Facial reanimation surgery is performed to correct facial paralysis due to congenital (from birth) deformity, following Bell’s palsy, after trauma or cancer surgery which damage to the facial nerve.
Facial paralysis can be a devastating condition affecting the patient functionally and psychologically. There might be problems with eye closure and protection of the eyes, asymmetry of the eyebrows, significant asymmetry of the cheek and with a crooked smile, and deformity of the lower lip. The patient may have drooling, redness of the eye on the affected side. These symptoms can have major effects on their social interactions.
There is lots of progress in the reconstruction of the facial paralysis with nerve and muscle transfers. These procedures can be one or two staged and occasional further minor corrections may be required.
The aim of reconstructive surgery is to restore symmetry and coordinated dynamic animation. The reconstructive strategy is tailored to each patient’s needs. Normal appearance at repose, and symmetry during voluntary and involuntary expression, competent ocular and oral sphincters, preservation of existing facial function, and minimal loss of function in other donor motor nerves should be the goal.
During your Consolation factors that should be considered include:
- patient’s age
- aetiology of facial paralysis
- the patient’s life general medical and psychological status
- facial muscle denervation time
- if the paralysis is complete or incomplete
- specific functional deficits
- prospects of any recovery of facial nerve function
- previous facial reanimation operations
- patient’s expectations and priorities
- the surgeon’s experience, and comfort with different procedures.
Depending on each case, to restore facial symmetry and movements, there might be a need for various procedures and measures that should address deformities and functional problems involving the upper, middle and lower face. Such techniques could include the use of Botulinum Toxin Type A injections, and performance of brow lift or facelift procedures. Reconstructive options include the transfer of regional muscles from the head and neck area or distant tissue as free neurovascular transfers.
These operations are usually combined with the use of donor sensory nerves often taken from the legs, with no loss of motor function at the donor site. The advent of microsurgery allowed more sophisticated and efficient procedures, making free microneurovascular muscle transfer the gold standard method of management for the long-standing facial paralysis.
Immediate Care: An external splint is applied at the angle of the mouth on the operated side, to prevent the free muscle from detaching from fixation points.
If a muscle is transferred as a free flap, monitoring with Doppler takes place for the first 72 hours, along with other observations on the face. A rhytidectomy-type face mask is provided before discharge and is applied for the additional support of the transferred muscle. The patient is asked to be on a soft diet for about three to four weeks, so there is minimal chewing and mastication. Ultrasound and massage therapy at the cheek and scars could be used and start at six weeks following surgery, for six weeks, to facilitate the settling of facial oedema.
Long-term care: Increased resting tone is the first sign of reinnervation, and appears around four months postoperatively, while a return of motion in adults starts appearing from six months onwards, with improvement noted for up to two years. There have been occasions in the paediatric population, which full contractions were prominent at four months with full smile restoration at six months.
There might be a need for the patient to have some slow-pulse stimulation of the reinnervated muscles for a few months following surgery. Also, as soon as the patient notices some movement of the reinnervated muscle, he/she will need to have biofeedback exercises and practice standardised exercises in front of a mirror. In contrast to the adult situation, very little retraining is required in children due to their brain’s capacity to embrace changes in the periphery and effectively incorporate them into their facial animation.