Specific Surgical Techniques

1. Static suspension
There are many causes of facial paralysis and as we are learning it has to do with the seventh cranial nerve, in all cases. Thousands are affected by some type of nerve damage each year.

One of the first things that can be accomplished to create symmetry in the face is “Static Suspension”. Static suspension is utilized to create better facial symmetry as well improve some of the most difficult side-effects of facial paralysis including drooling and biting of the inner gum. Dr. Azizzadeh at the Facial Paralysis Institute typically uses tensor fascia lata (a tendon like structure from the thighs) to support and create a laugh line. This procedure is able to create symmetry of the lips, corner of the mouth and laugh line. The procedure is usually performed through a small incision in the scalp and the fascia is placed under the skin where it is not visible.

Although this sounds easy, there are four muscle groups under the skin and this operation should only be performed by a surgeon with the experience to accomplish the best results. At the Facial Paralysis Institute Director Azizzdeh grooms some of the top surgeons in their field to combine teams of specialists for every surgical procedure.

2. Temporalis transfer
The temporalis muscle is one of the muscles for chewing (mastication). The trigeminal nerve (cranial nerve 5) is responsible for its activity. As a result, we can use this muscle to provide voluntary facial movement. The procedure transfers the temporalis muscle from the scalp to the corner of the mouth. The patient then learns to move the face by moving this muscle. This procedure has been very successful in rehabilitating facial movement in patients who have had a long-standing facial paralysis. The procedure is performed via a facelift technique with very good results. (Source: Dr B. Azizzadeh Facial Paralysis Institute)

The Negative Results

With a careful postoperative training program in physiotherapy we tried to achieve automatic facial activity after muscle transfer in facial palsy. In a primary stage of exercises voluntary control of the new function was achieved in all cases. The second stage in which we tried to bring these newly learned movements to a state of automatic function in normal facial expression was not successful. Therefore we feel that muscle transfers give only minor advantages over static suspension operations. (Source: K. Wintsch1 Department of Plastic and Reconstructive Surgery, Kantonsspital, CH-5001 Aarau, Switzerland http://www.springerlink.com/content/h75345r368681lw8/ )

The Positive Results

Patient satisfaction was high, with a mean score of 8.5 (possible score of 10). Four patients were physician graded as excellent to superb. The other 3 patients were rated as having good postoperative results. Movement was identified in every patient and ranged from 1.6 to 8.5 mm, with mean movement of the oral commissure of 4.2 mm. One patient developed postoperative salivary fluid collection that required drainage. (Source: Patrick J. Byrne, MD; Michael Kim, MD; Kofi Boahene, MD; Jennifer Millar, MSPT; Kris Moe, MD http://archfaci.ama-assn.org/cgi/content/abstract/9/4/234 )

Conclusions

Temporalis tendon transfer is a relatively easy procedure to perform that has distinct advantages compared with other forms of facial reanimation and provides very good results. This procedure results in improved form and function, may often be performed in a minimally invasive manner, and eliminates the facial asymmetry typically produced by temporalis transfer. (Source: Patrick J. Byrne, MD; Michael Kim, MD; Kofi Boahene, MD; Jennifer Millar, MSPT; Kris Moe, MD http://archfaci.ama-assn.org/cgi/content/abstract/9/4/234 )

Summary

When the right surgical procedure accomplished by a well trained professional that has done extensive testing on the patient, good to very good results are apparent. Dr. Azizzadeh has spent his life working toward and creating state of the art techniques to accomplish the goals other doctors only talk about. The Facial Paralysis Institute had one of the top surgical teams for Temporalis Transfer.

3. Hypoglossal-facial (12-7) nerve transfer
In patients with long-term facial paralysis who are older than 55, cross-facial nerve grafts have not produced great results. As a result, Dr. Azizzadeh likes to utilize the hypoglossal nerve or trigeminal nerve as the neural supply for the gracilis muscle transplant (see gracilis muscle section). The nerve of the gracilis muscle is attached to the hypoglossal nerve in the neck. The hypoglossal nerve is responsible for moving the tongue muscle and by attaching a partial portion of the nerve to the transplanted gracilis muscle; the patient has the ability to move the face voluntarily by tongue thrusting. This advanced state of the art procedure creates a natural appearance to the face with the ability for voluntary facial movement. (Source: Dr. B. Azizzadeh, Facial Paralysis Institute)

Uses

The primary use of gracilis free tissue transfer in the head and neck region is in the form of a muscular free flap for the dynamic rehabilitation of long-standing permanent facial paralysis. When combined with cross-facial nerve grafting or used as a single-stage reconstruction, free tissue transfer offers the best prospect for restoring spontaneous emotional facial expression. Benefits of this muscle over other free flaps used for dynamic facial reanimation include consistent anatomy with large caliber vessels, ease of harvest, a 2-team approach, reliability, and acceptable donor site morbidity. Drawbacks include excessive bulk, skin tethering, and a donor site scar that may be minimized with minimally invasive techniques. Secondary procedures to refine the results are often necessary to achieve a good final result. Ultimately, the choice of muscle for dynamic facial reanimation depends on the surgeon's experience and comfort level. (Source: Jason H Kim, MD, Assistant Professor, Department of Otolaryngology

-Head and Neck Surgery, University of California at Irvine http://www.emedicine.com/ent/topic709.htm )

Summary

For older individuals the Hypoglossal-gracilis free flap will have less pain and less recovery time for most. Over 95% of individuals will have some pain and minor complications but will also have great results with the surgery. This procedure is used on persons 55 years of age and older to make post operative trauma and recuperation easier. All patients will receive a better looking face regardless. Re-animation of the face will take more therapy and sometimes minor surgeries to get the overall look the patient wants.

4. 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 (> 2 years) have non-functional muscles; therefore, new vascularized muscle needs to be attached to the cross-facial nerve grafts after the nerve has been “activated”. The nerve grafts need to be activated for 8-12 months before the muscle in 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.

5. Gracilis free flap
In patients with long-term paralysis (> 2 years), the native facial muscles are not functional. A transplanted muscle from the groin (gracilis muscle) is necessary if one desires to create a natural and spontaneous facial movement. The gracilis muscle is located in the inner aspect of the thigh. This muscle is very special because it can be transplanted to the face with its nerve, artery and vein. A small segment can be used which can then be attached to cross-facial nerve grafts or hypoglossal nerve (see cross facial nerve grafts). Dr. Azizzadeh utilizes microsurgical techniques to perform this operation. For patients under the age of 55, he usually uses cross-facial nerve grafts as the nerve source. In patients older than 55, he will use the hypoglossal nerve.(Source: Facial Paralysis Institute; Dr. B. Azizzadeh)

Why use Gracilis free flap transfers

The most common indication for gracilis free flap in head and neck reconstruction is for dynamic reanimation of the mid face and, occasionally, for the eye and forehead of the patient with permanent long-standing or congenital facial paralysis. In these 2 types of facial paralysis, the native facial musculature is absent because of either severe atrophy or congenital causes. In cases of long-standing secondary facial paralysis, a branch of the contralateral normal facial nerve via a cross-facial nerve graft is used for neural input. In cases of congenital facial paralysis, an alternative nerve graft (trigeminal or hypoglossal nerve) can be used for neural input. Less common indications include reconstruction of total or near-total glossectomy defect, repair of full-thickness scalp defects due to surgery or trauma, and soft tissue filling for surgical defects (eg, orbital exenteration). (Source: Tissue Transfer, Gracilis, Author: Jason H Kim, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of California at Irvine http://www.emedicine.com/ent/topic709.htm )

Uses of the Gracilis Flap

The Gracilis free flap surgery is used for many purposes in reanimation surgery including rebuilding breast in cancer survivors. The Gracilis Free flap method, does have drawbacks for recovery of the donor site in length of time, however the results for the new site are outweigh these drawbacks.

Summary

The Gracilis Free flap, if warranted, is a major player in reanimating the nerves and muscles of the face. With the right surgeons and surgical teams this surgical operation can be quick and painless. However recovery time for both the donor site and the reanimation can be longer than other methods. The use of this method of reanimation is used in extreme cases where the surgical team feels other methods would not be as helpful. The Gracilis free flap uses tissue and muscle from the donor area and is most often used when an area of the face is indented because of trauma, or birth defect in the face or neck.

6. Hypoglossal-gracilis free flap
In patients with long-term facial paralysis who are older than 55, cross-facial nerve grafts have not produced great results. As a result, Dr. Azizzadeh likes to utilize the hypoglossal nerve or trigeminal nerve as the neural supply for the gracilis muscle transplant (see gracilis muscle section). The nerve of the gracilis muscle is attached to the hypoglossal nerve in the neck. The hypoglossal nerve is responsible for moving the tongue muscle and by attaching a partial portion of the nerve to the transplanted gracilis muscle; the patient has the ability to move the face voluntarily by tongue thrusting. This advanced state of the art procedure creates a natural appearance to the face with the ability for voluntary facial movement. (Source: Dr. B. Azizzadeh, Facial Paralysis Institute)

Uses

The primary use of gracilis free tissue transfer in the head and neck region is in the form of a muscular free flap for the dynamic rehabilitation of long-standing permanent facial paralysis. When combined with cross-facial nerve grafting or used as a single-stage reconstruction, free tissue transfer offers the best prospect for restoring spontaneous emotional facial expression. Benefits of this muscle over other free flaps used for dynamic facial reanimation include consistent anatomy with large caliber vessels, ease of harvest, a 2-team approach, reliability, and acceptable donor site morbidity. Drawbacks include excessive bulk, skin tethering, and a donor site scar that may be minimized with minimally invasive techniques. Secondary procedures to refine the results are often necessary to achieve a good final result. Ultimately, the choice of muscle for dynamic facial reanimation depends on the surgeon's experience and comfort level. (Source: Jason H Kim, MD, Assistant Professor, Department of Otolaryngology

-Head and Neck Surgery, University of California at Irvine http://www.emedicine.com/ent/topic709.htm )

Summary

For older individuals the Hypoglossal-gracilis free flap will have less pain and less recovery time for most. Over 95% of individuals will have some pain and minor complications but will also have great results with the surgery. This procedure is used on persons 55 years of age and older to make post operative trauma and recuperation easier. All patients will receive a better looking face regardless. Re-animation of the face will take more therapy and sometimes minor surgeries to get the overall look the patient wants.

7. Trigeminal-gracilis free flap
Cross facial nerve grafts cannot be utilized in patients with the birth defect called Mobius syndrome and long-term facial paralysis older than 55. As a result, the Facial Paralysis Institute likes to utilize the hypoglossal nerve or trigeminal nerve as the neural supply for the gracilis muscle transplant (see gracilis muscle section). The nerve of the gracilis muscle is attached to the trigeminal nerve in the face. The trigeminal nerve is responsible for moving the chewing muscle and by attaching a portion of the nerve to the transplanted gracilis muscle; the patient has the ability to move the face voluntarily. This advanced state of the art procedure creates a natural appearance to the face with the ability for voluntary facial movement. Several high-end clinics have started to incorporate this operation in place of temporalis transfer in patients with long-term paralysis because of more consistent results. (Source: Dr. B. Azizzadeh, Facial Paralysis Institute) <

What can be done? <

There is no cure for Mobius syndrome or facial paralysis. In spite of the impairments that characterize the disorders, proper care and treatment give many individuals a normal life expectancy. Plastic reconstructive surgery may be beneficial in some individuals. Nerve and muscle transfers to the corners of the mouth have been performed to provide limited ability to smile. (Source: Congenital Facial Diplegia, Neurological Disorders and Stroke http://www.ninds.nih.gov/disorders/mobius/mobius.htm ) <

Summary <

The Trigeminal-gracilis free flap procedure when suggested by the surgical team is used when other procedures will not work to improve the facial nerves and reanimation. Although the face will appear more natural results will vary, usually depending upon the facial therapy and length of time the patient practices using the new muscles and nerves. There have been outstanding results and those that received just a minimal change, this will depend on the age, disposition, length of time the surrounding muscles and nerves have been dead and post operative therapy. Dr. B. Azizzadeh and his surgical team must evaluate each patient for the best procedures to follow, for the best results. <

The patient evaluation is the most important part of facial reanimation and surgery. These are highly technical operations and only the best micro surgeons should be performing them. Dr. Azizzadeh has chosen the best micro surgeons available as associates at the Facial Paralysis Institute. We understand second opinions when it comes to micro surgery, please feel free to contact us at any time so we can get through the lengthy process of getting you or your loved ones to get the looks and self confidence that we all should enjoy. <

8. Eyelid gold weight

Eyes, Lips, Brow, Facial Botox, Sulptura and Implants


There are two times the above topics may be brought up by your surgeon. The first being if there is a minor problem with the face, and the second being when a major procedure has been made for facial paralysis and a little extra is needed for the eyes, lips and brow. Botox and Sulptura may also be used in certain circumstances.

Most of these procedures are minor and take less than an hour to accomplish, depending upon the abilities and experience of your surgeon. Facial paralysis does not have to be disfiguring for the rest of your life, there are many things that the right surgeon can do.

Eyelid gold weight


The function of the eye is extremely important. If a patient’s eye does not close completely as a result of facial paralysis, the cornea (outer shield of the eye) can develop permanent damage. Gold weight placement is an easy one stage procedure to reduce the risk of corneal injury and improve the function of the eye.


Palpebral eyelid spring


Eyelid spring (also known as palpebral spring) allows natural spontaneous blinking mechanism for patients with facial paralysis. Individuals who desire the most dynamic eyelid reconstruction with natural opening and closure will benefit from this operation. The Center for Facial Nerve Function at the House Clinic is one of select centers to offer this advanced surgical reconstruction. In fact, thousands of patients have undergone this procedure at the House Clinic in the last three decades.


Lower lip wedge resection


Patients who continue to have drooling despite advanced reconstructive efforts often require removal of lax lower lip tissue to tighten the area and allow better control of food during the oral phase.


BOTOX®


Patients with Bell’s palsy as well as individuals who have undergone hypoglossal-facial nerve transfer or cable nerve grafting often develop synkinesis (involuntary movements) which can be very bothersome. Physical therapy is the first-line treatment for these patients. However, we often utilize BOTOX to reduce the involuntary movement. BOTOX can also be used for the normal side of the face to reduce its activity especially in the forehead in order to symmetrize the face.


Sculptra

Patients who have complete facial paralysis often develop facial wasting on the side of the paralysis. This accelerated aging occurs because of atrophy of the muscles and overlying fat. Sculptra is an injectable product (poly-lactic acid) that is injected in the areas of atrophy in the office. It can improve facial wasting by increasing facial volume. This procedure has consistent results and is an incredible addition to the armamentarium of the facial plastic surgeon. Sculptra has been shown to last about 2 years and requires bi-annual touch up procedures.


Facial implants


Patients who have complete facial paralysis often develop facial wasting on the side of the paralysis. This accelerated aging occurs because of atrophy of the muscles and overlying fat. Facial implants can be an alternative to Sculptra as a permanent solution for facial atrophy. This procedure can be performed with facial reanimation procedures to improve the overall appearance of an individual with facial paralysis.


Endoscopic browlift


Patients with paralysis of the upper face often develop drooping of the brow region which can inhibit the visual field and create asymmetry of the face. The endoscopic browlift can improve this problem in a minimally invasive manner. The procedure takes about 1 hour and the results are long-lasting. (Source: Eyes, Lips, Brow, Facial Botox, Sulptura and Implants Dr B. Azizzadeh, Facial Paralysis Institute)

Summary

The whole point of having a Surgical Clinic with a complete team of doctors is make sure the treatment you receive is the best. Believe it or not, it is also so receive the least surgery that is warranted. To do this it really does take a team of dedicated doctors to take care of all your problems. You deserve the most inexpensive, and least time consuming procedures available. The testing procedures and every aspect of your recovery depends on quality care. The Facial Paralysis Institute, under the Direction of Dr. Azizzadeh, wants you to have the best treatment and get you back to a point, where you can live in peace with your reanimation.

9. Nerve repair


Going beyond other articles we have seen, facial paralysis can be caused by many other things. For instance a vehicle collision may cause trauma to the head and face. Medical center doctor’s first line of duty is to keep you alive. They have no time for micro-surgery when it comes to your life. This is just one of thousands of traumas that can impair the patient.

In instances like this and others, facial paralysis may occur but if caught soon enough, micro-surgery can bring the nerve back into play keeping the nerve alive. The sooner micro-surgery procedures can be ordered, the better off the patient, and the nerve itself.

Patient’s who have developed facial paralysis secondary to tumor resection, trauma or facelift procedures should undergo immediate nerve repair. The nerve repair should be ideally performed as soon as possible within a three week window. Some studies have shown that nerve repairs can be performed as long as 6 months after injury. This gives the patients the best possible chance for recovery of facial function. If the nerves cannot be sewn together without significant tension, a nerve graft should be utilized. Nerve grafts can be taken from the neck region, arm or lower leg (sural nerve). High magnification microscopes should be utilized in order to perform the best possible nerve repair, also known as neurorrhaphy.

Summary

It is hard to believe that it was not long ago broken arms were severed so the patient wouldn’t die. Less than fifty years ago micro surgery was only dreamed of, micro facial surgery is important to the lives of victims and patients everyday. As time has gone on, things have gotten better and children and adults have benefited from these medical advances.

However not every surgeon is qualified to perform such surgeries. Scaring is a major issue with most surgeons, they do their best to keep it to a minimum. A plastic surgeon has another agenda, to recreate the face that should be, and make the smallest scars as possible and hide those they cannot.

Reanimating, or reconnecting something as small as a nerve, takes highly trained micro surgeons. These surgeons spend most of their lives getting to the point of being the best in their field. The Facial Paralysis Institute, under the direction of Dr B. Azizzadeh has the surgeons and the training to get you back to the health you deserve.

16 Simulation of patient with hemifacial microsomia undergoing craniofacial reconstruction, cross facial nerve graft and gracilis free flap for facial reanimation. (Source – www.zib.de)