Center for Facial Nerve Disorders

Early Options
(Under two years since injury)

• Direct nerve repair
  If a facial nerve is injured by a sharp force due to trauma, it may be repaired directly to itself. Direct nerve repair is the most successful and simplest method of facial nerve repair.
• Cable or interposition grafting
  In a situation where there is a segment of nerve missing, such as in tumor surgery or severe traumatic injury, a donor nerve must be brought in to connect the gap between the separate ends of the facial nerve. Cable or interposition grafting results in meaningful improvements of facial function.
• Nerve transposition
  In situations where facial movement can no longer be powered by the patient’s brain telling the face to move, whereas the nerve segment closest to the brain is missing, alternate nerves can be chosen to power the facial musculature. In these situations, we use another nerve to power the facial muscles such as the masseteric nerve (cranial nerve V), the hypoglossal nerve (cranial nerve XII) or the facial nerve on the other side of the face (cranial nerve VII), otherwise known as a cross facial nerve graft.
• Masseter to facial nerve transposition (V-VII)
  In the V-VII procedure, the facial nerve is attached to a nerve that powers a muscle of the jaw, the nerve to the masseter or cranial nerve V, to recover facial movement. The advantages of this procedure are a strong smile and some improvement of facial tone.
• Hypoglossal to facial nerve transposition (XII-VII)
  The XII-VII procedure has been used for many years to offer recovery to patients suffering from facial paralysis. The facial nerve is attached to part of the hypoglossal nerve (cranial nerve XII), the main motor nerve to the tongue, to power the facial musculature. The advantages of the XII-VII are a nice return of facial tone with some directed movement and for many, a good smile.
• Cross face nerve grafting
  The facial nerve on the normal side can be used to improve the function of the reanimated side or to power other nerve grafts or flaps such as in the gracilis free tissue transfer.
• Dual Innervation Techniques
  Some of the newer procedures for facial reanimation involve the use of multiple nerves for improvement of facial function. Our highly trained surgeons are now performing procedures utilizing both the nerve to the masseter or cranial nerve V with the hypoglossal nerve, or cranial nerve XII. Our early outcomes offer improvements in both smile and overall facial tone.

(Greater than two years since injury)

Muscle transposition:

• Free Tissue Transfer
  Gracilis free tissue transfer is used in our patients with longer standing facial paralysis. In this situation, the muscles of the face are no longer viable and outside muscle must be transplanted. The gracilis muscle is harvested from the inner thigh, with its corresponding nerve, and transplanted to the face to allow for reanimation of the smile.
• Temporalis muscle
  The temporalis muscle may be used in multiple ways to reanimate the paralyzed face. It has replaced the use of the masseter muscle as a regional option to facial reanimation for a couple of reasons, most notably the direction of pull of the temporalis muscle more closely mimics the muscles used when smiling. The temporalis muscle can be used as a dynamic option for the paralyzed eye as well as the mouth and smile. More recently, the orthodromic temporalis tendon transfer is performed with great success when a patient is not a candidate for a more formal nerve transposition but would like some reanimation options.

Static Adjunct Procedures:

• Static Sling
  Static support of the facial tissues can be performed with several different materials. Often a tendon from the outer thigh may be used, fascia lata, to support the corner of the mouth and nose. Less frequently, gortex or alloderm (cadaveric dermis) may be used as well. This procedure will not offer motion, hence the word static, however, can benefit our older population unable to go through a larger nerve surgery.
• Platinum weight insertion
  For the paralyzed eye struggling with protection and lubrication following facial paralysis, a platinum weight may be inserted within the upper eyelid. Platinum is now used over the previously popular gold weight as platinum is 11% denser allowing for a physically smaller weight resulting in less risk of extrusion.
• Lid tightening procedures
  The lower eyelid may suffer from laxity related to facial paralysis. The lower lid may hang forward and down, also called an ectropion, resulting in tear collection and complaints of a watery eye. Tightening of the lower lid may offer improved comfort, also reducing watering and dryness.
• Facelift/midface lift
  Our patients with a severe facial droop may benefit from a facelift on the affected side to re-support the soft tissues of the paralyzed face.
• Cheiloplasty
  Support of the lower lip in facial paralysis can be problematic. There are a couple of main procedures we can perform to improve symmetry such as a wedge resection of the lower lip as well as a cheiloplasty. Often balancing these procedures with botulinum toxin on the nonparalyzed side is most beneficial.

Selective Neurolysis:
While recovery from facial paralysis is always welcome, there are times when recovery can be incomplete or abnormal. Selective neurolysis is a newer procedure, pioneered within the last five years, that can be used as a more permanent solution to abnormal facial nerve recovery in the synkinetic patient and can decrease botulinum toxin requirements. The surgery involves exposing and cutting multiple small branches of the facial nerve to individual muscles of the face. This procedure is ideal for a select group of patients with a unique constellation of facial spasticity.

Depressor Anguli Oris or DAO resection:
In the synkinetic patient, tightness and spasticity of the muscle that depresses the corner of the mouth, the DAO, may reduce smile symmetry. In a select group of patients, we can create an incision on the inside of the mouth, directly releasing and removing a section of the depressor anguli oris muscle, improving smile symmetry.

Myectomy of the Platysma Muscle:
Spasm and tightness of a large neck muscle innervated by the facial nerve, the platysma, can cause significant discomfort and distort smile symmetry. Although well treated by botulinum toxin, direct excision of a strip of the muscle can be performed through a neck incision.

The Center for Facial Nerve Disorders is staffed by specialty-trained physical therapists dedicated to facial nerve recovery and retraining. The return of facial nerve function can be unpredictable and can result in poorly coordinated facial motion. Facial physical therapy is essential for the treatment of synkinesis and hemifacial spasm. Our therapists work closely with our facial plastic surgeon to optimize facial function by coordinating stretches and exercises, biofeedback and chemodenervation such as with botulinum toxin.

Chemodenervation with botulinum toxin
The return of facial nerve function and muscular activity can be uncertain. At times the facial muscles can become hyperfunctional, impairing meaningful motion such as smiling. Botulinum toxin may be used to reduce muscular function that may inhibit desired motion (smiling, eye closure). Chemodenervation may also be used to balance the facial appearance and enhance symmetry.