Treatment options for facial paralysis and associated movement disorders are numerous and vary based on individual deficits, needs, and preferences.
A set of clinical guidelines has been developed at New York Eye and Ear Infirmary of Mount Sinai's Facial Paralysis and Rehabilitation Center, in collaboration with physicians specializing in the fields of otolaryngology, neurotology, ophthalmology, and facial plastic and reconstructive surgery.
Recommended treatment strategies have been derived from a combination of published medical literature, strength of its evidence, and the experience of physicians practicing at New York Eye and Ear Infirmary.
Acute Facial Paralysis (0 days - 21 days)
Identifiable causes of acute paralysis are treated expediently with appropriate medical therapy, following proper identification of the cause (diagram - acute paralysis with facial nerve anatomically intact). In rare instances, surgical intervention may be necessary to control infection and/or swelling around the facial nerve.
In a setting of facial nerve transection, such as during trauma or resection of cancer invading the facial nerve, several reconstructive options are available. These assist in minimizing sequelae of paralysis, optimize immediate patient recovery, and promote the return of facial nerve function (diagram - acute paralysis with facial nerve injury / transection).
Intermediate Facial Paralysis (21 days - 2 years)
During this stage, facial nerve recovery is monitored with serial EMG (electromyography) exams, which provide useful prognostic data. In a setting of poorly recovering facial nerve, several procedures can be considered to restore facial appearance and rehabilitate function around the eye and mouth (diagram - intermediate facial paralysis).
In the early stages, at 6 weeks - 3 months, gold weight placement to aid upper eyelid closure and static sling suspension of the mid-face and lip can be performed with minimal associated downtime. These procedures do not interfere with the recovering facial nerve. In the later stages, if the facial nerve continues to display poor recovery on EMG, consideration is given to nerve transfer procedures designed to maintain neurological input of facial muscles. A graft from a nearby nerve, most commonly hypoglossal (CN 12), can provide such input.
This ultimately allows for preservation of tone in the native facial musculature, however, usually at the expense of developing synkinesis (involuntary simultaneous movement of multiple facial muscles). An alternative for definitive reconstruction, with vascularized gracilis muscle transfer, is also considered at this stage.
Chronic Facial Paralysis (>2 years)
Management of chronic facial paralysis depends on numerous factors, including patient preferences and desires. Depending on the situation, medical considerations may limit the available procedures. Reconstructive options range from static suspensions to reanimation via muscle transfers to the paralyzed side 1, 2, 3, 4 (diagram - chronic facial paralysis). Both have its merits and serve a useful purpose in aesthetic and functional rehabilitation of facial paralysis.
Static slings represent the simplest solution with the quickest recovery time. They effectively reposition displaced tissues of the face back to the midline and aid in functional aspects such as lip closure and prevention of food spillage. Native fascia 5, sutures 6, and various manufactured materials (Alloderm 7, 8, 9, Gore-Tex 10) can be utilized for this purpose. Static slings may relax and descend over time, thus potentially requiring additional tightening.
Muscle transfer allows one to regain symmetry and movement on the paralyzed side. These are more extended procedures with longer recovery times, when compared to static slings. Transfer of the temporalis muscle (one of the muscles of mastication, anatomically adjacent to tissues requiring suspension in facial paralysis) represents a simpler option, however, requires one to bite down in order to activate the smile 11. The procedure of choice to regain involuntary smile is a 2-stage transfer of the gracilis muscle (transferred from the inner thigh) 12, 13. In the first operation, a branch of the facial nerve on the healthy side is grafted and carried across to the paralyzed side.
Approximately 6-9 months later, after the nerve has grown across, a segment of the gracilis muscle is transferred to the face and connected to the grafted nerve. In approximately 6 months this muscle becomes functional, providing movement on the paralyzed side. The gracilis transfer affords a better precision with respect to the smile angle, and greater excursion (movement) of the commissure (corner of the mouth), when compared to temporalis transfer 14.
Synkinesis is a poorly coordinated, simultaneous, and involuntary contraction of several facial muscles during purposeful movement of the face. For example, while attempting eye closure, the corner of the mouth may move also, generating an unwanted smile. This poor coordination results from random growth of fibers within the facial nerve during its recovery. Successful management of synkinesis depends on selective chemodenervation with a paralytic agent (Botox), along with facial physical therapy. Injections need to be repeated every 3-4 months as their effect wears off in that time frame.
Other therapies, such radiofrequency ablation, may reduce the frequency of such injections, but are still investigational at this juncture. The combination of chemodenervation and physical therapy carries a high success rate in alleviating most of the discomfort associated with synkinesis 15, 16, 17.
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- Manktelow RT, Tomat LR, Zuker RM, et al. Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation. Plast Reconstr Surg 2006;118(4):885-99.
- Bae YC, Zuker RM, Manktelow RT, et al. A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve. Plast Reconstr Surg 2006;117(7):2407-13.
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