Facial Nerve Transplants: The Art of Facial Nerve Grafting

At the Facial Paralysis Institute in Beverly Hills, cross facial nerve grafts are utilized in advanced nerve transplants. Patients under the age of 55 who have had long-term paralysis may qualify for cutting-edge surgical procedures to recreate dynamic and spontaneous facial movements and smile mechanisms. These nerve transplants use the facial nerve in the normal side of the face to “drive” the facial movement in the paralyzed side.

Patients who have suffered from long-term paralysis for more than two years no longer have facial muscle function; therefore, new vascularized muscle needs to be attached to the cross-facial nerve grafts. The cross-face nerve graft is first implanted on the side of the face where the facial nerve is active. The implant then learns movement from the active facial nerve over 8-12 months. Once it is active itself, it can be transferred to the paralyzed side of the face to help restore the patient’s facial movements.

Cross facial nerve grafts can also benefit individuals with partial facial paralysis who need additional “input” to enhance their smile and make it more symmetrical.

Cross Facial Nerve Grafts: a Two-Stage Procedure

Stage 1: Nerve grafts are harvested from the lower leg (sural nerve) and attached to the normal facial 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.

Facial movements are gradually realized about 8 months following the second stage of cross face nerve graft surgery, and they continue to improve for 2 years. Physical therapy is continued for 18 months.

Use of the House Brackmann Grading System

The House Brackmann Grading System is a widely used scale that clinically rates the degree of a patient’s facial function. The best facial paralysis treatment options for the individual patient can then be determined once his or her specific case has been assessed.

“Normal” facial function is classified as “1,” and as a patient’s level of facial paralysis increases, the scale varies from “2 to 6.” “6” denotes no facial movement and full facial paralysis. Here are more details about each level of the scale:

Grade II: Mild dysfunction

Slight weakness noticeable on close inspection

• May have slight synkinesis
• Normal symmetry and tone at rest

Grade III: Moderate dysfunction

Obvious but not disfiguring difference between the two sides

• Noticeable but not severe synkinesis, contracture, or hemifacial spasm
• Normal symmetry and tone at rest

Grade IV: Moderately severe dysfunction

Obvious weakness and/or disfiguring asymmetry

• Normal symmetry and tone at rest

Grade V: Severe dysfunction

Only barely perceptible motion

• Asymmetry at rest

Grade VI: Total paralysis without any movement

Differential Diagnosis

Bell’s Palsy

• Trauma
• Temporal bone fracture
• Facial laceration
• Iatrogenic
• Barotrauma
• Birth trauma (forceps)

Tumor

• Cerebellopontine angle tumor: Schwannoma, meningioma
• Parotid
• Head & neck tumors

Congenital Toxic Melkersson-Rosenthal Syndrome:

Neurologic

• Opercular syndrome: cortical lesion in facial motor area
• Millard-Gubler syndrome

Infectious

• HSV; Zoster
• External & middle ear
• Lyme disease
• Other: Encephalitis, Poliomyelitis, Mumps, Mononucleosis, Leprosy, Influenza, Coxsackievirus, Malaria, Syphilis, Scleroma, Tuberculosis, Botulism, AIDS

Metabolic

• Diabetes mellitus
• Hyperthyroidism
• Pregnancy
• Hypertension
• Vitamin A deficiency

If you are suffering from facial paralysis or any other related condition, schedule a consultation with Beverly Hills facial paralysis expert Dr. Azizzadeh by calling (310) 657-2203 today!

Next, learn about gracilis muscle transplant