Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

Facial nerve paralysis is a devastating injury that can result in blindness, oral incontinence and social handicaps. The muscles of the face are exquisitely designed for both voluntary and involuntary expression.

The facial nerve emerges from the brainstem via the internal auditory canal and exits the brain through the stylomastoid foremen. At this point, the nerve travels a short distance to the pes where it divides into five motor branches--the temporal, zygomatic, buccal, mandibular and cervical branches.

The nerve is responsible for orchestrating an intimately designed facial musculature system. The facial musculature is capable of maintaining tone as well as expressing both voluntary and involuntary emotions.

First, we will discuss the importance of eye protection and methods used to achieve a healthy eye. Paralysis of orbicularis oculi results not only in drying of the cornea but also in poor distribution of tears. The lower lid is not able to contract and disperse the tears across the eye. Furthermore, loss of parasympathetic innervation can result in decreased tear production. This can result in keratitis and rarely, corneal ulceration and cataract formation. Therefore, the primary objective of the surgeon is to protect the eye via surgical and/or nonsurgical methods.

Surgical methods may involve both upper lid procedures such as tarsorraphy, gold weights, and palpebral springs as well as lower lid procedures.

Muscle transposition can be utilized to reanimate the face. Two muscles primarily used are the masseter and the temporalis. The patient must have an intact V for these procedures. Movement of the face can be achieved by instructing the patient to clench the teeth.

Masseter muscle transposition involves harvesting two anterior slips of masseter muscle and transposing it to the upper and lower lip. Advantages include supplementing other reanimation techniques such as XII-VII or temporalis sling and providing static tone for the face. However, a downwards vector may cause the lip to droop.

Temporalis muscle transposition is also commonly used. This muscle is used primarily to reanimate the mouth and lower aspect of the face. The temporalis muscle is harvested and sewn to upper lip, commissure and lower lip. The key to success is to ensure overcorrection and exaggeration of the lip. Goretex strips can be used to lengthen the muscle so that it can reach the mouth. The defect in the temporalis can be corrected with synthetic insert or a temporoparietal fascial flap. May & Drucker in 1993 reported that the success of temporalis muscle transfer to restore a smile was 80% and to improve mouth function was 96%.

Various neural methods have also been employed to attempt facial reanimation. Primary anastomosis can be utilized effectively in the acute injury. But in the chronic palsy, primarily three techniques are currently used--XII-VII traditional, XII-VII jump, and VII-VII cross face graft. 4-6 months usually pass before the facial muscles begin to show signs of recovery.

The XII-VII traditional anastomosis was first performed in 1903 by Korte. Indications for this procedure include an intact peripheral facial nerve and a nonatrophic facial musculature. However, if the patient has injured the peripheral facial nerve or has atrophied muscles, or if other cranial nerve palsies exist, this procedure is to be avoided. The patient must learn to push his tongue against the teeth when he wishes to smile. Advantages of the procedure are that majority of patients has good movement. However, some patients can develop synkinesis and mass motion as well as atrophy of the tongue.

Another method of XII-VII anastomosis is that of placing an interposition graft between the two, thus "jumping" from XII-VII. This procedure involves partially severing the XII nerve. One usually uses either the greater auricular nerve or the sural nerve as grafts. The former is preferred since it does not involve another operative exposure. However, the sural nerve can be advantageous for it provides a longer graft as well as larger diameter graft.

For best results, the anastomoses should be performed within one year of surgery. This jump graft procedure can diminish the incidence of tongue atrophy, the problems with synkinesis and mass motion and those with swallowing, mastication and speech. However, patients can have weak facial contractures. Another disadvantage is that the procedure involves two anastomoses rather than one as in the traditional XII-VII.

The incidences of swallowing deficiencies, mastication problems and speech difficulty are greater for XII-VII traditional grafts as compared to XII-VII jump. However, the results of achieving symmetry and excellent facial movement are similar between the two. One is able to reduce the incidence of mass movement with a jump graft.

VII -VII cross face grafts have also been used. Scaramella first described the procedure in 1970. It involves grafting VII from the functional side of the face to the stump on the paralyzed side. Obvious disadvantages include long operative time involving two anastomoses and surgical intrusion of the functional side of the face. Synkinesis and low grade neural input can result in less forceful contracture of the face. This procedure is often used in conjunction with free muscle transfers.

With the advent of microsurgery, it is also possible to transpose free flaps. Harii et al in 1975 were the first to transfer free muscle tissue for facial reanimation. Free muscle transfer provides soft tissue coverage of a defect as well as the opportunity for one to develop voluntary control of the face. This is usually a two stage procedure. The first stage involves anastomosing the nerve graft, usually a cross face graft. 6-12 months later, the free flap is harvested and anastamosed to the site. Commonly used donor sites include the gracilis, serratus anterior, latissimi dorsi, and rectus abdominis. The recipient vessels are typically facial artery and common facial vein.

In summary, the management of the permanently paralyzed face is threefold. First, one must provide protection of the eye. Second, muscle transposition is performed to restore tone to the patient's face. Third, efforts are made to restore facial movement that automatically reflects the breadth and depth of human expression. It is this last goal that remains elusive. However, with these methods, a patient can use the restored movement to express human emotion by practice and adaptation.

Case Presentation

A 65-year-old African American woman presented with a long history of right-sided hearing loss. Over the past few months, she has had dizziness and unsteadiness in her gait. Past medical history was significant for diabetes and hypertension. A hysterectomy was her only surgical history.

Imaging studies revealed a large 5 cm tumor in the cerebellopontine angle consistent with a vestibular schwannoma. Audiogram revealed a profound right sensorineural hearing loss.

Excision of the tumor was performed via a transotic and translabyrinthine approach. The VII nerve was not preserved and therefore the patient developed a right facial paralysis. She did not have other cranial nerve deficits.

Approximately 6 weeks after the initial surgery, the patient was evaluated for facial reanimation. At this time, gold weights were implanted in the right eyelid and a XII-VII hypoglossal-facial nerve interpositional-jump graft procedure was performed. The patient had an uneventful postoperative course and was discharged home two days after surgery.

Bibliography

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