- Email: [email protected]
Facial rehabilitation
Operative Techniques in Otolaryngology (2012) 23, 288-296
Facial rehabilitation Mara Wernick Robinson, PT, MS, NCS, Jennifer Baiungo, PT, MS, Mark Hohman, MD, Tessa Hadlock, MD From the Facial Nerve Center, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. KEYWORDS Facial paralysis; Facial nerve injury; Bell’s palsy; Facial Rehabilitation; Surgical facial reanimation; Facial Grading Scale; Facial Clinimetric Evaluation; Synkinesis Assessment Questionnaire
Facial rehabilitation following a facial nerve injury is effective in improving facial function, appearance, and self-confidence. We describe a treatment intervention algorithm for adults and children with chronic facial nerve injury. Details of the evaluation process and the facial rehabilitation strategies, for both incomplete and complete facial nerve injury, are described. © 2012 Elsevier Inc. All rights reserved.
The comprehensive management of the patient with a facial nerve injury is critical, although often overlooked. “I wish my doctor had told me that rehabilitation therapy could help. I was told that I have to live with facial paralysis!” Patients frequently begin the evaluation with such comments. Facial function, expression, and appearance are often taken for granted. When facial function is lost, patients are unsure of proper management. People who experience facial paralysis, whether related to facial nerve injury from birth, trauma, infection (eg, Bell palsy), or postsurgical sequelae (eg, after acoustic neuroma resection), frequently have the expectation that facial movement will spontaneously return. When the spontaneous recovery time frame has elapsed and facial paresis remains, patients are typically told there is nothing further that can be done to improve recovery. Lack of attention to inadequate facial function can lead to dysfunctional facial movements and psychosocial consequences. Individuals with facial paresis suffer from a host of functional limitations, including difficulty with eye closure, eating, drinking, speaking clearly, smiling, and expressing emotions.1-3 Address reprint requests and correspondence: Mara Wernick Robinson, PT, MS, NCS, Facial Nerve Center, Massachusetts Eye and Ear Infirmary, 243 Charles Street, 9th Floor, Boston, MA 02114. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.otot.2012.10.002
The facial muscles have unique characteristics that differentiate them from other skeletal muscles. These muscles lack fascial envelopment and tendinous or bony attachments that allow the muscles to move freely. Facial muscles lack muscle spindles, have small motor units, are relatively slow to degenerate, and most importantly, receive emotional as well as volitional neural inputs.4-6 Facial rehabilitation is effective because the techniques are based on those unique characteristics as well as the subtle nature of expression.5,6 One of the most common sequelae of incomplete facial nerve injury is synkinesis, or aberrant nerve regeneration. After nerve trauma, axons project from the facial nucleus and throughout the length of the nerve to “incorrect” peripheral muscle groups.7 For example, a portion of the axons that innervate the orbicularis oris aberrantly regenerates and innervates the orbicularis oculi. A common synkinetic muscle pattern involves cocontraction of the oculi muscles with lip puckering. One of the primary goals of facial rehabilitation, although often the most overlooked one, is synkinesis management. Specific neuromuscular reeducation exercises teach the patient how to symmetrically move the facial muscles, while simultaneously controlling associated synkinesis.5,8-11 Additionally, soft-tissue mobili-
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zation8-11 and relaxation techniques are taught to facilitate the control over synkinesis.12 An increasing body of research in facial rehabilitation has documented conservative options for recovery of facial nerve injury, and presents an attractive option for most patients before pursuing surgery. Facial rehabilitation, in the form of functional neuromuscular reeducation (NMR),5,8,9,11,13-16 surface electromyographic (EMG) biofeedback,14,17,18 mime therapy,19 and video self-modeling,20 has been shown to be effective for patients with long-standing facial paresis. Support for facial rehabilitation has been well documented, yet patients continue to be undermanaged based on lack of knowledge regarding effective treatment. Furthermore, when treatment is prescribed, a referral for electrical stimulation is often made despite the fact that electrical stimulation produces mass facial muscle action and may lead to more severe synkinesis.21,22 The objective of this article is to outline a treatment intervention algorithm for adults and children with chronic (⬎3 months) facial nerve injury, including the management of postsurgical facial reanimation. Our center’s goal is to establish a consensus among therapists and physicians regarding optimal facial nerve rehabilitation and expected outcomes. The multimodality management of the paralyzed face23 and suggested facial rehabilitation treatment algorithm11 have been previously described. In light of the increasing success of dynamic surgical reanimation,24,25 we present an algorithm that includes a comprehensive postsurgical rehabilitation program (Figure 1).
Evaluation All patients are evaluated by the team of an otolaryngologist and a physical therapist. Included in the initial evaluation are still photographs, and video analysis of facial expression. During physical therapy (PT) patients are also asked to complete the Facial Clinimetric Evaluation (FaCE) (Appendix). The FaCE is a disease-specific self-report questionnaire for the assessment of disabilities of patients with facial nerve disorders. Its reliability and validity have been previously demonstrated.26 Because the FaCE does not assess synkinesis, patients are also asked to complete the Synkinesis Assessment Questionnaire (SAQ)27 (Appendix). The SAQ is a simple patient-graded instrument designed to assess facial synkinesis associated with facial expression. It has been demonstrated to have high test–retest reliability, internal consistency, and construct validity after chemodenervation.27 The Sunnybrook Facial Grading Scale (FGS) (Appendix) is a performance-based measure of facial impairment in 3 areas: resting position, voluntary movement of 5 facial expressions, and associated synkinesis.28 The reliability and validity of the FGS has been demonstrated.28 Scoring of the FGS is out of 100 points: a low score indicates more severe facial dysfunction. Additional facial movements (eg, scowl, pout) that are not included on the FGS are also examined and graded with similar scoring. A systems review (eg, gait and balance) is performed to ensure
289 that the entire patient is screened, and relevant medical history is taken into account when making an assessment of the patient’s likelihood to meet the established goals. Finally, and most importantly, the therapist must gain an understanding of the patient’s goals and expectations. The entire process, from evaluation to assessment and treatment planning, is based on the patient’s level of nerve injury and degree of paralysis, the presence of synkinesis, the degree of functionality, and the patient’s individual goals. Patients with facial paresis who have incomplete loss of nerve function (eg, infection, trauma) will likely benefit from facial rehabilitation, and are placed in the Facial Rehabilitation for Incomplete Nerve Injury category. Patients with facial paralysis who have complete irreversible nerve loss or have known congenital facial paralysis are placed in the Facial Rehabilitation for Complete Nerve Injury and Surgical Consideration category (Figure 1).
Facial rehabilitation for incomplete nerve injury Patients in this category may begin rehabilitation 3 months after the onset of facial paralysis. Given the high rate of spontaneous recovery in viral facial paralysis (eg, Bell palsy) within the first 3 months, rehabilitation beyond patient education and eye protection is not typically provided. Patients with long-standing paresis (⬎3 months) are also eligible and can benefit from facial rehabilitation.11 Determination of the appropriate facial rehabilitation treatment category, initiation, facilitation, movement control, and relaxation is based on results of the FGS, FaCE, and SAQ. Classifying facial nerve disorders into treatment-based categories is a valid method for categorizing patients with specific impairments and guides treatment planning.8,9 During all initial PT evaluations, patient education regarding the anatomy and function of facial muscles, as well as the phenomenon of synkinesis, is provided. Patient education is a valuable tool in the facial rehabilitation process. Figure 2 is a simplified schematic given to patients to guide their understanding of the relationship between the nerves and the designated action of individual facial muscles.
Initiation Patients who have moderate to severe facial asymmetry at rest, who are unable to initiate movement on the affected side, and who lack synkinesis, are placed in the initiation treatment category. Patients are given instruction on gentle soft-tissue stretching and active assistive movement exercises, with the goal of stretching the affected muscles and increasing circulation. The superficial soft-tissue stretching typically begins with focus on the musculature involved in movement of the midface (Figure 3) and progresses to include other facial musculature. Patients with facial paresis or paralysis may lack complete eye closure. Functionally, this can lead to impaired corneal health and ocular discomfort. Patients are taught how to stretch the affected eyelid.
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Soft-Tissue
Soft-Tissue
Soft-Tissue
Soft-Tissue
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Figure 1
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Treatment algorithm for individuals with facial nerve injury.
The goal is to passively lengthen the fibers of the levator palpebrae superioris, resulting in improved closure of the affected eye. Instruction for active assistive exercise is also provided, in which the patient is taught to use his or her finger to guide the movement pattern. For example, if the goal is to elevate the lip using the levator labii muscle, the
patient is instructed to place his or her finger on the side of the nose and gently guide the muscle superiorly. Lastly, patients are taught to avoid mass movements and to avoid overuse of the unaffected side. The rationale behind avoiding mass movement patterns is based on the properties of the length–tension relationship. The affected flaccid mus-
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Figure 2
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291
Schematic diagram of facial nerve branches and muscles, provided for patient education.
cles will not contract effectively if they are lengthened by the pull of the opposite unaffected side. In a skeletal muscle fiber, the amount of tension generated during a contraction depends on the number of pivoting cross-bridges in all the sarcomeres along all the myofibrils. This disruption of the normal arrange-
ment of thick and thin filaments interferes with the binding of cross-bridges to active sites. As a result, little tension is produced when the muscle fiber is stimulated while stretched. Within the optimal range of sarcomere lengths, the maximum number of cross-bridges can form and the tension produced is
Figure 3 Soft-tissue mobilization of the zygomaticus major and minor. The patient places his/her thumb inside the mouth and 2 or 3 fingers on the outer surface of the cheek, just below the proximal section of the zygomatic arch. The patient then applies firm pressure, as the thumb and fingers slide inferiorly toward the commissure of the mouth.
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Figure 4 Neuromuscular reeducation along with mirror feedback to retrain a smile. The patient is instructed to look in the mirror and bring up both corners of the mouth slowly to form a symmetric smile, while also controlling the associated synkinesis.
highest. Any further increase in sarcomere length reduces the tension produced by reducing the size of the zone of overlap and the number of potential cross-bridge interactions. The muscle fiber cannot produce any tension, and a contraction cannot occur. In summary, facial muscle fibers may contract most successfully when positioned in their resting state.29
Facilitation Patients who have mild to moderate facial asymmetry at rest, who are able to initiate slight movement, and who do not have synkinesis are deemed appropriate to start treatment within the guidelines of the facilitation treatment category. Patients who are originally categorized or progress to the facilitation treatment category are taught soft-tissue stretching of the facial muscles, active assistive exercises, and NMR exercises. The mainstay of facilitation exercises is to foster axonal regeneration through guided small-movement exercise. NMR exercises are prescribed based on the motor control impairments of the individual patient. The goal of NMR exercises is to perform small, slow, and controlled facial movements with emphasis on symmetry between the 2 sides of the face. For example, when relearning to smile, patients are instructed to form a small “Mona Lisa” smile. While looking in the mirror, patients are encouraged to focus on moving the corner of the mouth upward, while simultaneously making an emotional connection to a pleasant experience. Owing to the lack of muscle spindles in the facial musculature, there is minimal proprioceptive input, so visual feedback is imperative for increasing awareness and performance of graded movements within the muscles. A mirror is used to provide patients with this necessary feedback. Surface EMG is also used to provide the patient with biofeedback during these exercises.17,18 An auditory or visual signal from the EMG electrodes placed on the desired muscles tells the patient that he or she is successful at generating muscle activity during the in-
tended action. For example, surface EMG electrodes placed inferiorly and superiorly on the affected orbicularis oris would signal that the lip muscles were active during pucker or articulation. Surface EMG electrodes can also be applied to the unaffected side to help the patient minimize overcontraction of the stronger oris, with the goal of a symmetrical pucker movement pattern. Lastly, patients in the facilitation category are educated about the possibility of synkinetic movement patterns as nerve regeneration progresses.
Movement control Patients who have mild to moderate facial asymmetry at rest, who are able to initiate at least slight movement, and who have developed synkinesis are placed in the movement control category. Patients who are originally categorized or who advance into the movement control category are taught more aggressive soft-tissue stretching of the facial muscles, NMR exercises with mirror and EMG biofeedback, and relaxation and meditation strategies. NMR for patients in the movement control category consists of teaching the patient to generate small movements while simultaneously controlling synkinesis. For example, the patient is taught to form a small symmetrical smile while also controlling his or her periocular synkinesis (Figure 4). Controlling synkinesis is described to the patient as releasing the tension, as in draining an inflated tire, or as directly opposing the unwanted contraction. Managing synkinesis is extremely challenging for most patients and initially requires the utmost concentration along with mirror feedback. Movement control, also termed small-movement therapy or NMR, takes many repetitions to achieve mastery. Patients are advised to practice the movement control exercises for at least 40 repetitions per independent session, 2 to 4 times per day. The notion that practice improves neuronal connection and facilitates new motor patterns underlies the recommenda-
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tion of the frequency of practice. At this stage, the goal is to improve motor control, not to improve muscle strength. Current theories in motor control support that proper practice is the most important in forming new movement patterns.30 EMG biofeedback can also be used as a means of providing the patient with feedback to control synkinesis by placing the EMG electrodes on the synkinetic muscle. In the common example of periocular synkinesis, the electrodes are placed on the lateral periocular muscles and the patient aims to minimize the EMG signal of the oculi muscles during smiling or during puckering. Because a majority of facial expressions are emotionally driven, video analysis during spontaneous conversations is an integral part of movement control.20 Patients with severe synkinesis may begin to have limited movement owing to tightness rather than weakness. Therefore, the relaxation and meditation strategies are provided.
293 lease synkinesis in targeted regions, mainly the orbicularis oris, mentalis, and platysma. Occasionally, the unaffected frontalis and depressor labii inferior are injected to achieve symmetry at rest for forehead rhytids and symmetrical coverage of the lower dentition during smiling, respectively. Contralateral lower lip weakening also provides a more symmetrical appearance during articulation. Botulinum toxin is considered after the patient has undergone at least 3 therapy sessions. The timing of the botulinum toxin injections in the facial rehabilitation process allows the patient to first learn conscious control over the synkinesis without reliance on medical intervention. For the attentive patient, the process of gaining control over synkinesis typically takes 2 to 3 months. Patients must fully understand the role of synkinesis and how it negatively affects motor control, before chemodenervation alters the muscle function.
Relaxation Patients with severe pan-facial tightness related to synkinesis are placed in the relaxation category. These patients typically have limited movement owing to tightness rather than weakness; therefore, the emphasis of treatment is relaxation–meditation. Meditation, using guided visual imagery, focuses on teaching patients how to release the tension in the synkinetic musculature. Verbal cues to help minimize synkinesis include “drain the tension around the eye” (ie, for ocular synkinesis) and “deflate the fully inflated balloon in your cheek” (ie, for midface synkinesis felt during eye closure). Patients are also instructed on soft-tissue mobilization. NMR with mirror or EMG biofeedback, described for patients in the facilitation and movement control category, is taught later, as movement control is more successful when the facial tightness is managed first. The general guideline for facial rehabilitation is to perform the individualized stretches, NMR exercises, and relaxation–meditation daily. Individualized treatment sessions are typically monthly, during which their program is reviewed and progressed as indicated. Patients are instructed on only 2 to 3 new exercises each session, to promote optimal learning and compliance. It is better to practice and achieve mastery of a few movement patterns than to practice multiple movement patterns ineffectively. The cumulative nature of patient education, individualized modifications of facial rehabilitation, and psychological support provide the individual with the necessary tools for the lifelong maintenance of their facial nerve injury.
The role of chemodenervation Chemodenervation, in the form of botulinum toxin type A (Botox, Allergan, Inc, Irvine, CA) injections, has a wellestablished record of minimizing synkinesis in patients with facial nerve disorders.31,32 Botolinum toxin is used to re-
Facial rehabilitation for complete nerve injury and surgical consideration for dynamic surgical reanimation When patients present with complete nerve injury, for example, after sacrifice of the facial nerve during skull base tumor excision, a trial of facial rehabilitation is provided. The purpose of the brief facial rehabilitation process (eg, 2-3 sessions) is to teach the patient compensatory functional movement strategies and monitor change during the potential for partial nerve recovery stage. Typically, patients remain in the initiation and facilitation category. The decision to advance from facial rehabilitation to dynamic surgical reanimation is made by the patient and the entire treatment team, with the primary motivation being patient satisfaction. When the goal is a meaningful smile, or the feeling of executing a smile, and this is not achieved through facial rehabilitation, the surgical options are presented as (1) trigeminally driven free muscle transfer, (2) temporalis muscle transfer, and (3) free muscle driven by cross-face nerve graft. After dynamic surgical facial reanimation, rehabilitation plays a significant role in training the newly placed free muscle. Patients are then reevaluated and recategorized to guide the appropriate treatment intervention. Typically, patients begin in the initiation category and progress to the facilitation category. More recently, dynamic surgical reanimation is provided for patients with a “frozen face” related to severe synkinesis. The term “frozen face” is used to describe the patient who is unable to generate commissure excursion owing to severe synkinesis, and who has been refractory to chemodenervation. Therefore, the patient with preexisting synkinesis who undergoes a free muscle transfer would be categorized into the facilitation category and would eventually progress to the movement control category.
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Facial rehabilitation after trigeminally driven free muscle transfer and temporalis muscle flap After the 1-stage trigeminally driven free muscle transfer surgery, movement in the midface occurs when the patient bites down, as a result of free muscle innervation by the masseteric branch of the trigeminal nerve. Patients are expected to see muscle activity at approximately 6 to 20 weeks postoperatively and are referred for PT at that time. If the patient does not have any visible movement, they are placed in the initiation category, and the treatment intervention is similar to the nonsurgical patient. The goal of soft-tissue mobilization when the patient is treated in the initiation category is to decrease postsurgical edema that commonly occurs after muscle surgery. Additionally, patients are advised to chew gum to foster activation of the free muscle driven by biting. If there is trace movement in the free muscle when the patient bites down, the patient is placed in the facilitation category. The patient is instructed to gently bite down using a mouth guard, a tongue depressor, or
gauze pad while using mirror feedback to form a smile. The verbal cue to gently bite and smile while making the connection to a happy thought, with the lips together, fosters a natural appearing grin without dentition exposure. The patient progresses to biting down using a thicker structure (stack of tongue depressors and thicker gauze) that demands less biting effort, to form the smile. The ultimate goal is to form a smile without biting. The facial rehabilitation exercises after the temporalis muscle transfer surgery are similar. Because the temporalis is a biting muscle and has been transposed to function as a prime mover of the oral commissure, the patient is instructed to bite down to form the smile. The long-term goal in both the temporalis muscle flap and the 1-stage trigeminally driven free muscle transfer is to provide commissure excursion without biting down, or at least biting down with minimal effort. Because the trigeminally driven muscle is not designed to reinnervate the lower facial muscles, a full smile with top and bottom dentition exposure is not typically expected, and therefore not encouraged during the
Figure 5 Four patients with history of facial nerve injury. The top row shows photos that were taken at the time of the initial evaluation. The bottom row shows photos taken after facial rehabilitation. Patient A has a history of congenital facial paralysis and had 3 years of facial rehabilitation only. Patient B has a 6 month history of Bell palsy and underwent facial rehabilitation ⫻ 3 months, followed by chemodenervation. Patient C has a 2-year history of complete right-sided facial paralysis related to an acoustic neuroma resection. She underwent a free muscle transfer driven by a cross-face nerve graft, followed by 16 weeks of facial rehabilitation. Patient D has a 39-year history of incomplete right-sided facial nerve injury related to an acoustic neuroma resection. She underwent a trigeminally driven free muscle transfer, followed by 16 weeks of facial rehabilitation. (Color version of figure is available online.)
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facial rehabilitation process. Patients in this surgical category may gain upper lip motion; therefore, exercises to facilitate lip mobility without biting are also taught. Surface EMG biofeedback is also a useful treatment tool for patients who have undergone a free or regional muscle transfer. Electrodes are placed on the midface musculature, now responsible for oral commissure excursion. The patient is provided with an audio or visual signal to signify that the muscle has been activated. EMG is used as a treatment technique, with the patient striving for increased motor activity consistent with free muscle contraction.
Facial rehabilitation after free muscle transfer driven by a cross-face nerve graft After the 2-stage free muscle transfer driven by a crossface nerve graft surgery, movement in the midface occurs when the individual smiles, as a result of innervation from the contralateral facial nerve to the free muscle. Patients who have undergone the 2-stage cross-face surgery are expected to see muscle activity at approximately 6 to 9 months after the second stage and are referred for PT at that time. If the patient does not have any visible movement, they are placed in the initiation category, and the treatment intervention is similar to that for nonsurgical patient. If there is trace movement in the free muscle when the patient smiles, the patient is placed in the facilitation category. Contraction of the free muscle is generated when the patient smiles either voluntarily or spontaneously. Rehabilitation is also based on small-movement therapy with the goal of placing the newly transferred muscle in optimal position for activation. Patients in this surgical category may gain upper lip motion; therefore, exercises to facilitate lip mobility are also taught. The most desirable outcome in facial reanimation surgery would be complete return of premorbid function and appearance. Unfortunately, this rarely can be achieved. However, with the appropriate facial rehabilitation and optimal procedures, satisfactory outcomes are achieved. In summary, patients with long-standing facial nerve disorders benefit from skillful facial rehabilitation, chemodenervation, and surgery. Figure 5 demonstrates baseline and follow-up photographs of 4 patients who have undergone facial rehabilitation and surgical reanimation.
295 succeed in the facial rehabilitation process. All rehabilitation interventions, whether in the nonsurgical or postsurgical patient, require a long-standing commitment on the patient’s behalf, and patients who possess the motivation necessary to commit to a consistent and thorough home program are most successful. Education of the individual with facial paralysis is a critical component of the program, which results in the patient’s ability to report specific details of functional deficits and self-monitor changes as the program progresses. Rehabilitation goals must be tailored to the impairments of the individual on a functional, cosmetic, and emotional level. Functional outcomes that can be expected include improved ability to smile, eat, drink, speak clearly, and blink or close the affected eye. Additionally, reduction of facial pain and tension in the affected musculature is achieved. At the interpersonal level, willingness to participate in social activities and improved self-confidence are realistic goals. The collaboration between and within disciplines is essential to ensure that thorough and appropriate treatment is provided to each individual patient. The interdisciplinary approach is an important component of a facial rehabilitation program, allowing for increased understanding of, and growth within, both the nonsurgical and surgical treatment realms, and has an impact on the advancement of options that can be provided to this patient population. The continued growth of the field of facial reanimation surgery will result in improved functional outcomes for patients with facial paralysis. The facial rehabilitation team plays an integral role in maximizing the quality of these functional improvements, as well as the quality of life for people affected by facial nerve injuries. Facial expression, especially smiling, is such an integral part of who we are and how we present ourselves to others. The loss of this ability can be devastating to many patients with a facial nerve injury, and these patients deserve the attention of the medical community. Increased awareness of the issues that patients encounter and increased awareness of current treatment options will only serve to advance effective patient management for patients with facial nerve disorders.
Appendix. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.otot.
Discussion Although facial rehabilitation cannot restore a “perfect” cosmetic or premorbid appearance, appropriate intervention can make a substantial difference in facial muscle motor control, with the ultimate goal of improved physical function, enhanced cosmesis, and increased self-confidence. Patients can be empowered by learning self-management tools to maximize function and appearance even if they were led to believe that nothing could be done to improve their facial paralysis. We believe that knowledge is power, and that the well-informed and fully involved patient is most likely to
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3. Bogart KR, Matsumoto D: Living with Moebius syndrome: adjustment, social competence, and satisfaction with life. Cleft Palate Craniofac J 47:134-142, 2010 4. Schaitkin BM, Eisenman DJ: Anatomy of facial muscles, in May M (ed): The Facial Nerve (ed 2). New York, NY, Thieme Medical Publishers, 2000, pp 95-105 5. Diels HJ: New concepts in non-surgical facial nerve rehabilitation, in Meyers E (ed): Advances in Otolaryngology Head and Neck Surgery, vol 9. Chicago, IL, Mosby Year Book Inc, 1995, pp. 89-315 6. Byrne PJ: Importance of facial expression in facial nerve rehabilitation. Curr Opin Otolaryngol Head Neck Surg 12:332-335, 2004 7. May M: Microanatomy and pathophysiology, in May M (ed): The Facial Nerve (ed 2). New York, NY, Thieme Medical Publishers, 2000, pp 57-65 8. VanSwearingen JM, Brach JS: Validation of a treatment-based classification system for individuals with facial neuromotor disorders. Phys Ther 78:678-689, 1998 9. Brach JS, VanSwearingen JM: Physical therapy for facial paralysis: a tailored treatment approach. Phys Ther 79:397-404, 1999 10. VanSwearingen J: Facial rehabilitation: a neuromuscular reeducation, patient-centered approach. Facial Plast Surg 24:250-259, 2008 11. Lindsay RW, Robinson M, Hadlock TA: Comprehensive facial rehabilitation improves function in people with facial paralysis: a 5-year experience at the Massachusetts eye and ear infirmary. Phys Ther 90:391-397, 2010 12. Robinson MW, Lindsay RW, Hadlock TA: The effects of audio relaxation on patients with chronic facial paralysis, in Symposium of Platform Presentation, International Facial Nerve. Rome, Italy, 2009 13. Segal B, Hunter T, Danys I, et al: Minimizing synkinesis during rehabilitation of the paralyzed face: preliminary assessment of a new small-movement therapy. J Otolaryngol 24:149-153, 1995 14. Ross B, Nedzelski JM, McLean JA: Efficacy of feedback training in long-standing facial nerve paresis. Laryngoscope 101:744-750, 1991 15. Manikandan N: Effect of facial neuromuscular re-education on facial symmetry in patients with Bell’s palsy: a randomized controlled trial. Clin Rehabil 21:338-343, 2007 16. Diels HJ: Facial paralysis: is there a role for a therapist? Facial Plast Surg 16:361-364, 2000 17. Cronin GW, Steenerson RL: The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation. Otolaryngol Head Neck Surg 128:534-538, 2003
18. Nakamura K, Toda N, Sakamaki K, et al: Biofeedback rehabilitation for prevention of synkinesis after facial palsy. Otolaryngol Head Neck Surg 128:539-543, 2003 19. Beurskens CH, Heymans PG, Oostendorp RA: Stability of benefits of mime therapy in sequelae of facial nerve paresis during a 1-year period. Otol Neurotol 27:1037-1042, 2006 20. Coulson SE, Croxson GR, Adams RD, et al: Reliability of the “Sydney,” “Sunnybrook,” and “House Brackmann” facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis. Otolaryngol Head Neck Surg 132:543-549, 2005 21. Ohtake PJ, Zafron ML, Poranki LG, et al: Does electrical stimulation improve motor recovery in patients with idiopathic facial (Bell) palsy? Phys Ther 86:1558-1564, 2006 22. Teixeira LJ, Soares BGDO, Vieira VP, et al: Physical therapy for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev 16:CD006283, 2008 23. Hadlock TA, Greenfield LJ, Wernick-Robinson M, et al: Multimodality approach to management of the paralyzed face. Laryngoscope 116:1385-1389, 2006 24. Hadlock T, Cheney ML: Facial reanimation: an invited review and commentary. Arch Facial Plast Surg 10:413-417, 2008 25. Hadlock TA, Malo JS, Cheney ML, et al: Free gracilis transfer for smile in children: the Massachusetts eye and ear infirmary experience in excursion and quality-of–life changes. Arch Facial Plast Surg 13: 190-194, 2011 26. Kahn JB, Gliklich RE, Boyev KP, et al: Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale. Laryngoscope 111:387-398, 2001 27. Mehta RP, WernickRobinson M, Hadlock TA: Validation of the synkinesis assessment questionnaire. Laryngoscope 117:923-926, 2007 28. Ross BG, Fradet G, Nedzelski JM: Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg 114:380-386, 1996 29. Cunningham DJ: Romanes GJ. Cunningham’s Textbook of Anatomy (ed 12). Oxford, University Press, 1981 30. Shumway-Cook A, Woollacott JH: Motor Control: Translating Research into Clinical Practice (ed 4). Baltimore, MD, Lippincott Williams & Wilkins, 2011 31. Husseman J, Mehta RP: Management of synkinesis. Facial Plast Surg 24:242-249, 2008 32. Mehta RP, Hadlock TA: Botulinum toxin and quality of life in patients with facial paralysis. Arch Facial Plast Surg 10:84-87, 2008
Facial rehabilitation Mara Wernick Robinson, PT, MS, NCS, Jennifer Baiungo, PT, MS, Mark Hohman, MD, Tessa Hadlock, MD From the Facial Nerve Center, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. KEYWORDS Facial paralysis; Facial nerve injury; Bell’s palsy; Facial Rehabilitation; Surgical facial reanimation; Facial Grading Scale; Facial Clinimetric Evaluation; Synkinesis Assessment Questionnaire
Facial rehabilitation following a facial nerve injury is effective in improving facial function, appearance, and self-confidence. We describe a treatment intervention algorithm for adults and children with chronic facial nerve injury. Details of the evaluation process and the facial rehabilitation strategies, for both incomplete and complete facial nerve injury, are described. © 2012 Elsevier Inc. All rights reserved.
The comprehensive management of the patient with a facial nerve injury is critical, although often overlooked. “I wish my doctor had told me that rehabilitation therapy could help. I was told that I have to live with facial paralysis!” Patients frequently begin the evaluation with such comments. Facial function, expression, and appearance are often taken for granted. When facial function is lost, patients are unsure of proper management. People who experience facial paralysis, whether related to facial nerve injury from birth, trauma, infection (eg, Bell palsy), or postsurgical sequelae (eg, after acoustic neuroma resection), frequently have the expectation that facial movement will spontaneously return. When the spontaneous recovery time frame has elapsed and facial paresis remains, patients are typically told there is nothing further that can be done to improve recovery. Lack of attention to inadequate facial function can lead to dysfunctional facial movements and psychosocial consequences. Individuals with facial paresis suffer from a host of functional limitations, including difficulty with eye closure, eating, drinking, speaking clearly, smiling, and expressing emotions.1-3 Address reprint requests and correspondence: Mara Wernick Robinson, PT, MS, NCS, Facial Nerve Center, Massachusetts Eye and Ear Infirmary, 243 Charles Street, 9th Floor, Boston, MA 02114. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.otot.2012.10.002
The facial muscles have unique characteristics that differentiate them from other skeletal muscles. These muscles lack fascial envelopment and tendinous or bony attachments that allow the muscles to move freely. Facial muscles lack muscle spindles, have small motor units, are relatively slow to degenerate, and most importantly, receive emotional as well as volitional neural inputs.4-6 Facial rehabilitation is effective because the techniques are based on those unique characteristics as well as the subtle nature of expression.5,6 One of the most common sequelae of incomplete facial nerve injury is synkinesis, or aberrant nerve regeneration. After nerve trauma, axons project from the facial nucleus and throughout the length of the nerve to “incorrect” peripheral muscle groups.7 For example, a portion of the axons that innervate the orbicularis oris aberrantly regenerates and innervates the orbicularis oculi. A common synkinetic muscle pattern involves cocontraction of the oculi muscles with lip puckering. One of the primary goals of facial rehabilitation, although often the most overlooked one, is synkinesis management. Specific neuromuscular reeducation exercises teach the patient how to symmetrically move the facial muscles, while simultaneously controlling associated synkinesis.5,8-11 Additionally, soft-tissue mobili-
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zation8-11 and relaxation techniques are taught to facilitate the control over synkinesis.12 An increasing body of research in facial rehabilitation has documented conservative options for recovery of facial nerve injury, and presents an attractive option for most patients before pursuing surgery. Facial rehabilitation, in the form of functional neuromuscular reeducation (NMR),5,8,9,11,13-16 surface electromyographic (EMG) biofeedback,14,17,18 mime therapy,19 and video self-modeling,20 has been shown to be effective for patients with long-standing facial paresis. Support for facial rehabilitation has been well documented, yet patients continue to be undermanaged based on lack of knowledge regarding effective treatment. Furthermore, when treatment is prescribed, a referral for electrical stimulation is often made despite the fact that electrical stimulation produces mass facial muscle action and may lead to more severe synkinesis.21,22 The objective of this article is to outline a treatment intervention algorithm for adults and children with chronic (⬎3 months) facial nerve injury, including the management of postsurgical facial reanimation. Our center’s goal is to establish a consensus among therapists and physicians regarding optimal facial nerve rehabilitation and expected outcomes. The multimodality management of the paralyzed face23 and suggested facial rehabilitation treatment algorithm11 have been previously described. In light of the increasing success of dynamic surgical reanimation,24,25 we present an algorithm that includes a comprehensive postsurgical rehabilitation program (Figure 1).
Evaluation All patients are evaluated by the team of an otolaryngologist and a physical therapist. Included in the initial evaluation are still photographs, and video analysis of facial expression. During physical therapy (PT) patients are also asked to complete the Facial Clinimetric Evaluation (FaCE) (Appendix). The FaCE is a disease-specific self-report questionnaire for the assessment of disabilities of patients with facial nerve disorders. Its reliability and validity have been previously demonstrated.26 Because the FaCE does not assess synkinesis, patients are also asked to complete the Synkinesis Assessment Questionnaire (SAQ)27 (Appendix). The SAQ is a simple patient-graded instrument designed to assess facial synkinesis associated with facial expression. It has been demonstrated to have high test–retest reliability, internal consistency, and construct validity after chemodenervation.27 The Sunnybrook Facial Grading Scale (FGS) (Appendix) is a performance-based measure of facial impairment in 3 areas: resting position, voluntary movement of 5 facial expressions, and associated synkinesis.28 The reliability and validity of the FGS has been demonstrated.28 Scoring of the FGS is out of 100 points: a low score indicates more severe facial dysfunction. Additional facial movements (eg, scowl, pout) that are not included on the FGS are also examined and graded with similar scoring. A systems review (eg, gait and balance) is performed to ensure
289 that the entire patient is screened, and relevant medical history is taken into account when making an assessment of the patient’s likelihood to meet the established goals. Finally, and most importantly, the therapist must gain an understanding of the patient’s goals and expectations. The entire process, from evaluation to assessment and treatment planning, is based on the patient’s level of nerve injury and degree of paralysis, the presence of synkinesis, the degree of functionality, and the patient’s individual goals. Patients with facial paresis who have incomplete loss of nerve function (eg, infection, trauma) will likely benefit from facial rehabilitation, and are placed in the Facial Rehabilitation for Incomplete Nerve Injury category. Patients with facial paralysis who have complete irreversible nerve loss or have known congenital facial paralysis are placed in the Facial Rehabilitation for Complete Nerve Injury and Surgical Consideration category (Figure 1).
Facial rehabilitation for incomplete nerve injury Patients in this category may begin rehabilitation 3 months after the onset of facial paralysis. Given the high rate of spontaneous recovery in viral facial paralysis (eg, Bell palsy) within the first 3 months, rehabilitation beyond patient education and eye protection is not typically provided. Patients with long-standing paresis (⬎3 months) are also eligible and can benefit from facial rehabilitation.11 Determination of the appropriate facial rehabilitation treatment category, initiation, facilitation, movement control, and relaxation is based on results of the FGS, FaCE, and SAQ. Classifying facial nerve disorders into treatment-based categories is a valid method for categorizing patients with specific impairments and guides treatment planning.8,9 During all initial PT evaluations, patient education regarding the anatomy and function of facial muscles, as well as the phenomenon of synkinesis, is provided. Patient education is a valuable tool in the facial rehabilitation process. Figure 2 is a simplified schematic given to patients to guide their understanding of the relationship between the nerves and the designated action of individual facial muscles.
Initiation Patients who have moderate to severe facial asymmetry at rest, who are unable to initiate movement on the affected side, and who lack synkinesis, are placed in the initiation treatment category. Patients are given instruction on gentle soft-tissue stretching and active assistive movement exercises, with the goal of stretching the affected muscles and increasing circulation. The superficial soft-tissue stretching typically begins with focus on the musculature involved in movement of the midface (Figure 3) and progresses to include other facial musculature. Patients with facial paresis or paralysis may lack complete eye closure. Functionally, this can lead to impaired corneal health and ocular discomfort. Patients are taught how to stretch the affected eyelid.
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Soft-Tissue
Soft-Tissue
Soft-Tissue
Soft-Tissue
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Figure 1
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Treatment algorithm for individuals with facial nerve injury.
The goal is to passively lengthen the fibers of the levator palpebrae superioris, resulting in improved closure of the affected eye. Instruction for active assistive exercise is also provided, in which the patient is taught to use his or her finger to guide the movement pattern. For example, if the goal is to elevate the lip using the levator labii muscle, the
patient is instructed to place his or her finger on the side of the nose and gently guide the muscle superiorly. Lastly, patients are taught to avoid mass movements and to avoid overuse of the unaffected side. The rationale behind avoiding mass movement patterns is based on the properties of the length–tension relationship. The affected flaccid mus-
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291
Schematic diagram of facial nerve branches and muscles, provided for patient education.
cles will not contract effectively if they are lengthened by the pull of the opposite unaffected side. In a skeletal muscle fiber, the amount of tension generated during a contraction depends on the number of pivoting cross-bridges in all the sarcomeres along all the myofibrils. This disruption of the normal arrange-
ment of thick and thin filaments interferes with the binding of cross-bridges to active sites. As a result, little tension is produced when the muscle fiber is stimulated while stretched. Within the optimal range of sarcomere lengths, the maximum number of cross-bridges can form and the tension produced is
Figure 3 Soft-tissue mobilization of the zygomaticus major and minor. The patient places his/her thumb inside the mouth and 2 or 3 fingers on the outer surface of the cheek, just below the proximal section of the zygomatic arch. The patient then applies firm pressure, as the thumb and fingers slide inferiorly toward the commissure of the mouth.
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Figure 4 Neuromuscular reeducation along with mirror feedback to retrain a smile. The patient is instructed to look in the mirror and bring up both corners of the mouth slowly to form a symmetric smile, while also controlling the associated synkinesis.
highest. Any further increase in sarcomere length reduces the tension produced by reducing the size of the zone of overlap and the number of potential cross-bridge interactions. The muscle fiber cannot produce any tension, and a contraction cannot occur. In summary, facial muscle fibers may contract most successfully when positioned in their resting state.29
Facilitation Patients who have mild to moderate facial asymmetry at rest, who are able to initiate slight movement, and who do not have synkinesis are deemed appropriate to start treatment within the guidelines of the facilitation treatment category. Patients who are originally categorized or progress to the facilitation treatment category are taught soft-tissue stretching of the facial muscles, active assistive exercises, and NMR exercises. The mainstay of facilitation exercises is to foster axonal regeneration through guided small-movement exercise. NMR exercises are prescribed based on the motor control impairments of the individual patient. The goal of NMR exercises is to perform small, slow, and controlled facial movements with emphasis on symmetry between the 2 sides of the face. For example, when relearning to smile, patients are instructed to form a small “Mona Lisa” smile. While looking in the mirror, patients are encouraged to focus on moving the corner of the mouth upward, while simultaneously making an emotional connection to a pleasant experience. Owing to the lack of muscle spindles in the facial musculature, there is minimal proprioceptive input, so visual feedback is imperative for increasing awareness and performance of graded movements within the muscles. A mirror is used to provide patients with this necessary feedback. Surface EMG is also used to provide the patient with biofeedback during these exercises.17,18 An auditory or visual signal from the EMG electrodes placed on the desired muscles tells the patient that he or she is successful at generating muscle activity during the in-
tended action. For example, surface EMG electrodes placed inferiorly and superiorly on the affected orbicularis oris would signal that the lip muscles were active during pucker or articulation. Surface EMG electrodes can also be applied to the unaffected side to help the patient minimize overcontraction of the stronger oris, with the goal of a symmetrical pucker movement pattern. Lastly, patients in the facilitation category are educated about the possibility of synkinetic movement patterns as nerve regeneration progresses.
Movement control Patients who have mild to moderate facial asymmetry at rest, who are able to initiate at least slight movement, and who have developed synkinesis are placed in the movement control category. Patients who are originally categorized or who advance into the movement control category are taught more aggressive soft-tissue stretching of the facial muscles, NMR exercises with mirror and EMG biofeedback, and relaxation and meditation strategies. NMR for patients in the movement control category consists of teaching the patient to generate small movements while simultaneously controlling synkinesis. For example, the patient is taught to form a small symmetrical smile while also controlling his or her periocular synkinesis (Figure 4). Controlling synkinesis is described to the patient as releasing the tension, as in draining an inflated tire, or as directly opposing the unwanted contraction. Managing synkinesis is extremely challenging for most patients and initially requires the utmost concentration along with mirror feedback. Movement control, also termed small-movement therapy or NMR, takes many repetitions to achieve mastery. Patients are advised to practice the movement control exercises for at least 40 repetitions per independent session, 2 to 4 times per day. The notion that practice improves neuronal connection and facilitates new motor patterns underlies the recommenda-
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tion of the frequency of practice. At this stage, the goal is to improve motor control, not to improve muscle strength. Current theories in motor control support that proper practice is the most important in forming new movement patterns.30 EMG biofeedback can also be used as a means of providing the patient with feedback to control synkinesis by placing the EMG electrodes on the synkinetic muscle. In the common example of periocular synkinesis, the electrodes are placed on the lateral periocular muscles and the patient aims to minimize the EMG signal of the oculi muscles during smiling or during puckering. Because a majority of facial expressions are emotionally driven, video analysis during spontaneous conversations is an integral part of movement control.20 Patients with severe synkinesis may begin to have limited movement owing to tightness rather than weakness. Therefore, the relaxation and meditation strategies are provided.
293 lease synkinesis in targeted regions, mainly the orbicularis oris, mentalis, and platysma. Occasionally, the unaffected frontalis and depressor labii inferior are injected to achieve symmetry at rest for forehead rhytids and symmetrical coverage of the lower dentition during smiling, respectively. Contralateral lower lip weakening also provides a more symmetrical appearance during articulation. Botulinum toxin is considered after the patient has undergone at least 3 therapy sessions. The timing of the botulinum toxin injections in the facial rehabilitation process allows the patient to first learn conscious control over the synkinesis without reliance on medical intervention. For the attentive patient, the process of gaining control over synkinesis typically takes 2 to 3 months. Patients must fully understand the role of synkinesis and how it negatively affects motor control, before chemodenervation alters the muscle function.
Relaxation Patients with severe pan-facial tightness related to synkinesis are placed in the relaxation category. These patients typically have limited movement owing to tightness rather than weakness; therefore, the emphasis of treatment is relaxation–meditation. Meditation, using guided visual imagery, focuses on teaching patients how to release the tension in the synkinetic musculature. Verbal cues to help minimize synkinesis include “drain the tension around the eye” (ie, for ocular synkinesis) and “deflate the fully inflated balloon in your cheek” (ie, for midface synkinesis felt during eye closure). Patients are also instructed on soft-tissue mobilization. NMR with mirror or EMG biofeedback, described for patients in the facilitation and movement control category, is taught later, as movement control is more successful when the facial tightness is managed first. The general guideline for facial rehabilitation is to perform the individualized stretches, NMR exercises, and relaxation–meditation daily. Individualized treatment sessions are typically monthly, during which their program is reviewed and progressed as indicated. Patients are instructed on only 2 to 3 new exercises each session, to promote optimal learning and compliance. It is better to practice and achieve mastery of a few movement patterns than to practice multiple movement patterns ineffectively. The cumulative nature of patient education, individualized modifications of facial rehabilitation, and psychological support provide the individual with the necessary tools for the lifelong maintenance of their facial nerve injury.
The role of chemodenervation Chemodenervation, in the form of botulinum toxin type A (Botox, Allergan, Inc, Irvine, CA) injections, has a wellestablished record of minimizing synkinesis in patients with facial nerve disorders.31,32 Botolinum toxin is used to re-
Facial rehabilitation for complete nerve injury and surgical consideration for dynamic surgical reanimation When patients present with complete nerve injury, for example, after sacrifice of the facial nerve during skull base tumor excision, a trial of facial rehabilitation is provided. The purpose of the brief facial rehabilitation process (eg, 2-3 sessions) is to teach the patient compensatory functional movement strategies and monitor change during the potential for partial nerve recovery stage. Typically, patients remain in the initiation and facilitation category. The decision to advance from facial rehabilitation to dynamic surgical reanimation is made by the patient and the entire treatment team, with the primary motivation being patient satisfaction. When the goal is a meaningful smile, or the feeling of executing a smile, and this is not achieved through facial rehabilitation, the surgical options are presented as (1) trigeminally driven free muscle transfer, (2) temporalis muscle transfer, and (3) free muscle driven by cross-face nerve graft. After dynamic surgical facial reanimation, rehabilitation plays a significant role in training the newly placed free muscle. Patients are then reevaluated and recategorized to guide the appropriate treatment intervention. Typically, patients begin in the initiation category and progress to the facilitation category. More recently, dynamic surgical reanimation is provided for patients with a “frozen face” related to severe synkinesis. The term “frozen face” is used to describe the patient who is unable to generate commissure excursion owing to severe synkinesis, and who has been refractory to chemodenervation. Therefore, the patient with preexisting synkinesis who undergoes a free muscle transfer would be categorized into the facilitation category and would eventually progress to the movement control category.
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Facial rehabilitation after trigeminally driven free muscle transfer and temporalis muscle flap After the 1-stage trigeminally driven free muscle transfer surgery, movement in the midface occurs when the patient bites down, as a result of free muscle innervation by the masseteric branch of the trigeminal nerve. Patients are expected to see muscle activity at approximately 6 to 20 weeks postoperatively and are referred for PT at that time. If the patient does not have any visible movement, they are placed in the initiation category, and the treatment intervention is similar to the nonsurgical patient. The goal of soft-tissue mobilization when the patient is treated in the initiation category is to decrease postsurgical edema that commonly occurs after muscle surgery. Additionally, patients are advised to chew gum to foster activation of the free muscle driven by biting. If there is trace movement in the free muscle when the patient bites down, the patient is placed in the facilitation category. The patient is instructed to gently bite down using a mouth guard, a tongue depressor, or
gauze pad while using mirror feedback to form a smile. The verbal cue to gently bite and smile while making the connection to a happy thought, with the lips together, fosters a natural appearing grin without dentition exposure. The patient progresses to biting down using a thicker structure (stack of tongue depressors and thicker gauze) that demands less biting effort, to form the smile. The ultimate goal is to form a smile without biting. The facial rehabilitation exercises after the temporalis muscle transfer surgery are similar. Because the temporalis is a biting muscle and has been transposed to function as a prime mover of the oral commissure, the patient is instructed to bite down to form the smile. The long-term goal in both the temporalis muscle flap and the 1-stage trigeminally driven free muscle transfer is to provide commissure excursion without biting down, or at least biting down with minimal effort. Because the trigeminally driven muscle is not designed to reinnervate the lower facial muscles, a full smile with top and bottom dentition exposure is not typically expected, and therefore not encouraged during the
Figure 5 Four patients with history of facial nerve injury. The top row shows photos that were taken at the time of the initial evaluation. The bottom row shows photos taken after facial rehabilitation. Patient A has a history of congenital facial paralysis and had 3 years of facial rehabilitation only. Patient B has a 6 month history of Bell palsy and underwent facial rehabilitation ⫻ 3 months, followed by chemodenervation. Patient C has a 2-year history of complete right-sided facial paralysis related to an acoustic neuroma resection. She underwent a free muscle transfer driven by a cross-face nerve graft, followed by 16 weeks of facial rehabilitation. Patient D has a 39-year history of incomplete right-sided facial nerve injury related to an acoustic neuroma resection. She underwent a trigeminally driven free muscle transfer, followed by 16 weeks of facial rehabilitation. (Color version of figure is available online.)
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facial rehabilitation process. Patients in this surgical category may gain upper lip motion; therefore, exercises to facilitate lip mobility without biting are also taught. Surface EMG biofeedback is also a useful treatment tool for patients who have undergone a free or regional muscle transfer. Electrodes are placed on the midface musculature, now responsible for oral commissure excursion. The patient is provided with an audio or visual signal to signify that the muscle has been activated. EMG is used as a treatment technique, with the patient striving for increased motor activity consistent with free muscle contraction.
Facial rehabilitation after free muscle transfer driven by a cross-face nerve graft After the 2-stage free muscle transfer driven by a crossface nerve graft surgery, movement in the midface occurs when the individual smiles, as a result of innervation from the contralateral facial nerve to the free muscle. Patients who have undergone the 2-stage cross-face surgery are expected to see muscle activity at approximately 6 to 9 months after the second stage and are referred for PT at that time. If the patient does not have any visible movement, they are placed in the initiation category, and the treatment intervention is similar to that for nonsurgical patient. If there is trace movement in the free muscle when the patient smiles, the patient is placed in the facilitation category. Contraction of the free muscle is generated when the patient smiles either voluntarily or spontaneously. Rehabilitation is also based on small-movement therapy with the goal of placing the newly transferred muscle in optimal position for activation. Patients in this surgical category may gain upper lip motion; therefore, exercises to facilitate lip mobility are also taught. The most desirable outcome in facial reanimation surgery would be complete return of premorbid function and appearance. Unfortunately, this rarely can be achieved. However, with the appropriate facial rehabilitation and optimal procedures, satisfactory outcomes are achieved. In summary, patients with long-standing facial nerve disorders benefit from skillful facial rehabilitation, chemodenervation, and surgery. Figure 5 demonstrates baseline and follow-up photographs of 4 patients who have undergone facial rehabilitation and surgical reanimation.
295 succeed in the facial rehabilitation process. All rehabilitation interventions, whether in the nonsurgical or postsurgical patient, require a long-standing commitment on the patient’s behalf, and patients who possess the motivation necessary to commit to a consistent and thorough home program are most successful. Education of the individual with facial paralysis is a critical component of the program, which results in the patient’s ability to report specific details of functional deficits and self-monitor changes as the program progresses. Rehabilitation goals must be tailored to the impairments of the individual on a functional, cosmetic, and emotional level. Functional outcomes that can be expected include improved ability to smile, eat, drink, speak clearly, and blink or close the affected eye. Additionally, reduction of facial pain and tension in the affected musculature is achieved. At the interpersonal level, willingness to participate in social activities and improved self-confidence are realistic goals. The collaboration between and within disciplines is essential to ensure that thorough and appropriate treatment is provided to each individual patient. The interdisciplinary approach is an important component of a facial rehabilitation program, allowing for increased understanding of, and growth within, both the nonsurgical and surgical treatment realms, and has an impact on the advancement of options that can be provided to this patient population. The continued growth of the field of facial reanimation surgery will result in improved functional outcomes for patients with facial paralysis. The facial rehabilitation team plays an integral role in maximizing the quality of these functional improvements, as well as the quality of life for people affected by facial nerve injuries. Facial expression, especially smiling, is such an integral part of who we are and how we present ourselves to others. The loss of this ability can be devastating to many patients with a facial nerve injury, and these patients deserve the attention of the medical community. Increased awareness of the issues that patients encounter and increased awareness of current treatment options will only serve to advance effective patient management for patients with facial nerve disorders.
Appendix. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.otot.
Discussion Although facial rehabilitation cannot restore a “perfect” cosmetic or premorbid appearance, appropriate intervention can make a substantial difference in facial muscle motor control, with the ultimate goal of improved physical function, enhanced cosmesis, and increased self-confidence. Patients can be empowered by learning self-management tools to maximize function and appearance even if they were led to believe that nothing could be done to improve their facial paralysis. We believe that knowledge is power, and that the well-informed and fully involved patient is most likely to
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