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Facial reanimations: part II—long-standing paralyses
YBJOM-4566; No. of Pages 6
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Facial reanimations: part II—long-standing paralyses Federico Biglioli ∗ Head of Maxillo-Facial Surgery Unit, San Paolo University Hospital, Milan Accepted 1 July 2015
Abstract Long-standing facial paralyses are those in which fibroadipose metaplasia of mimetic musculature has grown because of the time that has lapsed since the onset of the palsy: generally more than 18-24 months. Unlike the treatment of recent paralyses, to provide a neural input to reactivate the mimetic musculature is not enough. New healthy muscles must be transferred to the face. Operations may be subdivided into free-flap transplantations or masticatory muscle transpositions. The principles of treatment are correction of the asymmetry of the face by static means, and restoration of movements. Static correction of ptosis is achieved by deep-lifting, suspensions of fascia lata, and other procedures. Among movements, most efforts are concentrated on the restitution of smiling and closure of the eyelids. One of several techniques may be chosen after careful examination of the patient and paying close attention to their needs and expectations. Closure of the eyelids is generally achieved by a transposition of a double-belly temporalis flap or implantation of a gold/titanium lid plate. Other procedures are less used. Restoration of blinking remains impossible in most cases. The most popular techniques to restore smiling are rotation of a temporalis flap and transfer of a gracilis free flap with double innervation: both pros and cons must be considered. Surgery of the lower lip palsy is mainly based on limiting evident dragging upwards during smiling, because depressor function is difficult to achieve. Symmetry may also be reached by paralysing the lower lip on the other side. Movement of the forehead is a neglected area: reconstruction is possible, although the extent required seems disproportionate to the deficit. The need for ancillary surgery must be stressed. Only rarely are optimal results achieved without further fine-tuning of details. © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Facial palsy; Facial reanimation; Facial nerve
Introduction In patients with long-standing facial paralyses, the mimetic musculature is irreversibly atrophic and fibroadipose metaplasia is evident because of the passage of time between the onset of paralysis and the first consultation. Careful electromyography (EMG) can show when this point is reached, as no muscular fibrillations can be detected in patients with established fibrosis. The time to atrophy varies, but is generally between 18 and 24 months. The duration may be ∗ Unità Operativa di Chirurgia Maxillo-Facciale, Ospedale San Paolo, Via A. di Rudinì 8, 20142 Milano, Italy Tel.: +39 (0)2 8184 4143; fax: +39 (0)2 5032 3106. E-mail address: [email protected]
less if the surgical field is poorly vascularised, and if there has been previous irradiation or recurrent paralysis. Consequently many such paralyses are caused by late referral to a reconstructive surgeon, although some delays are attributable to patients’ fear of operation, and clinical conditions such as coma, and progression of congenital or developmental paralyses.1 Rarely, muscles do not atrophy even after many years, probably because there is still some low-level neural stimulation. Such stimulation is inadequate to maintain resting tone in the mimetic musculature, or to trigger any visible movement, but complete muscle atrophy is avoided. In such cases fibrillations are detected on EMG and facial reanimation by new neural stimulation (as in cases of recent paralyses) can be attempted, but the results are generally discouraging.
http://dx.doi.org/10.1016/j.bjoms.2015.07.001 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Biglioli F. Facial reanimations: part II—long-standing paralyses. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.07.001
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Table 1 Reanimation after long-standing hemifacial paralysis. Eye
Midface
Older patients
Temporalis flap/lid plate
Younger patients
No procedure if no particular disturbance evident Cross-face graft + platysma if corneal soreness is a problem. Lid plate Cross-face graft + platisma lip plate / cross-face graft + platysma
Temporalis flap/gracilis flap with double innervation Gracilis flap with double innervation
Patient requires an immediate outcome Patient requires the best possible outcome Deficit or possible future deficit of the fifth nerve Deficit or possible future deficit of the contralateral seventh nerve Paresis /little movement An urgent need to protect the cornea
Temporalis flap/lid plate Lid plate / cross-face nerve graft with end-to-side distal neurorrhaphy Lid weight placed under local anesthesia/temporary tarsorrhaphy
Temporalis flap Gracilis flap with double innervation One-time latissimus dorsi flap / cross face graft + free flap Gracilis innervated by the masseteric n./temporalis flap One-time latissimus dorsi flap
All treatments should be complemented by ancillary operations to correct positions of eyebrows, lids, the nasolabial fold, and lips, and to reduce the bulk of free flaps and reorientate such flaps.
The importance of re-establishing facial symmetry at rest is the main target. Usually, when we look at others mimicry is not activated, so resolution of the paralytic ptosis of the soft tissue greatly improves patients’ self-confidence. Static correction of asymmetry, however, only partially removes the signs of the condition, and should not be allowed to bias the entire treatment. Facial reanimation means restoration of facial movements, of course, and is achieved by transposing healthy musculature into the affected hemiface together with new neural input.2 Simple reactivation of the facial nerve, as in instances of recent paralysis, is insufficient. Fibroadipose metaplasia of the mimetic musculature has destroyed muscular function. The trunk of the ipsilateral facial nerve should not be used as a motor source even if it is surgically available preoperatively (generally, this is not the case). Axonal sprouting caused by a neural lesion decreases over time and cannot be guaranteed after 18-24 months. At present it is not technically possible to replace all mimetic muscles. Loss of the ability to close the eyelids is the biggest problem, as it potentially threatens the vision. Smiling is the most important form of social communication imparted by the face; loss of the ability to smile triggers reactive depression.3 Consequently, replacement of these 2 movements is the appropriate target of reanimation of paralysis of long standing. This is obviously less than what is attainable by reanimating the entire mimetic musculature when treating recent paralysis. Another way to look at the problem is to damage some branches of the contralateral facial nerve selectively (by botulinum toxin injections, selective neurectomies, and myectomies) to improve symmetry, both from static and a dynamic points of view. This is acceptable but should be limited to final refinements, when maximal attempts to recover facial movements of the paralysed hemiface have been made. Specific physiotherapy may also teach the patients how to reduce mimetic movements on the healthy side to improve dynamic symmetry.
Movements of the forehead and lower lip are often neglected, and reconstruction is possible although the extent required may seem disproportionate to the deficits being addressed. These problems are most commonly faced using static procedures or by production of paralysis on the other side to render the face symmetrical during execution of a specific movement. Paralysis of the platysma is generally considered less important than that of the forehead and lower lip, and no attempt is made to reanimate a paralysed platysma. On the contrary, platysmal spasm is often treated, which arises most commonly after incomplete recovery from Bell’s palsy. Part of the platysma is removed or the tissue is completely paralysed in one of several ways.4 Multiple operations have been described, but none is better than the others for all cases. A wide range of techniques helps the surgeon to choose the most appropriate one for each patient and for different circumstances (Table 1).
Midface reanimation Midface ptosis may be corrected by lifting the soft tissues; the more extensive procedures afford the most reliable long-term results.5,6 Several forms of suspension have been proved to be effective, fascia lata grafts being the most popular. The use of alloplastic materials is not advisable, because the outcomes are unstable and the infection rates high. Such materials can extrude to create an unnatural appearance, and become visible under the skin.7 Dynamic procedures seek to recover smiling, but generally also have the effect of lifting soft tissues, so correcting the ptosis. The most reliable dynamic procedure that affords such adjunctive static effects is transposition of a temporalis flap. Many techniques have been devised to reanimate the hemiface of patients affected by long-standing facial paralysis, which may be divided into 2 groups: free-flap transplantations
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and transpositions of masticatory muscles. However, masseter muscle rotation has been almost completely abandoned because the aesthetic outcomes were poor; the temporalis muscle is now used extensively. Rotation of a temporalis flap The temporalis muscle is innervated by the V cranial nerve, so after it has been ensured that trigeminal function is intact, and any possible future impairment of the muscle by a progressive cerebral lesion has been excluded, the muscle may be used for facial reanimation. Many variants of transposition of the temporalis muscle to reanimate the midface have been described since the technique was first described in 1911 by Lexer and Eden.8–10 Developments in free-flap surgery today render such transpositions second-choice procedures. Over the last two decades, Labbè et al. have revitalised the use of the temporalis muscle to restore smiling.11 The relevant procedure, termed temporalis lengthening myoplasty, involves detaching the posterior two-thirds of the muscle from the temporalis fossa to enable anterior transposition of the lower tendon of the muscle, which is secured by stitches to the nasolabial sulcus. The new success of temporalis muscle transposition is associated with the fact that the procedure is easy and quick, and immediate correction of soft tissue ptosis is achieved with the simultaneous development of a certain amount of movement. Labbé et al. suggested that the temporalis fibres should be completely detached from the surrounding masticatory musculature to facilitate spontaneity during smiling, because cortical adaptation is in play.12 However, spontaneity is almost never evident when some hours are spent with patients; this is the principal drawback of the procedure. The extent of movement is also smaller than that achieved by transposition of a free flap, and fixing of the tendon to the nasolabial sulcus tends to be difficult unless some strips of fascia lata or the deep temporalis fascia are added to the lower tendon. The procedure is a good option when bilateral facial paralyses are to be treated; the operation is associated with low morbidity, particularly when compared with 2 free flap transpositions. Another good indication is for those with a lot of soft tissue ptosis who are willing to obtain a quick correction of the paralysis. Free flap surgery The advantages of free flaps rapidly became apparent after they were introduced in the 1970s. It is possible to use donor muscles that give high-level excursions during contraction (affording bigger smiles). Opportunities for placement are much greater than those of masticatory muscles. Spontaneous activation to express the “funny” emotion is possible when the free flaps are combined with cross-face nerve grafts. The available techniques must be distinguished in 2 ways to understand the various possibilities. These are one-stage compared with 2-stage procedures, and the use of a branch of
Fig. 1. Patient with long-standing facial paralysis. The middle third of the face was reanimated by gracilis muscle free flap transplantation with double innervation. The masseteric nerve guarantees good innervation, used during voluntary smiling. Cross-face nerve grafting mixes its axons with those of the masseteric nerve, which leads to free flap activation during emotional smiling (published with the patient’s permission).
the contralateral facial nerve compared with another motor nerve. One-stage procedures have the obvious advantage of lower morbidity and more rapid recovery.13,14 However, if the masseteric nerve is chosen as the motor source, as in gracilis transfer, no spontaneous smiling is possible.15 However, if the contralateral facial nerve is used (as in one-stage latissimus dorsi transfer) the extent of contraction of the flap may be slight because of partial loss of ingrowing axons along the collateral branches of the nerve. Two-stage procedures feature cross-face nerve grafting before free flap transplantation, to ensure the maximum neural input, 16–17 and this is the most popular procedure in use today. The disadvantages are: the results take time to appear, and there is physical and psychological morbidity associated with 2 operations. One attempt to merge the advantages of both procedures is gracilis transplantation accompanied by double innervation using the ipsilateral masseteric nerve to ensure contractile power and the contralateral facial nerve to trigger spontaneous smiling18,19 (Figs. 1–3, video 1-2). Currently, this seems to be the best method by which to restore smiling to patients paralysed for a long time. Presentations of paralysis vary. Several other neural deficits may be associated with functional lack of the VII nerve. The armamentarium of the reconstructive surgeon must be sufficiently broad to allow adaptation to specific circumstances. For example, if the contralateral facial nerve is inadequate, or if it may subsequently be impaired by progression of disease, it seems logical not to use a doubly-innervated gracilis flap, but rather a muscle flap innervated by the masseteric nerve, or a temporalis flap rotation. Instead, if the V
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Fig. 2. Postoperative good tone at rest of the operated hemi-face. Symmetry has been improved by adding simultaneously to free-flap surgery a deep lifting procedure according to Biglioli et al6 (published with the patient’s permission).
cranial nerve is impaired, it is logical to prefer a single-stage latissimus dorsi flap served by the contralateral facial nerve. Many ancillary procedures, generally done under local anaesthesia, are often necessary to improve the final results. The most common are refinements of the nasolabial sulcus, improvement of symmetry by placement of fascia lata grafts or minitemporalis flap rotation, contralateral botulinum toxin injections, and trimming or repositioning of a free flap.
Fig. 3. Postoperative symmetrical and natural appearance of the face during smiling (published with the patient’s permission).
open, so preoperatively sample plates must be temporarily tacked to the skin of the lid to define the correct weight for each individual patient. The disadvantages of the technique are: the need for the patient to remain vertical to allow the system to function effectively, the introduction of a foreign body into the upper lid (the weight may become extruded because soft tissue coverage is thin), the high visibility of standard plates through the skin, and frequent discomfort.
Closure of the eyelids The eye is lubricated by distributing the tear film over the cornea, principally by blinking. Voluntary closure of the eyelids improves lubrication if the eyes become sore. Blinking normally occurs 10-19 times/minute, varying for several reasons. Consequently, surgical restitution of closure of the eyelid corrects only part of the deficit. The 2 most commonly used methods are insertion of a lid weight and rotation of a temporalis flap8,20 (Figs. 4–6, video 3). These may improve the little residual blinking that is caused by the inhibitory reflex of the levator muscle of the lid, but neither of those techniques will really restore blinking. A lid plate moves the upper lid downwards, and the weight of the plate opposes the tone of the levator muscle of the lid at rest. However, the weight must not neutralise levator tone when the eyelids are
Fig. 4. Paralytic lagophthalmos as a result of long-standing facial paralysis (published with the patient’s permission).
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Fig. 5. Surgical correction by a double bellies temporalis flap rotation. The lower belly is tightened to the medial canthus in order to correct drooping of the lid. The upper belly is sutured with a soft tension to allow upper lid elevation during standard vision (published with the patient’s permission).
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teeth. When the temporalis muscle is not active, the eyelids remain open. To achieve this, the upper belly is placed under minimal tension. The lower belly is positioned under greater tension, which allows static vertical correction of ptosis of the lower eyelid. This method is not associated with extrusion because the translated tissue is autologous. Drawbacks may include visible bulkiness of the upper lid, and erroneous tensing of the 2 bellies leading to narrowing of the rim of the eyelid or an ectropion. Sometimes, eyelids still will not close because movement of the flap is insufficient. A temporalis flap may simultaneously restore smiling and closure of the eyelid. The operation is short and morbidity minimal. However, synkinesis is evident between eyelid closure and smiling. A two-stage procedure featuring cross-face nerve grafting followed by transplantation of platysma into the lid has been used in attempts to restore voluntary eyelid closure and blinking. The sural nerve is stimulated by a branch of the contralateral facial nerve orientated to the upper lid. Transfer of platysma may feature grafting or the use of a vascularised free flap.22 Although the idea is attractive, the results are unfortunately inconsistent and the method finds few applications. Many ancillary procedures are often required to improve the results or the static symmetry of the eyelids, or both.23,24 Lateral and medial canthoplasties, canthopexy, and ectropion correction are commonly required.
Conclusions
Fig. 6. Activation of the temporalis muscle drives the lids to close (published with the patient’s permission).
Several types of lid weight have been developed. Titanium plates have the advantage over gold plates of compatibility with magnetic resonance imaging, which is particularly important if a residual cerebral tumour requires continuous monitoring. Also, titanium is heavier than gold, which renders the profile of the plate less visible through the thin skin of the lid. However, individualised gold plates may be manufactured using eyeball casts; such plates are better tolerated because their curvatures are exactly those of the eyeballs. These plates are also wider than standard ones because the individual plaster casts allow this. They can therefore be relatively thin and so less visible through the skin. Static correction of lower lid ectropion is usually required as well. Several types of temporalis flaps have been developed to treat deficits in eyelid closure.21 The most commonly used type is the double-belly temporalis flap. The cranial part of the flap lowers the upper eyelid when the temporalis muscle is voluntarily activated by opposition of the
It remains impossible to correct long-standing facial paralysis completely. All current techniques have both advantages and disadvantages. Successful reanimation might feature gracilis free-flap transfer with double innervation to recover smiling, and double-belly temporalis rotation to re-establish closure of the eyelids. Many other procedures may be required depending on the specific circumstances, and the patient’s needs and expectations. Ancillary procedures should be offered in most cases to improve the results.
Conflict of Interest I have no conflict of interest.
Ethics statement/confirmation of patients’ permission The patients have given consent to publication.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j. bjoms.2015.07.001.
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References 1. Terzis JK, Anesti K. Developmental facial paralysis: a review. J Plast Reconstr Aesthet Surg 2011;64:1318–33. 2. Tate JR, Tollefson TT. Advances in facial reanimation. Curr Opin Otolaryngol Head Neck Surg 2006;14:242–8. 3. Fu L, Bundy C, Sadiq SA. Psychological distress in people with disfigurement from facial palsy. Eye (Lond) 2011;25:1322–6. 4. Laskawi R, Rohrbach S, Rödel R. Surgical and nonsurgical treatment options in patients with movement disorders of the platysma. J Oral Maxillofac Surg 2002;60:157–62. 5. Rubin LR, Simpson RL. The new deep plane face lift dissections versus the old superficial techniques: a comparison of neurologic complications. Plast Reconstr Surg 1996;97:e1461–5. 6. Biglioli F, Frigerio A, Autelitano L, et al. Deep-planes lift associated with free flap surgery for facial reanimation. J Craniomaxillofac Surg 2011;39:475–81. 7. Constantinides M1, Galli SK, Miller PJ. Complications of static facial suspensions with expanded polytetrafluoroethylene (ePTFE). Laryngoscope 2001;111:2114–21. 8. Lexer E, Eden R. About the surgical treatment of peripheral facial nerve palsy (in German). Beitrage zur Klinischen Chirurgie 1911;73:116 (as quoted in Google Scholar). 9. McLaughlin CR. Surgical support in permanent facial paralysis. Plast Reconstr Surg (1946) 1953;11:302–14. 10. Viterbo F, de Paula Faleiros HR. Orthodromic transposition of the temporal muscle for facial paralysis: made easy and better. J Craniofac Surg 2005;16:306–9. 11. Labbè D, Bussu F, Iodice A. A comprehensive approach to long-standing facial paralysis based on lengthening temporalis myoplasty. Acta Otorhinolaryngol Ital 2012;32:145–53. 12. Garmi R, Labbé D, Coskun O, et al. Lengthening temporalis myoplasty and brain plasticity: a functional magnetic resonance imaging study. Ann Chir Plast Esthet 2013;58:271–6. 13. Harii K, Asato H, Yoshimura K, et al. One-stage transfer of the latissimus dorsi muscle for reanimation of a paralyzed face: a new alternative. Plast Reconstr Surg 1998;102:941–51.
14. Biglioli F, Frigerio A, Rabbiosi D, et al. Single-stage facial reanimation in the surgical treatment of unilateral established facial paralysis. Plast Reconstr Surg 2009;124:124–33. 15. Faria JC1, Scopel GP, Busnardo FF, et al. Nerve sources for facial reanimation with muscle transplant in patients with unilateral facial palsy: clinical analysis of 3 techniques. Ann Plast Surg 2007;59: 87–91. 16. Vedung S, Hakelius L, Stålberg E. Cross-face nerve grafting followed by free muscle transplantation in young patients with long-standing facial paralysis. Reanimation of the cheek and the angle of the mouth. Scand J Plast Reconstr Surg 1984;18:201–8. 17. Frey M, Michaelidou M, Tzou CH, et al. Proven and innovative operative techniques for reanimation of the paralyzed face (in German). Handchir Mikrochir Plast Chir 2010;42:81–9. 18. Watanabe Y, Akizuki T, Ozawa T, et al. Dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer for re-animation of established facial paralysis: simultaneous reinnervation of the ipsilateral masseter motor nerve and the contralateral facial nerve to improve the quality of smile and emotional facial expressions. J Plast Reconstr Aesthet Surg 2009;62:1589–97. 19. Biglioli F, Colombo V, Tarabbia F, et al. Double innervation in free-flap surgery for long-standing facial paralysis. J Plast Reconstr Aesthet Surg 2012;65:1343–9. 20. May M. Gold weight and wire spring implants as alternatives to tarsorrhaphy. Arch Otolaryngol Head Neck Surg 1987;113:656–60. 21. Frey M, Giovanoli P, Tzou CH, et al. Dynamic reconstruction of eye closure by muscle transposition or functional muscle transplantation in facial palsy. Plast Reconstr Surg 2004;114:865–75. 22. Terzis JK, Bruno W. Outcomes with eye reanimation microsurgery. Facial Plast Surg 2002;18:101–12. 23. Allevi F, Fogagnolo P, Rossetti L, et al. Eyelid reanimation, neurotisation, and transplantation of the cornea in a patient with facial palsy. BMJ Case Rep 2014 Aug19. 24. Rose EH. Autogenous fascia lata grafts: clinical applications in reanimation of the totally or partially paralyzed face. J Plast Reconstr Aesthet Surg 2005;116:20–32.
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British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Facial reanimations: part II—long-standing paralyses Federico Biglioli ∗ Head of Maxillo-Facial Surgery Unit, San Paolo University Hospital, Milan Accepted 1 July 2015
Abstract Long-standing facial paralyses are those in which fibroadipose metaplasia of mimetic musculature has grown because of the time that has lapsed since the onset of the palsy: generally more than 18-24 months. Unlike the treatment of recent paralyses, to provide a neural input to reactivate the mimetic musculature is not enough. New healthy muscles must be transferred to the face. Operations may be subdivided into free-flap transplantations or masticatory muscle transpositions. The principles of treatment are correction of the asymmetry of the face by static means, and restoration of movements. Static correction of ptosis is achieved by deep-lifting, suspensions of fascia lata, and other procedures. Among movements, most efforts are concentrated on the restitution of smiling and closure of the eyelids. One of several techniques may be chosen after careful examination of the patient and paying close attention to their needs and expectations. Closure of the eyelids is generally achieved by a transposition of a double-belly temporalis flap or implantation of a gold/titanium lid plate. Other procedures are less used. Restoration of blinking remains impossible in most cases. The most popular techniques to restore smiling are rotation of a temporalis flap and transfer of a gracilis free flap with double innervation: both pros and cons must be considered. Surgery of the lower lip palsy is mainly based on limiting evident dragging upwards during smiling, because depressor function is difficult to achieve. Symmetry may also be reached by paralysing the lower lip on the other side. Movement of the forehead is a neglected area: reconstruction is possible, although the extent required seems disproportionate to the deficit. The need for ancillary surgery must be stressed. Only rarely are optimal results achieved without further fine-tuning of details. © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Facial palsy; Facial reanimation; Facial nerve
Introduction In patients with long-standing facial paralyses, the mimetic musculature is irreversibly atrophic and fibroadipose metaplasia is evident because of the passage of time between the onset of paralysis and the first consultation. Careful electromyography (EMG) can show when this point is reached, as no muscular fibrillations can be detected in patients with established fibrosis. The time to atrophy varies, but is generally between 18 and 24 months. The duration may be ∗ Unità Operativa di Chirurgia Maxillo-Facciale, Ospedale San Paolo, Via A. di Rudinì 8, 20142 Milano, Italy Tel.: +39 (0)2 8184 4143; fax: +39 (0)2 5032 3106. E-mail address: [email protected]
less if the surgical field is poorly vascularised, and if there has been previous irradiation or recurrent paralysis. Consequently many such paralyses are caused by late referral to a reconstructive surgeon, although some delays are attributable to patients’ fear of operation, and clinical conditions such as coma, and progression of congenital or developmental paralyses.1 Rarely, muscles do not atrophy even after many years, probably because there is still some low-level neural stimulation. Such stimulation is inadequate to maintain resting tone in the mimetic musculature, or to trigger any visible movement, but complete muscle atrophy is avoided. In such cases fibrillations are detected on EMG and facial reanimation by new neural stimulation (as in cases of recent paralyses) can be attempted, but the results are generally discouraging.
http://dx.doi.org/10.1016/j.bjoms.2015.07.001 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Biglioli F. Facial reanimations: part II—long-standing paralyses. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.07.001
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Table 1 Reanimation after long-standing hemifacial paralysis. Eye
Midface
Older patients
Temporalis flap/lid plate
Younger patients
No procedure if no particular disturbance evident Cross-face graft + platysma if corneal soreness is a problem. Lid plate Cross-face graft + platisma lip plate / cross-face graft + platysma
Temporalis flap/gracilis flap with double innervation Gracilis flap with double innervation
Patient requires an immediate outcome Patient requires the best possible outcome Deficit or possible future deficit of the fifth nerve Deficit or possible future deficit of the contralateral seventh nerve Paresis /little movement An urgent need to protect the cornea
Temporalis flap/lid plate Lid plate / cross-face nerve graft with end-to-side distal neurorrhaphy Lid weight placed under local anesthesia/temporary tarsorrhaphy
Temporalis flap Gracilis flap with double innervation One-time latissimus dorsi flap / cross face graft + free flap Gracilis innervated by the masseteric n./temporalis flap One-time latissimus dorsi flap
All treatments should be complemented by ancillary operations to correct positions of eyebrows, lids, the nasolabial fold, and lips, and to reduce the bulk of free flaps and reorientate such flaps.
The importance of re-establishing facial symmetry at rest is the main target. Usually, when we look at others mimicry is not activated, so resolution of the paralytic ptosis of the soft tissue greatly improves patients’ self-confidence. Static correction of asymmetry, however, only partially removes the signs of the condition, and should not be allowed to bias the entire treatment. Facial reanimation means restoration of facial movements, of course, and is achieved by transposing healthy musculature into the affected hemiface together with new neural input.2 Simple reactivation of the facial nerve, as in instances of recent paralysis, is insufficient. Fibroadipose metaplasia of the mimetic musculature has destroyed muscular function. The trunk of the ipsilateral facial nerve should not be used as a motor source even if it is surgically available preoperatively (generally, this is not the case). Axonal sprouting caused by a neural lesion decreases over time and cannot be guaranteed after 18-24 months. At present it is not technically possible to replace all mimetic muscles. Loss of the ability to close the eyelids is the biggest problem, as it potentially threatens the vision. Smiling is the most important form of social communication imparted by the face; loss of the ability to smile triggers reactive depression.3 Consequently, replacement of these 2 movements is the appropriate target of reanimation of paralysis of long standing. This is obviously less than what is attainable by reanimating the entire mimetic musculature when treating recent paralysis. Another way to look at the problem is to damage some branches of the contralateral facial nerve selectively (by botulinum toxin injections, selective neurectomies, and myectomies) to improve symmetry, both from static and a dynamic points of view. This is acceptable but should be limited to final refinements, when maximal attempts to recover facial movements of the paralysed hemiface have been made. Specific physiotherapy may also teach the patients how to reduce mimetic movements on the healthy side to improve dynamic symmetry.
Movements of the forehead and lower lip are often neglected, and reconstruction is possible although the extent required may seem disproportionate to the deficits being addressed. These problems are most commonly faced using static procedures or by production of paralysis on the other side to render the face symmetrical during execution of a specific movement. Paralysis of the platysma is generally considered less important than that of the forehead and lower lip, and no attempt is made to reanimate a paralysed platysma. On the contrary, platysmal spasm is often treated, which arises most commonly after incomplete recovery from Bell’s palsy. Part of the platysma is removed or the tissue is completely paralysed in one of several ways.4 Multiple operations have been described, but none is better than the others for all cases. A wide range of techniques helps the surgeon to choose the most appropriate one for each patient and for different circumstances (Table 1).
Midface reanimation Midface ptosis may be corrected by lifting the soft tissues; the more extensive procedures afford the most reliable long-term results.5,6 Several forms of suspension have been proved to be effective, fascia lata grafts being the most popular. The use of alloplastic materials is not advisable, because the outcomes are unstable and the infection rates high. Such materials can extrude to create an unnatural appearance, and become visible under the skin.7 Dynamic procedures seek to recover smiling, but generally also have the effect of lifting soft tissues, so correcting the ptosis. The most reliable dynamic procedure that affords such adjunctive static effects is transposition of a temporalis flap. Many techniques have been devised to reanimate the hemiface of patients affected by long-standing facial paralysis, which may be divided into 2 groups: free-flap transplantations
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and transpositions of masticatory muscles. However, masseter muscle rotation has been almost completely abandoned because the aesthetic outcomes were poor; the temporalis muscle is now used extensively. Rotation of a temporalis flap The temporalis muscle is innervated by the V cranial nerve, so after it has been ensured that trigeminal function is intact, and any possible future impairment of the muscle by a progressive cerebral lesion has been excluded, the muscle may be used for facial reanimation. Many variants of transposition of the temporalis muscle to reanimate the midface have been described since the technique was first described in 1911 by Lexer and Eden.8–10 Developments in free-flap surgery today render such transpositions second-choice procedures. Over the last two decades, Labbè et al. have revitalised the use of the temporalis muscle to restore smiling.11 The relevant procedure, termed temporalis lengthening myoplasty, involves detaching the posterior two-thirds of the muscle from the temporalis fossa to enable anterior transposition of the lower tendon of the muscle, which is secured by stitches to the nasolabial sulcus. The new success of temporalis muscle transposition is associated with the fact that the procedure is easy and quick, and immediate correction of soft tissue ptosis is achieved with the simultaneous development of a certain amount of movement. Labbé et al. suggested that the temporalis fibres should be completely detached from the surrounding masticatory musculature to facilitate spontaneity during smiling, because cortical adaptation is in play.12 However, spontaneity is almost never evident when some hours are spent with patients; this is the principal drawback of the procedure. The extent of movement is also smaller than that achieved by transposition of a free flap, and fixing of the tendon to the nasolabial sulcus tends to be difficult unless some strips of fascia lata or the deep temporalis fascia are added to the lower tendon. The procedure is a good option when bilateral facial paralyses are to be treated; the operation is associated with low morbidity, particularly when compared with 2 free flap transpositions. Another good indication is for those with a lot of soft tissue ptosis who are willing to obtain a quick correction of the paralysis. Free flap surgery The advantages of free flaps rapidly became apparent after they were introduced in the 1970s. It is possible to use donor muscles that give high-level excursions during contraction (affording bigger smiles). Opportunities for placement are much greater than those of masticatory muscles. Spontaneous activation to express the “funny” emotion is possible when the free flaps are combined with cross-face nerve grafts. The available techniques must be distinguished in 2 ways to understand the various possibilities. These are one-stage compared with 2-stage procedures, and the use of a branch of
Fig. 1. Patient with long-standing facial paralysis. The middle third of the face was reanimated by gracilis muscle free flap transplantation with double innervation. The masseteric nerve guarantees good innervation, used during voluntary smiling. Cross-face nerve grafting mixes its axons with those of the masseteric nerve, which leads to free flap activation during emotional smiling (published with the patient’s permission).
the contralateral facial nerve compared with another motor nerve. One-stage procedures have the obvious advantage of lower morbidity and more rapid recovery.13,14 However, if the masseteric nerve is chosen as the motor source, as in gracilis transfer, no spontaneous smiling is possible.15 However, if the contralateral facial nerve is used (as in one-stage latissimus dorsi transfer) the extent of contraction of the flap may be slight because of partial loss of ingrowing axons along the collateral branches of the nerve. Two-stage procedures feature cross-face nerve grafting before free flap transplantation, to ensure the maximum neural input, 16–17 and this is the most popular procedure in use today. The disadvantages are: the results take time to appear, and there is physical and psychological morbidity associated with 2 operations. One attempt to merge the advantages of both procedures is gracilis transplantation accompanied by double innervation using the ipsilateral masseteric nerve to ensure contractile power and the contralateral facial nerve to trigger spontaneous smiling18,19 (Figs. 1–3, video 1-2). Currently, this seems to be the best method by which to restore smiling to patients paralysed for a long time. Presentations of paralysis vary. Several other neural deficits may be associated with functional lack of the VII nerve. The armamentarium of the reconstructive surgeon must be sufficiently broad to allow adaptation to specific circumstances. For example, if the contralateral facial nerve is inadequate, or if it may subsequently be impaired by progression of disease, it seems logical not to use a doubly-innervated gracilis flap, but rather a muscle flap innervated by the masseteric nerve, or a temporalis flap rotation. Instead, if the V
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Fig. 2. Postoperative good tone at rest of the operated hemi-face. Symmetry has been improved by adding simultaneously to free-flap surgery a deep lifting procedure according to Biglioli et al6 (published with the patient’s permission).
cranial nerve is impaired, it is logical to prefer a single-stage latissimus dorsi flap served by the contralateral facial nerve. Many ancillary procedures, generally done under local anaesthesia, are often necessary to improve the final results. The most common are refinements of the nasolabial sulcus, improvement of symmetry by placement of fascia lata grafts or minitemporalis flap rotation, contralateral botulinum toxin injections, and trimming or repositioning of a free flap.
Fig. 3. Postoperative symmetrical and natural appearance of the face during smiling (published with the patient’s permission).
open, so preoperatively sample plates must be temporarily tacked to the skin of the lid to define the correct weight for each individual patient. The disadvantages of the technique are: the need for the patient to remain vertical to allow the system to function effectively, the introduction of a foreign body into the upper lid (the weight may become extruded because soft tissue coverage is thin), the high visibility of standard plates through the skin, and frequent discomfort.
Closure of the eyelids The eye is lubricated by distributing the tear film over the cornea, principally by blinking. Voluntary closure of the eyelids improves lubrication if the eyes become sore. Blinking normally occurs 10-19 times/minute, varying for several reasons. Consequently, surgical restitution of closure of the eyelid corrects only part of the deficit. The 2 most commonly used methods are insertion of a lid weight and rotation of a temporalis flap8,20 (Figs. 4–6, video 3). These may improve the little residual blinking that is caused by the inhibitory reflex of the levator muscle of the lid, but neither of those techniques will really restore blinking. A lid plate moves the upper lid downwards, and the weight of the plate opposes the tone of the levator muscle of the lid at rest. However, the weight must not neutralise levator tone when the eyelids are
Fig. 4. Paralytic lagophthalmos as a result of long-standing facial paralysis (published with the patient’s permission).
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Fig. 5. Surgical correction by a double bellies temporalis flap rotation. The lower belly is tightened to the medial canthus in order to correct drooping of the lid. The upper belly is sutured with a soft tension to allow upper lid elevation during standard vision (published with the patient’s permission).
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teeth. When the temporalis muscle is not active, the eyelids remain open. To achieve this, the upper belly is placed under minimal tension. The lower belly is positioned under greater tension, which allows static vertical correction of ptosis of the lower eyelid. This method is not associated with extrusion because the translated tissue is autologous. Drawbacks may include visible bulkiness of the upper lid, and erroneous tensing of the 2 bellies leading to narrowing of the rim of the eyelid or an ectropion. Sometimes, eyelids still will not close because movement of the flap is insufficient. A temporalis flap may simultaneously restore smiling and closure of the eyelid. The operation is short and morbidity minimal. However, synkinesis is evident between eyelid closure and smiling. A two-stage procedure featuring cross-face nerve grafting followed by transplantation of platysma into the lid has been used in attempts to restore voluntary eyelid closure and blinking. The sural nerve is stimulated by a branch of the contralateral facial nerve orientated to the upper lid. Transfer of platysma may feature grafting or the use of a vascularised free flap.22 Although the idea is attractive, the results are unfortunately inconsistent and the method finds few applications. Many ancillary procedures are often required to improve the results or the static symmetry of the eyelids, or both.23,24 Lateral and medial canthoplasties, canthopexy, and ectropion correction are commonly required.
Conclusions
Fig. 6. Activation of the temporalis muscle drives the lids to close (published with the patient’s permission).
Several types of lid weight have been developed. Titanium plates have the advantage over gold plates of compatibility with magnetic resonance imaging, which is particularly important if a residual cerebral tumour requires continuous monitoring. Also, titanium is heavier than gold, which renders the profile of the plate less visible through the thin skin of the lid. However, individualised gold plates may be manufactured using eyeball casts; such plates are better tolerated because their curvatures are exactly those of the eyeballs. These plates are also wider than standard ones because the individual plaster casts allow this. They can therefore be relatively thin and so less visible through the skin. Static correction of lower lid ectropion is usually required as well. Several types of temporalis flaps have been developed to treat deficits in eyelid closure.21 The most commonly used type is the double-belly temporalis flap. The cranial part of the flap lowers the upper eyelid when the temporalis muscle is voluntarily activated by opposition of the
It remains impossible to correct long-standing facial paralysis completely. All current techniques have both advantages and disadvantages. Successful reanimation might feature gracilis free-flap transfer with double innervation to recover smiling, and double-belly temporalis rotation to re-establish closure of the eyelids. Many other procedures may be required depending on the specific circumstances, and the patient’s needs and expectations. Ancillary procedures should be offered in most cases to improve the results.
Conflict of Interest I have no conflict of interest.
Ethics statement/confirmation of patients’ permission The patients have given consent to publication.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j. bjoms.2015.07.001.
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Please cite this article in press as: Biglioli F. Facial reanimations: part II—long-standing paralyses. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.07.001