Facial Reanimation Surgery

During this surgery to restore facial movement, our surgeons will correct facial paralysis, where congenital or acquired through trauma or disease.

In patients with long-term facial paralysis (more than 1-2 years), the native muscles in the face, unfortunately, irreversibly lose their function; therefore, a new muscle must be used in order to restore smile and lower face movement. The purpose of these procedures is to achieve the best functional and aesthetic outcome possible. It may require more than one procedure to optimize the outcome, but the vast majority of patients are able to achieve the goal of improved symmetry and improved smile.

There are various procedures that can be used for facial reanimation surgery, depending on the specific needs and circumstances of an individual patient. These may include:

Chemodenervation for facial spasm (botox injection)

Hemifacial spasm (HFS) is a neurological disorder in which muscles of one side of the face intermittently and/or continually involuntarily contract, causing uncontrollable spasm/contortion of the face. The most common cause of hemifacial spasm is post-paralytic nerve dysfunction following incomplete recovery after sudden facial paralysis (i.e., Bell’s palsy). HFS is caused by hyperactivity of cranial nerve VII (the facial nerve), which originates in the brainstem and controls muscles of facial expression. The 2nd most common cause of HFS is irritation of the facial nerve from compression by an adjacent artery or vein.

Medications are ineffective for treatment of HFS, but Botulinum toxin (Botox®) injections can provide a temporary treatment of the symptoms of spasm associated with HFS. While Botox® does not treat the cause of HFS, it can help quiet down the undesirable pathways that have formed from improper nerve regeneration after facial paralysis.

Botox® is a bacterial toxin injected by needle into facial muscles that paralyzes the muscles in the area where it is injected. While this prevents the spasms seen in HFS, it also prevents normal movement at the sites of injection. A small amount of Botox® is injected into each of the desired areas using a 30 gauge (very tiny) needle. Each injection site will receive a small amount of the solution, which will leave a pinpoint needle-stick and small lump from the fluid itself, which usually resolves in about 15-20 minutes.

The Botox® takes effect within 3-7 days, which should result in less sensation of tightness and improved symmetry. If a bruise does occur (approximately 3-5%), icing for the first 24 hours and topical arnica gel/ointment can help expedite healing. These injections are temporary, with median length of effect lasting 11 weeks, and can be repeated. Botox injections may have lessening effect on treating hemifacial spasm in certain cases over time. However, overall this treatment shows excellent promise for not only treating the discomfort and visible asymmetries associated with incomplete recovery of facial paralysis, but also as an adjunct to neuromuscular physical therapy and rehabilitation.

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Static tissue repositioning

Static tissue repositioning procedures involves suspending the corner of the mouth and the fold between the nose and the mouth (laugh line) to an anchor point on the bone just below and behind the eye. This is typically done with a combination of sutures and either the patient’s own connective tissue (fascia lata) or a piece of cadaveric skin (Alloderm), which is used to bridge the gap between the mouth and the anchor point. These procedures are utilized to create better facial symmetry and to address side-effects of facial paralysis including drooling and biting of the lip. The procedure is usually performed through a combination of a small incision in the laugh line and a small facelift incision. The graft is then placed under the skin where it is not visible. Endoscopic equipment is utilized to minimize the incisions.

Muscle transfers

These procedures involve moving tendons and muscles from one part of your body, usually your legs or abdomen to your face. Some of the tendons that are moved include the temporalis tendon transfer and the gracilis muscle transfer.

Gracilis Muscle Transplant (Free Flap)

The gracilis muscle is located in the inner aspect of the thigh. A small portion of this muscle – with its blood supply (artery and vein) and nerve – can be transplanted in the face to replace the facial muscles that allow you to smile. Using highly specialized microsurgical techniques, the gracilis muscle’s artery and vein are attached to an artery and vein in the head/neck region. This connection is critical for the muscle to survive in its new environment in the face. The nerve that moves the gracilis muscle (obturator nerve) must then be attached to a new nerve supply in the face, in order to power the muscle to move.

Nerve Options to Power the Gracilis Muscle: The three most common options are described below. More than one option may be proposed to you based on your goals of care.

Contralateral/Normal Facial Nerve via Cross-Facial Nerve Graft: This usually requires two surgeries, unless in certain circumstances where two nerve options are used.

Temporalis Tendon 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, this muscle can be used to provide voluntary facial movement. The procedure transfers the temporalis muscle from the jaw bone (mandible) to the corner of the mouth. The patient then learns to move the face by contracting this muscle. This temporalis transfer is successful in rehabilitating facial movement for those who are not candidates for more advanced facial reanimation (such as cross facial nerve grafts). The procedure is performed via small internal and external incisions between the nose and mouth with very good results.

With dedicated exercises, patients are able to obtain voluntary control of the movement of the corner of the mouth, replicating a smile, though this movement does require effort and is rarely spontaneous.

Patient satisfaction following temporalis tendon transfer has been shown to be relatively high in several research papers. In a study published in Archives of Facial Plastic Surgery, a mean satisfaction score of 8.5 (possible score of 10) in patients who underwent this procedure.

Nerve grafting

These procedures include moving nerves from different parts of the body to the face, allowing you to better control the muscles. This may include connecting one of the following nerves in the area to the muscles that control the smile and other facial expression.

Masseteric Nerve

The masseter muscle is one of many muscles that help you chew. A branch of this nerve can be reconfigured to power the facial musculature or a new muscle that is transferred to replace the deficient facial movement called a gracilis muscle transplant.

The primary advantage is that the masseter nerve is a strong nerve that is easily accessible during surgery. The disadvantage is that this procedure requires teeth clenching in order to smile. This requires practice, but this learned pattern of movement can become relatively effortless in many patients.

Hypoglossal Nerve

The hypoglossal nerve moves half of the tongue. A portion of this nerve can be reconfigured to power the facial musculature or a new muscle that is transferred to replace the deficient facial movement called a gracilis muscle transplant.

The primary advantage is are that the hypoglossal nerve is a very strong nerve that is fairly accessible. The disadvantages are that there is a small risk of tongue weakness (that can result in difficulty speaking and eating) and there is a risk of inadvertent facial twitching when moving the tongue, such as during eating.

Like the masseteric nerve above, practice and exercise are required to coordinate tongue movement for smile, which typically becomes less of an effort over time.

Cross-facial Nerve graft

For patients desiring the best option for restoring spontaneous facial movement, a “cross-facial” nerve graft is the treatment.

A cross-facial nerve graft procedure is when a nerve graft is harvested from the lower leg (sural nerve graft) through a series of 3 or 4 two centimeter incisions. The nerve is then connected to one of the facial nerve branches on the unaffected side of the face. 

Modified Selective Neurectomy for the Treatment of Post-Facial Paralysis Synkinesis

Facial synkinesis is a phenomenon wherein various facial muscles move involuntarily with the voluntary movement of another muscle. For example, voluntary smiling will induce involuntary contraction of the neck and cheek muscles causing, the corner of the lip to tighten and even pull downward instead of upward. Synkinesis is a fairly common side effect of facial palsy. It occurs as the result of miswiring of nerves after Bell’s Palsy or other nerve trauma.

A selective neurectomy procedure involves the assessment of the individual nerves in the lower face and the transection of various nerve branches that are creating a sideways and/or downward pull on the corner of the mouth with attempted smile. The purpose of these procedures is to achieve the best functional and aesthetic outcome possible. It may require more than one procedure to optimize the outcome, but the vast majority of patients are able to achieve the goal of improved symmetry and improved smile. About 20% of patients will require additional neurectomy surgery if the results are not sufficient from this intervention.