Case Studies

Posted on   2009-07-01 02:07:55

Case Studies of Facial Paralysis and Bells Palsy

Case No. 1
6 year old girl developed facial paralysis at age of one following an upper respiratory tract infection. She presented with complete left sided facial paralysis.

The family was extremely concerned about her appearance and the fact that she would be entering school with this appearance. A treatment plan was created with the family after lengthy discussion about all of the patient?s options. Young patients who have had long-term paralysis are able to undergo advanced facial reanimation procedures to re-create dynamic spontaneous smile mechanism. Cross-facial nerve grafts gives patients the ability to utilize the facial nerve in the normal side of the face to ?drive? the facial movement in the paralyzed side. Patients with long-term paralysis (> 2 years) have non-functional muscles; therefore, new vascularized muscle needs to be attached to the cross-facial nerve grafts. The nerve grafts also need to be activated for 8-12 months before the muscle in transferred.

Treatment Plan- Two stage procedure

Stage 1: Cross facial nerve grafts are harvested from sural nerve and attached to the normal facial nerve (photo of sural nerve)
Stage 2: Gracilis muscle free flap is harvested from the inner thigh and attached to the cross-facial nerve graft and artery/vein in the neck

Physical therapy is continued for the next 18 months. Facial movements can be gradually seen at 8 months following the second stage of surgery and continued for 2 years. The chances of facial movement are better with younger patients.

Case No. 2
48 year old woman
developed Bell??s palsy 4 years earlier. She was devastated
emotionally and physically.

She could not close her eyes completely or smile. Her face was asymmetric. She drooled constantly and was unable to chew well on the affected side. All of her physicians had told her that she should live with these problems. She finally presented to Dr. Azizzadeh and a special surgical treatment was tailored for her after lengthy discussion.

Treatment Plan

1. Asymmetric facelift
2. Endoscopic brow lift
3. Gold weight placement upper eyelid
4. Lower eyelid canthoplasty
5. Static suspension of face with tensor fascia lata
6. Radiesse injection to the normal ??laugh line??
7. BOTOX? injection to the normal forehead to reduce its activity

Case No. 3
A 42 year old man presented following removal of acoustic neuroma 12 months earlier. He had developed complete facial paralysis following surgery without any return of facial nerve function.

MRI testing showed that the tumor was completely removed. Dr. Azizzadeh devised a plan to reconstruct the facial nerve using the hypoglossal nerve (cranial nerve 12). The hypoglossal nerve is responsible for moving the tongue muscle and by attaching a partial portion of the nerve to the facial nerve, the patient has the ability to move the face voluntarily by tongue thrusting. More importantly, the nerve allows the facial muscles to ?stay alive? and thereby giving excellent tone to the face that is extremely important in preventing long-term facial asymmetry. Furthermore, in younger patients, there is potential for ?plasticity? of the brain to naturally move the face. The patient also had additional procedures for eyes and brows. Furthermore, the patient underwent simultaneous static suspension to restore facial symmetry and improve his drooling.

Treatment plan:

1. Hypoglossal to facial nerve transfer (12-7 cranial nerve substitution)
2. Static suspension of face with tensor fascia lata
3. Endoscopic brow lift
4. Eyelid spring placement
5. Lower eyelid canthoplasty
6. Aggressive facial nerve rehabilitation