Treatment Of Facial Paralysis Research Articles

Cross-Face Facial Nerve Anastomosis: Historical Notes

The anastomosis between the two facial nerves for the treatment of facial paralysis, in which the proximal stump of the severed facial nerve is not accessible, was utilized in eleven patients. The palsy was secondary to resection of an acoustic tumor in nine patients, sarcoma of the petrous bone was the cause in one and an automobile accident in the other. The original concept of anastomosing a branch of the normal pes anserinus to the trunk of the paralyzed facial nerve, as first presented by the author at the Second International Symposium on Facial Nerve Surgery held in Japan in September, 1970, has been modified. The technique of anastomosing the cervico-facial division of the normal facial nerve, and directing it to the temporo-facial division of the paralyzed facial nerve via a sural autograft 20-22 cm long, was combined with the utilization of the ipsilateral descendens cervicalis (hypoglossi). This nerve was anastomosed to the cervico-facial division of the paralyzed facial nerve and utilized in four patients. The technique is illustrated in detail.

Treatment of Facial Palsies With External Eyelid Weights

Because ocular exposure is a major complication of facial paralysis, an external gold eyelid load weight was evaluated for effectiveness in the treatment of this problem. We prospectively studied 12 patients with unilateral facial paralysis who were treated with the external eyelid weights. Follow-up examinations included corneal exposure, amount of artificial tear usage, patient comfort, and complications associated with the weights. Treatment end points were the patient's decision to undergo a canthoplasty or placement of an implanted weight or resolution of the facial paresis to better than House's grade IV/VI. Of the 12 patients studied, ten had decreased corneal exposure on the affected side, with a coincident decrease in artificial tear drop use and increased comfort. One patient had no improvement in a corneal defect, and one was unable to apply the weight. Five patients had some difficulty in positioning the weight, which was related to upper eyelid dermatochalasis in four of the five. Only two weights were lost in over two years of total wearing time. External eyelid weights are useful in the treatment of ocular exposure associated with facial paralysis. The weights decreased corneal exposure, decreased reliance on artificial tear drops, and increased patient comfort. The weights were helpful as a trial before implantation of eyelid weights and as a longer-term treatment for ocular exposure in patients with temporary facial paralysis. Loose upper eyelid skin may limit their usefulness in some patients.

Free Vascularized Double Muscle Transplantation for the Treatment of Facial Paralysis

Two cases of free neurovascular double muscle transplantation for facial paralysis are reported, with detailed descriptions of the operative technique and follow-up study. The latissimus dorsi muscle segment is placed between the nasolabial fold and the zygoma to substitute for the zygomatic and levator labii muscles, while the serratus anterior muscle segment is placed between the lower lip and the mandibular margin to substitute for the depressor labii muscles. The thoracodorsal nerve is sutured to the stump of the cross-face nerve graft, and the lateral thoracic nerve is sutured to a part of the hypoglossal nerve. The procedure is able to restore a relatively symmetrical smile, especially in patients with a full denture smile. The satisfactory results of this procedure are expected to lead to new prospects in the treatment of facial paralysis.

Discussion: Free Vascularized Double Muscle Transplantation for the Treatment of Facial Paralysis

Discussion: Free Vascularized Double Muscle Transplantation for the Treatment of Facial Paralysis

Electromyographic Study of Functional Recovery of Free Vascularized Muscles Grafted to the Face

The functional recovery of gracilis muscles grafted for treatment of facial paralysis in combination with a cross-face nerve graft was evaluated on the basis of electromyography in 98 cases. Initial action potentials were recorded, on average, 8 months after transplantation. There was a tendency for such potentials to appear earlier in the case of patients who finally attained good muscle activity. Action potentials were polyphasic in the early stage and of short duration and low amplitude. An increase in the amplitude and duration of potentials and a shortening of the distal latency were observed with increase in the numbers of reinnervated muscle fibers. Thereafter, there was a tendency toward decreases in the duration and number of spikes due to the increasing similarity in the distal latency of each neuromuscular unit. The grafted gracilis muscles attained a stable state about 1 year after the initial recording of action potentials. It was expected that spontaneous action potentials during rest might serve to indicate the condition of reinnervation. Their absence during the first few months after transplantation may suggest necrosis of the grafted muscle, while those of long duration and high amplitude observed after 1 postoperative year may be suggestive of disturbance in the reinnervation process. In this study, we could not find any significant difference in the reinnervation process between that of a gracilis muscle grafted following a cross-face nerve graft and a muscle reinnervated following nerve transection and repair. We therefore believe that free gracilis muscle transplantation combining a cross-face nerve graft is appropriate for the reconstruction of muscle function.

Heerfordt症候群の顔面神経麻痺

In three cases of Heerfordt syndrome, we evaluated the severity of facial paralysis and topographically diagnosed the site of damage to the facial nerve. One patient with severe facial nerve paralysis showed lacrimal dysfunction, absence of stapedial reflex and taste dysfunction on the same side as facial paralysis, and the site of damage to the facial nerve was diagnosed as the geniculate ganglion. Two other cases showed infrastapedial lesion of the facial nerve. The presence of other cranial nerve disorders, i. e. VIIIth, PCt h and X th cranial nerves, was suspected in two patients. All three patients were treated by administration of steroids. One patient with only mild facial weakness showed rapid improvement but the other two patients were unable to achieve complete recovery. We concluded that positive administration of steroids is necessary in the treatment of facial paralysis associated with severe nerve damage or other cranial nerve disorders.

Free neurovascular muscle transplantation for the treatment of facial paralysis using the hypoglossal nerve as a recipient motor source.

Seventeen cases of free-muscle transplantation using the hypoglossal nerve as a recipient motor nerve for the treatment of long-standing or irreversible facial paralysis are reported with details of a follow-up study. The muscle, usually the latissimus dorsi muscle, is transferred to the cheek with microvascular anastomoses. The muscle's motor nerve is sutured to the hypoglossal nerve. There are three classifications of hypoglossal nerve sectioning: total section, central section, and lower section. The results were compared on the basis of these three methods, leading to the recommendation that branches of the hypoglossal nerve diverging inferiorly to innervate the suprahyoid muscles be utilized as a recipient motor source. This method permits acceptably natural movement of the grafted muscle without functional disability of the tongue. Good candidates for this procedure are considered to be those patients for whom muscle transplantation combined with a cross-face nerve graft cannot be adopted because of bilateral paralysis or surgical intervention on the healthy side of the face or who are so old that the long two-stage operation holds no hope for them.

Long-term follow-up of nerve conduction velocity in cross-face nerve grafting for the treatment of facial paralysis.

Motor nerve conduction velocity in a sural nerve graft crossing the face for the treatment of facial paralysis was measured postoperatively for more than 3 years. Forty-three cases of free gracilis muscle transplantation combined with a cross-face nerve graft were evaluated. The cross-face nerve graft was stimulated at two sites more than 5 cm apart by bipolar stimulating electrodes, and conduction velocity was calculated by dividing the length of this segment by the difference between the latencies of the evoked action potentials recorded from the grafted muscle. A tendency toward increase in motor nerve conduction velocity was noticed even 3 years after the sural nerve graft. This suggests that the grafted nerve has the potential to recover over a long period of time. The average velocity in measurements after the third postoperative year was 40.5 +/- 6.2 m/s (mean +/- SD), which corresponds to the lower limit of the normal value for the sural or facial nerve.

Long-term follow-up study of browlift for treatment of facial paralysis.

Browlift for patients with irreversible paralysis of the frontalis muscle was evaluated in a review of 40 patients who had undergone follow-up studies for durations of more than 3 years. The procedure consists of a lazy S-shaped excision above the upper border of the eyebrow and upward fixation of the lower skin margin. The results were as follows: (1) The percentage of patients for whom symmetrical positioning of the eyebrow was achieved was 65%. (2) The greater the preoperative severity of ptosis, the more often did recurrence occur. (3) Recurrence progressed rapidly during the first postoperative year, but thereafter recurrence was seen only in those patients in whom the affected eyebrow was still in a position higher than its counterpart. (4) No relationship could be seen between age at the time of surgery and postoperative position of eyebrow. (5) Improvement in contraction of the visual field was seen in 85% of patients postoperatively, and complaints were eliminated in 50%. (6) Careful preservation of the sensory nerve is required. (7) The postoperative scar was acceptable. This procedure is a simple and effective method of correction of paralytic ptosis. Although a degree of skill is required to obtain satisfactory results and a surgical scar remains at the upper border of the eyebrow, the advantages of the procedure surpass its disadvantages. It is believed that this method should be used more often in the treatment of facial paralysis.

Eutrophic electrical stimulation in long-standing facial palsy.

The use of electrical stimulation in the treatment of facial palsy has previously been shown to offer no significant advantage [1].

Results of reconstruction of the facial nerve.

The results of surgical treatment for facial paralysis are still difficult to compare as there is no universal scoring method. The purpose of this communication is to review the results of reconstruction of the extratemporal facial nerve with nerve grafts using our own evaluation system. Fifty-nine patients were operated on during the period 1981-1991. They had lacerations or other trauma to the face which resulted in loss of continuity of the facial nerve or branches. Three groups were considered: (a) 12 patients had injuries involving the trunk and extending up to the main branches of the facial nerve; (b) 32 patients had parotid laceration or contusion on the parotid area with resulting nerve defects extending from a main branch up to distal branches; and (c) 15 patients had injuries on the distal branches: frontal, zygomatic, or mandibular. The sural nerve was used as the graft in all instances. The grafting procedure was performed from three weeks to six months after the trauma. The method of evaluation compares the normal with the paralyzed side. A score is given of 0 (no motion), 1 (weak motion), or 2 (strong motion), for each of six voluntary contractions: forehead, closure of eyelids and lips, traction, elevation, and depression of the lips. The assessment of involuntary mimic actions was done while observing blinking, speaking, smiling, and laughing. Mass movements were scored negatively. The numbers were recorded and the ratio between the paralyzed and normal side gave an estimate of the lack of symmetry.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery of original nerve supply after hypoglossal-facial anastomosis causes permanent motor hyperinnervation of the whisker-pad muscles in the rat.

Hypoglossal-facial anastomosis (HFA), used in humans for the treatment of facial palsy, was experimentally performed in adult female Wistar rats. The time course of facial reinnervation and the extent of the new motor nerve supply of the vibrissal muscles that develops after HFA were estimated by counting all motoneurons in the brainstem labeled by injection of horseradish peroxidase (HRP) into the whisker pad; muscle innervation by motor endplates was not studied. In untreated animals, HRP injection labels 1,254 +/- 54 (mean +/- S.D.; n = 6) motoneurons, localized exclusively in the lateral subdivision of the facial nucleus. Immediately following HFA, this number drops to zero. The first HRP-labeled motoneurons appear in the hypoglossal nucleus at 28 days postoperation (dpo) and at 56 dpo their number reaches 1,096 +/- 48. Unexpectedly, the facial nerve, whose proximal stump has been left as blind end during surgery, additionally sends axons to the facial periphery. This resprouting is first detected at 42 dpo with HRP-marked neurons throughout the facial nucleus lacking somatotopic organization. The number of these labeled neurons also rises with time, and at 56 dpo, a total of 1,797 +/- 142 facial and hypoglossal motoneurons, that is, 43% more motoneurons than in normal animals, supplies the whisker pad. This hyperinnervation, that is, the projection of more motoneurons into the target muscle than under normal conditions--further increases to 1,978 +/- 92 motoneurons at 224 dpo and may provide a new animal model for studying the competitive relationships between motoneurons in their search for peripheral targets.

HELIUM NEON AND DIODE LASER THERAPY IS AN EFFECTIVE ADJUNCTIVE THERAPY FOR FACIAL PARALYSIS

This study presents our six-year experience in laser therapy for rehabilitation of facial paralysis. Mixed laser irradiation using a 904 nm diode GaAs and 632.8 (HeNe) was utilized. Laser irradiation was performed on the range of facial nerve ramifications in eight different places, 5 min on each place, four times a week. No other medicine was used if the patient arrived 48 h after having the lesion. When the patient arrived after the first week, meticorten was utilized as a supplement, a dosage of 40 mg per day, for seven days. Based on our experience, the patients who are more inclined to attend treatment sessions are those who have been suffering from paralysis for more that a month and who have submitted to other kinds of treatments with negative results. They were even offered surgery. For these patients, we have required up to a maximum of 30 sessions and we have achieved 100% recovery, even with patients who have had the lesion for three or six months. Patients who attended therapy within two weeks after suffering the paralysis recovered 100% with no additional medication-only laser therapy. With these patients we needed a maximum of 15 sessions. LLLT is presented as a safe, noninvasive, easy to apply and comparatively side-effect-free modality offering a complementary and effective tool in the treatment of facial paralysis.

The use of Gore-Tex Soft Tissue Patch to assist temporal muscle transfer in the treatment of facial nerve palsy.

Temporal muscle transfer remains one of the most widely practiced procedures in dynamic correction of paralysis of facial nerves. In case of shortage of temporal muscle volume, length, and strength, some type of autogenous tissue or implant is required to achieve great stretching and excursion. Several artificial materials have been used in the past, each with its own limitations or problems. We used Gore-Tex Soft Tissue Patch to lengthen and strengthen the muscle-fascia strip. This material is very successful as an implant; it shows excellent tissue tolerance, the porous microstructure encourages tissue attachment and infiltration, and it also resists infection. As a result, reasonable suspension and restoration of orbital and oral sphincters were achieved.

Animal model for ischemic facial nerve paralysis with selective vascular embolization.

An experimental model that reliably and easily produces acute ischemic facial nerve paralysis would be useful for the controlled study of treatment and to improve our understanding of the pathophysiology and treatment of facial nerve palsy. Most documented models that simulate clinical facial nerve palsy cause direct damage to the nerve. We describe an experimental model for ischemic facial nerve paralysis in the cat that employs arterial block of the internal and external maxillary and posterior auricular arteries using embolizing material (Avitene). All animals develop stable acute ischemic facial nerve palsy lasting for approximately 2 months. Electromyographic study of this model revealed that the site of the lesion resulting from selective embolization may be within the temporal bone. This model has the advantages of simplicity of technique, cost-effective use of cats, and reproducibility of facial nerve palsy.

Ancillary aids in the treatment of facial paralysis.

Ancillary aids in the treatment of facial paralysis.

Treatment of Facial Paralysis

To the Editor.—I enjoyed reading the article on Simultaneous Dual System Rehabilitation in the Treatment of Facial Paralysis by Casler and Conley.1However, I would like to comment on the timing of surgery in patients with Bell's palsy, ie, idiopathic peripheral facial paresis. In my study of 470 patients with Bell's palsy I have assessed the degree of paresis, with the face at rest and when performing specified active movements, at regular intervals; in the acute stage, ie, during the first few days after the onset of the paresis, at 3 weeks, and at 3, 6, and 12 months after the onset. Several of the patients who had a residual paresis at the 12-month examination were also examined at 18 and 24 months after the onset of paresis. In the untreated control group 67% of the patients regained complete facial motor function, while 80% of the patients in

Casler, J. D., and Conley, J. Simultaneous dual system rehabilitation in the treatment of facial paralysis

Casler, J. D., and Conley, J. Simultaneous dual system rehabilitation in the treatment of facial paralysis

Free muscle transplantation for treatment of facial palsy

Facial palsy is treated by many different operative procedures. In addition, factors such as the varying degree of paralysis, make postoperative comparisons difficult. The limited number of patients treated by free muscle transplantation at any one center also complicates evaluation of alternative treatments. This limitation has been overcome by development of an International Muscle Transplant Registry for collection, storage and analysis of data from different centers. As of June 1, 1988, 137 patients from 6 countries have been entered into the Registry. Significantly more USA/European patients had a congenital deficit and significantly more Japanese patients had a deficit resulting from surgery. According to a modification of the paresis scoring system proposed by Stennert et al. [3], USA/European patients also had a higher degree of nonsurgical facial paresis than Japanese patients. The most frequent preoperative treatment used in Japan was electrostimulation in 24% of cases, only 6% of European and American patients received this treatment. Evaluation of surgical procedures performed by the 2 groups of surgeons showed similar dimensions of muscle grafts used in the face, with a length of about 8.5 cm and a width of 3.4 cm. The extensor digitorum brevis muscle was the most popular, being used in 58% of European and American cases, whereas the Japanese choice was the gracilis muscle in 94% of cases. The length of the nerve graft used by Japanese surgeons was 6 cm, longer than that used by European and American surgeons. At this time, these preliminary data suggest evidence for paresis improvement in 79% of patients overall. Ultimately, the Registry should permit evaluation of the efficacy of different operative techniques and should influence experimental research and clinical application of muscle transplantation.

Simultaneous 'Dual System' Rehabilitation in the Treatment of Facial Paralysis

Simultaneous dual system rehabilitation of facial paralysis involves using two independent reanimation techniques to optimize facial movement in both a quantitative and qualitative manner. These techniques involve the use of nerve grafting or crossover procedures combined with a dynamic muscle transfer. A group of 37 patients who underwent five different combinations of reanimation was analyzed. The techniques were evaluated using a standard rating scheme for judging success of reanimation procedures. The combination of a masseter muscle transfer to the lower region of the face and a cable graft of the upper facial nerve division appeared to offer excellent results in terms of independent motion of the upper and lower regions of the face and good eye closure, while allowing spontaneous mimetic function in 50% of cases. The advantages and disadvantages of the other techniques are described. The clinical situations in which these techniques have advantage over single reanimation techniques are outlined.