The term facial palsy generally refers to weakness of the facial muscles, mainly resulting from temporary or permanent damage to the facial nerve Facial palsy not only cause a paresis of the target muscles, but as the nerve is responsible for a range of facial expressions, it causes serious disturbances in social life, facial expression being so important in transferring emotion.

1. Presented by Dr. Nishant Kumar

2. NERVE FIBER COMPONENTS
• Endoneurium
• Surrounds each axon
• Adherent to Schwann cell layer
• Vital for regeneration
• Perineurium
• Encases endoneural tubules
• Tensile strength
• Barrier to infection
• Epineurium (nerve sheath)
• Outermost layer
• Houses vasa nervosum for
nutrition

3.  Nerve of the 2nd branchial arch
 Has two roots. A large motor and a smaller
mixed sensory and parasympathetic (nervus
intermedius)
Facial nerve

4. Functional components
• Brancial motor(special visceral efferent)- Supplies;
Stapedius , Stylohyoid, posterior belly of digastric muscle
and the muscles of facial expression.
• Visceral motor(general visceral efferent)
Parasympathetic innervations of the lacrimal,
submandibular, and sublingual glands, as well as mucous
membranes of nasopharynx, hard and soft palate.
• Special sensory(special afferent)-Taste sensation from the
anterior 2/3 of tongue; hard and soft palates.
• General sensory(general somatic afferent)-General
sensation from the skin of the concha of the auricle and
from a small area behind the ear.

5. • Facial nerve is the seventh cranial
nerve
• Nerve of facial expression
• Facial function plays an integral
part in our everyday lives
• When a facial nerve is either non-
functioning or missing, the muscles
in the face do not receive the
necessary signals in order to
function properly.
• Facial paralysis is devastating on
many levels
• Functional
• Cosmetic
• Fortunately, a plethora of techniques
are available to treat the paralyzed

6. • The term facial palsy generally refers to weakness of
the facial muscles, mainly resulting from temporary
or permanent damage to the facial nerve
• Facial palsy not only cause a paresis of the target
muscles, but as the nerve is responsible for a range
of facial expressions, it causes serious disturbances
in social life, facial expression being so important in
transferring emotion.

7. Functions of the facial nerve
• Contraction of the muscles of the face
• Production of tears from a gland (lacrimal gland)
• Conveying the sense of taste from the front part of the tongue (via the chorda
tympani nerve)
• The sense of touch at auricular conchae

8. Level of nerve injury and symptoms

9. Facial palsy
• Facial paralysis represents the end result of a wide array of disorders and
heterogeneous etiologies, including congenital, traumatic, infectious,
neoplastic, and metabolic causes.
• Thus, facial palsy has a diverse range of presentations, from transient
unilateral paresis to devastating permanent bilateral paralysis. although
not life-threatening, facial paralysis remains relatively common and can
have truly severe effects on one's quality of life, with important
ramifications in terms of psychological impact and physiologic burden.

10. Facial paralysis
 Nuclear- from destruction of the
nucleus
 Central or cerebral or Supranuclear
 Peripheral- from a lesion of the nerve

11. Nuclear lesions
 Supranuclear lesions- usually a part of
hemiplegia, only the lower part of the
face is paralysed. The upper part
(frontalis and part of orbicularis
oculi)escapes due to bilateral
representation in the cerebral cortex.
 Infranuclear lesions- entire face is
paralysed, as seen in bell’s palsy

12. Differences between UMN and LMN type
Upper motor neuron Lower motor neuron
Upper face is unaffected Both upper and lower face is affected
Emotional movements are not affected in
unilateral cases .The whole half of the face
is paralyzed affecting the emotional
movements in bilateral cases
Emotional movements are lost .
Bells phenomenon is absent Present
No atrophy of the facial muscles Atrophy of the affected side is seen
Taste sensation is retained Taste sensation is lost.
Corneal reflex is not affected Absent
Hemiplegia is ipsilateral Hemiplegia is always crossed

13. Etiologic Classification Of Facial Palsy
• Various classification have been suggested in this respect.
• Course of the nerve
• Various etiologic causes
• Degree of dysfunction observed

14. • Vascular abnormalities
• CNS degenerative diseases
• Tumours of the intracranial cavity
• Trauma to the brain
• Congenital abnormalities and agenesis
Intracranial (central) causes

15. • Bacterial and viral infection
• Cholesteatoma
• Trauma- blunt temporal bone trauma, longitudinal and
horizontal fractures of the temporal bone and gunshot
wounds.
• Tumours invading the middle ear, mastoid and facial nerve
• Iatrogenic causes
Intratemporalcauses

16. • Malignant tumours of the parotid gland
• Trauma
• Iatrogenic causes
• Primary tumours of the facial nerve
• Malignant tumours of the ascending ramus of the mandible, pterygoid
region and skin.
Extracranial causes

17. Rainer schmelzeisen classification
• Congenital
• Moebius syndrome
• Myotonic dystrophy
• Melkersson rosenthal
syndrome
• Congenital cholesteatoma
• Birth injuries
• Osteopetrosis
• Neurologic
• Myasthenia gravis
• Multiple sclerosis
• Guillain barre syndrome
• Neoplastic
• Facial nerve tumours
• Glomus tumours
• Meningiomas, acoustic
• Neuroma
• Parotid tumours
• Temporal bone/external
auditory meatus tumours
• Infections
• Otitis media, mastoiditis
• Bacterial causes
• Viral causes

18. HOUSE-BRACKMAN(1985)
CLASSIFICATION
• Grade I-normal function without weakness.
• Grade II-mild dysfunction with sligth facial asymmetry with a minor
degree of synkinesis.
• Grade III-moderate dysfunctions-obvious, but not disfiguring,
asymmetry with contracture and/or hemifacial spasm, but residual
forehead motion and incomplete eye closure.
• Grade IV-moderately severe dysfunction- obvious, disfiguring
asymmetry with lack of forehead motion and incomplete eye closure.
• Grade V-severe dysfunction-asymmetry at rest and only slight facial
movement.
• Grade VI-total paralysis-complete absence of tone or motion.

19. Bell’s palsy
• It is defined as an idiopathic paresis or
paralysis of the facial nerve of sudden
onset.
• The name was ascribed to sir charles bell,
who in 1821 demonstrated the separation
of motor and sensory innervation of
face.

20. • Incidence-15-40 cases per 1 lakh cases
• Sex predilection- women more affected than men.3.3 more times common in
pregnancy and in the third trimester.
• Age- can occur at any age, common in middle aged people.
• Side involvement- can be equally seen, usually unilateral.

21. The palsy is not Bell's if one of the following is present
• Signs of tumour
• Bilateral simultaneous palsy
• Vesicles
• Involvement of multiple motor cranial nerves
• History and findings of trauma
• Ear infection
• Signs of central nervous system lesion
• Facial palsy noted at birth
• Triad of infectious mononucleosis (fever, sore throat, cervical
lymphadenopathy).

22. Clinical features
• There is sudden onset, usually pt gives h/o
occurrence after awakening early morning.
• Unilateral involvement of entire side of the
face.
• Abrupt loss of muscular on one side of face.
• Inability to smile, close the eye or raise the
eyebrow on affected side.
• Whistling is not possible.

23. • In an attempt to close eyelid, the eyeball rolls
upward.
• Inability to wrinkle forehead or elevate upper
or lower lip.
• Obliteration of nasolabial fold.
• Face appears distorted and mask like
appearance to the facial features.
• Speech becomes slurred.
• Occasionally there is loss or alternative of taste.

24. • Partial paralysis always resolves completely within a few weeks.
• Recovery from complete paralysis takes longer (months) and is
complete in only about 60-70% of cases.
• Approximately 15% of patients are left with troublesome residual palsy
and or synkinesis.
Course and prognosis

25. Psychological
Trauma
• The most significant complication is the social isolation
these patients often succumb to.

26. • The most serious complication is corneal
damage.
• One of the greatest problems with Bell's palsy
is the involvement of the eye if the lid fissure
remains open.
• In this case, eye care focuses on protecting
the cornea from dehydration, drying, or
abrasions due to insufficient lid closure or
tearing
Facial paralysis severely hinders:
• Normal facial expressions
• Mastication
• Speech production
• Eye protection.
Complication

27. Assessment and planning
• Cause of facial paralysis
• Functional deficit/extent of paralysis
• Time course/duration of paralysis
• Likelihood of recovery
• Other cranial nerve deficits
• Patient’s life expectancy
• Patient’s needs/expectations

28. History:
• A detailed and careful history
• The onset of symptoms , duration, rate of progress, chronology of
events and associated features.
• History of prior episodes, family history, medical history, history of
trauma , and surgical history .
Physical examination :
• Head and neck examination
• Detailed examination of ears, eyes, precise palpation of parotid gland
• Complete neurological examination
Diagnostic evaluation of facial palsy

29. Bell's palsy
(1) Acute onset of unilateral facial palsy
(2) Numbness or pain of ear, face, neck, or tongue (50%)
(3) Viral prodroma (60%)
(4) Recurrent facial palsy (12%) (ipsilateral 36%, alternating 64%)
(5) Positive family history (14%)
(6) Loss of ipsilateral tearing and/or submandibular salivary flow (10%)
(7) Decrease in or loss of ipsilateral stapes reflex (90%)
(8) Self-limiting and spontaneously remitting

30. Herpes zoster cephalicus
(1) Same as for Bell's, except pain more common and severe
(2) Vesicles on pinna, face, neck, or oral cavity (100%)
(3) Sensorineural hearing loss and/or vertigo (40%)

31. Tumour
(1) Sudden complete onset similar to Bell’s;
(2) Recurrent same side (17%)
(3) Slowly progressive weakness beyond 3 weeks (59%)
(4) No recovery after 6 months
(5) Twitching with paresis
(6) Mass in parotid, submandibular gland, or neck
(7) Mass between ascending ramus and mastoid tip
(8) Progression of other motor cranial nerve deficits
(9) Some of branches of facial nerve spared
(10) History of cancer

32. Bilateral simultaneous facial palsy
(1) Guillain-Barré
(2) Moebius' syndrome
(3) Sarcoidosis
(4) Myotonic dystrophy
(5) Skull trauma
(6) Infectious mononucleosis
(7) Cytomegalovirus
(8) Acute porphyrias
(9) Botulism
(10) Lyme disease
(11) Bell's - herpes simplex

33. Birth
(1) Congenital diplegia (Moebius’ syndrome, thalidomide toxicity)
(2) Lower lip palsy (developmental)
(3) Trauma
(4) Tumour
Trauma
Skull fracture (acute or delayed)

34. Infection
(1) Bulbar palsy (viral meningitis, encephalitis, or immune reaction)
(2) Post influenza, rabies, or poliomyelitis immunization
(3) Infectious mononucleosis
(4) Botulism
(5) Tetanus
(6) Syphilis
(7) Malaria
(8) Lyme disease
(9) Herpes zoster cephalicus
(10) Otitis media (acute or chronic, with or without cholesteatoma)
(11) Leprosy

35. Metabolic
Acute porphyria
Neoplastic
Acute leukaemia
Iatrogenic
Bilateral arterial embolization
Idiopathic
(1) Guillain-Barré syndrome
(2) Sarcoidosis (Heerefordt syndrome uveoparotid fever)
(3) Polyarteritis nodosa
(4) Bell's palsy

36. Melkersson-Rosenthal syndrome
(1) Recurrent alternating facial palsy
(2) Fissured tongue
(3) Labial-periorbital facial oedema
(4) Non-specific labial granuloma
(5) Positive family history.

37. Special diagnostic tests for facial palsy
Topognosti
c tests
• Schirmer test,
• Stapedial reflex test,
• Taste testing
• Salivary flow rates and
pH
Electric
al
tests
• Maximum stimulation
tests
• Evoked
electromyograpthy
• Electromyography
Radiograph
ic tests
• CT Scans of temporal
bone
• MRI
• Chest X ray

38. Topognostic testing
• The principle behind topognostic testing is that lesions distal to the site of a
particular branch of the facial nerve will spare the function of that branch
Schirmer test :
• Evaluates the function of the greater superficial petrosal nerve .
• Filter paper is placed in the lower conjunctival fornix bilaterally.
• After 3 - 5 minutes, the length of the strip that is moist is compared to the normal side.
• A value of 25% or less on the involved side or total lacrimation less than 25 mm is
considered abnormal. An abnormal result can indicate injury to the GSPN or to the
facial nerve proximal to the geniculate ganglion and may predict patients at risk for
exposure keratitis.

40. Stapedial reflex:
• This test evaluates the stapedius branch of the facial nerve .
• One is the most objective and reproducible.
• A loud tone is presented to either the ipsilateral or contralateral ear which
should evoke a reflex movement of the stapedius muscle.
• An absent reflex or reflex that is less than one half the amplitude of the
contralateral side is considered as abnormal

41. Taste testing:
• This test is extremely subjective.
• Can be done by placing a small amount of salt, sugar, or lemon juice, quinine and on
the tongue.
• The patient is asked to indicate that he perceives the taste before he withdraws the
tongue.
• Loss of taste may indicate interruption of the ipsilateral chorda tympani nerve.

42. Taste testing (electrogustometry):
• Electirical stimulation (electrogustometry), has the advantages of speed and ease of
quantification.
• The tongue is stimulated electrically to produce a metallic taste & threshold of the test
is compared between two sides.
• In normal subjects, the two sides of the tongue have similar thresholds for
electrical stimulation.
• Thresholds difference of more than 25% is abnormal

43. Salivary flow test:
• Toevaluate functional integrity of the chorda tympani nerve.
• Involves cannulation of Wharton's ducts bilaterally with measurement of output
after five minutes.
• A 25% reduction in flow of the involved side as compared to the normal side is
considered significant.
• Salivary pH may be examined as an indirect measure of flow.
• As the rate of flow increases, the pH increases. therefore, a pH of less than 6.1
may predict loss of function of the chorda tympani.
Disadvantages :
• Time consuming
• Unpleasant.
• Cannot perform repeatedly

44. Electrophysiologic tests
• These tests are useful for patients with complete paralysis for determining prognosis for
return of facial function and the endpoint of degeneration by serial testing.
The nerve excitability test (NET)
• Is the most commonly used.
• This test involves placement of a stimulating electrode over the stylomastoid foramen.

45. • The lowest current necessary to produce a twitch on the paralyzed side of
the face (threshold) is compared with the contralateral side.
• A difference of greater than 3.5 milliamps indicates a poor prognosis for
return of facial function.
Disadvantage:
• Even few intact fibres can elicit a response when rest in
• undergoing degeneration.
• Muscle twitch response is subjective Uncomfortable procedure
• Requires patient co-operation

46. The maximum stimulation test (MST)
• Is a modified version of the NET.
• Instead of measuring threshold, however, maximal stimuli (current levels at
which the greatest amplitude of facial movement is seen) is employed.
• Increasing current levels are used until maximal movement is seen, and the
paralyzed side is compared to the normal side.
• Maximal nerve stimulation(~5ma).
• Movements on the paralyzed side are subjectively expressed as a percentage (0%,
25%, 50%, 75%, 100%) of the movement on the normal side.
• Symmetric response within first ten days – complete recovery > 90%.
• No response within first ten days – incomplete recovery with significant
sequelae.

47. Electromyography:
• The recording of spontaneous and voluntary muscle potentials by needles introduced
into the muscle is called electromyography (EMG).
• Records motor unit potentials of the orbicularis oculi & orbicularis oris muscle during
rest & voluntary contraction
• In a normal resting muscle biphasic / triphasic potentials are seen every 30-
50msec.

48. • Fibrillation potentials typically arises 2-3 weeks following injury.
• With regeneration of nerve after injury, polyphasic reinnervation potential
replaces fibrillation potential.
• Reinnervation potentials may precede clinical signs of recovery by 6-12
weeks.
• Polyphasic potential indicate regenerative process & surgical intervention is
therefore not indicated.
• Fibrillation indicate lower motor neuron denervation but viable motor end
plates, so surgical intervention needed(to achieve nerve continuity).
• Electrical silence indicates atrophy of motor end plates & need for muscle
transfer procedure.

49. • Records compound muscle action potential (CMAP) with surface
electrodes placed transcutaneously in the nasolabial fold (response)
and stylomastoid foramen (stimulus).
• Responses to maximal electrical stimulation of the two sides are
compared.
Evoked Electromyography (EEMG) or Evoked Electroneuronography (ENOG)

50. • Waveform responses are analyzed to compare peak-to-peak amplitudes
between normal and involved sides where the peak amplitude is
proportional to the number of intact axons.
• Response <10% of normal in first 3 weeks-poor prognosis.
• Response >90% of normal within 3 weeks of onset 80-100% probability of
recovery

51. • Computed tomography (CT) is valuable for surgical planning in
cholesteatomas and temporal bone trauma involving facial nerve paralysis but
probably is less useful than MRI in the investigation of atypical idiopathic
paralysis.
• Magnetic resonance imaging (MRI) with intravenous gadolinium contrast has
revolutionized tumor detection in the cerebellopontine angle and temporal bone
and is currently the study of choice when a facial nerve tumor is suspected (e.g.,
in a case of slowly progressive or longstanding weakness).
Imaging

53. Management of facial palsy
Medical
Management
Steroids
Boutulinum toxin
Vasodilator
therapy
Physiotherapy
Eye care
Reassurance
Surgical
Management
Decompressio
n Micro
surgery
Implants

54. Corticosteroids
• Prednisolone 1mg/kg. body wt. in divided doses .
• Then tapered dependent on whether the paresis progresses to
paralysis or remains stable
• If the palsy remains stable, we either stop steroids without tapering or
rapidly taper the dose for the next 5 days .
• If the patient presents with paralysis or progresses to complete
paralysis, the dose is proceeded for the next 15 days and tapered in 5
days
Ramsey et al. Corticosteroid Treatment for Idiopathic Facial Nerve Paralysis: A Meta-analysis Laryngoscope 110: March 2000

55. Boutulinum toxin
• Clostridium botulinum toxin (BOTOX)
• Neurotoxin
• Temporarily interfere with the acetylcholine release from
the motor nerve end plates causing skeletal
muscle paralysis .
• 4 to 6 months
• Used to weaken the contralateral side to allow
centering of the mouth , more symmetry on smiling and
treatment of hypertrophic platysmal bands.
Use of Botulinum Toxin A in the Rehabilitation of Facial Nerve Paralysis: A Cases Series. Susana Moraleda,MD (Hospital La Paz,Madrid,
Spain); Sandra Espinosa, MD; Mercedes Martinez, MD

56. Vasodialators
• Stennert’s protocol: In 1979, Stennert devised an infusion therapy
• Low molecular wt Dextran I.V infusion 1000cc/day for 3 days over 16 hour
period ; reduced to 500 cc/day for 8 days .
• Cortisone 200mg/day for 2 days, reduce to 50mg/day in 10 days and stop
between 11 & 12 days
• Pentoxyphilline 10 mg per day IV
• Acyclovir 200 to 400 mg 5 times daily for 10 days

57. A. Acute (< 3 wks)
1. Nerve exploration/decompression
2.Nerve repair
a.Primary anastomosis
b.Cable grafting
i.Great auricular nerve
ii.Sural nerve
B. Intermediate (3 wks- 2 yrs)
1. Nerve transfer
a.Hypoglossal-facial
b.Spinal accessory-facial
c.Masseteric-facial
2.Cross face nerve grafting using sural nerve
C. Chronic (>2 yrs)
1. Muscle transfers
a.Temporalis
b.Masseter
c.Digastrics
2.Free muscle flaps/ microneurovascular trans
a.Gracilis
b.Latissimus dorsi
c.Serratus anterior
d.Pectoralis minor
D. Static procedures/ancillary procedures (can
be performed at any time period listed
above)
1. Gold weight/spring implants
2.Slings
3.Lid procedures
Ryan Ridley. Facial Reanimation .Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
Surgical Treatment Modalities

58. Nerve decompression
• Can be carried out internally or externally
• Internal decompression- The nerve is exposed in the fallopian canal and pressure
in the canal is relieved by exposing the nerve and the epineural sheath is opened
to visualize the nerve fibers and release adhesions or reestablish continuity.
• External decompression is done by releasing the epineural sheath from
surrounding scar tissue ,bone or foreign body.
• To be effective, the surgery must be performed within 2 weeks of the
onset of symptoms.

59. Neurorrhaphy Procedures

60. Micro-neurological Surgery
• Facial nerve repair is the most effective procedure to restore
facial function in patients who have suffered nerve damage
from an accident or during surgery.
• It involves microscopic repair of a nerve that has been cut.

61. Direct end to end anastomosis
• Direct nerve repair: indicated when sharp precise lacerations of facial nerve .
• Can be performed with defect < 17 mm.
• Can beperformed < 72 hrs of injury
• Adequate preparation of nerve ends by resecting devitalized tissue/debris with
fine scalpel.
• Epineural sheath approximated with 9-0/10-0 nonabsorbable suture(nylon or
prolene )
• Avoid tension at suture line

62. Microsurgical suturing
Interfascicul
ar
Epineuriu
m
Perineuriu
m

63. • Recovery of function begins around 4-6 months and can last up to 2
years following repair
• Nerve regrowth occurs at 1mm/day
• Goal is tension free, healthy anastomosis

64. Nerve grafting
• Nerve grafting- whenever there is evidence of neuroma or loss of portion of
the nerve, nerve grafting can be considered.
• Used when defect > 17mm; nerve cannot be reapproximated without
tension
• Autogenous nerve grafts remains the standard
• The length of the graft should be 20% longer than the gap.
• Common donor sites
• Greater auricular nerve – up to 10 cm
• Sural nerve –for longer grafts(35 cm)
• Antebrachial cutaneous nerve

65. Greater auricular nerve grafting
• Harvesting;
• Located on lateral surface of SCM at the
midpoint of a line drawn between mastoid
tip and mandibular angle
• Postauricular incision or use separate
neck incision
• Advantages:
• Proximity to facial nerve
• Cross-sectional area
• Limited morbidity
• Limitations:
• Reconstruction of long defects
• Ideal for defects < 6cm in length

66. Sural nerve
• Is the branch of tibial nerve in the middle of the popliteal fossa .
• Can be identified adjacent to the lesser saphenous vein posterior to
the lateral malleolus
• Advantages :
• Length : as much as 40 cm
• Accessibility
• Low morbidity .
• Disadvantages:
• Variable caliber
• Often too large
• Difficult to make graft approximation
• Unsightly scar

67. Median antebrachial cutaneous nerve
• Can be harvested from the upper extremity .
• Identified adjacent to the basilic vein .
• Divides into anterior and posterior branches near antecubital fossa.
• Incision parallel to the plane formed by the fascial plane separating
the biceps and triceps muscles

68. • Branches from the cervical plexus, from the ipsilateral or contralateral
side are also most frequently used for facial nerve autografting

69. Nerve transposition/ crossover
• Nerve transposition is also known as facial- hypoglossal
transfer.
• Restores movement to the side of the face that has been
paralyzed.
• With the stump of the 12th nerve hooked up to the end of the
7th nerve, the face will move when the tongue is moved.
• Contralateral facial nerve is used to reinnervate paralyzed side
using a nerve graft Sural nerve often employed.

70. Indications:
• Irreversible facial nerve injury
• Intact facial musculature/distal facial nerve
• Intact proximal donor nerve
• Prior to distal muscle/facial nerve atrophy
• Ideal if performed within a year of facial paralysis
Advantage:
• Time interval until movement
• 4-6 months
• Avoid multiple sites of anastomosis
• Mimetic-like function achievable with practice

71. Disadvantages :
• Surgical intrusion on normal side
• Highly specialized technique & longer
time
• Longer time required for
reinnervation from long shafts by
which time there may be further
muscle atrophy
• Results not free of mass movements,
synkinesis

72. Hypoglossal-Facial Technique
1. Parotidectomy incision extended into cervical crease ~ 2-
3 cm below inferior border of mandible
2. Facial nerve identified and dissected distal to pes
anserinus
3. Identify hypoglossal nerve
a. SCM retracted posteriorly
b. Dissect superiorly until posterior belly of digastic is
identified
c. Retract digastric superiorly and CN XII is found
inferiorly.
d. Hypoglossal is within
2-3 c m of main trunk of the facial nerve
4. Hypoglossal nerve is dissected anteriorly and
medially into the tongue.
1. Transect distal to ansa hypoglossis
5. Facial nerve transected at the stylomastoid foramen
6. Anastomose nerves using 9-0 epineural suture.

73. Hypoglossal Facial Nerve Transfer
Entire hypoglossal nerve
transected
Hypoglossal nerve
reflected superiorly
Jump graft
modification

74. Cross-facial nerve grafting
• Contralateral facial nerve used to reinnervate
paralyzed side using a nerve graft
• Sural nerve often employed
• ~25-30cm of graft needed
• Restitution of smile and eye blinking obtained.
• Disadvantage
• 2nd surgicalsite
• Violation of the normal facial nerve

75. Cross-facial nerve grafting
Four techniques
 Sural nerve graft routed from buccal
branch of normal vii to stump of
paralyzed vii
 Zygomaticus and buccal branch of
normal vii used to reinnervate
zygomatic and marginal mandibular
portions respectively
 4 separate grafts from temporal,
zygomatic, buccal and marginal
mandibular divisions of normal CN
VII to corresponding divisions on
paralyzed side.
 Entire lower division of normal side

76. Muscle Transposition (“Dynamic Sling”)
• It is employed when there has been long standing paralysis and the muscles of
facial expression have atrophied.
• The masseter and temporalis muscles are the two most commonly used.
Indication:
– Congenital facial paralysis
– Facial nerve interruption of at least 3 years
• Loss of motor endplates
– Crossover techniques not possible due to donor nerve sacrifice

77. • Often used for reanimation of the oral
commisure.
• Middle 1/3 of muscle is best for transfer.
Temporalis

78. Temporalis transfer
1. Incision in preauricular crease extending to superior
temporal line
2. Obtain wide exposure of temporalis muscle by
dissecting above the SMAS
3. Incise down on periosteum to elevate muscle fibers -
Harvest middle 1/3
4. Large tunnel created over zygomatic arch
5. Orbicularis oris muscle exposed via vermilion border
incision at oral commissure
6. Large tunnel over zygomatic arch used to connect oral
commisure to zygomatic arch/superior incision.
7. Temporalis flap detached and elevated from its origin
and tunneled to the oral commissure.
8. 3-0 prolene used to suture orbicularis to temporalis at
oral commissure
9. Overcorrection of nasolabial fold and oral commissure

79. Masseter
• Used when temporalis muscle is not opted.
• May be preferred due to avoidance of large facial incision
Disadvantage:
– Less available muscle compared to temporalis
– Vector of pull on oral commisure is more horizontal than
superior/oblique like temporalis

80. Masseter transfer
1. Expose muscle with gingival incision along mandibular
sulcus
2. Dissection carried out in a plane between mucosa and
muscle.
3. Muscle freed off of mandible medially and from the
inferiolateral edge of mandible.
4. Vertical incision made in inferior portion of muscle
5. Anterior half of muscle is split into 2 divisions.
6. The 2 anterior slips of muscle are tunneled anteriorly to
reach the oral commisure via external vermillion border
incisions.
7. Muscle slips are attached to lips and oral commisure in the
deep dermal layer using suture

81. • They have potential of achieving individual segmental
contractions reduction of synkinesis
• Muscle flaps used are:
• Gracilis
• Latissimus dorsi
• Inferior rectus abdominus
Microneurovascular transfer free muscle flaps

82. • Requires viable muscle and nerve innervation
• They have potential of achieving individual segmental contractions
• Reduction of synkinesis
• Traditionally done in 2 stages
• 1st: cross-face nerve graft 1 yr prior to muscle
transfer
• 2nd:muscle transfer performed after neural ingrowth of graft, 9 to
12 months later.

83. Gracilis
• “Workhorse” for free muscle transfer
• Long, thin muscle in medial thigh
-Good neurovasular pedicle
• Adductor artery and vein
• Anterior obturator nerve
• 2 stages involved:
• Sural nerve employed for cross-face
graft
• Gracilis muscle transferred after 6-12
months
• Vascular anastomosis to the facial artery
and vein or to superficial temporal
vessels.
Anterior Obturator nerve
Adductor a. & v.

84. • Static facial suspension is used to lift the corner of the mouth so that
balance is restored to the face and drooling out of the mouth is
helped.
Indications:
• Debilitated individuals; poor prognosis
• Nerve or muscle not available for dynamic procedures
• Adjuct procedure with dynamic techniques to provide immediate benefit
Advantages:
• Immediate restoration of facial symmetry at rest
• No oral commissure ptosis
• Drooling, disarticulation, mastication difficulties
• Relief of nasal obstruction caused by alar collapse
Static slings

85. • Variety of materials used
• PTFE (Polytetrafluoroethylene) (Gor-Tex)
• Alloderm
• Fascia lata
• Gor-Tex and alloderm have advantage of no
donor site morbidity but higher risk of
infection.

86. Static facial sling technique
1. Preauricular, temporal or nasolabial fold incision may be
used
2. Additional incisions made adjacent to oral
commisure at vermillion border of upper and lower
lip
3. Subcutaneous tunnel dissected to connect temporal to
oral commisure incisions
4. Dissection may be carried out in midface adjacent to
nasal ala, if needed (for alar collapse)
5. Implant strip is split distally to connect to the
upper/lower lips
6. Implant secured to orbicularis oris/commisure using
permanent suture
7. Implant is suspended and anchored superiorly to
superficial layer of deep temporal fascia, or zygomatic
arch periosteum, using permanent suture.

87. Addressing paralytic eyelids
Complications of orbicularis oculi paresis
• Delayed blinking
• Impairment of nasolacrimal system
• Dry eye
• Risk of exposure keratitis, corneal ulceration and blindness
Goal of treatment is to maintain cornea
Treatment options
• Tarsorrhaphy
• Gold weight/spring implants
• Open / endoscopic brow lifts for significant brow ptosis

88. Gold weight implantation
1.Small incision made several millimeters above
the upper eyelid margin.
2.Tarsal plate exposed with sharp dissection.
3.Gold weight secured to tarsus using 8-0 nylon.
4.Wound closed in 2 layers.

89. Tarsorrhaphy
• Tarsorrhaphy is a surgical procedure in which the
eyelids are partially sewn together to narrow the
eyelid opening.
• Horizontal mattress 5-0 nylon.
• Begin 3mm medial to lateral canthus, 6mm
from lid margin.
• Stitch travels through gray line to 5mm below
lower lid margin.
• Cosmetically unappealing, visual field affected.

90. • Addresses the aging neck and lower two-thirds of the face.
• A small window is made in the orbicularis oculi muscle just lateral to the
lateral orbital rim at the lateral canthus level with deep temporal fascia
exposed.
• Suture is with consecutive bites of 0.5 cm to 2 cm below the lateral
canthus in a purse-string fashion causing microimbrications in a
subcutaneous plane.
• This technique provides a simple, quick, and stable result for midface
elevation and support of the lower eyelid, reducing vertical lid height.
• However, it does result in excess lower eyelid skin
Minimal Access Cranial Suspension (MACS) Lift

91. • Patients with a ‘‘negative vector’’ have poor
lower lid support and are particularly
challenging to manage in facial paralysis.
• They tend to develop lower lid retraction that is
not amenable to typical techniques such as tarsal
strip procedures.
• Often, a midface-lift is necessary to support the
lower lid.
• The author prefers the subperiosteal midfacelift
utilizing the CoApt midface Endotine .

92. • The nose
• The collapse of the nasal side wall can be
corrected either from the outside or the
inside of the nose.
• Outside techniques involve placing strips of
suspension material from the cheekbone,
under the skin, to the nasal sidewall , and
suspending the nasal sidewall in its anatomic
position,
• To widen the nasal cavity from inside small
cartilage gtafts can be inserted into the
framework of the nose.

93. Adjunctive procedures
Soft tissue procedures to improve symmetry
• Rhytidectomy
• Excision of redundant intraoral mucosa
• Blepharoplasty
• Brow lift
Procedures for drooling
• Wilkie procedure
• Submandibular gland resection with parotid gland ligation
Modification of normal side to improve symmetry
• Neurectomy
• Myectomy

95. Recent advances
• Surgeons from UC Davis Medical Center have
demonstrated that artificial muscles can restore the
ability of patients with facial paralysis to blink
• Sling that is attached to the electroactive polymer
artificial muscle device (EPAM) after passing through
an interpolation unit that is implanted in the lateral
orbital wall (note screw fixation). The power supply
and artificial muscle are implanted in the temporal
fossa. conceptually, when the normal right eyelid
blinks, the electrical sensor (green) sends a signal to
the battery to activate the EPAM

96. • The basic EPAM is a three layered structure with a thin film of dielectric
elastomer layered on each side with conductive electrodes made of carbon
particles suspended in a soft polymer matrix.
• When a voltage is applied to the electrodes, they attract to each other and
expand, compressing the dielectric elastomer and expanding the sheet.
• Removal of the voltage contracts the sheet.
• Additional study will needed, including biocompatibility and durability
studies, which are being performed, for further development of the EPAM
device.

97. • Addressing paralytic eyelids
• More recently, flexible platinum chains have
been used as this is better able to contour the
upper eyelid tarsus, of lower profile with the
same mass secondary to a higher density and
better biocompatibility.

98. Conclusion
• The human face signals expressions of happiness, anger, fear, and surprise
that appear to be universal in character.
• Impairment of the facial nerve interferes with the transmission of this
intimate information that is an essential addition to the flow of our
conversation that significantly supplements the meaning of our speech.
• Therefore it is highly essential to have a precise diagnosis of the
problem and then the surgeon should use his skill and imagination to
bring back the expressions of the face which will eventually take a long
way in improving the patients functional esthetical and emotional
status.

99. Thank you