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Special Communication | Journal Club

A Contemporary Approach to Facial Reanimation

Nate Jowett, MD1,2; Tessa A. Hadlock, MD1,2
[+] Author Affiliations
1Facial Nerve Center and Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
2Harvard Medical School, Boston, Massachusetts
JAMA Facial Plast Surg. 2015;17(4):293-300. doi:10.1001/jamafacial.2015.0399.
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Published online

The management of acute facial nerve insult may entail medical therapy, surgical exploration, decompression, or repair depending on the etiology. When recovery is not complete, facial mimetic function lies on a spectrum ranging from flaccid paralysis to hyperkinesis resulting in facial immobility. Through systematic assessment of the face at rest and with movement, one may tailor the management to the particular pattern of dysfunction. Interventions for long-standing facial palsy include physical therapy, injectables, and surgical reanimation procedures. The goal of the management is to restore facial balance and movement. This article summarizes a contemporary approach to the management of facial nerve insults.

Figures in this Article


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Figure 1.
Acute Flaccid and Long-standing Nonflaccid Facial Palsy in Ramsay Hunt Syndrome (Varicella-Zoster Virus Facial Palsy)

A-H, Acute facial palsy. Complete flaccid paralysis on the affected side (asterisk) is demonstrated at rest (A), and with brow elevation (B), gentle eye closure (C), full-effort eye closure (D), gentle smile (E), full-effort smile (F), lip pucker (G), and lower lip depression (H). The patient lacks Bell’s phenomenon (C and D). I-P, Long-standing nonflaccid facial palsy. One year following symptom onset, the affected brow remains depressed, while hyperactivity has developed in the orbicularis oculi, mentalis, and platysma muscles at rest (I). Volitional brow elevation remains impaired (J), while marked brow synkinesis is present with eye closure (K and L). As is usual in nonflaccid facial palsy, eye closure is adequate (K and L). Smile symmetry is improved with light effort (M); commissure restriction is noted with full-effort smile. Near normal return to function of the orbicularis oris muscle is noted (O). Lip depressor function remains weak on the affected side (P). Periocular, mentalis, and platysmal synkinesis is worsened by smile, pucker, and lip depression (N-P).

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Figure 2.
Focal Facial Nerve Transection Injury and Outcome Following Repair

A-E, The patient was seen 6 weeks following revision rhytidectomy performed at an outside clinic and reported immediate postoperative mid-facial ptosis that did not improve. The nasolabial fold on the affected (asterisk) side is effaced (A), while brow elevation remains intact and symmetric (B), light-effort eye closure is incomplete (C), zygomaticus function is absent with full-effort smile (D), upper orbicularis oris function is absent with lip pucker while lip depressor and platysmal function is noted to be intact (E). Exploration under general anesthesia seven weeks following insult revealed a complete transection of a large mid-facial branch. F and G, One year following direct end-to-end repair, facial symmetry is restored at rest (F), brow elevation remains symmetric (G), light-effort eye closure is improved but remains incomplete (H), smile symmetry is markedly improved (I), and near normal return of orbicularis oris function is noted (J). Left lower lip depressor weakness is also demonstrated (D and I), first noted following platysmaplasty at the same outside clinic several years prior.

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Figure 3.
Management Options for Flaccid Facial Palsy and Nonflaccid Facial Palsy by Facial Zone and Side

DLI indicates depressor labii inferioris; NLF, nasolabial fold.

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Figure 4.
Static Reanimation Procedures in Flaccid Facial Palsy

A and B, Brow ptosis correction and lower lid tightening in flaccid facial palsy. The patient was seen with upper trunk paralysis secondary to a recurrent invasive basal cell carcinoma of the left cheek and subsequently underwent radical parotidectomy. A, On the affected side (asterisk), brow ptosis resulting in lateral hooding is noted together with lower lid ectropion. B, Correction of ectropion and lateral hooding is noted two-weeks following the lateral tarsal strip procedure and minimally invasive brow suspension using polypropylene sutures and a titanium plate. C and D, External nasal valve correction in flaccid facial palsy. The patient had undergone resection of an extensive glomus tumor with interposition grafting 20 years previously, without return of function. C, The external nasal valve is markedly narrowed at the base (arrowhead). D, Improvement is demonstrated 2 months following static fascia lata suspension. The patient reported substantial improvement in nasal breathing on the affected side. E and F, Static nasolabial fold suspension in flaccid facial palsy. The patient underwent a radical parotidectomy with interposition graft two years previously for a high-grade carcinoma ex pleomorphic adenoma with frank facial nerve invasion. No recovery of function was observed. E, Effacement of the nasolabial fold is demonstrated at rest with inferior malposition of the oral commissure. F, Facial symmetry at rest is improved two-weeks following minimally invasive suspension using polypropylene sutures passed subcutaneously using a long Keith needle under local anesthesia.

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Figure 5.
Dynamic Reanimation of Smile in Nonflaccid and Flaccid Facial Palsy

A-D, Cross-facial nerve graft transfer to a free-gracilis muscle for dynamic reanimation of smile. The patient presented with nonflaccid facial palsy 2 years following resection of a temporal bone facial schwannoma with cable grafting, having symmetry at rest (A) with severe limitation of commissure excursion with full-effort smile (B). The patient underwent cross facial nerve grafting transfer to free-gracilis muscle three years later. On follow-up 18 months later, the midface remains symmetrical at rest (C), while significant improvement in symmetry is seen with smile (D). E-H, Nerve transfer to native facial musculature in flaccid facial palsy. Twelve months following resection of an acoustic neuroma with an anatomically intact facial nerve, the patient demonstrates persistent flaccid facial palsy with effacement of the nasolabial fold and inferiorly malpositioned oral commissure on the affected side at rest (E) and absence of commissure movement with smile (F). Eight months following combined cross facial nerve grafting and masseteric nerve transfer to a large mid-facial branch, rest appearance appears mostly unchanged (G), with significant improvement in smile symmetry demonstrated with light-effort (H).

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