Rehabilitation of Facial Paralysis: Key Points

Rehabilitation of Facial Paralysis 172
James M. Ridgway | Prabhat K. Bhama | Jason H. Kim
Key Points
Paramount to the rehabilitation of facial nerve paralysis is a complete understanding of the nature
of the injury, extent of the defect, viability of remaining facial nerve segments, integrity of potential
donor nerves and tissues, the patients overall health status, and the patients personal desires and
expectations for rehabilitation.
A detailed history and physical examination should include a description of the mechanism of the

injury, time of onset, duration of symptoms, previous surgery or radiation therapy, ocular
symptomology, speech and swallowing function, and previous treatment and rehabilitation.
Division of the face into upper, middle, and lower thirds allows for a more precise characterization

of nerve defects and potential therapeutic options.
Management of facial paralysis is dependent on the specific cause of the paralysis. Options for facial
nerve rehabilitation include spontaneous nerve regeneration (observation), facial nerve
neurorrhaphy, facial nerve cable graft, nerve transposition, muscle transposition,
microneurovascular transfer, and static procedures.
Electromyography is indispensable in determining the existence of denervation atrophy or

subclinical innervation. Electromyography is the single most important test for determining the type
of operative procedure to be performed.
An operative electric nerve stimulator may be used only in acute injuries to identify severed distal

nerve segments. Wallerian degeneration with impairment of nerve conduction has occurred by 72
hours after injury, and the surgeon is left to rely on visual identification after this point in time.
The most desired source for rejuvenation of the paralyzed face is the ipsilateral facial nerve.

Early protection of the eye in the setting of facial nerve paralysis is of the highest priority. Failure
to recognize and treat eyelid dysfunction will result in devastating ocular complications that are
entirely preventable.
Tension-free nerve repair is critical to the success of nerve anastomosis. When operative

circumstance does not permit such an end-to-end anastomosis, cable or interposition nerve
grafting is the desired surgical approach.
When grafting to the proximal facial nerve segment is not an option in rehabilitation, attention is

then shifted to the muscle (masseter or temporalis), nerve transfer procedure (hypoglossal), or
microneurovascularization (muscle and nerve).
Static techniques are best used in debilitated patients with limited prognostic survival and in those

for whom nerve or muscle is not available for dynamic procedures.
Patients with incomplete recovery from facial nerve paralysis typically present with hyperkinetic,
uncoordinated mass facial movements known as synkinesis. Botulinum toxin has dramatically
improved the management of this condition and is the current first-line therapy.
T he consequences of unilateral facial nerve paralysis are both of patient compliance, understanding, satisfaction, and accep-
physically and emotionally devastating for all affected patients. tance of reality. A recent review of all state and federal civil trials
For these reasons, the restoration of facial symmetry and alleging malpractice and facial nerve paralysis demonstrates the
motion is one of the most rewarding skills of the facial recon- importance of careful explanation and documentation in addi-
structive surgeon. The focus of this chapter is to provide a tion to the importance of good patient rapport and bedside
comprehensive review of facial nerve injury and rehabilitation. manner in preventing lawsuits.1
Many of the diagnostic considerations and surgical techniques
described are applicable to otogenic paralyses (intratemporal)
as well as to injuries and diseases that affect the parotid and
PATIENT ASSESSMENT
facial portions of cranial nerve (CN) VII. A complete patient evaluation is critical in attaining optimal
Once damaged, the facial nerve rarely regains complete facial paralysis rehabilitation. It is essential to properly under-
function. Given the challenges to the patient, consultations stand the nature of the injury, the resulting defect, and viability
regarding facial nerve paralysis require a clinicians fullest of the proximal and distal facial nerve segments and to prop-
thought and compassion. A realistic approach yields the rewards erly assess the viability of potential donor nerves and facial
2643
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2644 PART VII | OTOLOGY, NEUROTOLOGY, AND SKULL BASE SURGERY
musculature. The surgeon must also thoroughly assess the

TABLE 172-1. House-Brackmann Grading System
patients health status and personal desires for rehabilitation,
and the expertise of other medical specialists should be sought Grade Description Characteristics
out when necessary. I Normal Normal facial function in all areas
An outline of assessment of facial nerve paralysis is pre- II Slight Appearance: slight weakness noticeable
sented in Box 172-1. on close inspection; may have very
slight synkinesis
At rest: normal symmetry and tone
ASSESSMENT OF THE DEFORMITY Forehead motion: moderate to good
Physical examination includes complete head and neck exami- function
nation with attention to cranial nerve function and the pres- Eyelid closure: complete with minimal
effort
ence of functional masseter and temporalis muscles. The
Mouth motion: slight asymmetry
degree of facial nerve function is commonly recorded using the
House-Brackmann Facial Grading System2 (Table 172-1). A III Moderate Appearance: obvious but not
number of facial nerve grading scales have been developed, disfiguring weakness between the
two sides; noticeable but no severe
but the House-Brackmann scale was adopted by the Facial
synkinesis, contracture, and/or
Nerve Disorders Committee of the American Academy of hemifacial spasm
OtolaryngologyHead and Neck Surgery in 1985 because of its At rest: normal symmetry and tone
reproducibility and ease of use.2 This scale is useful for evalua- Forehead motion: slight to moderate
tion of overall function, but it is insufficient for precise assess- movement
ment of defects that affect one or more branches of the facial Eyelid closure: complete with effort
nerve. Further, it does not allow precise measurement of effec- Mouth motion: slightly weak with
tiveness of treatments isolated to one region of the face. For maximal effort
these reasons, the physical examination should assess deformity IV Moderately Appearance: obvious weakness and/or
of the upper, middle, and lower thirds of the face indepen- severe disfiguring asymmetry
dently. This approach allows more precise characterization of dysfunction At rest: normal symmetry and tone
defects, aids the decision-making process for rehabilitation, Forehead motion: none
and allows more precise assessment of treatment results. Facial Eyelid closure: incomplete
Mouth motion: asymmetric with
tone is also noted, as is the presence of any reinnervation. maximal effort
Thorough assessment of the eye also is performed. Visual
acuity, corneal integrity, eyelid closure, tearing, a Bell phenom- V Severe Appearance: only barely perceptible
enon, lagophthalmos, lower lid laxity, position of the lacrimal motion
At rest: asymmetric
puncta, and eyebrow position are all noted. Nasal examination Forehead motion: none
focuses on the position of the ala and nasal septum as well as Eyelid closure: incomplete
on the presence or absence of nasal obstruction. Oral compe- Mouth motion: slight movement
tence and height and position of the lower lip are carefully
VI Total No facial function
reviewed. In long-term paralysisthat is, paralysis of more than
1 years durationelectromyography (EMG) of the facial From House JW, Brackmann DE. Facial nerve grading system. Otolar-
muscles is performed prior to reinnervation procedures. Occa- yngol Head Neck Surg 1985;93:146.
sionally, muscle biopsy provides additional information about
the presence of viable muscle for innervation. If nerve fibrosis
is suspected, nerve biopsy is occasionally indicated. of three types.3 The Mona Lisa smile is the most common smile
Another important component of the assessment is evalua- pattern (67%). It is dominated by action of the zygomaticus
tion of the patients smile pattern. The smile is created by the major muscle: The corners of the mouth move laterally and
muscles of the lips, and smile patterns can be classified into one superiorly, with subtle elevation of the upper lip. The canine
smile (31%) is dominated by levator labii superioris action,
appearing as vertical elevation of the upper lip, followed by
lateral elevation of the corner of the mouth. The least common
Box 172-1. ASSESSMENT OF FACIAL NERVE PARALYSIS
smile is the full denture smile (2%), or toothy smile, produced
History by simultaneous contraction of the elevators and depressors of
Type of injury the lips and angles of the mouth. Knowledge of facial muscle
Time since injury anatomy and the smile pattern exhibited by the patient is
Age, overall health, and life expectancy important in considering rehabilitation techniques other than
Radiation therapy (past or planned) nerve grafting to recreate a balanced facial appearance at rest
Nutritional factors and the simulation of a symmetric smile. Finally, assessment of
Previous operative reports patients with facial nerve injury should include the application
Physical Examination of patient-reported outcomes measures.4 A number of these
Previous incisions and scars validated instruments are available for assessment of disease-
Integrity of trigeminal, vagal, and hypoglossal nerves specific quality of life, including the Facial Clinimetric Evalua-
Facial motion (e.g., complete vs. partial paralysis) tion (FaCE) scale and synkinesis assessment questionnaire.5,6
Status of eye (e.g., lagophthalmos, ectropion)
Facial tone, structure (e.g., habitus)
Testing/Imaging
CONSIDERATIONS IN FACIAL
Electromyography is indicated in all patients who have had paralysis for NERVE REHABILITATION
more than 1 year A number of factors come into play in designing a plan of treat-
Computed tomography and magnetic resonance imaging of temporal ment for a patient with facial paralysis. In clinical situations
bone and parotid are indicated if the the cause of paralysis is in
question
that require facial reanimation, the technique used often
depends on the availability of a viable proximal facial nerve.
172 | REHABILITATION OF FACIAL PARALYSIS 2645
Tumor ablation with facial nerve sacrifice (e.g., radical

parotidectomy) dictates immediate facial nerve restitution, Status of the Proximal and Distal Facial Nerve
usually with a nerve cable graft. When the nerves continuity The optimal source for rejuvenation of the paralyzed face is the
and viability are in question, as may be seen during and after ipsilateral facial nerve. Other than the minor hypesthesia or
cerebellopontine angle surgery, it is wise to wait 9 to 12 months anesthesia from the harvesting of a nerve graft, anastomosis or
before an extratemporal facial nerve operative procedure is grafting to the ipsilateral nerve has no donor consequence, and
undertaken. These clinical extremes highlight the concept that it facilitates natural voluntary and involuntary control. Excep-
no single modality is universally appropriate in the treatment tions to this general rule are those cases in which the patient
of facial nerve impairment. Static procedures generally are needs prompt relief from corneal exposure or drooling. A
used when no viable reinnervation options exist, but these also tissue transfer or sling technique may be preferred because of
can be integrated with dynamic procedures to provide immedi- its immediate effects.
ate restoration of facial symmetry. The integrity of the proximal facial nerve is critical to surgical
A general order in preference for facial rehabilitation pro- outcome. As with other motor nerves, no reliable electrical tests
cedures is as follows: exist to confirm the viability of the proximal nerve when it is dis-
1. Spontaneous facial nerve regeneration (observation) continuous with its distal portion. Important factors that affect
2. Facial nerve neurorrhaphy proximal nerve viability include 1) nature of the nerve injury,
3. Facial nerve cable graft such as clean transection versus crush; 2) location of injury,
4. Nerve transposition whether proximal or distal; 3) patient age because younger
5. Muscle transposition nerves tend to regenerate more quickly and fully; 4) nutri-
6. Microneurovascular transfer tional status, which directly affects nerve regeneration; and
7. Static procedures 5) history of irradiation, which may impede neural regeneration.
The facial nerve distal to the injury site serves as a conduit
Time Since Transection for neural regeneration to the facial muscles after neurorrha-
A chronic, long-standing paralysis with complete muscle degen- phy, grafting, or hypoglossal-facial anastomosis. With acute
eration poses several problems with regard to eventual rein- injuriesthat is, those incurred within the previous 72 hours
nervation surgery because the facial muscles may undergo the electrical stimulator may be used to identify the distal nerve
denervation atrophy. Severe atrophy renders the reasonably and the muscular innervation of distal branches. After this
normal muscles incapable of reinnervation and contraction. golden period, the surgeon must rely on visual identification
Such atrophy may occur after 18 months of complete denerva- of the divisions and branches of the distal nerve because the
tion, although in some clinical situations, muscles have been capability of being stimulated electrically generally is lost after
known to persist inexplicably for many years without incurring approximately 72 hours. For this reason, transected nerve
such atrophy.7 EMG is the most helpful method for assessing branches in trauma or tumor cases should be tagged for iden-
facial muscle atrophy and is a prerequisite to surgery in all tification by placing a small colored suture around or adjacent
reanimation cases if the paralysis is of a 12-month duration or to each nerve branch. Any anatomic or surgical landmarks
more. The presence of nascent, polyphasic, or normal volun- should be precisely dictated in the operative note. If no suture
tary action potentials in a patient with facial paralysis indicates markers are available, and the so-called golden period has
the occurrence of reinnervation. If more than 12 months have elapsed, careful surgical searching with a loupe or an operating
passed since the facial nerve injury, the situation can be assumed microscope may reveal each of the divisions or branches of the
to be stable, and an attempt at surgical reanimation may be facial nerve; a topographic map is essential in guiding the dis-
warranted. However, within the first 12 months, the presence section. A review by Bernstein and Nelson describes the vari-
of these action potentials may represent a reinnervation ability with which these branches are placed, and the following
process. Continued monitoring for changes in facial movement landmarks are helpful (Fig. 172-1).8
over the next few months is of merit, and reanimation surgery The pes anserinus can be found 1.5cm deep to a point
should be postponed. Fibrillation or denervation potentials 1cm anterior and 2cm inferior to the tragal cartilage.
mean that the EMG electrode is positioned in denervated The superior division courses from the pes anserinus to
muscle. This is an optimal situation for cable nerve grafting or, the lateral corner of the eyebrow, and it is convex postero-
when no viable proximal facial nerve is available, for hypoglossal- superiorly (see Fig. 172-1). Bernstein and Nelson stressed
facial anastomosis. that these temporal branches may be multiple and reach
One of the most significant EMG findings is electrical as far posteriorly as the superficial temporal vessels.8
silence, which reflects denervation atrophy of the facial muscles. The buccal branch courses superiorly and then anterome-
The surgical implication is that nerve grafting or transfer is dially and passes 1cm inferior to the inferior border of
futile and is therefore contraindicated. If the facial muscles are the zygomatic arch (see Fig. 172-1).
absent or atrophied, muscle transfers are indicated. The marginal mandibular branch passes from the pes
Another effect of time includes endoneural scarring within anserinus directly over the angle of the mandible and then
distal nerve segments. It is not known whether endoneural under the inferior border of the mandible for approxi-
scarring acts as an impediment to nerve regeneration, but when mately 3cm. It then crosses above the mandible at the
associated with muscular atrophy, it probably further compro- level of the facial vessels. Any of several anatomic variations
mises nerve grafting or transfer. may exist, which necessitates ingenuity in nerve grafting.
When the facial nerve trunk and pes anserinus are intact,
Presence of Partial Regeneration a cable graft (or hypoglossal nerve graft) should be sutured
Partial regeneration often is overlooked but is extremely impor- to that portion of the main nerve trunk. However, certain
tant in determining which operation to perform. If the facial injuries and surgical procedures may sacrifice important
nerve has undergone enough regeneration to permit a few individual portions of the nerve and may require selective
axons to reach the facial muscles, this partial innervation may routing of reinnervation to specific divisions. The order
be sufficient to preserve the muscles for many years, even of priority for reinnervation of facial nerve branches is, in
though they may be totally paralyzed. In these clinical circum- order of highest priority, 1) buccal and zygomatic branches
stances, results with hypoglossal-facial anastomosis, which gen- (equal), 2) marginal mandibular, 3) frontal, and 4) cervi-
erally is preferable to muscle transfer, will be optimized. cal (the last may be disregarded or excluded).
considerable importance in the planning for the overall needs

and welfare of the patient. For example, a patient with previous
hypoglossal nerve injury on the opposite side could become an
oral cripple if the remaining hypoglossal nerve were to be
Superior transected for use in a CN XIICN VII anastomosis. Obviously,
division the surgeon must assess the donor nerve preoperatively in all
cases. The hypoglossal nerve must be tested for strength and
vitality before it is transected and anastomosed to the distal
1 cm
facial nerve. Similarly, the trigeminal nerve must be intact and
functional when its muscles, either masseter or temporalis, are
2 cm
1 cm considered for transposition into the facial muscle system.

The ideal reanimation procedure is one that yields 1) no
donor deficit, 2) immediate restitution of facial movement, 3)
Buccal
branch appropriate involuntary emotional response, 4) normal volun-
tary motion, and 5) facial symmetry. No currently available
Pes operative procedure satisfies all of these parameters. In fact,
anserinus
even with a bacteriologically sterile and precise surgical transec-
tion and immediate microsurgical repair of the facial nerve,
Inferior completely normal neurologic function cannot be restored.
division Therefore the surgeon must have a clear understanding of all
operations available, including potential outcomes and sequelae.
FIGURE 172-1. Topographic map of distal facial nerve anatomy is useful as Status of Donor Nerves
a guide in finding nonstimulable nerve branches for grafting. The pes anseri-
nus is 2cm inferior to a point 1cm anterior to the tragus. The marginal The hypoglossal nerve is the most frequently used nerve source
mandibular branch courses from the pes anserinus to the angle of the man- for transfer. Reflex and physiologic similarities between the
dible, and the buccal branch parallels the zygomatic arch 1cm below its hypoglossal and facial nerves have been described.12 The integ-
inferior border. The superior division arcs from the pes anserinus toward the rity of the hypoglossal nerve must be determined before it is
lateral end of the eyebrow, under a line that is convex superiorly. (From transferred for reinnervation. Irradiation of the brainstem,
House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck lesions of the skull base and hypoglossal canal, and surgical
Surg 1985;93:146.) procedures of the upper neck may affect the integrity and func-
tion of this nerve.
The trigeminal nerve has been used for facial reanimation
As an example of selective routing, when a parotid tumor in many ways. The methods currently used most often involve
operation results in excision of the pes anserinus and the proxi- masseter or temporalis muscle transfer and necessitate that the
mal facial branches, a branched nerve graft may be placed to motor portions of the trigeminal nerves remain intact. Palpa-
reinnervate the zygomatic and the buccal branches, excluding tion of the muscle during jaw clenching confirms whether the
unimportant branches. Fisch9 advises clipping branches of cer- muscle is functional.
vical branches in order to route innervation to the more impor- The cross-face nerve graft procedure (faciofacial anastomo-
tant portions of the face. Data that confirm the efficacy of this sis) initially was thought to be the most appropriate and inge-
technique, however, are very limited. nious facial reanimation procedure.13,14 The procedure is unique
If no nerve branches are found, and the EMG shows that in that it borrows appropriate neural input from the contralat-
denervated facial muscles are present, the nerve graft may be eral normal side and routes it to the paralyzed side. Such a
sutured directly to the muscles targeted for reinnervation (mus- procedure requires a fully intact (contralateral) facial nerve.
cular neurotization). In these instances, the most important
muscles are those of the midface (zygomaticus major and Age
minor, levator labii superioris) and orbicularis oculi muscles. The proximal neurons ability to regenerate declines with time
Reinnervation will not be as complete as in routine nerve graft- as a result of denervation and aging-related changes. The etio-
ing because the regenerating axons must form new connections logic mechanism probably involves diminishing regenerative
to the old motor endplates, or they must create their own.10 vitality of the perikaryon (cell body), although peripheral scar-
ring may play a role. The clinical implication is that facial reani-
Viability of Facial Muscles mation surgery should always be performed as soon as possible,
Four types of EMG responses are observed11: provided that the operative procedure does not interfere with
Normal voluntary action potentials indicate that functioning or injure existing innervation or ongoing reinnervation.15
motor axons have connections with and are stimulating
motor units of facial muscle. Health Status
Polyphasic potentials are seen during reinnervation and may Among patients with diabetes, regeneration of injured nerves
precede visible evidence of reinnervation. is notoriously poor. Microangiopathy is an additional factor
Denervation or fibrillation potentials indicate that otherwise that may affect the grafted segment. These factors do not pre-
normal denervated muscle exists. clude a nerve graft procedure in a diabetic patient, but when
Electrical silence, with no potentials seen, indicates atrophy combined with radiation, advancing age, and other factors,
or congenital absence of muscle, provided that the elec- they may cause the surgeon to consider muscle transfer or a
tromyographer has positioned the electrode correctly. suspensory operation rather than a neural anastomosis.
Donor Consequences Prior Radiotherapy
Many surgical procedures designed for facial reanimation Radiotherapy, a necessary component of treatment for certain
borrow neural elements or signals from other systems (i.e., salivary gland malignancies, appears to have a deleterious effect
the hypoglossal and trigeminal systems). The consequences of on reinnervation through facial nerve grafts. McCabe demon-
sacrificing the donor nerve, known as donor deficit, are of strated satisfactory muscle reinnervation from grafting despite
irradiation in animals.16 These investigators subsequently have consequences of failure to protect the eye. If the eyelid paralysis
documented return of facial function in nine patients who is temporary or partial, these local measures may be all that are
received postgrafting radiotherapy. McGuirt and McCabe16 and necessary to adequately protect the eye. Regular use of artificial
Conley and Miehlke17 published reports that indicate facial tears is commonly the first-line method used to keep the eye
nerve grafts function well even though irradiated and that moist. Ointments also may be used, but they are less practical
nerves are among the most radioresistant tissues of the human in the daytime because they tend to blur vision.
body. Pillsbury and Fisch18 found that radiotherapy reduced the Lacriserts, contact lenses, and occlusive bubbles commonly
average outcome from 75% to 25% of nerve function recovery are used, although patient compliance may be problematic
in a review of 42 grafted patients. Irradiation probably affects (Fig. 172-2).19 The eyelids frequently are patched or taped, but
the neovascularization of the nerve graft by decreasing vascu if incorrectly used, these methods may result in corneal inju-
larity of the tissue bed and probably injures the proximal ries. Tape should not be placed vertically across the eyelashes,
and distal segments of the nerve as well. The most radiosensi- rather it should be applied horizontally above the eyelashes on
tive portion of the nerve, the pontine nucleus, should be the upper eyelid, or it should support the lateral canthal por-
assessed to determine whether it was present in the field of tions of the lower eyelid.20 When an eye patch is used, care must
irradiation. be taken to ensure that the eye cannot open because this would
allow contact between the patch and the cornea.
Congenital Paralysis
In a series of 95 infants with neonatal paralysis, Smith and
associates11 found 74 of the cases to be secondary to intrauter- PROCEDURES TO TREAT PARALYSIS OF
ine injury or birth trauma, whereas 21 were thought to be THE LOWER LID (ECTROPION)
congenital. Such infants should be studied with nerve excit-
ability and EMG testing early in life to ascertain the status of Tarsorrhaphy
nerves and muscles. Most patients with injury-related neonatal The temporary lateral tarsorrhaphy is an expeditious and effec-
paralysis recover rapidly, whereas the paralysis associated with tive method for protecting the eye in patients with mild lagoph-
other congenital anomalies (such as Mbius syndrome) is per- thalmos and mild corneal exposure. A horizontal mattress
manent. Nerve exploration or transfer generally is futile in the suture of 7-0 silk or nylon is placed laterally to approximate the
latter cases. gray line (mucocutaneous junction) of the upper and lower
lids. Tarsorrhaphy sutures will remain effective longer if they
are placed through bolsters made of rubber (Robinson)
EARLY CARE OF FACIAL catheters.
For longer-lasting protection, the lid adhesion tarsorrhaphy
NERVE INJURY is preferred. The lid margin (gray line) of each lid is denuded
Failure to recognize and treat acute eyelid dysfunction will 4 to 6mm from the lateral canthus, and a similar suture tech-
result in devastating ocular complications. The ability to nique is used to approximate the denuded mucocutaneous
prevent, diagnose, and treat paralytic eyelid sequelae before
major complications occur is essential in the management of
any patient with facial paralysis. An important point is that the
outcome of the eyelid paralysis is directly related to patient
education and compliance.
EYE PROTECTION: EVALUATION AND

TREATMENT OF EYELID PARALYSIS
Paralysis of the orbicularis oculi results in exposure and drying
of the cornea. Patients at increased risk for exposure keratitis
may be identified by applying the acronym BAD: absence of
Bell phenomenon, corneal anesthesia, and history of dry eye.
An inability to protect the cornea is the result of incomplete
eye closure and ectropion. With the atonic lower lid and lacri-
mal punctum failing to appose the globe and bulbar conjunc-
tiva, the effective distribution of the tear film across the surface
of the eye is compromised. Epiphora may result from failure of
tears to enter the lacrimal punctum, secondary to pooling of
tears as a result of ectropion and the loss of the orbicularis oculi
tear-pumping mechanism. The response to abnormal corneal
sensation may be reflexive tear hypersecretion, which will
further increase the epiphora.
Any patient with facial paralysis who demonstrates a poor
Bell phenomenon is at risk for the development of exposure
keratitis. Eye pain may herald the onset of keratitis. In patients
with diminished corneal sensation, however, exposure keratitis
may asymptomatically progress to corneal ulceration. Accord-
ingly, all patients with diminished orbicularis oculi function FIGURE 172-2. Occlusive bubble worn by a patient after acoustic neuroma
require ophthalmologic consultation. surgery. The appliance has a foam rubber skin-contact surface that is firmly
Initial eye care is directed toward moisturizing the dry eye attached to a thin Plexiglas lens. In our experience, patient compliance is
and preventing exposure. In hopes of improved compliance, it relatively high with this type of device. (Courtesy of Moisture Chamber, Pro-
is important to communicate to the patient the potential optics, Palatine, IL.)
A B
FIGURE 172-3. A, Tiny single skin hook is used to evert the lower lid for denuding of the gray line (mucocutaneous junction). Note that a gray line of the
upper lid has been denuded. B, Healed tarsorrhaphy at 4 months. Increased eye closure may be achieved by extending the denudation and sutures
medially.
junctions of upper and lower lids (Fig. 172-3). Like the tempo- ing eyelid closure. The smallest weight that allows comfortable
rary lateral tarsorrhaphy, this procedure can be reversed if eyelid closure and does not cause fatigue of the levator muscle
function returns. The cosmetic deformity of tarsorrhaphy and is selected.
the availability of improved, alternative techniques to rehabili- Under local anesthesia, an incision is made that extends
tate the eyelids have reduced the use of tarsorrhaphies. equally between the medial and middle thirds of the supratarsal
crease, and the skin is elevated to the superior border of the
Wedge Resection and Canthoplasty tarsus. A pocket is formed immediately superficial to the tarsus
for Paralytic Ectropion to accommodate the dimensions of the weight. The weight is
Wedge resection of all layers of the lower lid is a simple and placed so that its inferior border is parallel to and just above
expeditious procedure, but it can result in notching of the the eyelash line. It is important to create a pocket directly on
eyelid margin. A more effective option for lower lid laxity is the the tarsal plate, and care should be taken to preserve a thin
lateral canthoplasty, which is more reliable, with a less notice- cuff of tissue at the lid margin to prevent inferior extrusion of
able defect. Several techniques have been described for lid the implant, which is secured with clear nylon sutures superior
shortening and resuspension, and they share the goal of elimi- and inferior to the tarsal plate; the orbicularis-levator complex
nating laxity of the lateral canthal tendon by shortening and/ is reapproximated, and the skin is closed.19
or resuspending the tendon posteriorly behind and above the Gold weights have some disadvantages. A very low incidence
Whitnall tubercle. The modified Bick procedure consists of of extrusion has been documented with their use, even when
lateral canthotomy and inferior cantholysis, followed by conser- they are inserted properly. In addition, weights depend on
vative resection of the lateral canthal tendon and fixation to gravity and therefore do not effectively protect the cornea when
the medial aspect of the lateral orbital wall above and posterior the patient is supine, so a nighttime ointment is often required.
to the Whitnall tubercle. If the weight is placed too far superior, it can result in paradoxic
The tarsal strip procedure, as described by Anderson and opening of the eye when the patient is in the supine position.
Gordy, modifies the previously described technique by denud- Finally, the gold weight can occasionally be noticed by the
ing the conjunctiva over the lateral tendon and separating the casual observer as a bump in the eyelid.
posterior lamella and the tendon from the anterior lamella.21 Palpebral springs and silicone (Silastic; Dow Corning,
The isolated tarsal strip is then suspended to the lateral orbital Midland, MI) slings as described by Morel-Fatio and Arion,
rim. In cases of severe ectropion, the lower lid punctum may respectively, also have been used for lagopththalmos.25,26 Silastic
be everted and displaced laterally after lateral canthoplasty. In slings are used less frequently and are complicated by lateral
these instances, a medial canthoplasty is used to restore the ectropion.27 Both types of implants share the disadvantage of
physiologic relationship of the punctum to the globe.22,23 The extrusion, and they are more difficult to place than eyelid
lower lid also may be augmented with auricular cartilage to weights. Currently, titanium chain-link implants are being used
address inadequate support of the medial tarsal plate in cases with greater frequency and with excellent results. These
not amenable to lateral tendon suspension alone.24 implants may be camouflaged to obtain a better cosmetic result
because they conform to the shape of the eyelid. Additionally,
the titanium implants have been shown to result in less corneal
PROCEDURES TO TREAT PARALYSIS OF astigmatism or cornea-altering effect on the globe itself than
THE UPPER LID (LAGOPHTHALMOS) that typical with gold weights.28
Weights, Springs, and Slings for Lagophthalmos
Gold weight insertion is extremely effective and very popular
because of its reliability, minimal cosmetic deformity, and rela-
FACIAL NERVE GRAFTING
tive ease of insertion. The implant weight used is determined Use of cable or interposition nerve grafts is frequently the
preoperatively by taping a weight to the upper eyelid and assess- desired approach to facial muscle reinnervation. The most
common setting for this procedure is likely to be in combina- of the sternocleidomastoid muscle at the Erb point and travels
tion with radical parotidectomy and facial nerve sacrifice. The obliquely along the sternocleidomastoid muscle toward the ear;
clinical uses of interposition grafts include 1) radical parotidec- the surgical landmarks are well defined with a line drawn from
tomy with nerve sacrifice, 2) temporal bone resection, 3) trau- the mastoid tip to the angle of the mandible that is then
matic avulsions, 4) cerebellopontine angle tumor resection, bisected by a perpendicular line that crosses the sternocleido-
and 5) any other clinical situation in which viable proximal mastoid muscle from inferoposterior to anterosuperior, passing
nerve can be sutured and distal elements of facial nerve can be toward the parotid gland. A small horizontal incision in an
identified. Tension-free repair is a critical element of successful upper neck skin crease is made along the path of the nerve,
nerve anastomosis. When tension-free apposition cannot be which is identified in the subcutaneous tissues and is followed
achieved using existing nerve ends, cable grafts are used. superiorly to the parotid gland that dissects each of the three
Facial nerve grafting for acute causes, such as parotid malig- branches and inferiorly to the posterior border of the sterno-
nancy, requires the surgeon to customarily identify the distal cleidomastoid muscle. The greater auricular nerve has several
facial nerve trunk divisions or branches for distal anastomosis. advantages: its size and fascicular pattern are similar to those
Nerve restitution should be performed at this time, unless of the facial nerve, it is easily harvested in familiar anatomy, and
extenuating circumstances such as anesthetic complications or it has a favorable distal branching pattern for facial nerve graft-
intraoperative emergencies rule out immediate grafting.29 If ing. Unfortunately, the nerve is limited to a maximum of 10cm
grafting is not undertaken at the time of nerve sacrifice, it for grafting.
should be completed within 72 hours thereafter, so that the In patients who have undergone neck dissection or paroti-
facial nerve stimulator may be used to identify the distal dectomy and in whom the greater auricular nerve is not a viable
branches. Conversely, the nerve ends can be tagged for identi- grafting option, the cervical plexus is the next ideal donor
fication at a later time. When grafting is not undertaken, the nerve. The cervical plexus can be harvested in the similar
distal branch becomes nonstimulatable and thus becomes fashion to the greater auricular nerve, but it requires a longer
much more difficult to locate and identify. neck incision. The nerve plexus can be located just posterior
and deep to the sternocleidomastoid muscle.
The sural nerve is also commonly used for facial nerve graft-
SURGICAL PLANNING ing. In contrast to the greater auricular nerve, the sural nerve
In planning the surgical procedure, the proximal site of nerve is the longest donor nerve available, with up to 70cm of graft
transection is often found to be in the intraparotid portion available when all branches are dissected into the popliteal
proximal to the pes anserinus. This location may present tech- fossa. The donor site is located distant from the surgical resec-
nical difficulties because the proximal stump may not be ade- tion, which allows a second team to simultaneously harvest
quate for technical ease in suturing. In other instances, the nerve tissue. Donor site morbidity is low. However, caution
nerve may be transected at the stylomastoid foramen. In these should be exercised when working with patients with diabetes
circumstances, a mastoidectomy should be performed. Distal or those with peripheral vascular disease because ischemic pres-
to the mastoid portion, the nerves sheath merges with perios- sure necrosis could result in an area of sensory deficit along
teum of the stylomastoid foramen and temporal bone, which the lateral aspect of the foot. The sural nerve is of larger diam-
makes this portion difficult to dissect free for grafting. This eter than the greater auricular nerve or the facial nerve, and it
difficult region exists roughly from 1cm above to 1cm below has more prominent connective tissue than the greater auricu-
the stylomastoid foramen. Use of the mastoid portion of the lar nerve or medial antebrachial cutaneous nerve.
facial nerve may require use of the longer sural or medial ante- The sural nerve is formed by the junction of the medial sural
brachial cutaneous nerve, rather than the greater auricular cutaneous nerve and the peroneal communicating branch of
nerve, for a cable graft. the lateral sural cutaneous nerve between the two heads of the
Distally, several situations may be encountered that require gastrocnemius muscle. The nerve lies immediately deep to and
some ingenuity in affecting reanimation. When the distal anas- behind the lesser saphenous vein, and multiple nerve branches
tomotic site is at or proximal to the pes anserinus, a simple arise near the lateral malleolus. A pneumatic tourniquet should
nerve-to-nerve suture will suffice. More frequently, however, be applied to the thigh, and a transverse incision is made imme-
after resection for parotid malignancy, several branches or divi- diately behind the lateral malleolus. Stair-step horizontal inci-
sions may require anastomosis. In such cases, priority must be sions along the course of the nerve provide appropriate
given to the zygomatic and buccal branches, sometimes to the exposure during the harvesting procedure. The nerve should
exclusion of other, less important facial nerve branches. Fre- be harvested immediately before grafting and should be placed
quently, a two-branch graft can be prepared from the greater in physiologic solution after debriding away any small pieces of
auricular nerve or the sural nerve. This situation favors suturing fat or other soft tissue that might interfere with graft revascu-
of one branch of the nerve graft to the buccal branch and the larization. At all times care is taken to avoid stretching the
other graft branch to the zygomatic branch or superior divi- nerve.
sion. This technique will direct innervation to the important The medial antebrachial cutaneous nerve has been described
orbicularis oculi muscle and the muscles of the buccal-smile in the orthopedic literature for peripheral nerve repairs and is
complex (Fig. 172-4). used in situ with forearm microvascular flaps for sensory inner-
vation in head and neck cancer reconstruction. This nerve has
Choosing a Donor Nerve several properties that warrant consideration for use in facial
Four of the nerves most commonly used are the greater auric nerve reconstruction: it has a consistent anatomy and travels in
ular nerve, the sural nerve, cervical plexus, and the medial the bicipital groove immediately adjacent to the basilic vein,30
antebrachial cutaneous nerve. Each has distinctive advantages the nerve diameter and branching pattern are similar to those
and limitations, and the reconstructive surgeon should be of the facial nerve, and donor-site morbidity is minimal with
familiar with each. nerve harvest.30
When harvesting the greater auricular nerve, tumor consid- All of the aforementioned donor nerves are sensory nerves
erations mandate that the ipsilateral nerve not be used. Conse- used to lead motor nerve regeneration. This is important
quently, the opposite neck should be prepped and draped for because harvesting a motor nerve for grafting material would
harvesting the contralateral nerve in parotid malignancy cases. certainly incur some degree of morbidity to the donor area or
The nerve is easily identified: it arises from the posterior surface muscle. Although a theoretic difference may exist between
Orbicular eye
Greater zygomatic
Lesser zygomatic
Levator labii
superioris
Orbicular mouth
A B
C D
E F
FIGURE 172-4. Facial muscles. A, The most important muscles for reanimation: The levator labii superioris is probably the most significant muscle, along
with the lesser zygomatic muscle, for elevation of the upper lip. The greater zygomatic muscle is also critical, as the strongest elevator of the oral commissura.
B to F, Example of a delayed nerve graft in a patient in whom a parotid malignancy was removed without immediate reconstruction because of intraoperative
anesthesia considerations. B, The patient was referred for nerve grafting after 9 months elapsed. Note elongation of the buccal-smile complex of muscles
(greater and lesser zygomatics, levator labii superioris) and paralysis of orbicular eye muscle. C, Preoperative surface markings for nerve branches. A nerve
stimulator cannot be used to locate distal branches after a 9-month time lapse. Markings are for the superior division and buccal branch, based on landmarks
described in Figure 172-1 and the previous operative report. D, Superior division is found; it is ready for transection and anastomosis to sural graft (from
midmastoid nerve segment). E, Result at 1 year after operation is typical for a delayed nerve graft. Orbicular eye and buccal branch muscle function is improved,
but the muscles are not normally or completely reinnervated. F, Voluntary motion in both zygomatic and buccal branches with synkinesia. This result also is
typical for most nerve grafts in that the temporal branch (to occipitofrontal muscle) shows no reinnervation. Note the hairstyle designed to camouflage the
occipitofrontal muscle paralysis.
using a sensory nerve versus a motor nerve, further investiga- Approximation of the nerve ends using an acrylic glue has
tion is required to determine whether this has any biologic been described (Histacryl or cyano-butyl-acrylate), and subse-
implication. quent investigators have revealed that neural anastomosis with
tissue adhesive yields results similar to nerve suture.31 This tech-
Surgical Technique nique is most helpful in the confined surgical considerations
For the surgical technique of neurorrhaphy, interrupted sutures of the temporal bone rather than in distal facial anastomosis.32
using 9-0 or 10-0 monofilament nylon are preferred. A straight Others have described using biodegradable nerve tubules.
and a curved pair of jewelers forceps and a Castroviejo needle Following temporal bone resection, the nerve may be routed
holder are satisfactory instruments for performing the anasto- from the tympanic or the labyrinthine portions directly to
mosis. Both ends of the nerve graft and the proximal and distal the face through a bony window near the posterior root of the
stumps should be transected cleanly with a fresh sterile blade. zygomatic arch. This will shorten the necessary length of the
For nerve trunk anastomosis, four simple epineural sutures will nerve graft. However, when using this technique, it is important
usually coapt the nerve ends accurately. However, obvious dis- to ensure the nerve grafts protection from trauma at the tem-
crepancies in size or other epineural gaps should be closed with poromandibular joint if the joint is preserved. Conley and Baker
additional sutures. The needle should pass through epineu- have reported excellent results using similar techniques.33,34
rium only to avoid injury to the fascicular neural contents. The Millesi35 introduced interfascicular nerve repair, reasoning
nerve graft should lie in the healthiest possible bed of support- that the exact microsurgical approximation of nerve fascicles
ing tissue, with approximately 8 to 10mm of extra length for or fascicle groups may minimize synkinesis or mass movement.
each anastomosis. Thus the graft should lie in a somewhat lazy It is well known that this type of repair is preferred in nerve
S configuration (see Fig. 172-4), which appears to minimize injuries in the extremities; however, such repairs have not been
tension during healing. Suction drainage systems should be universally accepted for use in the facial nerve. Several reasons
placed away from any portions of the nerve graft. underlie this limited acceptance. The tympanic and, in many
When one division is excised or injured and other portions cases, the mastoid portions of the nerve have only one or two
of the nerve remain intact, it may be desirable to graft from a fascicles, and the intraneural topography is questionable. Few,
fascicle within the pes anserinus to a distal branch. To accom- if any, sensory fibers are present in the extratemporal portion
plish this, fascicular dissection is performed in parallel and of the facial nerve, so performing sensory-to-sensory fascicular
along the plane of the nerve fascicles with curved jewelers repair is not of value.
forceps into the pes anserinus (Fig. 172-5). The distal buccal Along with May and Miehlke, Crumley reported (indepen-
branch often has several small filaments, so it may be necessary dently) that discrete, spatially oriented fascicles are present in
to select the larger of these for distal anastomosis. the nerve near the stylomastoid foramen.36-38 Other authors,
Superior division Zygomatic muscle
Buccal branch
Hypoglossal nerve Buccal branch

Inferior division
B C
FIGURE 172-5. A, Hypoglossal-facial anastomosis showing selective reinnervation of the inferior division, leaving the superior division innervation intact.
Inset shows fascicular dissection before anastomosis (see D and E). B and C, Preoperative photographs of patient with long-standing segmental paralysis of
the inferior division of the facial nerve. The zygomatic branch to the orbicular eye muscle shows preservation of innervation.
D E
G H
FIGURE 172-5, contd. D to F, Intraoperative photographs. D, Perineural dissection of the pes anserinus reveals fascicles destined for zygomatic and buccal
branches (see A). E, Buccal branch and inferior division transected. Neurosurgical loop protects intact superior division under a background piece of polymeric
silicone (Silastic). Hypoglossal nerve (at lower right) is ready for anastomosis. F, Completed anastomosis of hypoglossal nerve to the buccal branch and inferior
division of the facial nerve. The superior division is intact and is in continuity with the proximal facial nerve. G and H, Strong reinnervation to the entire face
1 year after operation. G, Patient uses hypoglossal innervation to buccal branch muscles to enhance eye closure. H, Upward movement of oral commissura
mediated by hypoglossal nerve, without associated or synkinetic eye closure.
notably Sir Sidney Sunderland and Tomander and colleagues, CROSS-FACE NERVE GRAFTING
have reported conflicting data that demonstrate that various
portions of the face are represented in a random fashion in the Overview
proximal nerve.39,40 At present, it probably is best to perform The creative and physiologic method of cross-face nerve graft-
fascicular repair when the injury obviously lends itself to the ing provides the possibility for facial nerve control of previously
technique (e.g., clean lacerations through the pes anserinus paralyzed facial muscles. It is the only procedure with the theo-
and branch nerve grafts that require fascicular dissection in the retic capability for specific divisional control of facial muscle
pes). Basic research has yet to reveal the exact neural topogra- groups (e.g., the buccal branch controlling the buccal branch
phy of the more proximal portions of the nerve. distribution, the zygomatic branch innervating the orbicularis
oculi). Originally described by Scaramella13 and Smith14 in with a similar drawback: mass movements and spasms preclude
independent reports in 1971, the technique has not proved to any voluntary control of eye closure, smiling, or other emo-
be as advantageous as was first thought. Anderl41 subsequently tional movements. In our practice, we have used hypoglossal
described his own results as good in 9 of 23 patients, whereas nerve transfer for reanimation of the upper or lower division
Samii42 reported that only 1 of 10 patients had good movement selectively by performing fascicular dissection in the pes anse-
as a result of this technique. An update by Ferreira43 indicated rinus to identify the specific fascicles that required reinnerva-
that those patients operated on within the first 6 months of the tion (see Fig. 172-5).
paralysis did better than those operated on at a later date. In May and coworkers46 attempted to decrease morbidity from
some of these patients, however, partial spontaneous reinnerva- tongue atrophy by performing partial transection of the hypo-
tion may have occurred because they appeared to have had glossal nerve with use of a jump graft from the partially tran-
lesions without total palsy, and the traditional waiting period of sected nerve to the distal facial nerve. Decreased effectiveness
1 year was not allowed to elapse. of partial transection with a jump graft has been reported by
some investigators.47
Surgical Technique Pure end-to-side anastomosis of the facial nerve or a jump
The operative technique of cross-face grafting begins with tran- graft into the donor hypoglossal nerve has been rediscovered48
section of several fascicles, usually of the buccal branch, on the and was reported in a small series of patients.49 Study investiga-
nonparalyzed side through a nasolabial fold incision. One to tors performed anastomosis of facial nerve, either mobilized
three sural nerve grafts are approximated to these normal con- from the mastoid or bridged by interposition graft into the
tralateral branches. The nerve grafts are then passed through intact hypoglossal nerve, without removal of epineurium or
subcutaneous tunnels, usually in the upper lip. Cross-face grafts perineurium. This technique relies on the presumed axon
for the eye region often are passed above the eyebrow. sprouting across intact epineurium of the hypoglossal nerve.
As described by most authors, this first surgical stage is per- Some evidence indicates lateral axonal growth after end-to-side
formed during the first 6 months of paralysis. Surgery, of nerve anastomosis occurs, and rat studies demonstrate axonal
course, is not advised unless the paralysis is of known perma- penetration of endoneurium, perineurium, and epineurium.50-52
nence. A Tinel sign often may be elicited after several months Whether this technique will be applicable in humans who have
of neural ingrowth because sensory fibers accompany the decreased nerve regenerative capacity and much thicker peri-
motor fibers through the cross-face graft. Anastomosis with the neurium and epineurium than in the rat remains to be seen.
paralyzed facial nerve branches is performed by most surgeons It may be more effective to remove an epineurial window and
during a second stage, 6 to 12 months after the first. At this perform the anastomosis without disruption of nerve fibers yet
time, the cross-face graft is explored and is sutured to the still induce enough axonal regrowth to provide tone and func-
appropriate branches of the paralyzed side. The approach is tion. Further animal and human studies will be necessary to
through a parotidectomy-rhytidectomy incision and usually is determine the usefulness and role of end-to-side neurorrhaphy
performed within the parotid portion of the paralyzed side. for facial rehabilitation.
The cross-face technique suffers from a lack of sufficient
axon population and neural excitatory vitality. It is of marginal Surgical Technique
value when used alone, but when combined with microvascular A modified facelift or parotidectomy incision with an extension
transfer of muscle (see below), it can provide suitable innerva- made inferiorly toward the hyoid bone usually is used in hypo-
tion. Conley44 and Conley and Baker45 have discussed the short- glossal nerve transfer. The parotid gland is dissected forward
comings and unproven status of cross-face grafting, and it is from the sternocleidomastoid muscle, and the facial nerve is
currently used only in conjunction with free muscle transfers. identified in its trunkpes anserinus region. The posterior belly
Reinnervation of paralyzed facial muscles has not been proved of the digastric muscle is then identified, and the hypoglossal
to be sufficient to justify use of this procedure without muscle nerve is dissected free immediately medial to the tendon of the
transfer. muscle. The ansa hypoglossi should be identified and dissected
free so that if desired, it may be sutured to the distal hypoglossal
stump for reinnervation of the strap musculature. The hypo-
NERVE TRANSPOSITION glossal nerve should be transected as far distally as possible to
Reinnervation by connecting an intact proximal facial nerve to provide extra length for the anastomosis. After the nerve ends
the distal ipsilateral facial nerve generally is the preferred are prepared carefully under high power using a blade, four to
method for facial paralysis rehabilitation. Only when a proximal eight epineural sutures of 10-0 monofilament nylon complete
facial nerve stump is not viable or available should attention be the anastomosis.
turned to other strategies, such as muscle or nerve transfer. The procedure for the hypoglossal-facial nerve jump graft is
similar to that for pure hypoglossal-facial nerve transfer. A
greater auricular nerve graft is harvested for use as a jump graft,
HYPOGLOSSAL NERVE TRANSFER and the facial nerve is transected on the main trunk. The hypo-
Of the various nerves available for anastomosis with the facial glossal nerve is incised in beveled fashion to expose approxi-
nerve, the hypoglossal nerve is preferred because an anatomic mately 30% of the nerve fibers. The jump graft is secured to
and functional relationship exists between the facial and the the proximal edge of the hypoglossal nerve and to the distal
hypoglossal nerves; both arise from a similar collection of end of the transected facial nerve. If the facial nerve is mobi-
neurons in the brainstem, and they also share similar reflex lized proximally from the mastoid, it can be directly anasto-
responses to trigeminal nerve stimulation.12 In addition, the mosed to the partially transected hypoglossal nerve to avoid
hypoglossal nerve is in close anatomic proximity and is readily placement of a jump graft.
available during other operations on the facial nerve. Hypoglos-
sal nerve transection results in less donor disability than that Results
typical with sacrifice of the spinal accessory, phrenic, or other In the largest series to date, which involved 137 patients,
regional nerves that have been used for facial reanimation. The approximately 95% regained satisfactory tone in repose and
most common criticism of hypoglossal nerve transfer is that it regained some mass facial movement.53 Of these patients, 15%
results in a lack of voluntary emotional control. Although this demonstrated hypertonia and excessive movement in the
is true, ipsilateral facial nerve anastomosis often is associated middle third of the face; however, none of these patients
A B C D
E
FIGURE 172-6. A, Patient with facial paralysis after acoustic neuroma excision. Lateral tarsorrhaphy is in place. B, Exposure of hypoglossal nerve. Note the
exit of the ansa cervicalis branch (lower right). This may be transected and sutured to the distal hypoglossal, although preservation of tongue innervation usually
is weak with this technique. C, Repose. Note the elevated commissura and reconstitution of the nasolabial fold. D, Movement instigated by pushing the tongue
tip against the lingual aspect of the mandible in the canine region. This maneuver usually results in the strongest facial movement after anastomosis of cranial
nerves XII and VII. E, Typical lingual deviation after the procedure.
requested that the transferred nerve be reoperated. This exces- nerve grafts and nerve transfers. The technique allows limited
sive movement was found to decrease gradually over 10 to 20 reanimated strength because of the small number of axons
years. However, Dressler and Schonle54 and Borodic and present in the donor nerve. In addition, sound electrophysio-
coworkers55 have had success treating facial hyperkinesia with logic confirmation that the technique produces reinnervation
selective injection of botulinum toxin. Seventy-eight percent of is somewhat lacking, despite a report by Anonsen and col-
the patients had moderate to severe tongue atrophy, whereas leagues on this topic.59 Until physiologic data are presented and
22% showed minimal atrophy. This wide variability in response confirmation by other surgeons is obtained, the procedure has
of the tongue to hypoglossal nerve transection has been con- potential but remains unproved.
firmed in other series (Fig. 172-6).56 Use of the interpositional
jump graft with partial hypoglossal nerve preservation pre-
served tongue function in a majority of patients and provided
NEUROTROPIC FACTORS
satisfactory function. In a series of 20 patients, good facial tone With several growth factors known to promote neuronal sur-
and symmetry were observed at follow-up evaluation in all vival, application and delivery of these factors constitute an
patients, and 13 had excellent restoration of facial move- attractive therapy for nerve injury and surgical repair. The
ment; development of twelfth-nerve deficits were noted in only trophic effects of nerve growth factor, glial cellderived neuro-
3 patients.46 tropic factor, brain-derived neurotropic factor, and insulin
growth factors I and II all are under current investigation.60 In
ongoing rat experiments, embryonic stem cells are used to
OTHER NERVE TRANSFERS provide the trophic support factors to the host motor neurons
The spinal accessory nerve was used before the hypoglossal in restitution of the neuromuscular junction.61 These prelimi-
nerve in nerve transposition techniques. Drobnik12 performed nary findings provide a model for motor unit restoration and
the first anastomosis of cranial nerves XI and VII in 1879. The a potential therapeutic intervention in the treatment of paraly-
phrenic nerve has been similarly used, but this technique sis. However, these studies are limited to the rat model and
causes paralysis of the diaphragm and induces undesirable require further basic and clinical investigation.
involuntary inspiratory movements in the facial muscles.57 The
technique is now obsolete.
The neuromuscular pedicle technique described by Tucker58 MUSCLE TRANSFERS
transfers a branch of the ansa hypoglossi nerve and a small
muscle bloc directly to paralyzed facial muscles; he states this MASSETER TRANSFER
procedure is valuable only for the perioral, depressor anguli Although masseter and temporalis muscle transfer techniques
oris, and zygomaticus muscles. The procedure is described as are effective, generally they should be used only if ipsilateral
transferring innervated motor endplates to the denervated cable nerve grafting is not possible. For most patients with viable
facial muscles without the usual delay period seen with free facial muscle endplates, a nerve transfer such as hypoglossal
facial anastomosis also is preferable to muscle transposition.

However, when the proximal facial nerve and the hypoglossal
TEMPORALIS TRANSFER
nerve are unavailable, or when facial muscles are surgically Although Gillies63 is usually given credit for introducing the
absent or atrophied, new contractile muscle must be delivered temporalis procedure, Rubin64,65 deserves much credit for refin-
into the face. A large group of patients who fit into this category ing the goals of the procedure and the operative technique in
are those whose complete paralysis has lasted 2 years or more. the United States. Like the masseter transfer, the temporalis
These patients usually are characterized by severe denervation transfer procedure requires an intact ipsilateral V3 nerve. The
atrophy as documented by EMG. In these situations, muscle nerve supply to the temporalis lies along the deep surface of
transfer is the preferred technique of reanimation. the muscle, and the blood supply comes from the deep tempo-
Since the masseter was first used for facial reanimation in ral vessels from the external carotid artery. Thus with total
1908, many modifications have been described.62 Many authors, parotidectomy, extensive neck dissection, or infratemporal
notably Conley and Baker,33 prefer the masseter muscle for fossa dissection, the neurovascular supply may be tenuous at
rehabilitation of the lower face and midface. The masseter best. The upper origin of the temporalis muscle is fan shaped
transfer procedure generally is performed for rehabilitation of and arises from the periosteum of the entire temporal fossa.
the sagging paralyzed oral commissure and the buccal-smile The muscle belly converges on a short tendinous portion deep
complex of muscles. The masseters upper origin from the to the zygomatic arch and inserts on the coronoid process. The
zygomatic arch allows a predominantly posterosuperior pull on muscle is best exposed through an incision that passes above
the lower midface. Transfer of the muscle can be accomplished the ear, slightly posteriorly, and then in an anteromedial arc;
externally through a rhytidectomy-parotidectomy incision, or it this will expose the entire upper portion of the muscle (Fig.
can be done intraorally using a mucosal incision in the gingi- 172-8). A convenient aponeurotic dissection plane exists lateral
vobuccal sulcus lateral to the ascending ramus of the mandible to the temporalis fascia.
(Fig. 172-7). The masseters blood supply is medial and deep, In Rubins technique, the muscle is dissected free from the
and its nerve supply passes through the sigmoid notch between periosteum and is attached to fascial strips, which are turned
the condylar and the coronoid processes of the mandible to down inferiorly to reach the oral commissure and eyelid area.
reach the upper deep surface of the muscle. The nerve supply If these fascial strips are omitted, the transposed muscles
then ramifies and courses distally and inferiorly to terminate length will be insufficient to reach the lateral oral commissure.
near the periosteal attachments on the lateral aspect of the More recently, Rubin65 refined his temporalis transfer tech-
mandibular angle and body. In general, the external approach nique by including a slip of masseter muscle sutured to the
is preferred, insofar as the intraoral approach is associated with oral commissure and lower lip. The resulting masseteric pull
somewhat limited access, poorer muscle mobilization, and less improves results by providing more posterior and lateral vectors
vascular control. to the oral commissure.
A generous parotidectomy incision is made to extend infe- We prefer to use the technique described by Baker and
riorly below the mastoid tip. The parotid gland and masseteric Conley, who describe retaining the integrity of the upper
fascia are exposed, and the posterior border of the muscle is muscle and its overlying fascia.53 The latter is dissected free and
freed from the mandibles ascending ramus and at the lower is then turned inferiorly for suturing to the oral commissure.
border of the mandible. The nerve supply courses along the A tunnel at least 1 to 1.5 inches wide must be made over the
deep surface approximately midway between the anterior and zygomatic arch to allow the muscle to turn inferiorly and elimi-
posterior borders of the muscle (see Fig. 172-7). It is advisable nate an unsightly bulge. The attachment of the strip should be
to preserve the deep fascial layer in dissecting the muscle free just medial to the nasolabial fold so that the natural crease is
from the mandible; mobilization of the periosteal attachments reproduced by the muscle pull. As with the masseteric proce-
along the inferior border will provide secure tissue for anchor- dure, a marked overcorrection is necessary on the operating
ing sutures and will provide greater length of the transposed table. A soft silicone block or a temporoparietal fascia flap may
muscle. be used to fill the temporal hollow. A modification of this tech-
Dissection is then carried forward to the nasolabial fold in nique by Sherris66 is performed by extending the transfer into
the subcutaneous plane using large Metzenbaum or rhytidec- the midregion of the upper and lower lips to reduce stretching
tomy scissors. The external incisions are made at or just medial and thinning of the lips over time.
to the nasolabial fold, the lateral oral commissure, and the Several modifications of the temporalis transfer have been
vermilion cutaneous junction of the lower lip. Each of these reported in attempts to avoid folding of the temporalis muscle
incisions is connected to the cheek tunnel to allow transfer of over the zygomatic arch. Labb and Huault describe partial
the masseter muscle; the muscle may be divided into three slips inferior mobilization of the temporalis muscle from the skull
for attachment at these sites, or the entire periosteal end of the by elevation of the posterior and superior attachments of the
muscle may be used to suture the remnants of the orbicularis muscle.67 The coronoid attachments of the muscle are detached,
oris muscle from the lateral upper lip to the commissure and the muscle is inferiorly mobilized toward the upper lip.
and below. These muscle slips are sutured to the dermis and The coronoid insertion of the inferiorly displaced muscle is
the orbicularis oris muscle using 3-0 clear nylon sutures. The secured to the perioral musculature.
best results depend on gross overcorrection with hypereleva- Although the gold weightcanthoplasty technique is often
tion of the oral commissure, preservation of masseteric nerve preferred, the temporalis muscle can be used for orbital reha-
supply, secure suture stabilization of the transposed muscle, bilitation. The anterior third of the temporalis muscle is turned
supportive tape dressing to maintain overcorrection of the oral laterally into the eyelids (see Fig. 172-8). Subcutaneous tunnel
commissure, and nasogastric feedings to minimize masseteric dissection between the paralyzed orbicularis oculi and the
movement. eyelid skin allows passage of the fascial strips medially through
Results from the masseteric procedure are quite gratifying both eyelids to the medial canthus, where they are sutured. As
and usually yield a high degree of facial symmetry. However, with any reconstructive procedure, adjustments and suture revi-
the masseters arc of rotation will not allow for rehabilitation sions should be checked carefully on the operating table to
around the orbit. For this reason, the temporalis transfer can ensure proper eyelid contour.
be combined with masseter transfer, or the reanimation of the With both masseter and temporalis transfer, facial muscle
orbital region can be approached separately with such proce- activation originates from the trigeminal nerve. Patients
dures as canthoplasty and gold weighting. need to learnthrough videotape, biofeedback, or similar
A B
C D
E F G
FIGURE 172-7. Masseter transfer procedure. A to D, Schematic depiction of key surgical principles. A, Intraoral approach to masseter. The procedure is
more difficult when performed in this manner; an external approach is preferred. B, Correct incisions in muscle and periosteum. Periosteum must be incor-
porated in the lower portion of the muscle flap to leave the tissue secure for suturing to the lip region. C and D, The entire muscle, rather than only anterior
elements, is transposed so that the masseteric nerve supply is transferred intact with the muscle belly. E to G, Use of intraoral masseter transfer for correction
of complete left peripheral facial paralysis in an elderly woman. E, Note severe brow ptosis, medial tarsorrhaphy, and severe redundancy of cheek, paranasal,
and lateral lip tissues on the left. F, Intraoperative photograph shows intraoral masseter transfer. Large Kelly clamp is used to grasp the inferior portion of the
masseter, which will be passed through the cheek tissues to a nasolabial fold incision (see A through D). G, Photograph taken after browlift procedure (tarsor-
rhaphy has been left for eye safety). Masseter transfer has successfully raised the corner of the mouth and the nasolabial fold. The patient declined further
excision of the nasolabial fold for improved cosmesis.
A B
C D
FIGURE 172-8. Temporalis muscle transposition. A, Dotted line illustrates the incision in the pericranium peripheral to the edge of the muscle. This results
in strong periosteum to hold sutures in the transposed position. Nerve supply on the deep side of the muscle is not shown. B, Temporalis muscle divided into
four slips. Note pericranium at the end of the slips sutured to the muscle to reinforce the suture site. Temporal fascia superficial to the muscle can be used
in the same way. C, Transposed slips sutured to perioral muscles. Creativity and compulsivity are crucial during this portion of procedure, and overcorrection
is mandatory. Sutures (A) must be placed in the subdermis inferior to the incision or in the submucosal portion of the wound deep to the orbicularis oris
muscle. D, Completed procedure. Wide tunnel over the zygomatic arch precludes an unsightly bulge of muscle that would otherwise be produced. Superior
pull of the temporalis muscle is somewhat preferred to posterolateral pull of the masseter muscle (see Fig. 172-7).
methodsthe proper way to contract the muscles by chewing segmental contractions, such as for superior elevation of the
or biting. Some younger patients may actually learn how to oral commissure. In patients with absence of facial muscula-
incorporate these movements into their own facial expressions ture, such as those with the congenital paralysis observed in
(e.g., smiles, grimaces). However, patients should be told pre- Mbius syndrome, microneurovascular muscle transfer has
operatively that muscle transfer procedures will not allow any strong potential.
emotional or involuntary reanimation. When performed in the A number of muscles and their respective nerve supply have
best hands, these techniques provide symmetry and tone in been used for microneurovascular transfers. The most popular
repose, with some learned and induced movements on muscles include the gracilis, latissimus dorsi, and pectoralis
attempted chewing. minor muscle flaps.69 The proximal stump of the ipsilateral
facial nerve may be used in selected cases, but this typically is
MICRONEUROVASCULAR not possible. Rather, reinnervation can be accomplished in two
stages; a preliminary cross-face nerve graft is performed
MUSCLE TRANSFER approximately 1 year prior to muscle transfer, and neural
Microneurovascular muscle transfer for smile reanimation was ingrowth within the nerve graft is monitored by recording pro-
introduced in the 1970s and has been combined with cross-face gression of the Tinel sign along the grafts path. When rein-
nerve grafting to restore some facial movement.68 Because nervation has occurred, typically 9 months after the cross-face
facial movements are highly complex and interrelated, enthu- nerve graft, microvascular muscle transfer is then performed.
siasm for free muscle transfer was stimulated by the potential This technique has several advantages that include the produc-
to use muscles that may provide isolated or independent tion of an emotive smile and the avoidance of the morbidity
associated with ipsilateral masseteric nerve dissection. Nonethe- immediately from static suspension of the nasal ala. Success
less, the two-stage method is less reliable when compared with depends on mastery of several techniques and selective applica-
one-stage procedures. One likely contribution to the lower tion using sound clinical judgment. Static suspension relies on
success rate in two-stage procedures is the need for two neural elevation and positioning the soft tissues of the oral commissure
coaptation sites. or nasal ala (or both), most commonly by attaching graft materi-
Single-stage procedures that use long neurovascular pedi- als, which are elevated and secured to the deep temporal fascia.
cles connected directly to the contralateral facial nerve have Several major benefits arise from the use of static slings. First,
been described.70-73 One comparison study found favorable out- facial symmetry at rest can be achieved immediately. Second,
comes with the one-stage reconstruction compared with the excellent control of problems associated with ptosis of the oral
more traditional two-stage reconstruction, but this study was commissure (e.g., drooling, disarticulation with air escape, dif-
limited by its sample size and subjective outcomes assessment.73 ficulty with mastication) is achieved. Finally, nasal obstruction
Muscle preservation using implantable intramuscular stimula- caused by alar soft tissue collapse can be dramatically relieved
tors is under investigation and may allow preservation of facial by resuspension and fixation of the nasal alar complex.
muscles while reinnervation occurs.74 This technique also shows Several materials have been used for static suspension. The
promise in management of peripheral nerve injuries, and most common have been fascia lata75 and acellular human
exploratory studies on the facial nerve have been initiated. dermis (Alloderm).79,80 In the past, expanded polytetrafluoro-
When facial nerve input is not available, alternative nerves ethylene (i.e., Gore-Tex) has been used more frequently.81 The
can be used for input and include the masseteric branch of V3, acellular dermis preparation and polytetrafluoroethylene have
ansa hypoglossi, or hypoglossal nerve.69,75 Innervation of the the advantage of avoiding donor-site morbidity, but use of
flap using the ipsilateral masseteric branch of V3 can result in foreign materials carries a small risk of infection, which is of
higher success rates when compared with the cross-face nerve greater concern in patients undergoing radiation therapy. The
graft, and in one study, it has been demonstrated to result in use of fascia lata requires an incision along the lateral aspect
greater excursion with smile when compared with flaps inner- of the leg, and it can result in mild cosmetic deformity but is
vated via a cross-face nerve graft.4 The donor nerve can be iden- typically well-tolerated in patients. The harvest itself is typically
tified consistently within the masseteric muscle approximately rapid, and patients are able to ambulate immediately after
7 to 11mm anterior to the articular tubercle.76 Composite tissue operation.
allograft procedures have gained considerable interest over the
last 10 years. Devauchelle77 and Dubernard78 and their col-
leagues detailed the preliminary functional improvements of
STATIC FACIAL SLING
the first human partial face transplant: the return of light touch, The suspensory implant can be placed through a preauricular
heat and cold perception, and mouth closure. These functional or temporal incision. In patients with a well-developed contra-
milestones were obtained by 10 months postoperatively; a lateral nasolabial fold, a nasolabial incision may be used instead.
normal smile was observed at 18 months. As with all tissue trans- Additional incisions are made at the vermilion border of the
plantation, however, immunosuppression is an essential adjunct upper and lower lips, adjacent to the commissure. A subcutane-
and is not without consequence. After transplantation, the ous dissection plane is created to connect the temporal region
patient suffered two episodes of acute rejection, two infectious to the oral commissure. In selected patients with nasal alar col-
complications (type 1 herpes simplex virus infection and mol- lapse and nasal obstruction from soft tissue ptosis, the dissec-
luscum contagiosum), renal failure, moderate thrombotic tion is extended to include the midface immediately adjacent
microanigiopathy, and hemolytic anemia. These preliminary to the nasal ala. A single strip of implant material is adequate
findings reveal a new dimension of reconstructive surgery and for the procedure. This is cut to appropriate size and can be
also underscore the inherent benefits of native tissues in facial split near the end to include slips for attachment to the upper
reconstruction. and the lower lips. Alternatively, separate slips of tissue approxi-
Significant advances in microvascular techniques and one- mately 1cm in width may be used to permit more individual-
stage microneurovascular facial rehabilitation have greatly ized manipulation of the midface. Permanent sutures are
improved the functional outcome for appropriately selected placed to secure the implant to the modiolus and deep dermis.
patients. These techniques are complex and require expertise Resorbable sutures are placed in the deep dermis to secure the
in both microvascular techniques and facial reconstruction. In material just medial to the proposed nasolabial fold, and similar
general, patients with absent distal facial nerve fibers or intact fixation is performed for a strip to the ala if desired. The sling
facial musculature who are motivated to attain dynamic func- is then suspended and secured with permanent suture to the
tion are potential candidates for these procedures. It is impor- deep layer of temporalis fascia or to the periosteum of the
tant for the clinician to understand that assessment of outcomes zygoma or zygomatic arch. If fascia lata or acellular human
following free gracilis transfer is challenging, and improved dermis is used, overcorrection of the smile is achieved before
excursion does not necessarily imply improved quality of life or fixation. Current interest has been developed in the suspension
patient satisfaction. Nonetheless, until more reliable patient- of implant materials along the nasolabial fold with suture
reported outcome measures become available for assessment anchoring to the deep temporal fascia.82 In similar fashion,
of facial function, anatomic assessments will have to suffice. mimicking of the contralateral crease is achieved through
suture tension along various points.
STATIC PROCEDURES
Although reinnervation techniques and dynamic slings (mus-
ADJUNCTIVE PROCEDURES
cular transfers) generally provide the best functional outcomes, A number of adjunctive procedures are available to fine-tune
a number of static procedures still constitute an appropriate the results in patients undergoing facial rehabilitative proce-
option for selected patients. Use of static techniques is indicated dures. Optimizing the care of patients with facial paralysis
in debilitated persons with poor prognosis for survival and in requires a full range of techniques in the surgical armamen-
those for whom nerve or muscle is not available for dynamic tarium. Although reinnervation techniques and measures to
procedures. The primary benefit of static procedures is immedi- protect the eye take precedence, a number of options allow
ate restoration of symmetry in the midface. Additionally, fine-tuning of results for the patient with facial paralysis. These
patients with external nasal valve collapse often benefit can be broadly subdivided into procedures to rehabilitate the
upper, middle, and lower thirds of the face. Finally, synkinesis PROCEDURES FOR THE MIDDLE
can be a major concern, and treatment options for synkinesis
are also available, such as chemodenervation and gracilis free
THIRD OF THE FACE
tissue transfer.83 The middle third of the face is most commonly rehabilitated
using reinnervation techniques, dynamic slings, or static slings.
A number of additional procedures are available to fine-tune
PROCEDURES FOR THE UPPER THIRD the results obtained with these procedures, and selection of the
appropriate procedures is determined by both the defect and
OF THE FACE the desires of the patient.
Paralysis of the upper third of the face produces significant Nasal obstruction after facial paralysis can occur because of
functional and cosmetic deformities. Brow ptosis may cause collapse of the alar sidewall from adjacent soft tissue ptosis and
superior visual field deficits as well significant facial asymmetry. loss of intrinsic dilator naris tone. As described, a properly
This asymmetry may be further accentuated after procedures designed static sling may alleviate this problem. Alar batten
to address the lower face. Browlift techniques to manage para- grafting also may provide relief.
lytic ptosis are the same as for a cosmetic browlift, the only Midface soft tissue laxity and sagging, characteristic of the
significant technical difference being exercise of restraint to aging midface, is abnormally pronounced in the paralyzed face.
avoid further compromise of eyelid closure. Direct, midfore- In older patients with significant skin laxity, performing a face-
head, endoscopic, and indirect browlifts are all effective. When lift enhances the results of other treatments for midface defor-
not overdone, a browlift in conjunction with lid loading and/ mity. Facelifts can be performed concurrently with other
or lower eyelid tightening generally produces satisfactory cos- procedures, whether dynamic or static, and some patients will
metic and functional results. Brow ptosis associated with normal benefit from and will prefer a bilateral facelift (Fig. 172-9).
aging may be accentuated unnaturally by a unilateral lift, and Like the aging patient, the patient with facial paralysis
in older patients, improved results are seen when bilateral acquires ptotic palpebral-malar and nasojugal sulci, which
browlifts are performed.84 produces a hollowed-out appearance to these areas. The
Many patients with facial paralysis, particularly older persons, lower eyelid fat may bulge, and the suborbicularis oculi fat
will express interest in additional adjunctive procedures in the (SOOF) and midface complex descend and produce a double
periocular region. In patients with excessive redundant eyelid convexity sign on lateral view. In the youthful patient, the
skin, conservative blepharoplasty can decrease superior visual SOOF typically lies at the inferior orbital rim between the orbi-
field defects while cosmetically addressing brow ptosis and cularis oculi muscle and the periosteum. The midface lift repo-
excessive tissue folds. Extreme caution is necessary in perform- sitions the SOOF and associated midface soft tissue superior to
ing blepharoplasty in conjunction with browlift procedures, its preexisting position. The lift has become a popular tech-
and the risk of further impairing eye closure mandates a con- nique in facial rejuvenation surgery, and it also has shown utility
servative approach. A maneuver to help assess the amount of in the treatment of facial paralysis. The midface lift can be
skin to be safely removed consists of manually holding the para- performed through a transconjunctival incision with a lateral
lyzed brow in the normal position with observation for impair- canthotomy and inferior cantholysis. The periosteum is incised
ment of eyelid closure. Similarly, it also is helpful to pinch near the orbital rim and is elevated down to the inferior maxilla,
together the excessive eyelid skin to be resected while holding where it is released; it also is important to release the attach-
the brow superiorly and observing its effect on eye closure. ment to the masseter muscle, and care should be taken to avoid
A B
FIGURE 172-9. Result with static rehabilitation techniques in a patient with right facial paralysis: Preoperative (A) and postoperative (B) photographs. Patient
underwent direct browlift, lateral transorbital canthopexy, alloderm facial sling repair, and gold weight placement.
injury to the infraorbital nerve. The periosteum and overlying

soft tissue are then elevated and secured superiorly to the deep
MANAGEMENT OF SYNKINESIS
temporal fascia. Patients with incomplete recovery from facial paralysis typically
are troubled by both weakness and hyperkinesis, or synkinesis,
which develops in many patients after facial paralysis of any
PROCEDURES FOR THE LOWER cause. These uncoordinated mass movements may begin within
weeks after paralysis as regeneration occurs. Although the
THIRD OF THE FACE classic description of synkinesis places the etiologic mechanism
The functional deficits with paralysis of the lower face are domi- in aberrant axonal regeneration, it is now known that the sites
nated by manifestations of oral incompetence. Drooling, air of pathology are multiple. Synaptic stripping also occurs in the
escape with speech, and difficulty with mastication may be facial nucleus of the brainstem, and ephaptic (nonsynaptic)
present. The asymmetry also produces a significant esthetic transmission among axons contributes to synkinesis. Future
deformity, which is due to the lack of a smile (loss of zygomati- efforts to prevent or treat synkinesis will require addressing
cus function) as well as the lack of depressor anguli oris (mar- each of these areas. Synkinesis ranges in severity from a mild,
ginal mandibular nerve) function. These defects can be barely noticeable tic to painful and debilitating mass facial
worsened by performance of static procedures on the middle movements.
third of the face, which can produce a troublesome gap in the Careful assessment of each region of the face is performed.
region of the commissure from elevation of the upper lip. It is essential to identify the patients most troublesome symp-
Reinnervation, free tissue transfer, dynamic slings, and to toms and then determine which symptoms result from
some degree even static slings assist in repositioning the oral decreased function and which are from synkinesis. The treat-
commissure to re-create a more symmetric smile. The asym- ment plan can then be individualized to address the patients
metry of depressor function, the so-called marginal mandibu- needs. Traditionally, neurolysis has been a mainstay in the man-
lar lip, is more troublesome and difficult to improve. The most agement of synkinesis, but it has been largely abandoned as
commonly used procedures are wedge resection and transposi- safer and more conservative, yet effective, techniques have
tion of the posterior belly of the digastric muscle. The wedge evolved. Such techniques include chemodenervation with botu-
resection, with or without supplemental cheiloplasty tech- linum A toxin injections and selective myectomies to target
nique to improve symmetry and oral competence, has been affected muscles.
described by Glenn and Goode.85 A 2- to 2.5-cm full-thickness
excision is performed 7 to 10mm lateral to the commissure Botulinum A Toxin
(Fig. 172-10). Botulinum A toxin is the most potent poison known to human-
The most common dynamic technique for depressor dys- kind, yet it has been used effectively for more than two decades
function is the digastric transposition, first described by Conley to treat a variety of hyperfunctional disorders including torti-
and colleagues.86 The digastric tendon is identified using a collis,55 blepharospasm,88 spasmodic dysphonia,89 strabismus,90
submandibular approach. It is released from the hyoid bone, hyperhidrosis,91 hyperdynamic skin creases,92 palatal myoclo-
transected near the mastoid tip, transposed superiorly, and nus,93 hemifacial spasm,94 and facial synkinesis.95,96 Botulinum
attached to the orbicularis oris through a separate vermilion toxin causes paralysis by blocking the presynaptic release of
border incision. Care is taken to preserve the mylohyoid nerve acetylcholine at the neuromuscular junction. This typically
that innervates the anterior belly of the digastric muscle. results in paralysis of the treated muscle for approximately 3 to
However, the anterior belly of the digastric muscle may not be 6 months. Systemic weakness can occur with doses greater than
available after extirpative cancer surgery.87 200U, and the lethal dose is approximately 40U/kg.97
Botulinum toxin has dramatically improved the manage-
ment of patients with facial movement disorders. It is now a
first-line agent for treatment of facial synkinesis. In most people,
surgical treatment is not necessary or desired. Synkinesis after
facial nerve injury can occur in any region of the face, and
botulinum toxin can be used to denervate specific muscle
groups. The location of the injections is targeted to the muscles
causing synkinesis. Typically, 1 to 5U is injected per site. Initial
treatments use conservative doses, which subsequently can be
titrated upward. No anesthesia is generally necessary, but many
patients prefer pretreatment of the area with ice or a topical
anesthetic. Drug effects are first seen several days after the
A B injection, with a maximal effect observed at 5 to 7 days. Addi-
tional toxin can be injected after this time if the initial effect is
insufficient.
Adverse effects can occur that are related to the diffusion of
toxin into surrounding muscles. An example is the develop-
ment of ptosis after periocular injection. This problem is
uncommon and occurs in less than 5% of cases. It can be treated
C D with apraclonidine 0.5% drops administered to the affected eye
three or four times a day until the ptosis resolves.98 Apracloni-
FIGURE 172-10. Lip wedge excision and cheiloplasty. A, Outline of inci- dine causes contraction of the Mller muscle to elevate the
sions for lip wedge excision. Excision tightens the lower lip and removes part upper eyelid. Other complications from botulinum toxin treat-
of the denervated muscle. B, Appearance after lip resection. Note the inten-
tional asymmetry of vermilion border during closure to evert the lower lip.
ment of the face include diplopia, further impairment of eyelid
C, Outline of incisions for cheiloplasty. D, Appearance of cheiloplasty after closure, lower eyelid ectropion, brow ptosis, and drooling.
resection. Note lowering and outward rotation of the lower lip. (Modified In some patients, the effectiveness of botulinum toxin
from Glenn MG, Goode RL. Surgical treatment of the marginal mandibular lip decreases over time. This diminishing effect may be the result
deformity. Otolaryngol Head Neck Surg 1987;97:464-465.) of resprouting of motor endplates or the development of
neutralizing antibodies and cannot be overcome with increased Borodic GE, Pearce LB, Cheney M, et al: Botulinum A toxin for treat-
doses of the toxin.99 Patients who do not benefit from botuli- ment of aberrant facial nerve regeneration. Plast Reconstr Surg 91:
num toxin treatments or who demonstrate the development of 1042, 1993.
resistance, or those who desire a more permanent solution, may Clark JM, Shockley W: Management of reanimation of the paralyzed
face. In Papel I, Larrabee W, Holt G, et al, editors: Facial plastic and
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Rehabilitation of Facial Paralysis 172

James M. Ridgway | Prabhat K. Bhama | Jason H. Kim

musculature. The surgeon must also thoroughly assess the

Tumor ablation with facial nerve sacrifice (e.g., radical

considerable importance in the planning for the overall needs

1 cm considered for transposition into the facial muscle system.

EYE PROTECTION: EVALUATION AND

Superior division Zygomatic muscle

Hypoglossal nerve Buccal branch

facial anastomosis also is preferable to muscle transposition.

injury to the infraorbital nerve. The periosteum and overlying

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