Presented by Jon-Paul Pepper, MD
Assistant Professor of Otolaryngology (Facial Plastic and Reconstructive Surgery)
October 4, 2018
The human face has never been such a widespread icon of communication as it is now. Many digital media platforms rely on our facial photos to identify who we are and connect us with others.
That’s why people who experience facial paralysis may feel the impact more than ever. A smile can be crucial to conversations. A frown or a drooping eyelid may convey a different emotional message than what a person with facial paralysis actually feels.
“Communication relies on so many nonverbal cues,” said Jon-Paul Pepper, MD, director of the Stanford Facial Nerve Center. That’s why advances in treatment for facial paralysis can improve our social lives as well as restore movement and improve appearance.
There so are many ways that we frame the things we say that depend on the “obedient” movement of the muscles of our face.
“When we lose that, we lose the ability, quite frankly, to communicate normally,” Dr. Pepper told the audience at a lecture at Stanford Health Library.
Dr. Pepper has developed surgery techniques to improve facial paralysis, a field called “facial reanimation.” Yet he is also a champion of using physical rehabilitation and other nonsurgical treatments to retrain facial muscles to move. Many patients have a choice of several treatment options, he said, and often a combination of treatments is most effective.
Facial paralysis may be the result of a condition called Bell’s palsy. That’s caused by a virus that inflames the facial nerve and the tissues around it. Most often, people recover and the paralysis goes away. In some people, however, the paralysis lingers.
Facial paralysis can also have other causes, such as a tumor or injury to the facial nerve. Often only one side of the face is paralyzed.
“You can imagine that not moving one side of your face would profoundly impact how you express emotion, and how people interact with you,” Dr. Pepper said.
Symptoms include a drooping eyelid, sagging muscles, and uneven smile or no smile at all. Sometimes when a person tries to smile, instead their muscles trigger an expression that looks like a grimace.
The result is not just cosmetic. A drooping eyelid can interfere with vision. It can also cause drying of the eye’s outer later, the cornea. The lips may not close fully, interfering with speech. They can also leak food or drink from the corner of the mouth.
The first steps in treatment for many people involve rehabilitation. They get exercises to train their facial muscles to control movement correctly. Rehabilitation can also clarify which nerve is impaired, and whether surgery is necessary.
For people who have severe or complete facial paralysis that will not improve on its own, surgery will most likely be needed to recover movement. The type of surgery best for any individual may depend on how long their face has been paralyzed, Dr. Pepper said.
- If it’s less than 2 years, nerve transfer surgery is often recommended.
Nerve transfer surgery involves taking a nerve from elsewhere in the head or neck, and moving it to the face to connect to the paralyzed facial nerve. There are different types of nerve transfer surgery.
- For paralysis that’s lasted 2 years or more, muscle is typically taken from the leg, near the inner thigh, and is used to replace the muscles that produce a smile.
Nerve transfer surgery
One of the most common surgeries, the masseteric nerve transfer, can enable people to smile again. The surgery connects the (paralyzed) facial nerve with the masseteric nerve on the side of the face. This connects to the masseter muscle that enables us to chew and bite down. With this, people can learn to “bite to smile,” Dr. Pepper said.
It can take 6 to 12 months for this to work fully. People must be trained how to use their muscles with rehabilitation therapy.
“Patients can bite down, and then initiate the smile,” Dr. Pepper said. “In my opinion, it provides the most effective and natural-looking smile” achieved by reanimation surgery.
One disadvantage is that the person must think ahead to activate this. “You have to think, I’m going to bite now in order to smile. It requires training and practice,” he said.
Even the best results, however, aren’t perfect. “It doesn’t make for perfect symmetry,” Dr. Pepper said, “but it does make for a significant improvement.”
Other reanimation surgery
Another kind of nerve transfer surgery can restore balance to the face when it’s paralyzed on one side. The surgery cuts into the hypoglossal nerve and moves part of it, so it regrows into the facial nerve.
This is a good source of tone to the face, Dr. Pepper said. It doesn’t help someone smile. “It makes for nice symmetry but really a limited smile,” he said.
A newer treatment option is to combine both nerve transfer methods. Called a “dual nerve transfer,” it is a technique developed by Dr. Pepper that achieves good results, he said.
Dual nerve transfer can improve the tone and symmetry of the face, and also enable someone to smile. “In my opinion, this does offer some pretty impressive results,” he said.
Surgery for longer-term paralysis
When people have endured facial paralysis for more than 2 years, different treatments necessary. That’s because injured nerves develop scars that leave the nerves “shut” or closed. Connecting a scarred-shut facial nerve to another nerve won’t work, Dr. Pepper said.
But there are alternative surgeries. One of the most common is called the gracilis muscle transfer.
Taken from a thigh
The gracilis muscle grows in the inner thigh. It is transplanted to the face and used to suspend the corner of the mouth.
If the transplanted muscle is connected to the masseter nerve, it can let a person use their bite-down muscle to smile. This is an older, reliable surgery that was originally developed in the 1970s, and has been modified and improved over the past 40 years.
This surgery takes about 7 or 8 hours to complete and requires a hospital stay.
Although the gracilis free tissue transfer surgery is considered the gold standard for facial paralysis of 2 years or more, there are other alternatives. One is called the temporalis tendon transfer, which uses a muscle on the side of the head that we normally use for chewing. Surgery reconnects this muscle so it resuspends the corner of the mouth.
This enables people to “chew to smile,” Dr. Pepper said. “You’re initiating another muscle group in the effort to elevate the corner of the mouth to produce a smile.”
While this surgery gives people some ability to smile, the drawback is that it doesn’t help the lower lip. That leaves some asymmetry that can only be improved with another strategy.
Fortunately, the vast majority of people who have facial paralysis will eventually recover some movement. However, the movement may be uncoordinated or difficult to control, and is called synkinesis. Dr. Pepper described it as a “mishmash of muscle movement of the face.”
In synkinesis, a person tries to move one part of the face but ends up moving other parts at the same time. Their eyes may close when they are trying to smile, for example.
“It is quite a nuanced disorder to treat,” Dr. Pepper said. The condition is essentially a cross-wiring of the nerve. If the nerve had an injury, it may have regrown to connect to the wrong targets.
The solution to this disorder is a multistep process that starts with intensive rehabilitation. This includes facial retraining exercises to reduce the unwanted movements.
If more treatment is necessary, options include:
- Injecting botulinum toxin (“Botox”) to temporarily stop muscle contractions causing the unwanted movement. This usually lasts about 3 months.
- Injecting hyaluronic filler to add volume to an area where it is lacking. This can help people close their lips together more effectively to talk or keep food in their mouth.
- Facelifts and brow lifts can help resuspend a face drooping from paralysis, some combined with targeted muscle release to mimic the impact of botulinum toxin injection.
“Rehabilitation is really the core and the first step,” Dr. Pepper said. Sometimes rehabilitation combined with Botox, for example, can help retrain muscles. Other times that may not help enough, but it reveals where the problem starts and how to fix it.
“It’s treatment, but it’s also a powerful diagnosis,” Dr. Pepper said. “It tells us turning off certain groups of muscles is therapeutic for this patient.” That can point to way to doing surgery on the offending muscle for a longer lasting improvement.
Overall, people with facial paralysis or synkinesis have multiple options for treatment. “We have a lot of things to offer and not all of them are reanimation surgery,” Dr. Pepper said.