Specific Surgical Techniques
1. Static suspensionStatic 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 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. Dr. Azizzadeh is one of the leading surgeons who have utilized this technique.
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.
3. Hypoglossal-facial (12-7) nerve transfer
The hypoglossal nerve (cranial nerve 12) is responsible for moving the tongue muscle. They hypoglossal-facial nerve transfer utilizes this nerve to activate the facial nerve. By attaching a partial portion of the hypoglossal 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, several papers have showed that this procedure with correct facial nerve therapy can result in spontaneous facial movement. 12-7 transfer needs to be performed within two years of facial paralysis because facial muscles atrophy and become non-functional even with nerve input after this time.
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.
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.
7. Trigeminal-gracilis free flap
Cross facial nerve grafts cannot be utilized in patients with Mobius syndrome and long-term facial paralysis (older than 55). 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 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. Many centers have started to incorporate this operation in place of temporalis transfer in patients with long-term paralysis because of more consistent results.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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.
13. 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.
14. 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.
15. Nerve repair
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.
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)
