Many options also exist for the lower face. “The first choice is to try to directly repair the nerve or use cable nerve grafts,” said Dr. Hom. If this is not possible, then hypoglossal-facial nerve anastomosis or cross-facial nerve grafting can be used as long as the motor end plate of the muscle has not fibrosed. After one year of injury, EMG is helpful to determine the state of the distal facial nerve injury. After one to two years, if nerve repair is not possible, muscle transposition techniques using the temporalis sling can be successfully used for chronic paralysis, taking into consideration the patient’s age, health and personal preferences (Curr Opin Otolaryngol Head Neck Surg. 2006:14(4):242-248). More recently, the orthodromic approach for temporalis tendon transfer, which reanimates the lower face without the disadvantage of creating fullness over the zygomatic arch or a concavity at the temporal fossa, has been gaining popularity (Otolaryngol Head Neck Surg. 2011:145(1):18-23).
Explore this issue:September 2012
For static support of the lower face, a minimally invasive procedure to suspend the corner of the mouth can be achieved by making an incision in the melolabial crease and anchoring a heavy permanent suture to the zygoma periosteum. Under intravenous sedation, this suture can then be tightened by placing the patient in an upright position to tailor the precise pull needed to improve lip competency, with immediate patient feedback, said Dr. Hom.
Like many of his colleagues, including Dr. Azizzadeh, Dr. Tollefson utilizes 3-D video animation to help patients visualize movement deficits and then has them work with physical therapists to teach them biofeedback techniques to retrain muscles (Facial Plast Surg Clin North Am. 2010;18(2):351-356). In his own research, Dr. Tollefson has been investigating electroactive polymer artificial muscle to restore eyelid closure, having completed cadaveric studies and moved on to rodent models (Laryngoscope. 2007;117(11):1907-1911).
Goals of Treatment
During the patient’s recovery, facial nerve rehabilitation and botulinum injection are also very helpful in minimizing unwanted synkinesis. In addition, psychological support is an important part of facial nerve rehabilitation. To comprehensively treat patients with permanent facial paralysis, a long-term commitment to follow-up is needed to maximize their facial function and appearance, because future surgical adjustments after facial reanimation procedures are required to optimize results due to the aging process and healing. Long-term goals are to maximize eye protection, oral competency, facial movement and facial symmetry.
In interacting with his patients, Dr. Samy chooses to emphasize the positive aspects of their recovery, giving them a sense of hope and optimism. For example, one of his patients suffered significant intracranial injuries in addition to facial paralysis as a result of a work-related trauma. Luckily, the patient has no residual cognitive deficits. “I tell him that while he has some minor residual signs of facial palsy, ‘this is just one more step in your recovery, which has gone very well.’ Unfortunately, there is still a sense in the community that there is nothing that can be done for facial paralysis. But there are things that can be done, and patients need to feel that they are listened to.”