Surgical Rehabilitation of the Paralyzed Face
M. Bradley Evans M.D.
July 8, 2004

The talk today deals with surgical rehabilitation of the paralyzed face. Our patient is a 17-year-old Hispanic male who originally presented to Ben Taub Emergency Room with a gunshot wound to the left temporal bone. Initial examination revealed a complete left facial paralysis along with paresis of his right extremities. He was taken to the operating room by the Neurosurgery Service for an emergent craniotomy and subsequently underwent a transmastoid exploration of the facial nerve by our service. He was noted to have an intact nerve upon mastoid exploration; however, he had severe damage to his middle ear and otic capsule with a CSF leak. A mastoid obliteration using temporalis muscle and fat was performed. Subsequent examination after the patient was stabilized and extubated confirmed a complete left facial paralysis and profound hearing loss. A left lateral tarsorrhaphy was performed by the Ophthalmology Service before the patient was discharged for eye protection and, after a year of watchful waiting for return of facial function in which there was none, the patient underwent a static facial sling with Alloderm one year after the initial injury. The patient obtained satisfactory results with improvement in his aural competence as well as facial symmetry at rest. He subsequently underwent release of his tarsorrhaphy by the Ophthalmology Service followed by gold weight placement and a lateral tarsal strip procedure. We will talk about all of these in just a few minutes.

First of all, facial paralysis is devastating both cosmetically and functionally to patients who sustain injuries to their facial nerve. In today’s society great emphasis is placed on facial appearance and expression; however, more importantly, facial paralysis severely hinders mastication, speech production, and eye protection resulting in significant morbidity. Because of this, there are numerous reanimation techniques, which have been popularized over the last several years to rectify the problem of facial paralysis. Sir Charles Bell is the first person to note that the facial nerve was responsible for moving the muscles of the face. It was in his book that he published in 1829, called “The Nerves of the Face,” in which he is quoted, “It was proved that the seventh nerve of the face controlled the motions of the features performing all the motions, voluntary or involuntary, such as breathing, sucking, swallowing, and speaking with all the varieties of expressions.” This is a picture of Sir Charles Bell along with his original illustration of the nerves of the face in his book. Schwartze and Eysell in 1873 were the first to describe the indications and the technique of cortical mastoidectomy and, because this operation was originally performed with a mallet and chisel without the use of magnification, you can imagine that the incidence of facial nerve injury was quite high. This ushered in the area of facial nerve surgery. Interestingly enough, it was cranial nerve substitution which originally gained favor in facial nerve surgery. In 1873, Drobnik described the XII-VII anastomosis. Harvey Cushing was the first to perform this anastomosis in America in 1903.

Direct nerve repair was first attempted in 1894 by Ballance. Unfortunately, this patient’s repair failed because of subsequent sepsis. It was not until 1925 that Bunnell reported the first successful facial nerve repair. Other notable dates are that in 1931, Ballance and Duel documented that it was not necessary to suture the ends of a repaired nerve within the temporal bone because of the relative immobility of the nerve ends. And in 1933, Duel finally reported on the success and the superior results from direct repair versus nerve substitution. This became the standard of care when possible.

In 1975, Dr. Conley wrote a book, called “Salivary Glands in the Facial Nerve,” in which he extensively described the management of the peripheral facial nerve with respect to parotid tumors. In modern years several facial reanimation procedures have been pioneered or popularized by several different people in our specialty and other specialties.

Before diving into a talk on facial reanimation procedures and techniques, a good grasp of facial nerve anatomy is important. What we are concerned with here is the motor division, which I will go over now. The nerve takes a complex course through the temporal bone, as we all know, but it all starts in the facial motor nucleus, which contains 7,000 motor neurons, located in the lower pons. These neurons exit the brainstem and travel across the cerebellopontine angle for approximately 25 mm. The nerve then enters the temporal bone through the porus acousticus and runs through the internal auditory canal, which continues for approximately 8-10 mm. It then becomes the labyrinthine segment. The labyrinthine segment is notable because it is the shortest (3-5 mm) as well as narrowest segment of the facial nerve. The labyrinthine segment ends at the geniculate ganglion. It is here that the facial nerve takes its first genu and turns posteriorly to run across the middle ear, becoming the tympanic segment. This segment travels for about 8‑11 mm. Just anterior to the lateral canal, it takes a second genu and turns vertically to travel inferiorly through the mastoid and the fallopian canal for approximately 10-14 mm. It exits the stylomastoid foramen and becomes the extratemporal facial nerve. It exits the stylomastoid foramen in a lateral and anterior direction, and typically travels for a distance of about 20 mm before bifurcating at the pes anserinus. The nerve does have a variable branching pattern; however, five main divisions are well known--temporal, zygomatic, buccal, marginal mandibular, and cervical divisions.

The nerve travels in groups of fascicles, and these fascicles vary throughout the course of the nerve. It is also surrounded by three types of connective tissue, which will become more important later--endoneurium, perineurium, and epineurium. There have been at least 80 causes identified in the literature of facial nerve paralysis; and it is pretty much beyond the scope of this presentation to discuss all of the causes. We can narrow it down, though, to over 90% of facial nerve paralyses being attributed to one of five categories--Bell’s palsy, trauma, Herpes Zoster oticus or Ramsey-Hunt syndrome, tumor, and infections.

Several facial reanimation procedures have developed as a result of facial paralysis. Each one of these we will go over in more detail now; but first, there are some questions that you need to ask yourself or at least consider before jumping into a facial reanimation procedure. First of all, what is the duration of paralysis? If you are considering a neural anastomosis technique, including direct nerve repair, interpositional grafting or cross-facial/cross-nerve graft, the neural anastomosis success depends on the survival of motor end plates. It has been well documented that the motor end plates are not viable greater than three years after facial paralysis. So it is important to know how long the patient’s face has been paralyzed. Also, you might ask yourself, is the facial nerve disrupted? If you know that the facial nerve is intact, such as in our patient, or after acoustic neuroma surgery, the patient may have a transient facial nerve paralysis. In this case it is recommended to wait at least a year to see if any facial nerve function will return, because obviously surgical interruption to put in a graft or a cross-nerve graft will result in irreversible damage to that nerve. If it is in question, an EMG should be performed looking for motor unit potentials. Some people perform muscle biopsy to determine if the distal facial musculature contains surviving motor end plates. This is not very sensitive, however, as there will be some motor end plates viable in certain areas of the muscle and others might not be. Also, it is important to make sure that the patient has realistic expectations regarding their facial reanimation procedure. They should know that it is impossible to restore complete normalcy and it is well documented that House-Brackmann Grade III is the best result that you can get from neural anastomosis. However, some people have reported better results (House-Brackmann Grade II).

The first surgical technique to discuss is direct facial nerve anastomosis. This is the best technique to use when it is possible. It has been shown definitively the earlier repair results in a better outcome. So if you know that the facial nerve is transected, it is best to do this repair as early as possible. The repair is done primarily by neurorrhaphy. The key portion of the technical aspect is that the anastomosis should have no tension or minimal tension. There are some maneuvers which can be performed to provide a tension with anastomosis, and these include release from the parotid gland as well as rerouting within the temporal bone. An epineural suture repair is pretty much what most people do nowadays. This is done with a 9-0 or 10-0 suture in the epineural layer, and as few sutures as possible are used to reapproximate the nerve to decrease the risk of scar formation or granuloma formation. And as Ballance and Duell noted in 1931, it is not necessary to reapproximate with sutures in the intratemporal portion of the facial nerve because of the relative immobility of the nerve ends. So, when direct nerve grafting is impossible either because of too large of a gap and you cannot perform a tensionless anastomosis, then an interpositional graft can be performed. This will be your next step in facial reanimation procedures. It is indicated, as I said, in inadvertent trauma, either surgical or traumatic, or deliberate removal of a portion of the nerve in which direct nerve anastomosis cannot be performed. The disadvantage is that the regenerating fibers of the nerve must cross two anastomoses instead of one, and this leads to the nerve gap dilemma: What is too much tension? What is not? Is there a number you can peg on it? And it has pretty much been decided that if the resected segment is greater than 2 cm in length, then interpositional grafting would be appropriate in that situation. There are three main options that people use in interpositional grafting, either the greater auricular nerve, the sural nerve, or the medial antebrachial cutaneous nerve. The greater auricular nerve is the most commonly used graft. It results in minimal loss of function to the patient, and it can easily be located by drawing an imaginary line between the mastoid tip and the angle of the mandible. Up to 5-10 cm may be harvested; however, in certain situations this may not be enough, so if that is not enough to use, then the next option for many surgeons would be a sural nerve graft. The sural nerve easily provides greater than 20 cm if needed, and some have documented even up to 40 cm of nerve can be used. It is distant from the ablated field. This nerve is located 1-2 cm lateral to the saphenous vein, medial and posterior to the lateral malleus. However, many surgeons in the literature recently have raised concern about the associated sensory loss which is on the lateral aspect of the foot and can be somewhat debilitating to a number of patients. In addition, the incision site is located right around where the top of the patient’s shoe might rub and cause irritation. This has led to the popularization by some surgeons of the medial antebrachial cutaneous nerve. This nerve is advantageous because it has a good diameter match to the facial nerve, favorable branching pattern for the distal nerve, and greater than 20 cm of length can be used if needed. This nerve is easily located between the biceps and triceps muscles, just adjacent to the basilic vein. It provides sensation to the anterior and posterior ulnar forearm. This brings us to our next procedure. The crossover procedures are used when direct nerve grafting or interpositional grafting is not possible. The indications are similar to the indications for direct nerve or interpositional grafting, and likewise a functional distal facial nerve must be present along with viable musculature. So again, if the paralysis is over three years’ in duration, this is probably not the best procedure to use. The techniques, which have been described in the literature, are numerous and include hypoglossal to facial, spinal accessory to facial, facial to facial, and even phrenic to facial.

The XII-VII anastomosis is the most commonly performed crossover and is probably associated with the least donor nerve morbidity. Unilateral tongue denervation is generally well tolerated by most patients; however, some patients will develop speech and articulation problems from loss of one hypoglossal nerve. Obvious disadvantages of other cranial nerve substitutions are that in an XI-VII anastomosis, the patient will have a painful shoulder droop. In addition, facial movement will be elicited with an awkward shoulder movement. In contrast, when the hypoglossal nerve is used in the crossover, patients are able to train themselves to elicit facial movement by pressing their tongue up against their teeth. Again, obvious disadvantages of the phrenic to VII anastomosis are that it impairs respiration and the facial movements move in synchrony with respirations. This technique has pretty much been abandoned.

Very briefly, some technical aspects of the XII-VII anastomosis are as follows. The distal facial nerve is first identified and transected at the stylomastoid foramen; however, if additional length of facial nerve is needed, it can be drilled out of the temporal bone and transposed to provide more length. The hypoglossal nerve has been identified just inferior to the digastric muscle, and it is transected as far anteriorly as possible to provide adequate length. Again, a tensionless repair is important, and similar to interpositional grafting and direct anastomosis the neurorrhaphy is performed using an epineurial suture repair.

Because of the speech and articulation problems that some patients develop after XII-VII crossover, a partial XII-VII anastomosis has been described. This procedure preserves ipsilateral lingual innervation, or at least part of it. Several techniques have been described. An end to side anastomosis can be performed by transposing the facial nerve out of the temporal bone and anastomosing it to a partially transected, but intact, XII nerve. Jump grafting is a procedure in which an interpositional nerve graft, either greater auricular, sural or medial antebrachial cutaneous is anastomosed to the distal stump of VII and then in an end-to-side fashion with the hypoglossal nerve. Multiple branches can be reconstructed in this manner.

Bascom and May in 2000 reported on a series of 103 patients who underwent various types of neurorrhaphy. They noted that grafting was more successful the sooner the repair was performed, and the best results were obtained with primary repair. Shelton and Brackmann in 1994 reported on 22 patients who sustained iatrogenic nerve injuries. They noted that none of their patients with a nerve repair had better than a House-Brackmann Grade III result. They also noted that all patients who underwent direct anastomosis did obtain a House-Brackmann Grade III, and the most common result in patients undergoing cable nerve grafting was Grade IV. Finally, Dr. Conley and Baker in 1978 reported on their series of 137 XII-VII crossovers and noted that 95% of their patients developed satisfactory tone and voluntary response, whereas 16% of those patients complained of problems pertaining to mastication, speech, and swallowing.

This brings us to our next procedure--dynamic muscle transposition. This procedure is indicated when neural techniques are unsuitable, such as in the absence of the facial neuromuscular system, as in Mobius syndrome. In addition, when the facial paralysis has been greater than three years in duration, and loss of motor end plates has occurred, dynamic transfer is a viable option. If the hypoglossal or vagus nerves have been sacrificed, precluding a crossover graft, then this is also an appropriate procedure. Finally, if an unsatisfactory degree of improvement has been obtained from prior nerve repairs, dynamic transposition can be performed. The available muscles for use are the temporalis muscle, masseter muscle and even the anterior digastric muscle in limited situations. It is important to note that for all of these procedures the third division of the trigeminal nerve must be intact because this provides the motor to the dynamic facial expression.

Very briefly, the temporalis muscle is a large fan-shaped muscle attached to the coronoid process of the mandible in the broad temporal fossa. It is mostly used for reanimation of the corner of the mouth in which the middle third of the muscle is harvested, elevated, and tunneled over the zygomatic arch. It is then bisected and sutured to the superior and inferior portions of the orbicularis oris muscle. The sling is then pulled in a superior vector to provide over-correction, which will settle at a later time. Good results as far as smiling and better tone have been reported with the temporalis muscle transposition.

If the temporalis muscle is unavailable, the masseter muscle can be used to provide dynamic smiling and movement. It can be approached intraorally or extraorally. The intraoral approach avoids a facial incision. Disadvantages to this procedure are that there is less muscle to use in comparison to the temporalis muscle, and the vector force is in a more horizontal plane, which provides less superior angulation to the corner of the mouth.

Static facial reanimation is essentially the creation of suspensory mechanisms to support the mouth and the nose. This produces facial symmetry and repose; however, it does not, as its name suggests, restore the ability to participate in volitional and emotional movement. There have been a variety of materials used for static facial suspension. Some native materials to the patient include fascia lata as well as Palmaris longus tendon. Foreign materials which can be employed include a variety of materials with just a few named here: Marlex mesh, Alloderm, and Gortex. Incisions are made in the nasolabial fold area as well as preauricular. A tunnel is created; the sling is passed through this, and then wrapped around the zygomatic arch. The sling can either be sutured to itself or plated directly to the zygomatic arch.

Free muscle transfer is uncommonly performed by otolaryngologists, and it is utilized mostly by plastic surgeons who are not familiar with the other neuroanastomosis techniques. The indications for this are basically the same as for muscle transposition. Some advantages cited in the literature are that it does offer the possibility of a more natural and possibly a subconscious smile. These procedures often require two stages, although single-stage procedures have been described in the literature. Just to go over it very quickly, an appropriate nerve graft is harvested and anastomosed to the contralateral normal facial nerve. A free muscle flap is then harvested. A second procedure with an intact neurovascular bundle is anastomosed to the previous graft six to nine months later. There have been a variety of muscles which have been used in the free muscle transfer, as you can see here.

There are several adjunctive procedures which can be performed to improve the cosmetic and functionality of the patient. These can be divided into areas of the face. Resection of a portion of the paralyzed orbicularis oris muscle can be performed to provide improved symmetry and tone to the lower lip. In addition, Botox injections or resection of the depressor muscles on the normal side can be performed to provide more symmetry.

Wedge resection of an upper paralyzed lip can be performed to provide more symmetry, as well as facelifting techniques. Skin resection from the nasolabial fold can be performed to elevate the upper lip, as well as Botox injections to the contralateral zygomaticus major and minor muscles.

A common complaint of patients with facial paralysis is nasal obstruction. This occurs secondary to loss of dilator muscles in the nose and nasal valve collapse. Several well-described open and closed rhinoplasty techniques can be used to reconstruct the internal nasal valve in addition to lateralization of the nasal alae. Techniques which can be used to elevate a depressed brow and provide better symmetry of the brow include brow lift techniques, as well as Botox to the normal contralateral side. However, it is important to note that the paralyzed forehead may actually assist in eye closure, so you have to be careful not to do too much.

I want to talk about eye rehabilitation for just a few minutes which is probably the most important aspect of treating facial nerve paralysis. Ocular complications are potentially the cause of greatest morbidity in the facial paralysis patient. The initial eye care can be thought of as three Rs. First is to Rewet the exposed cornea and conjunctiva. This can be done through a variety of mechanisms of ocular lubrication using artificial tears or ophthalmic ointment as well as dissolvable ophthalmic inserts. Other adjunctive devices include moisture chambers or goggles, as well as punctual plugs which can occlude the puncta and provide lacrimation and wetting the eye. Also, bandage contact lenses and room humidifiers have been used. The next two Rs are to Restore the lower lid to the physiologic position and to Reclose the upper lid. The simplest method is to tape the upper and lower lids. This is generally well accepted for short-term use. As can be seen in this picture, it can be effective if done correctly. Also, external weights and lid sutures, as well as Botox, to close the eyelid can be used. Again, these are good for short-term; however, if the facial paralysis is going to be of long duration, then a more definitive surgical restoration is indicated.

What are the surgical options for long term eye care? Upper lid procedures including permanent tarsorrhaphy can be performed, although not much anymore secondary to unappealing cosmetic results and functional devastation for the patient. More commonly performed is gold weight implantation which is a relatively simple procedure to perform. It generally has satisfactory results. An incision is made in the upper tarsal crease, and dissection continues down to the tarsal plate. An appropriately sized gold weight is then sutured to the tarsal plate to provide for lid closure. Palpebral springs have been described, although these procedures are technically difficult and have been shown to have a high extrusion rate. Lower lid procedures include lid slings, utilizing fascia lata or silastic rods, for example. Also, lid stents and augmentation, using either auricular cartilage or an alloplastic material such as Medpor, can be performed. The the lateral tarsal strip is a commonly performed procedure. Steps are outlined here. Without going into too much detail, this procedure shortens and elevates the lower lid to correct lower lid laxity and entropion.

I want to mention just a few brief words about non-surgical means of facial rehabilitation. These include facial retraining techniques, the most important of which is patient education. The patient must understand what the facial muscles do. They should be shown diagrams of the facial muscles as well as which muscles are responsible for specific movements. This can help lead them in retraining their face. Muscle relaxation or stimulation for hyper- or hypotonicity of the facial musculature can be performed. In addition, mirror exercises to try and simulate facial movement have been described. Surface EMG biofeedback has been described, as well as a passive hold technique in which the patient basically takes their fingers, holds their face in the position they want to keep it in, and then as they let it go they try to cause a contraction of the face. Also, visual feedback is used in the form of placing adhesive dots on the corner of the mouth or the brow, and trying to keep those dots in the same position as they try to smile or elevate their forehead. Finally, it should always be remembered that cosmetic camouflage can be used with the appropriate hairstyling and corrective makeup for women, as well as fashion and wardrobe changes.

In summary, there are a variety of techniques available for use in facial reanimation. Better results have been shown if the nerve is repaired early in cases of nerve transection. Duration of paralysis is important in determining the type of reanimation procedures. As I said, greater than three years means loss of motor end plates, and the neural techniques have poor results in this situation. A dynamic or static reanimation is more appropriate in these settings. Also, contemporary facial plastic procedures should be in your armamentarium for improvement in the cosmetic appearance as well as functionality of the patient. Special attention should be directed toward adequate closure and protection of the eye through a variety of means, as this is the cause of greatest potential morbidity to the patient. And finally, non-surgical rehabilitation, such as facial retraining and cosmetic camouflage, should be remembered in cases of facial paralysis.

Case Presentation

G.C. is a 17-year-old Hispanic male who originally presented to the Ben Taub General Hospital Emergency Department after sustaining a gunshot wound to the left temporal bone. Initial neurologic examination revealed complete left facial paralysis along with paresis of his right extremities.

After initial stabilization, radiologic imaging confirmed the presence of intracranial injury, and he underwent emergent craniotomy by the Neurosurgery service. Transmastoid exploration of the patient’s facial nerve was undertaken and it was noted to be intact within the temporal bone. Mastoid obliteration was subsequently performed secondary to severe damage to the otic capsule with CSF leak.

On subsequent examination after extubation, the patient was conformed to have a complete left facial paralysis along with complete hearing loss in the left ear. In addition, he had paresis of his right extremities and Broca’s aphasia. Ophthalmology service performed a left lateral tarsorrhaphy prior to discharge. After a prolonged hospitalization, the patient was discharged and followed up as an outpatient.

After no return of facial function after one year of observation, the patient underwent static facial sling with Alloderm. The patient obtained satisfactory results with improvement in his oral competence and facial symmetry at rest. He has since undergone release of his tarsorrhaphy followed by gold weight placement and lateral tarsal strip by the Ophthalmology service with good results.

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