Long-standing Facial Paralysis Research Articles

A Contemporary Approach to Facial Reanimation.

The management of acute facial nerve insult may entail medical therapy, surgical exploration, decompression, or repair depending on the etiology. When recovery is not complete, facial mimetic function lies on a spectrum ranging from flaccid paralysis to hyperkinesis resulting in facial immobility. Through systematic assessment of the face at rest and with movement, one may tailor the management to the particular pattern of dysfunction. Interventions for long-standing facial palsy include physical therapy, injectables, and surgical reanimation procedures. The goal of the management is to restore facial balance and movement. This article summarizes a contemporary approach to the management of facial nerve insults.

Effectiveness of plastic procedures managed with anatomic sub-unit zone on advanced facial paralysis

Objective To investigate the surgical efficacy of the anatomic subunit zone and affiliated procedures on long-standing facial palsy. Methods A total of 533 long-standing facial palsy cases were treated from Mar. 2003 to Dec. 2013 according to the anatomic division into the subunit: eyebrow, upper eyelid and lower eyelid, upper lip and lower lip, and chin. The surgical procedures were done to prevent complications: skin resection for eyebrow plasty, heavy implant for upper eyelid plasty, temporal muscle transfer for lower eyelid plasty, and mini muscle transplantation for lip and chin. We evaluated the surgical effects by Douglas Harrison standard and the paralysis appearance by Stennert international score system. Results Of the above 533 cases evaluated by Douglas Harrison methods, 475 (89%) were good, 48 (9%) were satisfactory, and 6 (1%) were not obviously improved. The paralysis appearance evaluated by Stennert score system showed that 533 (100%) cases were less than 1 of static state score (full score was 4), 475 (89.1%) cases were less than 2 of dynamic state score (full score of 6). Conclusions The proper procedures combined with the deformity location and symptoms with subunit anatomy in facial palsy cases seem to be safe and effective, which not only improve the successful rate of surgery, but also prevent the complications. Key words: Long-standing facial paralysis; Synthetic plasty; Complication; Prevention

Spontaneous Blinking Kinetics on Paralytic Lagophthalmos After Lid Load with Gold Weight or Autogenous Temporalis Fascia Sling

ABSTRACTPurpose: To assess the upper eyelid kinematics during spontaneous blinking in unilateral paralytic lagophthalmos before and after upper eyelid load with gold weight (GW) or autogenous temporalis fascia (TF) sling.Design: Comparative case series.Subjects: Patients with long-standing unresolved unilateral facial palsy who underwent surgical treatment with GW (n = 8) or upper lid cerclage with TF (n = 10). The contralateral eyelid served as the control for each patient (control group).Methods: Preoperative and postoperative measurements of spontaneous blink kinematics with magnetic search coil and clinical assessment of lid margin position, lagophthalmos and ocular surface exposure, and determine amplitude, maximum velocity and main sequence of spontaneous blinks; relative amplitude of blinks to the pupil center; ocular surface exposure scores; magnitude of lagophthalmos and mid-pupil lid distances.Results: The mean (±SE) down-phase amplitude ratio between paralyzed and contralateral eyelids (blink gain) was 10.0% preoperatively for both groups and significantly increased to 29 ± 6% for the GW group (p < 0.05) and 23 ± 4% for the TF group (p < 0.05). At 6 months the gain was significant for the GW group only (32 ± 7%, p < 0.05). There was no effect on the maximum velocity of the blinks or the main sequence of paretic and contralateral blinks with either surgery. Both procedures lowered the lid margin increasing the number of blinks that reached the pupil center. At 6 months this effect was prominent only for the GW group. Exposure keratopathy scores and lagophthalmos decreased postoperatively especially in the GW group.Conclusions: The beneficial effect of lid load surgeries result from a combination of a small increase on the spontaneous blink amplitude and a static effect due to the reduction of the distance between the lid margin and pupil center.

One-stage dual latissimus dorsi muscle flap transfer with a pair of vascular anastomoses and double nerve suturing for long-standing facial paralysis

Various types of neurovascular free-muscle transfers have been reported as surgical treatments for long-standing facial paralysis. Among one-stage methods, two approaches, that is, latissimus dorsi transfer with nerve suturing to the contralateral facial nerve and gracilis transfer with nerve suturing to the ipsilateral masseteric nerve, have recently become popular. The former method has the advantage of making spontaneous smiling possible, but the contraction strength of the transferred muscle varies, whereas the latter approach has the advantage of guaranteeing voluntary contraction of the transferred muscle, but makes spontaneous smiling difficult. Recently, dual innervation methods have also been reported, but uncertainty remains about the utility of such approaches. To overcome these drawbacks, we devised a hybrid method combining the two previously established techniques. Two latissimus dorsi muscle flaps containing the thoracodorsal vessels from one side are transferred with a pair of vascular anastomoses. The true trunk of the thoracodorsal nerve, which innervates one of the muscle flaps, is sutured to the contralateral facial nerve, while the short branch of the thoracodorsal nerve, which innervates the other muscle flap, is sutured to the ipsilateral masseteric nerve. From November 2011 to October 2013, we used this method in four patients with long-standing facial paralysis. Smiling was assessed in the three patients who were followed up for more than 1 year, and satisfactory results were obtained (Harii score: 4-5). In one patient, the movement mediated via the contralateral facial nerve was a little weak, but this was compensated for by the muscles controlled by the ipsilateral masseteric nerve. Our novel one-stage method, which involves a combination of two previously established methods, guarantees early voluntary smiling, and spontaneous smiling becomes possible later. In addition, it is free from the uncertainty associated with double innervation and does not require nerve grafts. So, stable results can be expected in most patients with long-standing facial paralysis.

A new paradigm in facial reanimation for long-standing palsies?

Background:A chance observation of return of excellent facial movement, after 18 months following the first stage of cross-face nerve grafting, without free functional muscle transfer, in a case of long-standing facial palsy, lead the senior author (RBA) to further investigate clinically.Patients and Methods:This procedure, now christened as cross-face nerve extension and neurotization, was carried out in 12 patients of very long-standing facial palsy (mean 21 years) in years 1996-2011. The mean patient age and duration of palsy were 30.58 years and 21.08 years, respectively. In patients, 1-5 a single buccal or zygomatic branch served as a donor nerve, but subsequently, we used two donor nerves. The mean follow-up period was 20.75 months.Results:Successive patients had excellent to good return of facial expression with two fair results. Besides improved smile, patients could largely retain air in the mouth without any escape and had improved mastication. No complications were encountered except synkinesis in 1 patient. No additional surgical procedures were performed.Conclusion:There is experimental evidence to suggest that neurotization of a completely denervated muscle can occur by the formation of new ectopic motor end plates. Long-standing denervated muscle fibres eventually atrophy severely but are capable of re-innervation and regeneration, as validated by electron microscopic studies. In spite of several suggestions in the literature to clinically validate functional recovery by direct neurotization, the concept remains anecdotal. Our results substantiate this procedure, and it has the potential to simplify reanimation in longstanding facial palsy. Our work now needs validation by other investigators in the field of restoring facial animation.

Double innervated free functional muscle transfer for facial reanimation

Background: The treatment of long-standing facial palsy represents a challenge for the reconstructive surgeon. Treatment is based on dynamic procedures such as functional muscle flaps. The benefit of added axonal load has recently been reported. This study describes a two stage technique involving dual innervation of a gracilis muscle flap with initial cross-facial nerve graft (CFNG) followed by free muscle transfer co-apted to both the CFNG and a masseter nerve for facial reanimation. Methods: A total of nine patients from August 2008–July 2011 were operated on with the double innervated gracilis muscle flap. Pre- and postoperative electromyography was documented, and video analysis with the five-stage classification of reanimation outcomes was performed. Results: All patients recovered voluntary and spontaneous smile abilities, with an average of 70% motor unit recruitment. Based on the Terzis reanimation outcome classification, four patients had an excellent result, four good, and one moderate. Conclusions: The double innervated gracilis muscle flap is a viable technique for the treatment of long-standing facial palsy. It enables a fast recovery with fast muscle activity, and allows an emotional smile and aesthetic symmetry.

Facial Reanimation Surgery With Micro-vascular Gracilis Free Flap for Unilateral Facial Palsy

Introduction and objectivesMicro-neurovascular free muscle flap transfer is currently the procedure of choice for long-standing facial paralysis. We present a case series of patients treated with gracilis muscle free flap with motor innervation by the masseteric nerve. We discuss the surgical technique and quantify the movement granted by the muscle, the improvement in quality of life and aesthetic results. Materials and methodsWe report ten patients with unilateral facial paralysis who underwent free gracilis muscle flap, between the years 2010 and 2012 in two tertiary hospitals. ResultsAny failure of the microsuture with survival of all flaps is not reported. The muscle movement was quantified by vectors at rest and contraction with an average of 1.7cm that initiated around the fourth month after surgery. Patients also reported a significant improvement in symmetry at rest as well as oral and ocular competition. ConclusionAs currently presented in literature, microvascular free flaps are the technique of choice for facial reanimation. In our experience, we believe that gracilis muscle flap innervated by the masseteric nerve is a reliable and secure technique that provides adequate functional and aesthetic results.

Cirugía reparadora de la parálisis facial mediante colgajo libre microvascularizado de músculo gracilis

Introduction and objectives Micro-neurovascular free muscle flap transfer is currently the procedure of choice for long-standing facial paralysis. We present a case series of patients treated with gracilis muscle free flap with motor innervation by the masseteric nerve. We discuss the surgical technique and quantify the movement granted by the muscle, the improvement in quality of life and aesthetic results. Materials and methodsWe report ten patients with unilateral facial paralysis who underwent free gracilis muscle flap, between the years 2010 and 2012 in two tertiary hospitals. ResultsIt is not reported any failure of the microsuture with survival of all flaps. The muscle movement was quantified by vectors at rest and contraction with an average of 1.7cm that initiated around the fourth month after surgery. Patients also reported a significant improvement in symmetry at rest as well as oral and ocular competition. ConclusionAs currently presented in literature, microvascular free flaps are the technique of choice for facial reanimation. In our experience, we believe that gracilis muscle flap innervated by the masseteric nerve is a reliable and secure technique that provides adequate functional and aesthetic results.

Reconstruction of the Nasolabial Fold Using a Fascia Lata Sheet Graft

A refinement over existing static facial sling techniques to reconstruct the nasolabial fold in longstanding facial palsy is presented. The innovative use of fascia lata sheet graft instead of strips facilitates greater intraoperative control over the contour of the reconstructed fold and provides a wide area of attachments of the graft. This technique has a reduced incidence of complications and can be adjusted with minimal scarring as a secondary procedure if necessary. Therapeutic, V.

Comparison of 3 Procedures for Hypoglossal–Facial Anastomosis

We aimed to evaluate rehabilitation of complete facial palsy with 3 procedures for hypoglossal-facial anastomosis: end-to-end ("original"), partial end-to-end with interpositional jump grafting ("jump") and the new partial end to end without grafting ("modified"). A medical jury reviewed videos of 36 patients with complete facial palsy who underwent surgery from 1998 to 2008 by original (n = 13), jump (n = 13), and modified (n = 10) procedures. The jury of 5 ear, nose, and throat surgeons who were blinded to the procedure evaluated rehabilitation by 3 facial nerve grading systems-House and Brackman (HB), Sunnybrook, and Freyss scales-and 3 subjective scores for the face at rest and during voluntary and emotional motions. Recovery time was shorter with the modified and original procedures than jump procedure (5, 6, and 8 mo, respectively). All patients achieved at least good results. Scores on the HB scale (I-VI) were mainly III. HB and Sunnybrook scores did not differ by procedure. Freyss score was better for the modified procedure than original and jump procedures. Scores for the face at rest did not differ by procedure, but those during voluntary and emotional movements were worse for the jump procedure than for other procedures. Synkinesis was more severe with the original procedure than other procedures. The 3 procedures give satisfactory results for rehabilitation after surgery for facial palsy. The original procedure should be performed in patients with strong mimic or long-standing facial palsy. The jump procedure is delicate and entails risk of weak reinnervation. The modified procedure is a good compromise in terms of muscle tone and side effects.

Static reconstruction of malar region in facial paralysis: A new alternative technique for plasty of symmetric mouth appearance

Static suspension using fascia lata graft is used as a reconstructive procedure against drooping of the mouth corner for treating longstanding facial paralysis. Although it achieves symmetry at rest, movement of the mouth corner at mouth opening is restricted to some extent because it is fixed with fascia lata to the immovable temporal fascia, the parotid fascia, or bones. This was overcome by suspending the mouth corner to the mandibular coronoid process with fascia lata, which enabled a shift of the mouth corner with mouth opening and closure. The nine patients discussed in this study were operated on since 1994 for longstanding facial paralysis and followed-up for over 1.5 years. As in conventional static suspension, the fascia lata was harvested and split into two bands. Next, one semi-oval fascial loop was inserted around the paralysed part of the mouth and tied with another fascial band at the mouth corner, which was looped to the mandibular coronoid process. The suspended fascia lata graft was relaxed with anteroinferior movement of the coronoid process at mouth opening, enabling the mouth corner to shift inferiorly. The mouth corner returned to its original position at mouth closure, and the nasolabial fold deepened during mastication. No limitation in mouth opening was observed. Suspension of the mouth corner to the mandibular coronoid process provided a dynamic element, thereby restoring a near-normal shift. The procedure is considered as an alternative for reconstructing the malar region of patients with facial paralysis and in whom dynamic reconstruction is not indicated.

Endoscopic access to fascia lata for use in static facial reanimation—a cadaveric and clinical study

Background Current methods of autogenous fascia lata harvest for the static surgical treatment of longstanding facial paralysis often result in a high level of donor site morbidity and unsightly visual scarring on the patient’s lateral thigh due to the open technique traditionally used. With endoscopic access already being widely used in other areas of plastic and reconstructive surgery, it was hypothesised that it would be feasible to retrieve sufficient amounts of fascia lata endoscopically to achieve satisfactory static facial reanimation.

Facial Reanimation with Gracilis Muscle Transfer Neurotized to Cross-Facial Nerve Graft versus Masseteric Nerve

Longstanding unilateral facial paralysis is best addressed with microneurovascular muscle transplantation. Neurotization can be obtained from the cross-facial or the masseter nerve. The authors present a quantitative comparison of both procedures using the FACIAL CLIMA system. Forty-seven patients with complete unilateral facial paralysis underwent reanimation with a free gracilis transplant neurotized to either a cross-facial nerve graft (group I, n=20) or to the ipsilateral masseteric nerve (group II, n=27). Commissural displacement and commissural contraction velocity were measured using the FACIAL CLIMA system. Postoperative intragroup commissural displacement and commissural contraction velocity means of the reanimated versus the normal side were first compared using the independent samples t test. Mean percentage of recovery of both parameters were compared between the groups using the independent samples t test. Significant differences of mean commissural displacement and commissural contraction velocity between the reanimated side and the normal side were observed in group I (p=0.001 and p=0.014, respectively) but not in group II. Intergroup comparisons showed that both commissural displacement and commissural contraction velocity were higher in group II, with significant differences for commissural displacement (p=0.048). Mean percentage of recovery of both parameters was higher in group II, with significant differences for commissural displacement (p=0.042). Free gracilis muscle transfer neurotized by the masseteric nerve is a reliable technique for reanimation of longstanding facial paralysis. Compared with cross-facial nerve graft neurotization, this technique provides better symmetry and a higher degree of recovery. Therapeutic, III.

Hypoglossal‐facial‐jump‐anastomosis without an interposition nerve graft

The hypoglossal-facial-anastomosis is the most often applied procedure for the reanimation of a long lasting peripheral facial nerve paralysis. The use of an interposition graft and its end-to-side anastomosis to the hypoglossal nerve allows the preservation of the tongue function and also requires two anastomosis sites and a free second donor nerve. We describe the modified technique of the hypoglossal-facial-jump-anastomosis without an interposition and present the first results. Retrospective case study. We performed the facial nerve reconstruction in five patients. The indication for the surgery was a long-standing facial paralysis with preserved portion distal to geniculate ganglion, absent voluntary activity in the needle facial electromyography, and an intact bilateral hypoglossal nerve. Following mastoidectomy, the facial nerve was mobilized in the fallopian canal down to its bifurcation in the parotid gland and cut in its tympanic portion distal to the lesion. Then, a tensionless end-to-side suture to the hypoglossal nerve was performed. The facial function was monitored up to 16 months postoperatively. The reconstruction technique succeeded in all patients: The facial function improved within the average time period of 10 months to the House-Brackmann score 3. This modified technique of the hypoglossal-facial reanimation is a valid method with good clinical results, especially in cases of a preserved intramastoidal facial nerve. Level 4.

Contralateral Botulinum Toxin Injection to Improve Facial Asymmetry After Acute Facial Paralysis

The application of botulinum toxin to the healthy side of the face in patients with long-standing facial paralysis has been shown to be a minimally invasive technique that improves facial symmetry at rest and during facial motion, but our experience using botulinum toxin therapy for facial sequelae prompted the idea that botulinum toxin might be useful in acute cases of facial paralysis, leading to improve facial asymmetry. In cases in which medical or surgical treatment options are limited because of existing medical problems or advanced age, most patients with acute facial palsy are advised to await spontaneous recovery or are informed that no effective intervention exists. The purpose of this study was to evaluate the effect of botulinum toxin treatment for facial asymmetry in 18 patients after acute facial palsy who could not be optimally treated by medical or surgical management because of severe medical or other problems. From 2009 to 2011, nine patients with Bell's palsy, 5 with herpes zoster oticus and 4 with traumatic facial palsy (10 men and 8 women; age range, 22-82 yr; mean, 50.8 yr) participated in this study. Botulinum toxin A (Botox; Allergan Incorporated, Irvine, CA, USA) was injected using a tuberculin syringe with a 27-gauge needle. The amount injected per site varied from 2.5 to 3 U, and the total dose used per patient was 32 to 68 U (mean, 47.5 +/- 8.4 U). After administration of a single dose of botulinum toxin A on the nonparalyzed side of 18 patients with acute facial paralysis, marked relief of facial asymmetry was observed in 8 patients within 1 month of injection. Decreased facial asymmetry and strengthened facial function on the paralyzed side led to an increased HB and SB grade within 6 months after injection. Use of botulinum toxin after acute facial palsy cases is of great value. Such therapy decreases the relative hyperkinesis contralateral to the paralysis, leading to greater symmetric function. Especially in patients with medical problems that limit the medical or surgical treatment options, botulinum toxin therapy represents a useful alternative.

Microsurgical reconstruction of the smile—contemporary trends

The treatment of facial palsy is a complex and challenging area of plastic surgery. Microsurgical innovation has introduced the modern age of dynamic reconstruction for facial palsy. This review will focus on microsurgical reconstruction for smile restoration in patients with long-standing facial palsy. The most common donor muscles and nerves will be presented. The advantages and disadvantages of single-stage versus multi-stage reconstruction will be discussed. Contemporary trends will be highlighted and the authors' preferred practice outlined.

Botulinum toxin to improve lower facial symmetry in facial nerve palsy

In long-standing facial palsy, muscles on the normal side overcontract causing difficulty in articulation, eating, drinking, cosmetic embarrassment, and psychological effects as patients lack confidence in public. We injected botulinum toxin A (BTXA) into the normal contralateral smile muscles to weaken them and restore symmetry to both active and passive movements by neutralising these overacting muscles. A total of 14 patients received BTXA (79% women, median age 47 years, average length of palsy 8 years). They were all difficult cases graded between 2 and 6 (average grade 3 House-Brackmann). All 14 patients reported improved facial symmetry with BTXA (dose altered in some to achieve maximum benefit). Average dose was 30 units, but varied from 10 to 80 units. Average time to peak effect was 6 days; average duration of effect was 11 weeks. Three patients had increased drooling (resolved within a few days). The improvement in symmetry was observed by both patient and examining doctor. Patients commented on increased confidence, being more likely to allow photographs taken of themselves, and families reported improved legibility of speech. Younger patients have more muscle tone than older patients; the effect is more noticeable and the benefit greater for them. BTXA improves symmetry in patients with facial palsy, is simple and acceptable, and provides approximately 4 months of benefit. The site of injection depends on the dynamics of the muscles in each individual patient.

Fifteen-year survey of one-stage latissimus dorsi muscle transfer for treatment of longstanding facial paralysis

Neurovascular free muscle transfer is one of the main reconstructive options for established or long-standing facial paralysis. The two-stage gracilis muscle transfer combined with the cross-face nerve graft (two-stage method) has been supplanted by one-stage reconstruction using the latissimus dorsi muscle (LD) at our institution. This study retrospectively evaluated the results of one-stage LD transfer. Between September 1993 and December 2008, 344 patients (133 males, 211 females; age range, 5-75 years) with unilateral facial paralysis underwent 351 one-stage LD transfers. Patients were evaluated with a custom grading scale. Differences in grading scale score were compared according to age, past surgical history and the duration from operation to neuromuscular recovery. Contraction of the transferred muscle was recognised in 305 (87.0%) transfers. The duration until neuromuscular recovery ranged from 3 to 16 months (average±standard deviation: 6.48±1.92 months). The grading scale was significantly lower in middle-age group than in younger and elder groups (P<0.01). Duration until neuromuscular recovery was significantly different when comparing the younger group and the oldest group. There was no difference in grading scale score or in duration until neuromuscular recovery when comparing the patients with a past surgical history and those without. The grading scale negatively correlated with the duration until neuromuscular recovery. The results are consistent and statistical analysis revealed the versatility of the one-stage LD transfer. Although we believe the two-stage method is still a good option for facial reanimation, the one-stage method is advantageous regarding the shorter period of recovery and little donor-site morbidity.

Double innervation in free-flap surgery for long-standing facial paralysis

One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patient's ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch. Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve. All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noah's five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes. In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

Grading Facial Nerve Function Following Combined Static and Mimetic Surgical Techniques

The most commonly used facial nerve grading systems were designed to assess progressive neural recovery with an anatomically in-tact facial nerve. Advanced lateral skull base tumors that require facial nerve and adjacent musculature resection and cases of longstanding facial paralysis may necessitate the use of free muscle transfer in conjunction with neural grafting, oculoplastic techniques, and static soft-tissue tightening to optimize the long-term functional and cosmetic results. Traditional facial recovery grading tools are not sufficient to describe and compare functional recovery results in this patient population.