INNOVATIONS IN THE SURGICAL TREATMENT OF FACIAL PARALYSIS: Reanimating the Paralyzed Face

Facial paralysis is a potentially devastating disorder. Few impairments have a more negative effect on the quality of an individual's life. The paralysis, which results from injury to the facial nerve, can lead to a variety of troubling symptoms, including ocular problems, speech difficulties, drooling, and nasal obstruction. Thus, this disorder can be quite debilitating for patients who suffer the emotional impact from the facial disfigurement as well as difficulties with communication, eating, and drinking in a social setting.

At Stony Brook, Maisie L. Shindo, MD, associate professor of surgery (otolaryngology-head and neck surgery) and director of head and neck oncology, is using the latest microsurgical techniques in the treatment of facial paralysis which have the ability to reanimate the face and restore spontaneous facial mimetic function.

A highly respected figure in her subspecialty, Dr. Shindo has gained national recognition for her expertise in the treatment of facial paralysis, as well as the art of microvascular free-flap reconstruction in the head and neck region. In addition, her specialties include the treatment of thyroid and parathyroid disorders, head and neck cancers, voice disorders, and paralyzed vocal cords.

The Facial Nerve

The facial nerve has many functions, of which the most physically obvious are the conveyance of emotion, eye closure, and assistance with speech and chewing. Nerve injury causing facial paralysis may result from tumor growth; trauma; surgical procedures involving the parotid gland, ear, and skull base; infection; and several other causes. The facial nerve is further susceptible to spasm from compression by nearby intracranial vessels or tumors. It has a tortuous bony course longer than any other nerve through the densest bone in the body, making surgery on it quite difficult.

Depending on the type of injury to the nerve, the resulting facial paralysis may be temporary or permanent. When the insult does not sever the facial nerve, functional recovery is generally expected, which may take anywhere from weeks to months. Therefore, if the facial nerve injury is suspected to be due to inflammation or contusion of the nerve, the patient is observed, and protective care is given to the paralytic eye to prevent corneal abrasion.

If the nerve is suspected to be severed, for example, from a temporal bone fracture or following parotidectomy, the suspected site of injury should be explored and the nerve repaired to provide the patient with the best chance for recovery. The decision regarding whether or not to explore can be difficult in situations in which the nature and degree of the injury are unclear. Advances in electrodiagnostic testing and radiographic imaging have provided greater insights into the pathophysiology and diagnosis of facial nerve injury, and aid in the decision process.

Treating Facial Paralysis

Treatment of facial paralysis is aimed at restoring facial symmetry: 1) at rest, 2) during voluntary facial movements, such as smiling, and 3) during involuntary facial movements, such as spontaneous laughter or blinking. Of the three, the last function is extremely important because lack of it would be most noticeable, since human facial expressions are seen mostly as involuntary facial movements during awake hours.

Numerous options are available for rehabilitation of prolonged facial paralysis (see Table 1). The majority of these will restore facial symmetry at rest and during voluntary movements, but rarely involuntary motion. Prolonged, chronic facial paralysis is challenging to treat and rehabilitate, particularly if one wishes to restore spontaneous facial mimetic function.

The rehabilitation procedures can be categorically divided into dynamic and static reanimation procedures. Static procedures are simple to perform, but they restore facial symmetry only at rest and do not restore movement. These procedures include static slings, ocular protective procedures, and adjunctive cosmetic procedures.

Dynamic procedures are aimed at restoring symmetry at rest as well as during facial expressions. Dynamic reanimation can be accomplished using neurorrhaphy (nerve repair) procedures, or if the facial nerve is not available for neurorrhaphy, by transferring a muscle flap to the face.

Improvements in microsurgical technique and instrumentation have yielded increasing success in restoring symmetric facial movement using microneurovascular muscle transfer from such muscles as the gracilis and latissimus dorsi. These muscles are typically grafted to the upper lip and oral commissure. Such transfers are benefiting patients in terms of both return of function and independent function of the two sides of the face.

Surgical Advances

Several surgical procedures have been proposed through the years for the treatment of facial paralysis. The multiplicity and diversity of techniques portray the complexity and challenge represented by this disorder. Two basic dynamic reanimation options, as noted above, are currently available: 1) reconstruction of nerve continuity through direct micro suture, with interposition grafts or nerve transpositions; and 2) regional muscular transposition, most often using the temporalis.

Dr. Shindo has been using these advanced microsurgical approaches with considerable success.

Facial reanimation with the temporalis transfer has withstood the test of time and still is a reference technique. In a few weeks, good results can be obtained with a single and rather simple surgical procedure.

In the last two decades, functional free-flaps have been used with increasing frequency, most often combining a cross-facial nerve graft followed by a gracilis free-flap nine months later. With this method there is a potential for restoration of spontaneous facial mimetic function.

At present, the functional results achieved with this technique are good to excellent. Restoration of function, however, is at times limited by lack of axonal regeneration in the nerve(s). Current research is now actively studying and identifying nerve growth factors and pharmacological agents that might have an important and complementary role in the near future.

For consultations/appointments with Dr. Shindo, please call 631-444-4121.