Cross Facial Nerve Graft

Patients (under the age of 55) who have had long-term paralysis are able to undergo advanced surgical procedures to re-create dynamic and spontaneous smile mechanism. These nerve transplants give 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, more than two years, have non-functional muscles; therefore, new vascularized muscles need to be attached to the cross-facial nerve grafts after the nerve has been “activated”. Typically, the gracilis muscle is utilized in this case. The nerve grafts need to be activated for 8-12 months before the muscle is transferred. We have also started using these nerve grafts for individuals with partial paralysis who need additional “input” to help better their smile.

Two stage procedures is typically required for cross-facial nerve grafts

Stage 1: Nerve grafts are harvested from the lower leg (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 18 months. Facial movements are gradually realized about 8 months following the second stage of surgery and continued for 2 years.

Disadvantages

The disadvantages of cross-facial nerve grafting have been summarized by Baker and Conley. (9) Certainly, the surgical intrusion into the normal side of the face is a significant disadvantage, but protection of the normal side might reduce the degree of axonal input that is necessary for an optimal result. Obviously, no nerve grafting technique is perfect. Patients might experience mass movement and synkinesis, and the reinnervated side might never appear to be completely normal again. Even so, a patient stands only to gain from increased tone, improved symmetry, and purposeful movement. Cross-facial nerve grafting remains the most powerful tool in addressing facial paralysis. Source: Facial reanimation by cross-facial nerve grafting: Report of five cases - Original Article - Brief Article; Ear, Nose & Throat Journal, Jan, 2002 by Suzanne K. Doud Galli, Fredrick Valauri, Arnold Komisar http://findarticles.com/p/articles/mi_m0BUM/is_1_81/ai_82471785/pg_4?tag=artBody;col1

Physical Therapy

After damage or injury to the facial nerve, including after any type of tissue manipulation for facial paralysis, it is critical to optimize the cosmetic and functional outcome by learning to control facial movement. Physical therapy uses facial neuromuscular retraining to optimize the motor control of the facial muscles. A comprehensive review of the literature supports the use of neuromuscular retraining, in both the acute stage (less than one year since injury or surgery) and in the post acute stages of recovery. The use of electrical stimulation to improve the motor control in the face is not recommended, and it is a treatment technique that is not supported in the literature.

Neuromuscular retraining uses selective motor training techniques to facilitate symmetrical movement and to control undesired gross motor activity (synkinesis). Teresa England is one of the most experienced therapists in the country and part of the team at the Facial Paralysis Institute who will help you with your facial muscle retraining. Tools such as surface electromyography (EMG) and specific mirror exercises provide augmented sensory information to enhance neural adaptation and learning. Motivation through individualized instruction and active patient participation are crucial to success. Because each patient presents differently, there are no generic lists of exercises. Although each patient's program differs, some general principles apply. For example, it is imperative the movement of the face be initiated slowly, not rapidly. Small movements, rather than large motions of the facial muscles are taught to improve coordination and accuracy.

The length of treatment time and number of physical therapy session varies from patient to patient, and typically depends on patient's motivation, compliance, need for EMG, and geographic location affecting scheduling. Patients are typically seen for an hour initial evaluation. Follow-up appointments are usually 30 minutes and can be as frequent as once per week or as infrequent as once every 4-6 weeks over the course of 4-6 months. Some patients are followed for up to one year.

Summary

Most surgeries of the facial nerves will require several months of facial physical therapy to achieve the maximum results. With the cross facial nerve graft most patients will enjoy 95% recovery; however, all will receive better tone and re animation. The more therapy they receive or practice after surgery the better the results will be. The Facial Paralysis Institute will schedule after surgery appointments for further treatments after surgery to acquire the best results possible for each patient.