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Integrated Approaches For Reconstruction of Facial.12
Integrated Approaches For Reconstruction of Facial.12
Annals of Plastic Surgery • Volume 90, Supplement 2, May 2023 www.annalsplasticsurgery.com S165
Presentations Solutions
Upper face Eyebrow symmetry Contralateral medial frontalis-periosteal flap transfer
Corrugator and procerus wrinkles Myotomy for the affected side or Botox injection
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outcome of facial palsy reconstruction have been conducted over the The following are our general principles to plan the treatment for
years.16–25 Several investigations also addressed eyelid problems with facial paralysis patients:
cartilage grafting, which was subsequently refined by botulinum toxin 1. Facial nerve injury should be repaired or nerve grafted immediately
A and hyaluronic acid injections.26–31 if it is timely recognized. Inadvertent injury should be treated as soon
The present study was aimed to delineate treatment plans for fa- as possible.32,33 If remained untreated, the facial muscles end up with
cial paralysis with different clinical scenarios and to report the results of atrophy and undergo fatty metamorphosis gradually.
these patients. 2. For facial palsy with infectious origin, younger patients might show
various degrees of neurotization from the contralateral facial nerve or
underlying masticatory muscle, and the deformity might not be as se-
PATIENTS AND METHODS vere. However, spontaneous neurotization is usually not observed in
Having been working at the tertiary referral medical center, the elderly patients so that deformity and asymmetry in appearance
authors have been dealing with treatments for a variety presentations would be more prominent. Early neurotization with cross-facial
of facial palsies, amounting 362 patients during 40 years (Table 1 and nerve grafting is beneficial to elderly patients as well as young pa-
Table 2). However, some data had been lost. Now only the data of tients with partial recovery.
179 cases with follow-up for more than 3 years are available. The data 3. Because the presentation of facial palsy is diverse, treatment strategy
are presented in the tables. should be multimodal, including both surgical and nonsurgical ap-
proaches. Surgical modalities include cross-facial nerve graft, free
TABLE 2. Evaluation of Results After Reconstruction muscle transfer, local muscle transfers, sling procedures using fascial
or tendon grafts, and fat grafting. Nonsurgical treatments, including
A. Functional
botulinum toxin and filler injection, are usually applied as touch-ups
to refine the symmetry after surgical management or for patients
No drooling from mouth angle
who are unable or unwilling to undergo surgeries.
Speech intelligibility 4. Facial paralysis affects not only the appearance of the patient but also
Can close the eye completely creates tremendous psychosocial stress, especially social withdrawal,
Can lift eyebrow and severe depression. The affected individuals usually wish to re-
B. Aesthetic cover in no time with limited surgeries and costs. Therefore, detailed
Eyebrow symmetry explanation and achievable goals should be clarified and explicitly
No lower eyelid laxity explained to the patients before obtaining the consents.
Symmetry of bilateral nasal ala
Lower lip symmetry on expression
Symmetry of face, static TABLE 3. Data of Group 1: Facial Palsy With Incomplete Recovery,
Symmetry while smiling Treated With Cross-Facial Nerve Grafting and Partial Weakening of
C. Social Contralateral Overacting Muscles
Can assume a job
Case Average Result
Does not need to wear mask Number Age Sex Radiation/Trauma (Symmetry of Face)
Total points 12
10 points: excellent 24 34.2 y M/F = 10/14 2/24 had RT* before Good in 22 cases
8 points: good 1/24 due to trauma Fair in 2 cases
(radiated)
6 points: fair (acceptable)
4 points: poor *RT indicates radiation therapy for nasopharyngeal cancer.
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was attempted to obtain facial balance, and upper and lower blepha-
TABLE 4. Group 2: Young Patients of Facial Palsy Without roplasties with strip myectomy of orbicularis oculi muscles might
Recovery, Treated With Cross-Facial Nerve Graft Followed by significantly mitigate the severity of periocular twitching; and
Free-Functioning Muscle Transfer 7. Group 7, facial paralysis with dynamic asymmetry and soft tissue/
muscle atrophy in patients who did not want major reconstructive
Result (Facial surgery: subtle weakening of contralateral side levator labii superioris
Case Number Average Age Sex Radiation Symmetry)*
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28 25.6 y M/F = 3/25 1/27 Good in 17 cases palmaris longus sling for nasal ala, lateral canthopexy, followed by filler
Acceptable in 11 cases or fat injection for soft tissue augmentation to improve facial symmetry.
Photographs with focal obscuring permit had been obtained
*All had auxiliary procedures for eyelids, fat grafts, and weakening for contra- from all the presented patients.
lateral depressor anguli oris and depressor inferioris, and so on.
RESULTS
In our series, patients with facial palsy were categorized based on Group 1 patients achieved satisfactory results. Those in group 2
the following clinical scenarios: could achieve fair results, but several revisions were often required to
1. Group 1, facial paralysis with incomplete recovery: cross-facial achieve good results. Group 3 patients can effectively lift the affected
nerve grafting with spreading of branches to innervate facial expres- side of face. Partial weakening of contralateral facial expression mus-
sion muscles and partial weakening of overacting muscles on the cles might help to balance the facial expression. In group 4, significant
contralateral side; improvement of facial contour and facial symmetry could be obtained.
2. Group 2, young patients of facial paralysis without recovery: In group 5, for palsy of frontal branch of facial nerve, strip frontalis
cross-facial nerve graft with subsequent free muscle transfers; muscle-periosteal sling operation could provide good results. For palsy
3. Group 3, senile facial palsy without recovery: local muscle transfers of zygomatic branch of facial nerve, recovery could be reasonably ex-
and sling procedures, including temporal muscle, masseter muscle pected in 12 months. For palsy of marginal mandibular branch of facial
transfers, medial frontalis transfers, circumferential sling operation nerve, partial myectomy of contralateral side depressor anguli oris and
with lateral canthopexy for tightening of eyelids, plantaris or depressor labii inferioris could provide long-term results regarding
palmaris tendon sling to lift up nasal alar cartilage with fixation at symmetry of the lower lip. In group 6, for patients with partial recovery
lateral aspect of orbital floor to form a natural nasolabial fold, in con- and dyskinesia, chemical myectomy with Botox injection, followed by
junction with temporal muscle for dynamic action; partial myectomy of orbicularis oculi muscle with lateral canthopexy,
4. Group 4, combined facial palsy with mandibular deficiency: palmaris longus tendon sling operation showed good outcomes. In group
vascularized osteocutaneous flap transfer was required for reconstruc- 7, facial paresis with dynamic asymmetry and soft tissue/muscle atrophy,
tion of mandible, and facial palsy was addressed with (a) subsequent subtle weakening of contralateral levator labii superioris and zygomaticus
muscle transfer or (b) simultaneous sling operation or (c) simultaneous minor with botulinum toxin injection, in addition to palmaris longus ala
facial nerve exploration and cross nerve grafting, which might be used sling operation and lateral canthopexy, followed by filler injection for soft
for patients without atrophy of facial expression muscles (otherwise tissue augmentation could obtain a fair balancing effect (Table 3, Table 4,
regional functional muscle transfers or static sling operation with sub- Table 5, Table 6, Table 7, Table 8, and Table 9) (Chen’s classification;
tle weakening of contralateral facial expression muscles might help case presentations, Fig. 1, Fig. 2, Fig. 3, Fig. 4, and Fig. 5).
balance the contour and symmetricity of the face);
5. Group 5, palsy of individual branch of facial nerve (a) for palsy of
frontal branch of facial nerve: contralateral medial frontalis strip DISCUSSION
muscle-periosteal sling transfer, (b) for palsy of zygomatic branch Facial paralysis is clinically challenging. This condition causes
of facial nerve: lateral canthopexy for lower eyelid laxity and tendon not only facial deformity but also psychosocial embarrassment. Most
sling to lift nasal ala with fixation to lateral inferior orbital rim, (c) for patients are unilateral, owing to infection, trauma, brain tumor surgery,
palsy of buccal branch, spontaneous recovery was usually expected parotid tumor operations, or radiation necrosis. Mobius syndrome with
if the neighboring branches were functional, (d ) for palsy of mar- bilateral facial palsy has never been encountered in our group.
ginal mandibular branch, partial myectomy of the contralateral de- For patients with facial paralysis with incomplete recovery or
pressor anguli oris and depressor labii inferioris through intraoral in- young patients without recovery, cross-facial nerve grafting is the primary
ferior vestibular approach; treatment, and subsequent free muscle transfer could be performed if
6. Group 6, patients with partial recovery and dyskinesia and did not
have major reconstructive surgery: botulinum toxin injection at the
overacting muscles with weakening of the contralateral muscles
TABLE 6. Group 4: Facial Palsy Combined With Mandible Defect
(Treatment: See Text)
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TABLE 7. Group 5: Palsy of Individual Branch of Facial Nerve (Treatment: See Text)
Marginal mandibular branch 7 31.6 M/F = 7/0 Trauma in 7 cases Good in 7 cases
TABLE 8. Group 6: Patients With Partial Recovery and Dyskinesia (Treatment: See Text)
TABLE 9. Group 7: Facial Palsy With Dynamic Asymmetry and Soft Tissue/Muscle Atrophy (Treatment: See Text)
FIGURE 1. A and B, Image showed cross-facial nerve grafting with subsequent free gracilis muscle transfer. This 28-year-old female
patient had experienced complete left facial palsy since childhood, which did not recover. In the first stage, a cross-facial nerve graft
was done and Tinel sign was followed. Ten months later, a functioning muscle transfer was performed, and lateral canthopexy of left
lower eyelid was done. The patient showed good recovery with symmetry of face on smiling at 2 years of follow-up.
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FIGURE 2. This is a 48-year-old female patient of Ramsey-Hunt syndrome with involvement of multiple cranial nerves. For older facial
palsy patients without recovery, regional muscle transfer using temporalis muscle could be performed to restore the dynamic
symmetry of the face. Circumferential sling operation using palmaris tendon graft and lateral canthopexy was performed to tighten the
eyelids. Plantaris tendon sling was applied to lift left nasal alar cartilage for creation of left nasolabial fold for static symmetry, which
worked well with the transferred temporal muscle dynamic action (left upper photo: preoperative presentation; right upper and left
lower photos: during surgery, the temporalis muscle was elevate; left lower photo also showed the tendon sling facilitated
circumferential eyelid closure; right lower photo: good symmetry of face).
there is no return of local muscle function. Partial weakening of contralat- atrophy of facial expression muscles, which could be confirmed by
eral muscles using botulinum toxin could refine the results. obtaining the compound muscle action potential of the affected side.
For old patients experiencing facial palsy without recovery, re- Otherwise, regional functional muscle transfers or static sling operation
gional muscle transfer including temporalis muscle, masseter muscle, with subtle weakening of contralateral facial muscles may facilitate the
and medial frontalis muscles are helpful to restore dynamic motion balance of bilateral facial muscles and achieve facial symmetricity.
and symmetricity, whereas circumferential sling operations and lateral Regarding defect of the mandible, for minor mandibular defi-
canthopexy are a useful approach for eyelid tightening to avoid dry ciency as in some cases with Goldenhar syndrome, in patients with
eyes. Additional tendon sling operation could be used to restore static good occlusion, they chose not to do bone surgery such as sagittal split-
symmetry of the nasal ala and nasolabial fold, which could refine the ting or sliding genioplasty; instead, the patient preferred to receive
results of regional muscle transfer. Medpor mandibular implant onlay placement to correct hemifacial
For combined facial palsy with mandibular deficiency, recon- microsomia and also turned out to be successful. For major mandibular
struction with vascularized bone flap is inevitable to restore the contour deficiency, vascularized bone mandibular reconstruction is necessary.
and stability of mandible as well as soft tissue insufficiency. Simulta- Regarding eyelid weights, placement of custom-made eyelid
neously, cross-facial nerve grafting may be used for patients without gold weight had been tried in the past. Our experience was that it may
FIGURE 3. This 28-year-old patient had osteosarcoma treated with ablative surgery and radiation therapy, resulting in combined facial
palsy with mandible defect. She was treated with iliac osteocutaneous flap and temporalis muscle transfer. There was good symmetry
of face at 2 years of follow-up.
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FIGURE 4. This 18-year-old female patient experienced palsy of right frontal branch of facial nerve. For palsy of individual branch of
facial nerve such as frontal branch palsy, contralateral (left) medial frontalis strip muscle-periosteal sling transfer was done. There was
good recovery resulting in symmetry of upper face.
cause eye discomfort, looked unnatural, and may cause thinning of skin CONCLUSIONS
and possibility of extrusion. Nowadays, the ophthalmologist may use
injection of hyaluronic acid as a source of adding weight to the upper Paralysis of the face has been a challenging and complicated
eyelid. However, it seemed that the effect of correction was minimal. theme regarding how to alleviate the trauma caused by face cripple. The pa-
In old patients, nerve procedures could bring about variable de- tient may face the problem of time and energy spent for correction of facial
gree of improvement, then other auxiliary procedure were performed deformities. For reconstruction of facial paralysis, multimodal integrated
for further correction as mentioned in Table 1. approaches are mandatory, depending on the condition of the clinical
FIGURE 5. This 26-year-old woman had trauma in childhood resulting in palsy of marginal mandibular branch palsy. Myotomy of
depressor labii inferiois muscle was performed. There was good symmetry of lower face at 1 year of follow-up.
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presentation of each individual patient. Lengthy operations with 16. Terzis JK, Noah ME. Analysis of 100 cases of free-muscle transplantation for fa-
multiple stages should be retained until the problems cannot be cial paralysis. Plast Reconstr Surg. 1997;99:1905–1921.
solved otherwise. 17. Terzis JK, Karypidis D. Outcomes of direct muscle neurotization in pediatric pa-
tients with facial paralysis. Plast Reconstr Surg. 2009;124:1486–1498.
18. Terzis JK, Olivares FS. Long-term outcomes of free-muscle transfer for smile res-
ACKNOWLEDGMENTS toration in adults. Plast Reconstr Surg. 2009;123:877–888.
The authors would like to thank Mr Ming-Chieh Li for his assistance 19. Harrison DH, Grobbelaar AO. Pectoralis minor muscle transfer for unilateral fa-
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in editing this manuscript. This work was presented at the World Associ- cial palsy reanimation: an experience of 35 years and 637 cases. J Plast Reconstr
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 07/19/2023
ation of Plastic Surgery of Chinese Descendent, Paris, November 2021. Aesthetic Surg. 2012;65:845–850.
20. Garcia RM, Gosain AK, Zenn MR, et al. Early postoperative complications fol-
lowing gracilis free muscle transfer for facial reanimation: a systematic review and
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