzed before and after operation.T-FGS and facial nerve function index(FNFI) were used to evaluate the facial nerve function before and after operation.Meanwhile,the survival of the graft,the width of the face,the scar,and the function of the foot were analyzed and compared.Results: All patients obtained satisfactory symmetric faces in static state and voluntary contraction of the transferred muscles.Twenty-two patients obtained ideal smiling faces.The T-FGS score increased by(27±7.2) points and the score of FNFI increased by(57±10.7)% after transplantation(P0.05).Furthermore,the scars on the face were well concealed and there was no functional impairment in the donor foots.Conclusion: Free transfer of abductor hallucis muscle plus anastomosis of blood vessels and nerves has satisfactory long term outcome in dynamic reanimation of established facial paralysis,without functional impairment to the donor foot and is worth of popularizing.

Single-Stage Facial Reanimation in the Surgical Treatment of Unilateral Established Facial Paralysis

Surgical treatment of unilateral long-standing facial paralysis requires transposition of new musculature to restore the function of the atrophied mimetic musculature. Facial reanimation with free neuromuscular flaps is actually the accepted standard treatment. Two-stage procedures have been used for years, with a total flap recovery time of 18 to 24 months. In 1998, Harii proposed single-stage facial reanimation using the latissimus dorsi flap, showing a faster recovery compared with two-stage procedures. The present study evaluated the results of the authors' center applying the single-stage facial reanimation. From April of 1999 to April of 2006, 33 patients with unilateral established facial paralysis underwent single-stage facial reanimation via latissimus dorsi free flap transplantation. Time from the onset of paralysis ranged from 20 months to 64 years (mean, 11.6 years). Patients were followed postoperatively for at least 24 months. Results were studied and compared using Terzis and Noah's 1997 classification. Among the 33 patients included in the study, there was an average reinnervation time of 8.9 months. According to Terzis and Noah's classification system, 12 patients (36.3 percent) were considered grade V, 12 (36.3 percent) were grade IV, four (12.2 percent) were grade III, two (6.1 percent) were grade II, and three (9.1 percent) were grade I. Single-stage facial reanimation with a latissimus dorsi flap achieved morphofunctional results similar to those obtained with the classic two-stage technique. In addition, the authors were able to reduce the morbidity associated with treatment and the time required for recovery.

Dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer for re-animation of established facial paralysis: simultaneous reinnervation of the ipsilateral masseter motor nerve and the contralateral facial nerve to improve the quality of smile and emotional facial expressions

One-stage microneurovascular free muscle transfer is a common surgical procedure for re-animation of established facial paralysis. However, innervation of the transferred muscle by the contralateral facial nerve prevents smile and other facial expressions on one side, and reinnervation requires about 7 months. To overcome these drawbacks, we report a dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer. Three patients were treated with the dual innervation method, which is based on the one-stage method with some modifications: the soft tissue present over the ipsilateral masseter muscle and the hilum where the thoracodorsal nerve proceeds into the muscle segment is removed; the muscle is harvested to locate the hilum in the cranial one-third of the segment; and the muscle is transferred to the malar pocket of the paralysed face such that the hilum contacts the masseter muscle. On average, muscle movement was recognised on voluntary biting at 3.4 months and on spontaneous smiling at 5.9 months after surgery. A dual innervation sign was recorded on electromyographs 6.4 months after surgery. The patients developed a spontaneous symmetrical smile and facial expressions on one side with minimum synkinesis after postoperative mirror rehabilitation. The advantages of the dual innervation method include faster reinnervation of the transferred muscle compared to one-stage options; achievement of spontaneous smile and voluntary smile on each side; augmentation of neural signals to the muscle for more symmetrical smiling; minimum synkinesis of the transferred muscle on biting for eyelid closure and emotional facial re-animation through a learning program to enhance cerebral cortical reorganisation.

Masseteric-facial nerve coaptation – an alternative technique for facial nerve reinnervation

Reinnervation of the facial musculature when there is loss of the proximal facial nerve poses a difficult clinical problem. Restoration of spontaneous mimetic motion is the aim and, to this end, the use of cross-facial nerve grafts has long been considered the reconstruction of choice. The nerve to masseter has been used very successfully for reinnervation of microvascular functioning muscle transfers for facial reanimation in established facial palsy but its use as a direct nerve transfer to the facial nerve to reinnervate 'viable' facial musculature has been scarce. Electron micrographic studies of axonal counts in the nerve to masseter and nerve to gracilis in a clinical series of seven patients undergoing surgery for facial nerve palsy were made. Based on these results, and previous success with the use of the nerve to masseter for reinnervation of free gracilis transfers, we report our experience with the transfer of the nerve to masseter for direct coaptation with the ipsilateral facial nerve to restore facial motion. Our axonal counts of the nerve to masseter have, on average, 1542+/-291.70 (SD) axons. Historical data have shown that the buccal branch of the facial nerve has 834+/-285 (SD) where the distal end of a cross-facial nerve graft has 100 to 200 axons. Our clinical use of the nerve to masseter as a direct nerve transfer in three patients based on these data has resulted in significant improvement in facial symmetry in repose (at a minimum of 1 year follow up), restoration of facial motion with occasional spontaneous activity and minimal synkinesis without any donor morbidity. The advantages of this technique include the ease of dissection, constant and reliable anatomy, powerful reinnervation of the facial muscles without donor site morbidity and the potential for return of spontaneous facial movement.

Retrospective outcome analysis of temporalis muscle transfer for the treatment of paralytic lagophthalmos

Temporalis muscle transfer for paralytic lagophthalmos, which was first proposed by Gillies and later developed by Andersen, has been one of the most common treatment modalities for paralytic lagophthalmos. However, there have been no scientific reports statistically analysing the efficacy of temporalis muscle transfer. We, therefore, retrospectively analysed the functional and aesthetic results of temporalis muscle transfer. Between 1994 and 2006, we carried out temporalis muscle transfer (the so-called Gillies-Andersen method) on 95 established facial paralysis patients. We sent a postal questionnaire to these patients and 47 of them responded. The functional and aesthetic results were analysed based on the patients' replies together with clinical records and photographs, and unfavourable factors of this procedure were investigated. After surgery, most ocular symptoms (mechanical irritation, dry eye, soreness, and discharge) improved significantly. Achievement rate of complete eye closure was 78.7%. A morphometric study revealed that possible unfavourable factors (old age, intracranial disease, use of dentures, etc.) did not affect the achievement rates of complete eye closure. Deformity of eyelid fissure due to undue tension of the temporal fascia fixation was found in nine patients (19.1%) and six of these patients underwent secondary revision. Unlike lid loading with a gold implant, the results of temporalis muscle transfer depend greatly on the surgeon's skill. However, if this procedure is performed properly, strong eye closure can be obtained. We, therefore, recommend temporalis muscle transfer as the preferred option for reconstruction of paralytic lagophthalmos.

陳旧性顔面神経麻痺に対する各種治療法・術式の検討とビデオ画像からのコンピュータ解析による表情運動の定量的評価法

陳旧性顔面神経麻痺に対する各種治療法・術式の検討とビデオ画像からのコンピュータ解析による表情運動の定量的評価法

A modified longitudinally split segmental rectus femoris muscle flap transfer for facial reanimation: Anatomic basis and clinical application

Summary The present study was conducted to investigate the intra-muscular neurovascular anatomy and the intra-muscular tendon distribution of the rectus femoris muscle to reassess the reliability of technique of harvesting a longitudinally split segmental muscle flap, and to present our clinical experience on usefulness of the longitudinally split segmental rectus femoris muscle flap as a method for reconstruction of the paralysed face in a series of 25 patients. Twenty fresh cadavers were systemically injected with lead oxide, gelatin and water. Based on the anatomy of intra-muscular neurovascular structure in the rectus femoris muscle, 25 consecutive patients with established facial paralysis were treated by using a two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting. Follow-ups were 15–24 months. All of the 25 patients showed significantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases having poor movement of transferred muscle 2 years postoperatively. No complications occurred in the donor site. In conclusion, the present study has demonstrated the suitability for subdivision of the segment muscle flap of the rectus femoris into two functional units with a common neurovascular pedicle. This series has further demonstrated the safety and reliability of using the rectus femoris muscle flap for facial reanimation.

A modified longitudinally split segmental rectus femoris muscle flap transfer for facial reanimation: Anatomic basis and clinical applications

The present study was conducted to investigate the intra-muscular neurovascular anatomy and the intra-muscular tendon distribution of the rectus femoris muscle to reassess the reliability of technique of harvesting a longitudinally split segmental muscle flap, and to present our clinical experience on usefulness of the longitudinally split segmental rectus femoris muscle flap as a method for reconstruction of the paralysed face in a series of 25 patients. Twenty fresh cadavers were systemically injected with lead oxide, gelatin and water. Based on the anatomy of intra-muscular neurovascular structure in the rectus femoris muscle, 25 consecutive patients with established facial paralysis were treated by using a two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting. Follow-ups were 15-24 months. All of the 25 patients showed significantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases having poor movement of transferred muscle 2 years postoperatively. No complications occurred in the donor site. In conclusion, the present study has demonstrated the suitability for subdivision of the segment muscle flap of the rectus femoris into two functional units with a common neurovascular pedicle. This series has further demonstrated the safety and reliability of using the rectus femoris muscle flap for facial reanimation.

One-stage reconstruction of facial paralysis associated with skin/soft tissue defects using latissimus dorsi compound flap

Neurovascular free muscle transfer is now the mainstay for smile reconstruction in the treatment of established facial paralysis. Since facial paralysis due to ablative surgery or some specific disease sometimes accompanies defects of the facial skin and soft tissue, simultaneous reconstruction of defective tissues with facial reanimation is required. The present paper reports results for 16 patients who underwent reconstruction by simultaneous soft tissue flap transfer with latissimus dorsi muscle for smile reconstruction of the paralysed face. Soft tissue flaps comprised skin paddle overlying the latissimus dorsi muscle (n=6), serratus anterior musculocutaneous flap (n=5), serratus anterior muscle flap (n=2), and latissimus dorsi perforator-based flap with a small muscle cuff (n=3). The latissimus dorsi muscle can be elevated as a compound flap of various types, and thus offers the best option as a donor muscle for facial reanimation when soft tissue defects require simultaneous reconstruction.

Neurovascularized Free Short Head of the Biceps Femoris Muscle Transfer for One-Stage Reanimation of Facial Paralysis

The single-stage technique for cross-face reanimation of the paralyzed face without nerve graft is an improvement over the two-stage procedure because it results in early reinnervation of the transferred muscle and shortens the period of rehabilitation. On the basis of an anatomic investigation, the short head of the biceps femoris muscle with attached lateral intermuscular septum of the thigh was identified as a new candidate for microneurovascular free muscle transfer. The authors performed one-stage transfer of the short head of the biceps femoris muscle with a long motor nerve for reanimation of established facial paralysis in seven patients. The dominant nutrient vessels of the short head were the profunda perforators (second or third) in six patients and the direct branches from the popliteal vessels in one patient. The recipient vessels were the facial vessels in all cases. The length of the motor nerve of the short head ranged from 10 to 16 cm, and it was sutured directly to several zygomatic and buccal branches of the contralateral facial nerve in six patients. One patient required an interpositional nerve graft of 3 cm to reach the suitable facial nerve branches on the intact side. The period required for initial voluntary movement of the transferred muscles ranged from 4 to 10 months after the procedures. The period of postoperative follow-up ranged from 5 to 42 months. Transfer of the vascularized innervated short head of the biceps femoris muscle is thought to be an alternative for one-stage reconstruction of the paralyzed face because of the reliable vascular anatomy of the muscle and because it allows two teams to operate together without the need to reposition the patient. The nerve to the short head of the biceps femoris enters the side opposite the vascular pedicle of the muscle belly, and this unique relationship between the vascular pedicle and the motor nerve is anatomically suitable for one-stage reconstruction of the paralyzed face. As much as to 16 cm of the nerve can be harvested, and the nerve is long enough to reach the contralateral intact facial nerve in almost all cases. The lateral intermuscular septum, which is attached to the short head, provides "anchor/suture-bearing" tissue, allowing reliable fixations to the zygoma and the upper and lower lips to be achieved. In addition, the scar and deformity of the donor site are acceptable, and loss of this muscle does not result in donor-site dysfunction.

Rectus femoris muscle flap donor-site morbidity

Donor-site morbidity in four patients after reconstruction with free neurovascular rectus femoris muscle was examined through a series of strength tests in which the leg with rectus femoris muscle harvested was compared with the contralateral leg with an intact rectus femoris muscle. The tests were conducted with three testing devices: (1) the 'Con-Trex Leg-press' in which the force and power of right and left leg extensions at 0.2 and 0.4 m/s in a knee angle from 50 to 90 degrees were tested separately; (2) the isometric power tester, which enabled the unilateral evaluation of the isometric leg extension at three knee angles: 50, 70 and 90 degrees ; and (3) at the 'SP-Force Platforms' in which the patients performed a counter-movement jump where the amplitude of the ground reaction force, the parameters maximum force, and the jump height were calculated in order to compare the right and left leg during a single dynamic movement. Our results showed that the patients (with one exception) demonstrated a balanced relationship between the donor leg and the intact contralateral leg. The patient that primarily demonstrated a large strength deficit was retested 3 months later and showed, after an extensive rehabilitation and training program, an impressive increase in strength. The authors concluded that there is no significant limitation in the strength of the donor leg after removal of the rectus femoris muscle and consequently no significant functional donor-site morbidity. We believe that for the realisation of such results that the intraoperative linking of the vastus lateralis muscle with the vastus medialis muscle, especially in their lower third, and an extensive postoperative rehabilitation and training program are essential.

A Comparison of Temporalis Transfer and Free Latissimus Dorsi Transfer in Lower Facial Reanimation Following Unilateral Longstanding Facial Palsy

The ultimate goal in the treatment of facial palsy is the restoration of voluntary and spontaneous movement to the paralyzed side of the face, symmetrical to the normal side. We report our experience treating 40 patients with established facial palsy over a 4-year period. All patients underwent either temporalis transfer or free latissimus dorsi transfer as a single stage to improve lower facial symmetry. We believe that both techniques reliably achieve an increase of movement in facial reanimation after oncological, traumatic, or congenital facial palsy.