Dynamic Reconstruction For Facial Nerve Paralysis: More..

11/3/2015 Dynamic Reconstruction for Facial Nerve Paralysis: Overview, Anatomy of the Facial Nerve, Etiology in Prognosis and Treatment
Dynamic Reconstruction for Facial Nerve Paralysis
Author: Alan Bienstock, MD; Chief Editor: Mark S Granick, MD, FACS more...
Updated: Nov 11, 2014
Overview
Dynamic and static reconstruction procedures are employed for facial reanimation in
patients suffering from facial nerve paralysis. However, dynamic strategies tend to
be more successful and fruitful and should be offered to each patient considering
reconstruction, unless health risk contraindications exist.
The most common approaches for reconstruction are direct facial nerve repair with
or without grafting, nerve transfer, crossfacial nerve grafting, and muscle transfer
(either regional muscle or freemuscle neurotized transfer). [1, 2, 3, 4]
Facial nerve denervation and paralysis imposes significant psychological and
functional impairment. Facial paralysis can inhibit and mar facial expression,
communication, symmetrical smile, eye protection, and oral competence. Myriad
modalities and stratagems exist for each patient; the physician must accurately
evaluate and examine the patient and determine the etiology, duration, and the
scale of the paralysis.
Understanding facial nerve anatomy with precise assessment of the patient's
paralysis and health status dictates the potential for recovery and the most
appropriate reconstructive scheme.
The goals of the reconstruction in facial paralysis include the following:
Facial symmetry at rest
Symmetrical smile
Voluntary, coordinated, spontaneous facial movements
Oral competence and eyelid closure with corneal protection
Absence or limitation of synkinesis and mass movement
Limitations of surgery
The facial nerve innervates a total of 23 paired muscles and the orbicular oris, but
only 18 of these muscles, working in a delicate balance, produce facial animation
and expression. No current reconstructive stratagem can reproduce every facial
expression and movement.
The patient and the surgeon should thoroughly discuss the patient's expectations.
As part of patient education, surgeons need to establish realistic expectations and
determine whether the patient is willing to expend the time and financial resources
required for a successful result.
Anatomy of the Facial Nerve
The precentral gyrus emits the voluntary motor portion of the facial nerve, where
most of these nerve fibers cross in the pontine region to approach the facial nerve
nucleus in the contralateral pons. At the cerebellopontine angle (CPA), the facial
nerve is near the nervus intermedius and the eighth cranial nerve.
Note the drawings below.
Superior view of the intracranial, meatal, labyrinthine, and tympanic segments of the facial
nerve; anterior inferior cerebellar artery (AICa), cochlea (C), chorda tympani (CT), external
auditory canal (EAC), geniculate ganglion (GG), greater petrosal nerve (GPN), and labyrinthine
artery (La).
http://emedicine.medscape.com/article/1289133overview#showall 1/13
Terminal branches of the facial nerve, demonstrating its variability; buccal (B), mandibular (M),
temporal (T), and zygomatic (Z).
Intratemporal facial nerve
The first branch of the facial nerve is the greater petrosal nerve, which departs from
the geniculate ganglion and is responsible for parasympathetic secretion of the
nose, mouth, and lacrimal gland. The nerve to the stapedius is the next branch and
arises from the proximal mastoid segment. The chorda tympani nerve emerges
proximal to the stylomastoid foramen and carries parasympathetic secretory fibers
to the submandibular and sublingual glands, as well taste fibers to the anterior two
thirds of the tongue.
Extratemporal facial nerve
The extratemporal branching of the facial nerve has myriad patterns and variations.
Dingman and Grabb present the largest dissectionbased series for the surgical
anatomy of the marginal mandibular branch, [5] while Pitanguy identifies the course
of the temporal branch. [6]
Etiology in Prognosis and Treatment
Etiology is the most important factor in determining the timing and choice of
reconstructive technique. Reconstructive efforts should not commence prior to
establishing the etiology of the paralysis.
Bell palsy
Bell palsy, an idiopathic form of facial paralysis, is a diagnosis of exclusion. Eighty
percent of patients with facial paralysis suffer from Bell palsy. (Trauma is the
second most common cause of facial paralysis.) Eightyfive percent of these
patients begin to recover nerve function spontaneously within 3 weeks of onset; the
other 15% do not have any movement for 36 months.
If the patient has Bell palsy, the potential for complete recovery is excellent,
especially in incomplete paralysis. Peitersen found 94% of patients with partial
paralysis completely recovered facial nerve function in 1 year without medical or
surgical intervention; of those with complete paralysis, 71% completely recovered. [7]
Therefore, irreversible techniques to reanimate the face may not be the best choice
in these patients.
Malignancy
If a tumor is suspected, proper evaluation of the patient is of the utmost importance
to appropriately treat the malignancy and choose the best reconstructive option. If
paralysis is caused by a malignancy or is a result of resection for a malignancy, the
risk of recurrence and prognosis may influence the choice of reconstruction.
Malignancy of the posterior fossa, temporal bone, skull base, or parotid region can
present with facial paralysis.
Denervation
The etiology of the denervation dictates the timing of surgical treatment, if any is to
be done. In a patient with a paralyzed face secondary to traumatic surgical
disruption, the surgeon should initiate reconstruction as soon as possible, generally
within the first month. On the other hand, a patient with an intact nerve can be
monitored for recovery for up to 12 months. The duration of the facial paralysis is
essential.
Patient History
Evaluation of a patient with facial paralysis commences with a thorough and
detailed history and physical examination. Keep in mind that the reconstructive
options for acute paralysis, paralysis for less than 1824 months, and paralysis for
greater than 1824 months differ significantly.
A thorough history includes onset, initial degree of paralysis, duration, and
associated symptoms. These details often can help to identify the etiology. Facial
nerve injuries from Bell palsy, trauma, and malignant neoplasm need to be
identified, with the reconstructive efforts and interventions based on the etiology of
the disorder.
For example, a slowly progressive paralysis suggests malignancy, while a sudden
onset of complete paralysis suggests Bell palsy. The workup, treatment, and
prognosis of these 2 disorders differ vastly from each other.
In addition, the surgical team must investigate previous surgical procedures for
reanimation, since these may limit reconstructive options. The patient's overall
health, psychological stability, and life expectancy are significant considerations.
Patients with significant health risks and medical problems are not appropriate
candidates for invasive reconstructive operations, the results of which do not
manifest for 23 years postoperatively.
Physical Examination
The surgeon must perform a comprehensive physical examination of the patient
with facial paralysis, scrutinizing the face at rest and during voluntary and reflex
emotional movement. The physician must determine the involvement of unilateral
or bilateral facial nerves, facial asymmetries, and synkinesis. The degree of brow
ptosis, ectropion, lid laxity, and oral competence must also be noted. The surgical
team cannot neglect other cranial nerve or neurologic deficits and soft tissue defects
in conjunction with the paralysis.
Audiometry and Imaging Studies
Audiometry
Audiometric testing, including acoustic reflexes and tympanometry, may be useful in
identifying the etiology of facial palsy secondary to retrocochlear pathology or mass
lesions of the middle ear.
CT scanning and MRI
Highresolution computed tomography (CT) and magnetic resonance imaging (MRI)
scans are essential in the evaluation of a patient with traumatic facial nerve palsy to
delineate features of the temporal bone, which may impact the facial nerve. Scans
are also used to evaluate patients with possible parotid, skull base, temporal bone,
intracranial, or extratemporal tumors.
Electrodiagnostic Tests
Electrodiagnostic tests of facial nerve function include nerve excitability tests (NET),
electroneuronography (ENog), and electromyography (EMG).
Nerve excitability testing
Nerve excitability testing involves percutaneous stimulation of the facial nerve until
muscle contraction is observed. The minimal NET determines the threshold
stimulation required for muscle contraction compared with the unaffected side.
The maximum stimulation test (MST) is a modification of the NET but is a
supramaximal stimulus compared with the unaffected side, and the stimulus is
increased until the patient encounters discomfort. The subjective nature of the
measurements and lack of recorded data limit both methods, and they do not reflect
denervation at the moment it is occurring.
Electroneurography
Electroneurography (ENog) is an objective measure of facial nerve function that
measures the amplitude of evoked compound muscle action potentials (CMAPs)
with electrodes over the skin of the nasolabial fold. The compound action potential
is compared between the 2 sides of the face, and the response of the affected side
is expressed as a percentage of the response of the unaffected side. A percentage
of nerve fiber degeneration is calculated.
A 95% decrease in CMAP compared with the contralateral side signifies a 50%
chance that the patient will have unsatisfactory recovery of facial nerve function.
Surgery is indicated if a 90% decrease in CMAP is reached within the initial 2
weeks of the onset of paralysis. ENog is objective and is the most accurate
reproducible test, but it is expensive and time consuming.
Electromyography
EMG is a measure of volitional muscle response that is unlike the other modalities.
Needle electrodes are used to monitor activity of the facial muscles. Normal muscle
exhibits activity upon needle insertion, electrical silence at rest, and diphasic or
triphasic action potentials during voluntary contraction. Fibrillation potentials are
observed in the denervated muscle, and polyphasic potentials are observed in
muscle undergoing reinnervation. Complete electrical silence is observed in
denervated muscle with significant fibrosis.
EMG is useful in evaluating patients with acute or traumatic nerve injury and in
assessing the viability of the facial musculature when evaluating patients for
reinnervation procedures. EMG does not show any signs until 3 weeks after
paralysis and should not be utilized until 3 weeks after facial paralysis without any
signs of recovery.
Objective Measures of Facial Motion
Objective measures of facial motion include digital photography and video recording
of the patient at rest and during motion. Dated visual documentation and
preoperative and postoperative facial function are salient for preoperative planning
and outcome assessment.
One method of objective measurement is the maximum static response assay of
facial motion. This method quantifies facial motion preoperatively and serially during
the postoperative period. Mark the patient's face and ask him or her to perform
regionspecific movements, including brow lift, eye closure, smiling, frowning, and
whistling or puckering. The images of the face in repose and the maximum
response movements are recorded and processed for computer display. The images
are calibrated and normalized, and vectors of movement are determined and
measured using a grid and an internal facial coordinate system. Even slight
improvements in facial movement can be detected over the long recovery periods
that often accompany facial reanimation procedures.
Objectives of Nerve Repair
Patients desire a countenance and visage with a normal or almost normal balance
when the person's face is at rest. Objectives of treatment are corneal protection,
establishing a normal resting tone, and restoring a symmetrical dynamic smile.
Little information is available on the denervation of human facial muscles.
Denervated muscles cannot be voluntarily stimulated and have no response to
electrical stimulation. A longer period of denervation translates into a lesser degree
of recovery after reinnervation. There is a decrease in efficiency of muscle
reinnervation after 1218 months of paralysis/denervation. Muscles that are
reinnervated may not undergo full recovery or respond to regenerated nerves.
Repair of the facial nerve is the most effective procedure to restore the function of
the face. Repair is indicated in patients who have experienced acute disruption or
transection of the nerve from an accident, trauma, resection during extirpation, or
inadvertent division during surgery.
Principles of Nerve Repair
Early identification and repair of nerve injuries
The most critical factor in achieving good postoperative facial function is early
identification and repair of nerve disruption. Several investigators have
demonstrated that earlier repair of the facial nerve produces superior results. Some
authors report function in patients who were grafted 1836 months after injury, but
superior results are found with repairs performed within 1 year. May advocates
repair within 30 days; this recommendation is based on clinical results and
neurobiologic investigations that reveal that the regenerative process begins almost
immediately following injury.
Following axotomy, the nerve cell body immediately undergoes changes in
morphology and protein synthesis to support axonal replacement. The proximal
portion of the interrupted axon transforms into a growth cone, and, within a few
days, axon sprouts push out, seeking the distal motor endplate. Neuron metabolic
activity peaks approximately 21 days after injury. The distal portion of the
interrupted axon undergoes Wallerian degeneration, and, within 2 weeks, collagen
and scar tissue begin to replace axons and myelin in the distal nerve stump.
Traumatic nerve injuries must be repaired expediently. In the instance of a grossly
contaminated wound (eg, shotgun injury), the nerve ends can be tagged and
repaired at a later date. A nerve accidentally transected during surgery (eg, facelift)
should be attacked with an endtoend anastomosis. If the facial nerve is resected
because of tumor involvement, frozen sections of both ends can be sent for
histopathologic examination to exclude microscopic invasion before attempting
repair. When margins are clear, either endtoend anastomosis or graft repair can be
performed immediately.
Evaluation of nerve condition
The condition of the nerve at the time of injury dictates whether nerve repair is
indicated and whether it will presage functional repair. The condition of the nerve
depends on the type of injury or trauma. A patient with preoperative facial palsy
secondary to tumor involvement of the facial nerve is unlikely to experience a good
result following resection and repair. The amount of functioning nerve fibers existing
at the time of surgery does not increase after repair; do not expect improved
postoperative facial function over preoperative status.
A sharp facial nerve laceration from glass or a knife should be suitable for endto
end anastomosis. Gunshot wounds, however, either crush or avulse the nerve,
which propagates further nerve degeneration/denervation. These injuries should not
be repaired in the immediate setting until the extent of the nerve damage has
declared itself. In a delayed intervention, scar tissue and neuromas must be
removed, and unhealthy nerve ends must be excised. Identifying healthy nerve
stumps may necessitate histologic or microscopic confirmation.
Matching of endoneurial surfaces
Matching of the endoneurial surfaces is essential in promoting neural regeneration
and is more important than a match of the total nerve diameter. The endoneurium
is examined more easily by removing the overlying perineurium at the ends of the
nerve. Occasionally, a significant mismatch between proximal and distal nerve ends
requires a double cable graft (eg, when grafting from the main facial nerve trunk to
segmental branches).
Epineural versus perineural suturing
Various neurorrhaphy techniques and adjunctive measures have been investigated
in attempts to improve neural regeneration, including epineural versus perineural
sutures, tissue adhesives, laser neurorrhaphy, tubulization, and trophic factors.
However, the most efficacious method of reapproximation remains unproven, and
no specific adjunctive measure has been found to be beneficial. The use of a
minimal number (usually 2 or 4) of epineural or perineural sutures, employing a fine
monofilament suture under microscopic vision, or loupe magnification, remains the
timetested criterion standard for nerve repair.
Tensionfree anastomosis and nerve grafts
Any tension on the nerve ends after repair results in the formation of scar tissue and
poor neural regeneration. Primary neuropathy can be achieved if the proximal and
distal facial nerve ends can be approximated without tension. If tensionless nerve
repair is not feasible, then a nerve graft (usually the sural nerve) will be interposed
between the proximal trunk and distal branches.
Mobilization of the nerve may add up to 2cm of relative length but also may result
in devascularization and further neural injury. Any defect greater than 2cm should
be tackled with a nerve graft. The surgeon must design a nerve graft of adequate
length, without any tension and with a small amount of slack when bridging the
defect.
Cable grafts function as conduits in which sprouting axons from the proximal nerve
stump travel to the motor endplates. The graft provides cellular and humoral
promoters for neural growth, such as Schwann cells, extracellular matrix, and
neurotrophic growth factor.
Success of a nerve graft depends on the following factors:
The number of axons remaining in the nerve
The potential for regeneration of axons
The status of the facial muscles Ie, the more axons that are available, the
greater the chance of recovery and a satisfactory result
Donor nerves for facial nerve grafting
The great auricular nerve and sural nerve are the most commonly selected nerves
for facial nerve grafting. Disadvantages include a sensory deficit of the earlobe
when using the great auricular nerve or of the lateral foot when using the sural
nerve.
The great auricular nerve is harvested easily; since it is located near the surgical
field in which the nerve repair is taking place, it tends to be a good match in size,
and its extensive arborization allows the anastomosis of the proximal facial nerve
stump to several segmental branches. However, only 710cm of the great auricular
nerve can be harvested safely, which limits its use in extensive repairs.
The sural nerve is larger, with a greater axonal volume, and up to 35cm is harvested
easily from the posterior lower leg. It is especially useful in crossfacial grafting.
The principles and technique of graft anastomosis are identical to those of primary
repair. The patient should not expect return of facial function following nerve
grafting for 46 months, as regenerating axons travel a distance of approximately
1mm/day. Improvement in function can be expected for up to 2 years.
In general, results after nerve grafting are not as good as those observed with
primary repair. Spector et al found incomplete reinnervation of facial divisions,
decreased voluntary contractions, and more severe synkinesis when comparing
cable grafts to direct endtoend anastomoses. [8] However, 9295% of patients who
undergo facial nerve grafting experience some return of facial function, and 7279%
have good functional results.
Rehabilitation
After surgery, the rehabilitation of patients with facial paralysis necessitates
electromyography (EMG) protocols, behavioral modification, and patient exercises.
The patient needs to obtain voluntary control of facial regions. Another adjuvant
therapy is the use of percutaneous electrical stimulation to stimulate motor function.
Location of Injury
Intracranial
Intracranial nerve injury most commonly occurs during resection of an acoustic
neuroma or other tumor of the cerebellopontine angle (CPA). Prior to the advent of
the operating microscope in 1961, rates of facial palsy following acoustic neuroma
removal approached 95%. House, by implementing the use of the operating
microscope, reported a 72% rate of normal facial function in patients who
underwent tumor resection from 19611968. [9] More recently, a 97.7% rate of facial
nerve preservation following CPA tumor surgery was reported.
In the event of nerve injury in the CPA, immediate repair with direct anastomosis or
graft is advocated. Rerouting the tympanic and mastoid segments of the nerve may
add enough length for endtoend anastomosis, but a graft is often required.
Interposition grafts can be placed from the intracranial nerve segment to the
temporal segment or from the intracranial nerve segment to the extracranial
segment, thus bypassing the temporal bone. These repairs are technically difficult.
The proximal nerve end, as it enters the brainstem, usually is short and has no
epineurial covering. The brainstem is pulsatile, and cerebral spinal fluid constantly
flows through this area.
However, despite the difficult nature of intracranial repair of the facial nerve, it is a
highly reliable technique to restore facial function. Arriaga and Brackmann reported
that 87.5% of patients who undergo this type of repair developed some degree of
facial function, with 57% achieving grade IV or better. [10]
Intratemporal
Intratemporal facial nerve injury is observed in patients who have experienced
external head trauma or iatrogenic injury during otologic procedures.
Temporal bone trauma
Temporal bone fracture is the most common mechanism of facial nerve injury from
external trauma. Most temporal bone fractures result from motor vehicle accidents,
and 710% of these fractures result in facial nerve dysfunction.
In temporal bone trauma, facial nerve injury most often occurs in the perigeniculate
and labyrinthine areas, with axonal degeneration extending a variable distance,
possibly involving the entire intratemporal length.
Management of facial nerve injury following temporal bone trauma remains
controversial. However, a review of the literature concludes that patients with
complete paralysis at the time of injury have a poorer prognosis than those with
incomplete or delayed paralysis.
Chang and Cass proposed a reasonable algorithm for the management of
intratemporal facial nerve injury from temporal bone trauma, in which patients with
delayed onset or incomplete paralysis are observed. If the paralysis progresses to
complete paralysis, perform serial ENog. [11] In addition, monitor patients with
immediate complete paralysis with serial ENog. If ENog shows greater than 95%
degeneration in the first 14 days after injury, offer the patient facial nerve
exploration and decompression. Explore the entire length of the nerve from the
meatal foramen to the stylomastoid foramen. Perform nerve repair via primary
anastomosis or graft only if total or neartotal transection is certain.
Otologic procedure injuries
Intratemporal nerve injury occurs in 0.63.6% of otologic procedures. A review by
Green et al revealed mastoidectomy, with or without tympanoplasty, as the most
common otologic procedure resulting in facial nerve injury. [12]
Green et al also reported injury of the facial nerve during tympanoplasty alone and
during removal of exostoses. [12] Patients with previous surgery, infection, tumor, or
congenital anomalies of the ear are at a higher risk for inadvertent nerve injury. If
the injury is recognized immediately, repair it during the primary procedure.
Explore a postoperatively recognized facial paralysis that does not recover over
several hours. Monitor a delayedonset paralysis with serial ENog and explore if
more than 90% degeneration occurs within the first week. Strongly consider nerve
repair if more than 50% of the nerve is transected.
Extratemporal
Extratemporal injury to the nerve may occur during surgery of the parotid or
submandibular gland, temporomandibular joint procedures, or facelift procedures, or
from traumatic lacerations of the face. Paralysis of the facial nerve following
uncomplicated parotid procedures is reported at a 20% rate of temporary palsy, with
a 10% rate of permanent paresis of temporal or mandibular branches.
Children are at higher risk for facial nerve injury during parotid surgery, as are
patients who undergo total parotidectomy. Surgery of the parotid gland often is
performed for benign or malignant tumors that may involve the facial nerve. If the
nerve is resected because of a tumor, histopathologic confirmation of clear margins
is required prior to repair by direct anastomosis or graft.
Inadvertent transection recognized during facelift or parotid surgery warrants
immediate primary repair. Postoperative paralysis with known facial nerve integrity
usually recovers within 6 months of the procedure. Traumatic transections,
iatrogenic injuries, and division of segmental branches proximal to the lateral
canthus should be explored and repaired.
Facial nerve injury following submandibular gland surgery, which usually involves the
marginal mandibular branch of the nerve, is not uncommon. Sacrifice of this branch
may be unavoidable because of involvement by the disease process, most
commonly chronic infection or tumor.
Temporomandibular joint procedures may injure the temporal branch or, less
commonly, the main trunk of the facial nerve. Facial nerve injury during
rhytidectomy is rare, usually temporary, and most often involves the segmental
branches.
The surgeon is obliged to explore traumatic or iatrogenic transections that involve
the main trunk of the facial nerve and repair them as soon as they are recognized.
The surgeon should explore and repair segmental branches proximal to the lateral
canthus and nasolabial fold. Medial to the lateral canthus, extensive
interconnections between the zygomatic and buccal branches provide neurotization
of denervated muscle and satisfactory functional recovery. Nonetheless, the surgeon
should also explore and repair medial temporal and marginal branch injuries, if
possible.
Nerve Substitution and Grafting
Nerve substitution via grafting or nerve transfer should be achieved in patients with
facial paralysis who lack the proximal nerve segment but have an intact distal
neuromuscular pathway, including an intact distal segment of nerve and facial
musculature suitable for reinnervation. A donor nerve, transferred and anastomosed
to the distal facial nerve stump, innervates the facial muscles in place of the injured
proximal facial nerve.
The spinal accessory, phrenic, and trigeminal nerves have been used in nerve
transfer procedures. However, sacrificing these nerves involves significant
morbidities. Therefore, the hypoglossal nerve transfer/graft and crossfacial grafting
have remained the mainstays in treatment.
Selection of patients
Eighteen months after the original nerve injury, the facial muscles atrophy and do
not regain any modicum of function. When the interval of facial nerve dysfunction is
less than 18 months, primary repair, nerve grafting, or nerve transfers can be
explored. Denervated facial musculature undergoes atrophy immediately after nerve
injury and takes several years to complete. If the status of the facial musculature is
in question, the team should perform electromyography (EMG), muscle biopsy, or
both prior to the reinnervation procedure.
Proximal facial nerve segment
Several factors must be considered when selecting patients for nerve substitution.
The availability of the distal neuromuscular unit is the most essential requirement
for this technique. Unavailability of the proximal facial nerve segment most
commonly occurs following cerebellopontine angle (CPA) surgery, in which the
nerve is resected at the brainstem. It also occasionally occurs following radical or
ablative procedures for tumors of the parotid gland, temporal bone, or skull base.
Intact distal neuromuscular unit
The surgeon must evaluate the distal neuromuscular unit. Denervated facial
musculature undergoes atrophy and eventual fibrosis in a process that begins
immediately after nerve injury and takes several years to complete. As stated
above, if the status of the facial musculature is in question, perform EMG and
muscle biopsy prior to the reinnervation procedure. The distal nerve stump also
undergoes degeneration, as previously described, and severe neurofibrosis may limit
axonal regrowth.
Suitable donor nerve and loss of donor nerve function
Nerve transfer always results in either total or partial loss of function in the donor
nerve, depending on the technique used. Hypoglossal substitution results in
paralysis or weakening of the ipsilateral tongue muscles, which may result in
significant problems with speech, mastication, and swallowing.
Nerve Grafting Techniques
Direct hypoglossaltofacial graft
Korte performed the first hypoglossalfacial nerve anastomosis in 1901. [13] May
reports improvement of tone and symmetry in more than 90% of patients who
undergo this procedure. Initial results usually are observed within 46 months,
indicating the amount of time necessary for axons to travel to the distal motor
endplate. Voluntary movement develops and continues to improve for up to 23
years.
Spontaneous, symmetrical movement is unlikely following this type of procedure.
Patients must undergo biofeedback and motor sensory reeducation to learn
voluntary control of movement, decrease synkinesis, and limit facial grimacing that
can occur with mastication.
The team evaluates function of the facial nerve following hypoglossalfacial
anastomosis by the degrees of tone, symmetry, movement, and synkinesis
exhibited rather than by the traditional HouseBrackmann scale.
A review of several large series of patients found that 4265% of patients
experienced good to excellent results, which were described as the presence of tone
and symmetry, with fair to good movement and moderate to mild synkinesis.
Complications following hypoglossaltofacial anastomosis include variable degrees
of hemitongue atrophy and functional disability, including difficulty with chewing,
swallowing, and speaking. In general, these impairments improve over time, and
many patients report fewer problems chewing postoperatively than preoperatively.
This likely is due to improvement of buccal tone.
Partial hypoglossaltofacial jump graft
A partial hypoglossaltofacial nerve transfer using a jump graft can reanimate the
facial muscles while curbing the complications of complete hypoglossal sacrifice. In
this technique, a cable graft is anastomosed in a notch in the hypoglossal nerve and
attached to the intact facial nerve stump using microsurgical principles.
May analyzed results and complications between cranial nerve XIIVII directtransfer
and XIIVII jumpgraft techniques and found that only 8% of patients undergoing
jump grafting experienced permanent tongue deficit, compared with 100% of nerve
transfer patients. Good facial movement and expression were noted in 41% of jump
graft patients, and the patients experienced less synkinesis than did the nerve
transfer patients. [14]
Facial motor function generally is not as strong following a jump graft, and recovery
of facial function has been found to take longer in jump grafts.
Crossfacial nerve graft
Smith and Scaramella first reported crossfacial nerve grafting in 1971. This
technique provides the potential for symmetry and involuntary mimetic function.
Disadvantages include weakening of the contralateral facial nerve and inadequate
power to innervate the ipsilateral musculature.
Crossface nerve grafting is indicated if the proximal ipsilateral facial nerve is not
available but the distal stumps are available. Outcome of crossnerve grafting
depends on timing and technique and can provide the best facial reanimation
scheme if performed on the right patient.
The surgeon must select appropriate segmental branches of the contralateral facial
nerve as donors, with the sural nerve serving as a cable graft. Many techniques
have been described, such as a single segmentalto – main trunk anastomosis and
multiple anastomoses from segmental branches to segmental branches. The grafts
are tunneled above the supraorbital ridge for the orbicularis oculi, the upper lip for
the zygomatic and buccal branches, and below the lower lip for the marginal
mandibular branch.
Facial muscle movement will not emerge until 912 months after the procedure (ie,
the allotted time for axonal growth to cross the graft). Crossfacial nerve grafting
remains polemic, and many investigators relegate it to serving an adjunctive
procedure in combination with other reanimation strategies.
Muscle Transposition
When facial nerve dysfunction has exceeded 18 months, dynamic slings and free
muscle transfers can be executed to restore facial and oral motor function. Severe
neurofibrosis and myofibrosis in the distal neuromuscular unit preclude successful
reinnervation. Patients with congenital facial paralyses cannot be reinnervated,
since the neuromuscular units never developed in these individuals. Regional
muscle transposition and freemuscle transfer are the 2 modalities to reanimate the
face in this subset of patients.
Regional muscle transfer can reanimate the lower third of the paralyzed face. This
new neuromuscular unit is composed of the transferred muscle (to its new origin)
with its original nerve and vascular supply.
Temporalis
The temporalis muscle may improve the symmetry of the commissure of the mouth
and reestablish a voluntary smile. The vector of the temporalis muscle resembles
that of the zygomaticus major and, thus, results in a lateral smile. Transposition will
not produce spontaneous mimetic function. Each movement necessitates a specific
volitional action, in which the patient must consciously contract the transposed
muscle in conjunction with the smiling.
Temporalis muscle transposition can also reanimate the eyelids. However,
reanimation of the eye with the temporalis transfer can produce eyelid distortion. To
avoid a contour defect, do not use the muscle anterior to the hairline.
The temporalis muscle is harvested through a vertical incision in front of the ear that
extends to the scalp. The middle section of the muscle and fascia is elevated and
detached superiorly from the skull while the inferior attachments are preserved. Two
tongues are created by bisecting the muscle, and the muscle is tunneled through a
subcutaneous pocket from the zygomatic arch to the vermillion border. The ends of
the temporalis are secured to the orbicularis and the corner of the mouth. The ends
should be secured with enough tension to create some level of overcorrection.
The patient initiates a smile by consciously tensing the temporalis muscle. Patients
will require therapy to master this technique.
In his study, May reported improvement in 95% of patients with temporalis transfer
for lowerface reanimation and good to excellent results in 78% of patients. The
complication rate was 18%; the most common complications were infection and
implantrelated complications. Other potential complications include failure of
attachment, pulling away of the temporalis muscle from the commissure, and
overcorrection of the upper lip. The transfer may also generate excess muscle bulk
and a facial deformity, particularly over the zygoma.
Masseter
The masseter muscle is another muscle used for reanimation of the commissure of
the mouth, either alone or in conjunction with the temporalis. Unlike the temporalis,
the vector of smile of the masseter muscle is in the buccinatorrisorius direction,
which produces a less natural smile.
This muscle is elevated by detaching the anterior portion from its mandibular
insertion. It is similarly bisected and secured to the modiolus. The muscle is quite
bulky and can create facial irregularity or surface deformity, such as a bulge at the
commissure. Postoperatively, patients must train the masseter with aggressive
physical therapy to learn how to use the transposed masseter to produce a smile.
[15]
Digastric
The smile is one of the most important facial expressions, and facial paralysis can
debilitate an individual. Conley developed the modern method of transposing the
tendon of the digastric muscle to the orbicularis of the lower lip. The blood supply
and nerve to the anterior belly remains intact, and dynamic depression of the lower
lip border is achieved. Of 36 patients treated in this manner by Conley, 33 were
reported to have satisfactory results. This method is ideal for isolated palsy of the
marginal mandibular nerve only, since it can create oral incompetence in patients
with more extensive palsy of the lower face.
Depressor muscle function is important to dentured smile, as well as to expressions
of sadness, anger, and sorrow. The lower lip is animated by interactions of the
orbicularis oris, depressor labii inferioris, depressor anguli oris, mentalis, and
platysma. Terzis described a technique to improve this type of smile by transfer
either of the anterior belly of the digastric tenor or of the platysma. [16] Other authors
argue that this symmetrical smile could be achieved with less invasive approaches,
including BOTOX® injections or myectomy of the depressor labii inferioris.
Regional muscle transposition is limited by anatomic constraints of size and vectors
and often produces results slightly better than static strategies. Regional muscle
procedures are appropriate in patients who are in poor health or who will not survive
beyond the 1224 month period of neurotization of a free muscle transfer. Such
procedures provide immediate reanimation and are technically less demanding than
crossfacial nerve grafting with free muscle transfer.
Principles of FreeMuscle Transfer
Crossfacial nerve grafting with microneurovascular muscle transfer is the best
strategy for facial reanimation when a patient has longestablished facial paralysis
(>24mo). Other approaches leave residual asymmetry, an unnatural appearance,
and unwanted facial movements while eating.
The advent of microsurgical technique and freemuscle transfer introduced a new
era for facial reconstruction in patients with chronic facial palsy. Freemuscle
transfer supplies a new neuromuscular unit to the face via a freemuscle flap and a
grafted donor cranial nerve, usually a crossfacial nerve graft. This modality
establishes more precise vectors in addition to spontaneous mimetic facial
expression.
Most commonly, the surgeon executes a 2stage technique of crossfacial nerve
graft followed by a delayed freemuscle transfer. The rationale for the delay is to
prevent atrophy of the muscle graft while waiting for axons to travel the length of
the nerve graft.
Crossfacial nerve graft
Occasionally, the proximal segment of the ipsilateral facial nerve is available for
grafting to innervate a freemuscle transfer. This situation most commonly occurs in
the event of a failed interposition nerve graft, resulting in facial musculature that no
longer can be reinnervated.
The contralateral facial nerve is chosen as the donor nerve, and a redundant
zygomaticus branch is selected for grafting. The hypoglossal nerve also can act as a
donor, either by a direct or jump graft alone or in conjunction with a crossfacial
graft. The sural nerve is anastomosed to the contralateral facial nerve or substituted
cranial nerve and tunneled subcutaneously from the donor nerve to the planned site
of freemuscle transfer, and the distal segment of the graft is tagged. The ideal
time for the muscle transfer occurs when a Tinel sign is detected in the distal nerve
end, indicating completion of axonal growth.
Muscles suitable for transfer
Freemuscle transfer is usually performed 912 months after nerve graft. A plethora
of muscles have been assiduously investigated for free transfer to the paralyzed
face, including the gracilis, serratus, pectoralis minor, latissimus dorsi, platysma,
rectus abdominis, rectus femoris, and extensor digitorum brevis.
The original report by Harii in 1976 of freemuscle transfer for facial paralysis
described use of the gracilis muscle. [17] It remains the muscle of choice because of
its relative ease of dissection, adequate neurovascular pedicle, and muscle fiber
length, which corresponds to the action of the zygomaticus major muscle. The
vascular pedicle is derived from the medial femoral circumflex artery and provides
up to 8cm of length. Innervation of the gracilis is provided by the anterior branch of
the obturator nerve, which can be dissected to a length of 1012cm.
During the secondstage procedure, the surgeon must identify the distal end of the
nerve graft and send a frozen section for confirmation of viable axons. The muscle
flap is harvested and transferred to the face. The flap is secured to the periosteum
of the zygomatic arch and the modiolus in a vector that corresponds to the smile on
the contralateral face. Subsequently, the microanastomosis between the flap and
recipient vessels is executed, followed by the nerve anastomosis as close to the
muscle as possible. Movement can be expected in 69 months, with improvement
over the following 23 years.
Based on their anatomical findings, Lifchez and Gasparri endorse the serratus
anterior for freemuscle transfer. [18] Each serratus slip, divided along fascial planes,
can generate a distinct force vector for facial reanimation, with a total of 5 slips and
10 subslips. This serratus anterior can, therefore, be used as a single donor muscle
with multiple vectors of action and multiple functions (eg, restoration of a
symmetrical smile with simultaneous, but independent, eyelid closure).
Terzis and Noah found no significant effect associated with age, gender, or
ischemia time on outcome in their series of 100 freemuscle transfers. [19] They
reported moderate or better results in 80% of patients undergoing freemuscle
transfer, based on a 5step scale of judgment.
O'Brien et al report good to excellent results in 51% of 47 patients treated by
microvascular freemuscle transfer; the surgeons most commonly used crossfacial
nerve grafts and gracilis muscle transfers in their technique. [20]
Onestage freemuscle transfer
In their study of 25 patients, Kumar and Hassan compared singlestage freetissue
transfer with dualstage freetissue transfer for facial reconstruction. [21] The gracilis
obturator nerve branch can yield a length of 12cm, which allows primary
anastomosis of this nerve to the contralateral facial nerve. However, this technique
produces an additional scar on the cheek. The singlestage transfer has fewer
complications and a reduced recovery time with decreased rehabilitation, but the
dualstage approach achieves better overall symmetry.
In their investigation of 166 free gracilis transfers, Manktelow and Zuker explored
muscle transfer with crossfacial nerve graft versus singlestage transfer to the
masseter nerve. The excursion of the free gracilis innervated by the masseter
nerves is greater than that of the crossfacial nerve graft. This is probably
attributable to the different motor nerve used to reinnervate the muscle. The cross
face nerve graft provides improved spontaneity in terms of movement, which is vital
to a normal smile in children. This is a more important characteristic than degree of
excursion. Their future studies will explore the nature of spontaneity in their muscle
transfers utilizing the masseter nerve as a donor.
Although use of the masseter nerve with freetissue transfer was previously explored
and considered only in the setting of Möbius syndrome, bilateral facial paralysis,
and facial paralysis not suitable for crossfacial nerve grafting, the masseter nerve’s
applicability and role has been recently extended to patients with unilateral facial
palsy. This onestage strategy, incorporating the masseter nerve with free tissue
transfer, has become a reasonable alternative (and may become the criterion
standard) to the dualstage approach with crossfacial nerve grafting.
The enormous advantage of the masseter nerve freetissue transfer technique is
that, unlike the crossfacial nerve, the masseter nerve donor produces a movement
and muscle excursion (in relation to smile and commissure excursion) in normal
range with consistent movement. Also, this technique obviates the need for a
second operation.
A study by Liu et al concluded that onestage reconstruction with free abductor
hallucis muscle transfer can effectively restore dynamic facial animation in long
standing, unilateral facial paralysis. The study involved 41 patients who underwent
the procedure and were followed up for a mean 54.6month period. The surgery
produced satisfactory results in 37 patients with regard to facial symmetry at rest
and voluntary contraction of the transferred muscles; significant increases were
achieved in mean values for the Toronto Facial Grading System and the facial
nerve function index, at 2year followup, with even greater increases attained at
longerterm followup. The remaining four patients experienced complications,
including infection, hypertrophic scar, hematoma, and muscle loss. [22]
Revisions
Takushima and Harii determined that predicting muscle bulkiness to obtain
symmetry of facial contour is difficult during the initial freemuscle transfer. In their
study of a patient population of 486 patients and 183 revisions, Takushima and
Harii analyzed excessive muscle bulk and dislocation of the transferred free muscle.
[23] Their report illustrated the wide gamut of revisions, including muscle debulking
of cheek, adjustment of tension and attachments of transferred free muscle, and
lipoinjection to the cheek for better volume symmetry.
Mobius Syndrome
Möbius syndrome involves bilateral facial nerve paralysis and can often attack
cranial nerves VI, III, and XII. The syndrome generates psychological disability due
to lack of facial animation and lack of emotional expression. Patients with an
immobile face cannot use it to show happiness, sadness, or anger.
The surgical goals for patients with Möbius syndrome are far more modest than and
differ from the goals for patients who have unilateral developmental facial paralysis.
The restoration of a true smile in these masklike faces is impossible. Movement can
be restored along only 1 vector.
A detailed neurologic evaluation can identify possible motor donors or residual
function, which can be used for additional dynamic restorations. Because of cranial
nerve involvement, a thorough clinical and electrophysiologic examination is
obligatory.
Most frequently, the reconstructive surgeon performs freetissue transfers with
bilateral gracilis muscles anastomosed to the masseter nerves on both sides in
order to achieve smile restoration.
Summary
The patient with facial paralysis presents a daunting challenge to the reconstructive
surgeon. A thorough evaluation, including complete history and careful physical
examination, directs the surgeon to the appropriate treatment modality.
Dynamic reanimation involves nerve repair, nerve transfer, regional muscle transfer,
or freemuscle transfer. None of the procedures can restore all of the complex
vectors and balance of facial movement and expression. However, dynamic
reconstructive techniques can yield improved facial symmetry, spontaneous and
symmetrical smile, eye closure and protection, and oral competence, all of which
refurbish patients' emotional, psychological, and cosmetic state and disabilities.
Contributor Information and Disclosures
Author
Alan Bienstock, MD Consulting Staff, Division of Plastic and Reconstructive Surgery, Department of Surgery,
Lennox Hill Hospital, St Luke's/Roosevelt Hospital
Alan Bienstock, MD is a member of the following medical societies: American Medical Association, American
Society of Plastic Surgeons
Disclosure: Nothing to disclose.
Coauthor(s)
Perry J Johnson, MD Assistant Professor, Department of Plastic and Reconstructive Surgery, University of
Nebraska Medical Center
Perry J Johnson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of
Facial Plastic and Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery,
American College of Surgeons, American Medical Association, Nebraska Medical Association
John Y S Kim, MD, MA Assistant Professor, Department of Surgery, Division of Plastic Surgery, Northwestern
Medical Faculty Foundation; Consulting Staff, Northwestern Plastic Surgery
John Y S Kim, MD, MA is a member of the following medical societies: American College of Surgeons,
American Society of Plastic Surgeons
Disclosure: Received grant/research funds from Musculoskeletal Transplant Foundation for principal investigator.
Chief Editor
Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New Jersey
Medical School
Mark S Granick, MD, FACS is a member of the following medical societies: American College of Surgeons,
American Society of Plastic Surgeons, Phi Beta Kappa, Northeastern Society of Plastic Surgeons, New Jersey
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Waterjel, Inc.;
Reconstat, LLC; DSM<br/>Serve(d) as a speaker or a member of a speakers bureau for: Novadaq<br/>Received
none from Waterjel Inc. for board membership; Received none from Reconstat LLC for board membership;
Received none from Open Science Co., LLC for board membership.
Acknowledgements
Jaime R Garza, MD, DDS, FACS Consulting Staff, Private Practice
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American
Academy of OtolaryngologyHead and Neck Surgery, American College of Surgeons, American Society for
Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas
Mary C Snyder, MD Division of Plastic Surgery, Monument Plastic Surgery
Mary C Snyder, MD is a member of the following medical societies: American Academy of Facial Plastic and
Reconstructive Surgery, American Academy of OtolaryngologyHead and Neck Surgery, American Cleft
Palate/Craniofacial Association, American College of Surgeons, American Medical Association, and American
Rhinologic Society
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; EditorinChief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
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11/3/2015 Dynamic Reconstruction for Facial Nerve Paralysis: Overview, Anatomy of the Facial Nerve, Etiology in Prognosis and Treatment

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