FACIAL PARALYSIS

1. Reanimation of Facial paralysis

2. The aim of facial reanimation is to restore the
tone, symmetry and movement of the face
Facial symmetry at rest with oral competence,
Eye protection and creation of dynamic smile.

3. GENERAL PRINCIPLES
Reinnervation of facial muscles should occur
as early as possible
Upper and lower face should be reanimated
separately ( Avoids mass movement)
Both static and dynamic procedures can be
employed.
Procedure tailored to patient’s needs

4. ASSESSMENT
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

5. Anatomy of facial nerve
 emerges from the
brainstem between the
pons and the medulla.
 The motor part of the
facial nerve arises from
the facial nerve nucleus
in the pons.
 sensory part of the
facial nerve arises from
the nervus intermedius.

6. Intracranial part
 The portion of the nerve
from the brainstem to
the internal auditory
canal
 Carries preganglionic
parasympathetic fibers
and special afferent
sensory fibers

7. Intra temporal part
 Important branches of facial
nerve in this part :
1. Greater superfacial petrosal
nerve
 Carries parasympathetic
fibers to lacrimal gland and
glands of the nose and
palate.
2. Nerve to Stapedius muscle
3. Chorda tympani
 carries parasympathetics to
the submandibular and
sublingual glands & Taste to
anterior 2/3 of the tongue .

8. Extracranial part
 Main trunk ( 15 – 20 mm) :
1. Give branches to the
posterior belly of the
digastric and stylohyoid
muscles.
2. Postauricular to
occipitofrontalis muscles
 Branching of the extracranial
segments in the parotid
gland that splits into
 Temporal
 Zygomatic
 Buccal
 Marginal mandibular
 cervical

9. Sunderland Nerve Injury Classification
Class I (Neuropraxia)
 Axon remain intact
 Conduction block caused by cessation of axoplasmic flow
 Full recovery
Class II (Axonotmesis)
 Axons are disrupted
 Endoneural tube still intact
 Full recovery expected
Class III (Neurotmesis)
 Neural tube is disrupted
 Poor prognosis

10. Class IV
Epineurium remains intact
Perineurium, endoneurium, and axon disrupted
Poor functional outcome with higher risk for
synkinesis
Class V
Complete disruption
Little chance of regeneration
Risk of neuroma formation

12. The symptoms according to the level
of injury of facial nerve
At internal auditory meatus;
 loss of lacrimation, stapedial
reflex, taste from most of
anterior two-third of tongue, lack
of salivation and paralysis of
muscles of facial expression.
Below geniculate ganglion;
 loss of stapedial reflex, taste
from anterior two third of
tongue, lack of salivation and
paralayis of facial expression
muscles.
Region below stylomastoid
foramen
 paralysis of facial expression
muscles.

14. House-Brackmann Grading System
• Grade Definition
I Normal
II Very mild weakness
III Obvious weakness,
• asymmetry of mouth
• Complete eye closure
IV Obvious weakness,
• asymmetry of mouth
• Incomplete eye closure
V Very slight movement only
VI No movement at all

15. Preoperative evaluation
History : focusing on the onset and duration of
weakness.
complete physical exam of the head and neck
including a cranial nerve examination.
The muscles of facial expression are evaluated for
symmetry and function—both statically and
dynamically.
electrical testing is performed to determine the
physiological status of the facial nerve branches
and the muscles of the face. (EMG & ENG)

16. electrical testing of facial nerve
ELECTRONEUROGRAPHY
(ENOG) measure of the
amount of intact axons
relative to the healthy side.
 used to determine
prognosis pre-operatively
ELECTROMYOGRAPHY (EMG)
is often used for muscle
viability
NERVE EXCITABILITY TEST
(NET) determine prognosis
for facial nerve recovery

17. A general order in preference for facial
rehabilitation procedures
1. Spontaneous facial nerve regeneration
(observation)
2. Facial nerve neurorrhaphy
3. Facial nerve cable graft
4. Nerve transposition
5. Muscle transposition
6. Free Micro-neurovascular transfer
7. Static procedures

18. Surgical Reanimation Techniques
Broadly classified into:
I . Neural methods:
 Facial Nerve Decompression
 Nerve graft (to overcome gaps)
 Cross-Facial Nerve Grafting
 Nerve Transfers
-Hypoglossal to facial
-Spinal accessory to facial
-mandibular to facial
II . Musculofascial transpositions:
III . Prosthetics.

19. OTHER CLASSIFICATION
• Dynamic
– Nerve grafting
– Muscle transfer
Regional
Free flap
• Static
– slings
– gold weight
– tarsorrhaphy
– lower lid shortening

20. CONCEPT OF DYNAMIC REANIMATION
Proximal and Distal Systems Intact
Proximal system intact, Distal unavailable
Both systems unavailable
Proximal system unavailable and Distal system
intact

21. Facial Nerve Decompression
• Performed in severe cases when the facial nerve is
seriously deteriorating.
• Patients are at risk of permanent paralysis and have a
poor prognosis without aggressive intervention.
• To be effective, the surgery must be performed within 2
weeks of the onset of symptoms.

22. Direct nerve repair
 should be done as soon as
possible, before
significant muscle
degeneration occurs
(preferably < 6 month)
 The nerve stumps should
be realigned in fascicular
groups without tension.
• Group fascicular repair
• -Epineural repair

23. Nerve grafting
 There is a gap in the facial
nerve that cannot be
primarily repaired.
 The graft must also be
placed in a tissue bed that
is free of scar.
 Commonly - Greater
Auricular Nerve, Sural
nerve,Medial antebrachial
cutaneous nerve

24. Nerve commonly used for grafting
 Great auricular nerve
– Usually in surgical field.
– Can only harvest 7-10cm
of this nerve.
-Located on lateral surface
of SCM at the midpoint
of a line drawn between
mastoid tip and
mandibular angle

25.  Sural nerve
– Located 1-2 cm posterior
to the lateral malleolus.
– Can provide 35cm of
length.
-Multiple transverse
incisions/longitudinal
incision.
– Loss of sensation to
lateral calf and foot.

26. Nerve transfer
 Hypoglossal nerve
– Direct hypoglossal-to-facial
graft
 Distal branch of facial
nerve is attached to
hypoglossal nerve.
 Complications – atrophy of
ipsilateral tongue,
difficulties with chewing,
speaking, and swallowing.
– Partial hypoglossal-to-facial
jump graft

28. Cross facial nerve grafting
 a nerve graft (typically the
sural nerve) that acts as a
conduit for motor axons
from the normal side,
contralateral facial nerve.
– Options
 Single contralateral branch
to distal nerve
anastomosis.
 Multiple anastomoses from
segmental branches to
segmental branches

29. Dynamic transfers
Local Muscle Transposition
Free functioning muscle transfer.

30. Local Muscle Transposition
 It is employed when there
has been long standing
paralysis and the muscles
of facial expression have
atrophied.
 The masseter and
temporalis muscles.
 These may be transposed
to the upper and lower
eyelids and the ala and
the upper and lower lips.

33. MASSETER TRANSFER

35. Free muscle transfer
 It is appropriate for those with
intracranial or congenital
causes of facial paralysis.
 The muscles like gracilis,
latissimus dorsi, pectoralis
minor.
 The procedure is performed in
two steps ;
-In the first step, a cross face
nerve graft is performed.
-The second stage is the muscle
transfer which is done 9 to 12
months later.

36. STATIC FACIAL REANIMATION
PROCEDURES
poor candidates for prolonged general
anesthesia
Patients with a poor prognosis in whom
reanimation over a long time is not
appropriate
dynamic reanimation failures.

37. Static Suspension Procedures
 It is used for suspension of the forehead , eyelids,
nares, oral commissure,
 Autologous materials
-Tensor fasciae lata.
-Temporalis fascia.
 Synthetic materials

39. Eye Care
 Glasses should be worn whenever the patient outside.
 Contact lenses should not be worn in this situation.
 If the eye is dry, (artificial tears). Ointment at bedtime.
 During night/sleep hours can be secured in place with
tape.
 If facial weakness is anticipated following surgery, a
silk thread is sometimes placed in the lid to help close
it.
 In some cases of long-standing paralysis, it may be
necessary to insert a weight ( gold plate) into the eyelid
to close the eye or perform some other procedure to
help the eyelid close (i.e. tarsorrhaphy).

41. Lid gold weight

42. The Nose
 The collapse of the nasal
sidewall can be corrected
by placing strips of
suspension material from
the cheekbone, under the
skin, to the nasal
sidewall.

43. Adjunctive Procedures
 Soft-tissue procedures to improve symmetry
-Rhytidectomy
-Excision of redundant intraoral mucosa.
-Blepharoplasty
-Brow lift
 Procedures for drooling
-Submandibular gland resection with parotid duct
ligation
 Modification of normal side to improve symmetry:
-Neurectomy.
-Myectomy.

44. Summary
Acute (< 3 wks)
1. Nerve exploration or
decompresion
2. Nerve repair
a. Primary anastomosis
b. Cable grafting
Intermediate (3 wks- 2yrs)
1. Nerve transfer
a. Hypoglossal-facial
b. Spinal accessory-facial
c. Masseteric-facial
2. Cross face nerve
grafting using sural
nerve

45. Chronic (>2 yrs)
1. Muscle transfers
a. Temporalis b. Masseter c. Digastrics
2. Free muscle flaps/microneurovascular
transfer
a. Gracilis b. Latissimus dorsi c. Serratus anterior
d. Pectoralis minor
Static procedures/ancillary procedures (can be
performed at any time period listed above)
1. Gold weight/spring implants 2. Slings 3. Lid
procedures

46. Thank you