Facial reanimation surgery

Overview

Facial reanimation surgery helps people with facial paralysis restore symmetry and function to their face. People with facial paralysis develop weakness or a complete lack of movement, usually in half of their face. The weakness creates an imbalance between the two sides of the face, known as asymmetry. This affects the way the face looks and functions, and sometimes causes discomfort or pain.

People with facial paralysis often have trouble smiling and communicating with others. They also may have trouble closing their eye and mouth. This may affect eye health, speech and eating, and sometimes causes drooling. Facial asymmetry and weakness can be disabling and may affect people's confidence.

There are many treatment options available for facial paralysis, both surgical and nonsurgical. And there are several different types of surgery. Some involve moving a nerve in the face from one place to another to regain function. Sometimes a muscle from another part of the body is transferred to the face to improve a specific function, such as smiling. You may need more than one procedure to achieve your surgery goals.

Facial reanimation surgery can help people with facial paralysis smile and make other facial movements. The surgery is highly technical and personalized, so it's important to see a surgeon who specializes in facial nerve and facial reanimation surgery.

Why it's done

Facial paralysis can occur for many reasons. The most common causes are Bell's palsy and Ramsay Hunt syndrome. An injury, a stroke or a tumor also can cause facial nerve damage and loss of function. In infants, facial paralysis can happen due to injury during childbirth or during development.

Not being able to move certain muscles of the face can make it hard to smile and show other emotions. Facial paralysis also may cause damage to eye health and vision due to not being able to voluntarily close the eye or blink. The paralysis also may cause a collapse of the nostril so that airflow is partially or completely blocked. This happens because the cheek muscles aren't able to pull the side of the nose toward the cheek.

Another condition called synkinesis sometimes results following facial paralysis. In this condition, all the nerves in the face stimulate the muscles at the same time. This causes a "tug of war" effect. This can happen because the facial nerves didn't recover properly after paralysis. Synkinesis may affect speaking, chewing and swallowing. It also can cause the eye to close when moving the mouth or smiling.

Depending on the cause, people with facial paralysis may recover without treatment over time. Sometimes nonsurgical treatments can help people regain symmetry and function. For example, physical therapy and onabotulinumtoxinA (Botox) injections can help people with synkinesis by relaxing some of the muscles.

Facial nerve specialists can decide if early treatment is needed. Seeing a facial reanimation specialist is critical to get an evaluation and, in some cases, surgery. Some treatment options are only available soon after facial paralysis develops, so it's important to see a specialist early.

Treatment is especially important if facial paralysis makes it hard to close the eye. Surgery can allow you to close your eye and protect it from becoming dry.

If facial reanimation surgery is recommended, the procedure can give your face more balance and give you the ability to smile and regain other functions.

The type of surgery you have depends on your symptoms. There are many techniques to restore movement to a paralyzed face. Some of these techniques include:

• Microsurgical facial nerve repair.
• Facial nerve grafting.
• Nerve transfer surgery.
• Muscle transfer surgery.
• Muscle transplant surgery, known as gracilis muscle facial reanimation.
• Face lifts, browlifts and other procedures that restore symmetry.
• Eyelid reanimation surgery to improve blinking and eyelid closure.

People with synkinesis who have facial muscle tightness, spasms or contraction of all of the muscles in the face at once may benefit from:

• Injections of Botox, known as chemodenervation, to block nerve signals.
• Physical therapy including massaging and stretching, and neuromuscular retraining.
• Selective neurectomy, which involves cutting specific branches of the facial nerve. The goals of the operation are to relax some of the muscles in the face that feel tight, in addition to weakening muscles in the face that oppose the smile. Sometimes branches to the eyelids are cut to prevent the eyelids from closing when the person attempts to smile.
• Selective myectomy with terminal neurolysis, which involves dividing one or more of the muscles in the face.

Risks

As with any surgery, facial reanimation surgery carries some risk. The risks depend on the exact type of facial reanimation surgery. It's common to have temporary swelling, bruising and numbness in the area of the surgery that resolves with healing. Less common but possible risks include infection, a change in facial contour, nerve injury and blood collection under the skin, known as hematoma.

If you have a nerve transfer, there is a risk that the nerve may not grow correctly. This can result in synkinesis. When a muscle is transplanted, there is a potential risk of lack of blood flow to the muscle, resulting in poor movement. However, these complication are rare.

It may take several months before you see an improvement in facial paralysis. This is particularly true if you have nerve transfer or muscle transplant surgery. After these surgeries, it takes time for the nerve cells to grow after being connected.

Almost always, people experience improvement after facial reanimation. However, you may find that the surgery doesn't completely restore function or that your face still has some imbalance. If this happens, your surgeon will likely find other options to improve your function.

Some people require more procedures to get the best results. This can be due to a complication of the surgery or simply to enhance the outcome and achieve better symmetry and function.

Facial reanimation surgery is specialized and personalized. It's best to talk about the risks and benefits with your surgeon and other members of your healthcare team before you have surgery.

How you prepare

Work with a surgeon and a healthcare team with a specialty in facial nerve and facial reanimation. This gives you access to advanced and comprehensive care. If you're seeking treatment for your child with facial paralysis, see a surgeon who specializes in this surgery in children.

Because facial reanimation surgery is planned around your needs, your surgeon works to understand the cause of your facial paralysis. Your surgeon also asks how your facial paralysis impacts your life and what your treatment goals include. Using this information, along with a review of your health history, your surgeon works with you to develop a treatment plan.

You'll likely have a comprehensive facial function exam. You may be asked to raise your eyebrows, close your eyes, smile and make other facial movements. Photos and videos of your face are taken, which can be compared to the results after surgery.

Your healthcare team also looks for the cause and timing of the facial paralysis. If the cause is not known, you may need imaging tests such as computerized tomography (CT) scans or magnetic resonance imaging (MRI). If the cause is a tumor or trauma that can be treated, you'll likely receive treatment for the cause before considering facial reanimation surgery.

Other tests can help your healthcare team determine how much nerve injury is present. Tests also may reveal if nerve damage is likely to improve without surgery. These tests include electromyography (EMG) and electroneurography (ENoG).

You may meet with a physical therapist. The physical therapist looks at the movement you currently have and teaches you techniques of stretching, massaging and strengthening. The treatment plan is tailored to your individual needs. You also may see other specialists such as a neurologist and ophthalmologist. These experts work together with your surgeon to create a treatment plan.

Before deciding on surgery, your healthcare team may have you try other treatments such as Botox injections.

If you have a child with facial paralysis, the timing of surgery is important. Your surgeon may recommend waiting for your child to grow and develop before having facial reanimation surgery.

It's important to talk to your surgeon about the goals of surgery and whether more than one surgery is needed. Be sure that you understand the potential benefits and risks of the surgery, and the care you'll need after surgery.

What you can expect

Before the surgery

You may need to stop certain medicines a couple of weeks before surgery. These medicines include blood thinners such as warfarin (Jantoven). They also include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve).

If you take chemotherapy, immunotherapy or steroid medicines, you may need to stop taking them several weeks before surgery. Also be sure to follow your surgeon's instructions about when to stop eating and drinking before surgery.

During the surgery

The type of anesthesia used depends on the type of facial reanimation surgery you're having and your health history. Usually general anesthesia is used, in which you're given medicine that puts you to sleep during the surgery.

There are several techniques your surgeon may use for facial reanimation surgery. The technique determines what happens during surgery.

• In microsurgical facial nerve repair, your surgeon connects nerves together.
• In cross face nerve grafting, healthy nerves on the other side of the face are used to help animate the affected side. A cut, known as an incision, is made on the side of the face not affected by paralysis. A nerve graft from the leg is used to reach the nerve endings to the affected side. The nerve fibers grow over 6 to 12 months to bring movement to those areas of the face.
• In a nerve transfer, your surgeon uses part of the nerve that moves the tongue or that provides nerves to one of the chewing muscles. The nerve is connected to the facial nerve.
• If you have a tumor removed from the side of the face, a gap is created in a facial nerve. Parts of a nerve from the leg are used to bridge the gap.

• If you have muscle transfer surgery, your surgeon redirects part or all of a muscle in your temple, called the temporalis muscle. This helps create movement in the face.

  You may need a muscle transferred from another part of the body to give function to the face. This is often done in two stages. In the first stage, the surgeon borrows some of the nerves on the other side of the face to provide function on the affected side. The ends of the nerves are connected to a nerve that was removed from the leg to reach the affected side. In the second stage, a muscle from the leg is transferred.

• If you have muscle transplant surgery, also known as gracilis muscle facial reanimation, your surgeon removes part of the gracilis muscle in the thigh without causing any weakness in your leg. The artery and vein that supply the muscle and the nerve that powers the muscle also are removed. The artery and vein of the gracilis are connected to vessels in your face. The muscle is placed in the side of your face in a way that creates a smile when the muscle contracts. The nerve of the gracilis is connected to the cross face nerve graft, the nerve in the masseter muscle of the cheek or both.
• You may need a face lift or brow lift. This repositions the cheeks or the brows to bring symmetry to the face. If your eyelid is affected by facial paralysis, you may have a procedure to insert a platinum or gold weight that allows the eyelid to close. Procedures known as canthopexy and tendon grafting help reposition the lower eyelid. Or you may have eyelid reanimation surgery that involves transferring a muscle in the neck to the eyelid, known as platysma transfer.
• If you're having selective neurectomy, the surgery involves cutting specific branches of the facial nerve. The goals of the operation are to relax some of the muscles in the face that feel tight, in addition to weakening muscles in the face that oppose the smile. Sometimes branches to the eyelids are cut to prevent the eyelids from closing when the person attempts to smile. If you're having selective myectomy with terminal neurolysis, surgery involves dividing one or more of the muscles in your face.

All of the surgeries involve making incisions that are used for facial aesthetic surgery. The scars are visible, but they're placed in locations that make them hard to see.

A non-surgical treatment for facial paralysis involves injecting Botox into the muscle. This procedure, called chemodenervation, is performed with specialized facial physical therapy that helps you relearn how to move your facial muscles. This is known as neuromuscular retraining.

After the surgery

After surgery, you rest in a recovery area. Depending on the surgery you had, you may go home the same day, known as outpatient surgery. Or you may spend some time recovering in the hospital. Most surgeries that keep you in the hospital require a one- or two-day stay. When a muscle transplant is performed, you may stay in the hospital for up to five days. This allows your healthcare team to monitor your progress and to make sure the muscle is getting proper blood flow.

After facial reanimation surgery, you may experience swelling, bruising, numbness and some discomfort around the surgical area. You're given medicines to help with any postoperative pain. You may be given an antibiotic to prevent infection.

Your surgeon instructs you about how to care for the incision sites after surgery. You also receive instructions on what to eat after surgery and when you can return to regular activities.

Results

How quickly you see results depends on the type of facial reanimation surgery you had. You may notice some improvements right away. For example, an eyelid weight immediately improves your blink and eye comfort. A face lift or brow lift will show an improvement once the swelling goes down.

However, many facial reanimation techniques take time for the nerves to grow into the muscle and for movement to return. This is true for nerve repair, nerve transfers and muscle transplants. It may take months before you notice improvements. Your healthcare team continues meeting with you to check your progress.

Facial reanimation can be life-changing for people with facial paralysis. The ability to smile and display emotions through facial expressions improves communication and connection with others. Surgery also can improve your ability to close your eyelids, eat and speak more clearly.