The treatment of each patient is unique to that patient based on the cause of their paralysis; the extent and distribution of their paralysis; the duration of their paralysis; the age of the patient; the patient’s general medical condition; and the patient’s goals.
Patients afflicted with facial paralysis are first evaluated with a through history and physical examination, as well as diagnostic studies including MRI, CAT scans, and electrical conduction tests of facial nerve. Treatments are uniquely formulated for each patient’s particular case.
In some cases physical therapy with or without selective Botox muscle blocks and muscle exercises will help re-train and re-balance the partially weaken facial muscles.
In most cases, however, surgical intervention with local muscle slings, or cross-face nerve grafts combined with microvascular muscle auto-transplants may be necessary.
Choosing the Surgical Procedure
There are a variety of impairments associated with facial paralysis. A decision on which surgery or surgeries are needed is based on the individual patients pre-operative deficits. These include:
Eye exposure due to lack of eyelid closure
Folding out (ectropion) of the lower eyelid
Corneal erosion or irritation with conjunctivitis
Ptotic (fallen) eyebrow with or without visual obstruction
Flattening of the nasolabial fold
Nasal airway obstruction with external nasal valve collapse
Inability to smile
Oral incompetence with drooling and difficulty with speaking
Lower lip asymmetry
Surgical Treatment of Facial Palsy
The treatment strategies for each patient is based on an evaluation of the etiology of the problems, their unique anatomical impairment and their general medical condition.
The primary objectives are to prevent eye-exposure and corneal injuries, restore facial symmetry and a dynamic smile, improve nasal airway and oral competence. Procedures for the eye and brow include: a gold weight implant for upper eyelid closure; a canthopexy, or tightening of the lower lid for better closure; browlift procedure (open or endoscopic) for improvement of eyebrow position and symmetry.
Procedures for dynamic smile include: 1) regional muscle flaps of the temporalis or masseter muscles; cross-face nerve grafts with a gracilis muscle microvascular transplant; 2) combined with static suspension procedures for repositioning the corner of the mouth, and corner of the nostril to open the nasal airway and improve breathing; 3) creation of nasolabial fold for symmetry.
For the lower face and lips reconstruction includes: 1) facelift – like procedure to raise the ptotic cheek and improve facial symmetry; 2) Wedge resection of the lower lip and local (digastric) muscle transfer for improved position and function.
Microsurgical Reconstruction of Facial Paralysis
In the direct cross-facial nerve graft surgery, a nerve is taken from the leg and used like an extension cord to connect from a branch of the functioning facial nerve on the un-paralyzed side to a corresponding facial nerve branch on the paralyzed side.The nerve repair is performed using an operating microscope, microsurgical instruments, and 9-0 nylon micro-sutures that are thinnner than a strand of human hair.
Another microsurgical technique is to do a cross-facial nerve graft and muscle transplant. First a muscle that is auto-transplanted from the patient’s thigh to the paralyzed side of the face. Its circulation is restored by connecting the transplanted muscle’s blood vessels (artery and vein) to nearby facial vessels.
Then the nerve graft originating from a branch of the facial nerve on the unparalyzed side is connected to the transplanted muscle’s nerve. As a result, when the patient attempts to smile, an impulse goes from the facial nerve on the good side of the face along the cross-facial nerve graft activating the transplanted muscle which contracts to restore a smile to the paralyzed side of the face.
These reconstructions are developed as multistage plans individualized for each patient’s particular condition and requirements.
Physical therapy including biofeedback and electrical stimulations, often prescribed before and after facial paralysis surgery in order to enhance the potential result.