Facial Palsy: Diagnostic and Therapeutic Management

Contents

Foreword: You’re Never Fully Dressed Without a Smile xv

Sujana S. Chandrasekhar

Preface: Facial Palsy: Diagnostic and Therapeutic Management xvii

Teresa M. O, Nate Jowett, and Tessa A. Hadlock

The Importance and Psychology of Facial Expression 1011

Lisa E. Ishii, Jason C. Nellis, Kofi Derek Boahene, Patrick Byrne, and Masaru Ishii
Facial expression is of critical importance in interpersonal interactions. Thus,
patients with impaired facial expression due to facial paralysis experience
impaired social interactions. Numerous studies have shown that patients
with facial paralysis and impaired facial expression suffer social conse-
quences as demonstrated by being rated negatively with regards to attrac-
tiveness, affect display, and other traits. This has been demonstrated
subjectively and objectively. Fortunately, reconstructive surgeries that
restore the ability to express emotion can restore normalcy in these patients.

A General Approach to Facial Palsy 1019

Nate Jowett
Management of facial palsy can be daunting. This article presents a con-
ceptual framework for classification and therapeutic management of facial
palsy.

Outcome Tracking in Facial Palsy 1033

Joseph R. Dusseldorp, Martinus M. van Veen, Suresh Mohan, and
Tessa A. Hadlock
Outcome tracking in facial palsy is multimodal, consisting of patient-re-
ported outcome measures, clinician-graded scoring systems, objective
assessment tools, and novel tools for layperson and spontaneity assess-
ment. Patient-reported outcome measures are critical to understanding
burden of disease in facial palsy and effects of interventions from the pa-
tient perspective. Clinician-graded scoring systems are inherently subjec-
tive and no 1 single system satisfies all needs. Objective assessment tools
quantify facial movements but can be laborious. Recent advances in facial
recognition technology have enabled automated facial measurements.
Novel assessment tools analyze attributes such as spontaneous smile,
emotional expressivity, disfigurement, and attractiveness as determined
by laypersons.

Medical Management of Acute Facial Paralysis 1051

Teresa M. O
Acute facial paralysis (FP) describes acute onset of partial or complete
weakness of the facial muscles innervated by the facial nerve. Acute FP
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occurs within a few hours to days. The differential diagnosis is broad; how-
ever, the most common cause is viral-associated Bell Palsy. A compre-
hensive history and physical examination are essential in arriving at a
diagnosis. Medical treatment for acute FP depends on the specific diag-
nosis; however, corticosteroids and antiviral medications are the corner-
stone of therapy. Lack of recovery after 4 months should prompt further
diagnostic workup.

Surgical Management of Acute Facial Palsy 1077

Daniel Q. Sun, Nicholas S. Andresen, and Bruce J. Gantz
Bell palsy and traumatic facial nerve injury are two common causes of
acute facial palsy. Most patients with Bell palsy recover favorably with
medical therapy alone. However, those with complete paralysis (House-
Brackmann 6/6), greater than 90% degeneration on electroneurography,
and absent electromyography activity may benefit from surgical decom-
pression via a middle cranial fossa (MCF) approach. Patients with acute
facial palsy from traumatic temporal bone fracture who meet these same
criteria may be candidates for decompression via an MCF or translabyrin-
thine approach based on hearing status.

Management of Flaccid Facial Paralysis of Less Than Two Years’ Duration 1093
Andrew William Joseph and Jennifer C. Kim
Flaccid facial paralysis results in disfiguring facial changes. The treatment
of flaccid facial paralysis is complex and treatment approaches should be
determined based on duration and the causes of paralysis, status and
accessibility of the affected facial nerve, medical comorbidities, and pa-
tient-specific goals. Although primary nerve repair is the preferred treat-
ment strategy when possible, nerve substitution procedures are the
mainstay of treatment for patients with flaccid facial paralysis of less
than 2 years duration.

Management of Long-Standing Flaccid Facial Palsy: Periocular Considerations 1107

Natalie Homer and Aaron Fay
Ineffective eyelid closure can pose a serious risk of injury to the ocular sur-
face and eye. In cases of eyelid paresis, systematic examination of the eye
and ocular adnexa will direct appropriate interventions. Specifically, 4
distinct periorbital regions should be independently assessed: eyebrow,
upper eyelid, ocular surface, and lower eyelid. Corneal exposure can
lead to dehydration, thinning, scarring, infection, perforation, and blind-
ness. Long-term sequelae following facial nerve palsy may also include
epiphora, gustatory lacrimation, and synkinesis.

Management of Long-Standing Flaccid Facial Palsy: Midface/Smile: Locoregional

Muscle Transfer 1119
James A. Owusu and Kofi Derek Boahene
Masseter and temporalis muscle transfer is an effective technique for
restoring facial symmetry and commissure excursion in flaccid facial paral-
ysis. Adherence to the principles and biomechanics of muscle transfer is
essential for achieving optimal results. Muscle transfer has the advantage
 Contents xi

of being single staged with fast recovery of function. It is particularly useful

in patients with low life expectancy or multiple comorbidities where a more
complex, multiple stage procedure may be detrimental.

Free Gracilis Transfer and Static Facial Suspension for Midfacial Reanimation in
Long-Standing Flaccid Facial Palsy 1129
Nate Jowett and Tessa A. Hadlock
Video content accompanies this article at [Link]
com/.

This article presents an approach to reanimation of the midface in long-

standing flaccid facial palsy by means of functional free gracilis transfer
and static facial suspension.

Management of Long-Standing Flaccid Facial Palsy: Static Approaches to the

Brow, Midface, and Lower Lip 1141
Marissa Purcelli Lafer and Teresa M. O
Chronic flaccid facial paralysis (FFP>2 years) may be approached with
static and dynamic techniques. A horizontal zonal assessment evaluates
the upper, middle, and lower thirds of the face. Surgery is tailored to an in-
dividual’s deficits, goals, and health status. While dynamic reanimation is
the gold standard for rehabilitation, there are cases in which static ap-
proaches are more appropriate or may be used as an adjunct to dynamic
techniques. This article focuses on the surgical management of FFP pri-
marily using static approaches to the individual zones of the face to create
resting symmetry.

Facial Rehabilitation: Evaluation and Treatment Strategies for the Patient with
Facial Palsy 1151
Mara Wernick Robinson and Jennifer Baiungo
Video content accompanies this article at [Link]

This article describes the most widely used clinician-graded and patient-
reported outcome measures, and describes facial rehabilitation strategies
for acute and chronic facial palsy, and rehabilitation following dynamic
facial reanimation surgery. The multimodality rehabilitation of the facial
palsy patient is determined by the extent of facial nerve injury, specific
functional deficits, the presence of synkinesis, and the patient’s individual
goals. Appropriate intervention, including patient education, soft tissue
mobilization, neuromuscular reeducation, and chemodenervation, de-
creases facial tension and improves facial muscle motor control, physical
function, facial expression, and quality of life.

Surgical Management of Postparalysis Facial Palsy and Synkinesis 1169

Babak Azizzadeh and Julia L. Frisenda
Video content accompanies this article at [Link]
com/.

Modified selective neurectomy of the distal branches of the buccal, zygo-

matic, and cervical branches of the facial nerve in addition to platysmal
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myotomy is an effective surgical procedure for the treatment of postfacial

paralysis synkinesis. Success of this procedure depends on identification
of the peripheral facial nerve branches, preservation of zygomatic and
marginal mandibular branches that innervate key smile muscles, and abla-
tion of buccal and cervical branches that cause lateral and/or inferior
excursion of the oral commissure. Results are long-lasting; objective im-
provements in electronic clinician-graded facial function scale score,
House-Brackmann score, and decreased botulinum toxin-A requirements
have been observed.

Evaluation and Management of Facial Nerve Schwannoma 1179

Alicia M. Quesnel and Felipe Santos
Facial nerve schwannomas are benign peripheral nerve sheath tumors that
arise from Schwann cells, and most commonly present with facial paresis
and/or hearing loss. Computed tomography and MRI are critical to diag-
nosis. Management decisions are based on tumor size, facial function,
and hearing status. Observation is usually the best option in patients
with good facial function. For patients with poor facial function, the authors
favor surgical resection with facial reanimation. There is growing evidence
to support radiation treatment in patients with progressively worsening
moderate facial paresis and growing tumors.

Management of Vestibular Schwannoma (Including NF2): Facial Nerve

Considerations 1193
Vivian Kaul and Maura K. Cosetti
Current consensus on optimal treatment of vestibular schwannoma
remains poorly established; treatment options include observation, stereo-
tactic radiosurgery, microsurgical resection, medical therapy, or a combi-
nation of these. Treatment should be individualized and incorporate the
multitude of patient- and tumor-specific characteristics known to affect
outcome. Treatment paradigms for sporadic and neurofibromatosis type
2–related tumors are distinct and decision-making in neurofibromatosis
type 2 is uniquely challenging. In all cases, treatment should maximize tu-
mor control and minimize functional deficit.

Management of Bilateral Facial Palsy 1213

Leahthan F. Domeshek, Ronald M. Zuker, and Gregory H. Borschel
Bilateral facial paralysis is a rare entity that occurs in both pediatric and
adult patients and can have congenital or acquired causes. When paralysis
does not resolve with conservative or medical management, surgical inter-
vention may be indicated. This article presents the authors’ preferred tech-
nique for facial reanimation in patients with bilateral congenital facial
paralysis. Specifically, a staged bilateral segmental gracilis transfer to ipsi-
lateral nerve to masseter is discussed.