JAMA Facial Plastic Surgery
Journal Club Slides:
A Contemporary Approach to
Facial Reanimation
Jowett N, Hadlock TA. A contemporary approach to facial
reanimation. JAMA Facial Plast Surg. Published online
June 4, 2015. doi:10.1001/jamafacial.2015.0399.
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Introduction
•
Management of facial palsy (FP) is dictated by the pattern and time course
of dysfunction.
•
Therapeutic options include pharmaceutical agents, corneal protective
measures, physical therapy, chemodenervation agents, fillers, and a myriad
of surgical procedures.
•
The role of the clinician is to identify and tailor management to the patient’s
unique pattern of dysfunction, with targeted interventions applied to the
affected facial zones.
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Purpose
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This article summarizes a contemporary approach to the management of
facial nerve insults.
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Relevance to Clinical Practice
•
Muscles innervated by the facial nerve are pivotal to nonverbal
communication, corneal and hair cell protection, nasal breathing,
mastication, and articulation.
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Injury to the facial nerve results in functional, communicative, and social
impairment with profound negative impact on the quality of life and
emotional well-being of the patient.
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Establishing the correct diagnosis is paramount.
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Conservative, medical, and surgical options exist to minimize the sequelae
of acute and long-standing flaccid FP (FFP) and nonflaccid (synkinetic) FP
(NFFP).
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Relevance to Clinical Practice
Acute FFP (top) and long-standing NFFP (bottom) in Ramsay-Hunt syndrome (varicella-zoster viral FP). Complete flaccid paralysis on
the affected side (asterisk) is demonstrated at rest (A) and with brow elevation (B), gentle eye closure (C), full-effort eye closure (D),
gentle smile (E), full-effort smile (F), lip pucker (G), and lower lip depression (H). The patient lacks Bell phenomenon (C, D). One year
following symptom onset, the affected brow remains depressed, while hyperactivity has developed in the orbicularis oculi, mentalis,
and platysma muscles at rest (I). Volitional brow elevation remains impaired (J), while marked brow synkinesis is present with eye
closure (K, L). As is usual in NFFP, eye closure is adequate (K, L). Smile symmetry is improved with light effort (M); commissure
restriction is noted with full-effort smile. Near normal return to function of the orbicularis oris muscle is noted (O). Lip depressor
function remains weak on the affected side (P). Periocular, mentalis, and platysmal synkinesis is worsened by smile, pucker, and lip
depression (N-P).
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Description of Evidence
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Good evidence from well-designed studies supports the use of
glucocorticoids (level 1a) and antivirals (level 1b) in the setting of idiopathic
and acute viral FP, and botulinum toxin (level 1b) and physical therapy in
the setting of synkinesis (level 1b).
•
A plethora of surgical techniques and their respective outcomes have been
described in the literature, but few use controls, blinded assessment, and
validated scales to reduce bias (level 4).
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Description of Evidence
Therapeutic options for FFP and NFFP. NLF indicates nasolabial fold; DLI, depressor labii inferioris.
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Description of Evidence
Interventions in FFP
Setting
Acute
FFP
Medical management
Physical therapy Injections
 Corticosteroids - idiopathic
 Patient
 None
(Bell), varicella-zoster
education
indicated
(VZV/Ramsay-Hunt), acute otitis  Eyelid
associated, delayed traumatic,
stretching
delayed iatrogenic
 Antivirals - VZV, consider for
idiopathic
 Antibiotics (targeted) - indicated
for Lyme disease or acute otitis
 Corneal protection
-Daytime lubricating eye drops
-Nighttime lubricating ointment,
eyelid taping
Chronic
FFP
 Corneal protection
-Daytime lubricating eye drops
-Nighttime lubricating ointment,
eyelid taping
 Patient
education
 Eyelid
stretching
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Surgical management
Adjunctive
 Facial nerve decompression - indicated for idiopathic and
posttraumatic complete FFP with electroneurography response <90%
+ absent voluntary motor units on electromyography between 3 and 14
days of symptom onset
 Wide myringotomy +/- tube placement +/- mastoidectomy – indicated
for acute otitis
Static reanimation
 Eyelid weight (reversible if recovery ensues)
Dynamic reanimation
(Indicated in transections/resections)
 Direct end-to-end repair
 Interposition grafting
 Nerve transfer
 Botulinum
Static reanimation
toxin
 Brow ptosis correction
-Contralateral
 Eyelid weight
brow
 Lower lid tightening
-Contralateral DLI  External nasal valve correction
 Volumizing
 Rhytidectomy
fillers
 NLF suspension
-Contralateral
 Oral commissure suspension
NLF
 Contralateral DLI resection
-Ipsilateral upper Dynamic reanimation
lip
 Smile reanimation
-Temporalis transfer
-Nerve transfer to free muscle or native facial musculature within window
of muscle viability
Description of Evidence
Interventions in NFFP
Setting
Mild
NFFP
Medical management
 Corneal protection if blink
inadequate (rare)
-Daytime lubricating eye
drops
-Nighttime lubricating
ointment,
eyelid taping
Moderate  Corneal protection if blink
to severe
inadequate (rare)
NFFP
-Daytime lubricating eye
drops
-Nighttime lubricating
ointment, eyelid taping
Physical therapy
 Patient education
 Eyelid stretching
 Biofeedback
 Neuromuscular
retraining
Injections
 Botulinum toxin
-Contralateral or bilateral brow
-Ipsilateral periocular
-Contralateral DLI
-Mentalis
-Ipsilateral platysma
 Volumizing fillers
-Ipsilateral or contralateral NLF
-Ipsilateral upper lip
Surgical management
Static reanimation
 Contralateral DLI resection
 Platysmectomy




 Botulinum toxin
-Contralateral or bilateral brow
-Ipsilateral periocular
-Contralateral DLI
-Mentalis
-Ipsilateral platysma
 Volumizing fillers
-Ipsilateral or contralateral NLF
-Ipsilateral upper lip
Static reanimation
 Brow ptosis correction
 Highly selective periocular neurectomy
 NLF adjustments
 Contralateral DLI resection
 Platysmectomy
Dynamic reanimation
 Smile reanimation
-Temporalis transfer
-Nerve transfer to free muscle or native facial
musculature
Patient education
Eyelid stretching
Biofeedback
Neuromuscular
retraining
 Targeted physical
therapy following
dynamic reanimation
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Description of Evidence
Static reanimation interventions in FFP. A and B, Brow ptosis correction and lower eyelid tightening in FFP. A, On the affected
side (asterisk), brow ptosis resulting in lateral hooding is noted together with lower eyelid ectropion. B, Correction of ectropion and
lateral hooding is noted following the lateral tarsal strip procedure and minimally invasive brow suspension using polypropylene
sutures and a titanium plate. C and D, External nasal valve correction in FFP. C, The external nasal valve is markedly narrowed at
the base (arrow). D, Improvement is demonstrated following static fascia lata suspension. E and F, Static NLF suspension in FFP.
E, Effacement of the NLF is demonstrated at rest with inferior malposition of the oral commissure. F, Facial symmetry at rest is
improved following minimally invasive suspension using polypropylene sutures under local anesthesia.
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Description of Evidence
Dynamic reanimation of smile in NFFP and FFP. A-D, Cross facial nerve graft transfer to a free-gracilis muscle for dynamic
reanimation of smile in NFFP. Symmetry at rest is shown (A) with severe limitation of commissure excursion with full-effort smile (B).
The patient underwent cross facial nerve graft transfer to free-gracilis muscle. On follow-up, the midface remains symmetrical at rest
(C), while significant improvement in symmetry is seen with smile (D). E-H, Nerve transfer to native facial musculature in FFP. The
patient demonstrates FFP with effacement of the NLF and inferiorly malpositioned oral commissure on the affected side at rest (E)
and absence of commissure movement with smile (F). Following combined cross facial nerve grafting and masseteric nerve transfer
to a large midfacial branch, rest appearance appears mostly unchanged (G), with significant improvement in smile symmetry
demonstrated with light effort (H).
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Controversies and Consensus
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Administration of high-dose glucocorticoids within 72 hours of symptom
onset shortens the time to complete recovery in Bell palsy; further clinical
benefit may be seen with the addition of antivirals in severe to complete
paralysis.
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Surgical decompression in Bell palsy that involves the meatal foramen
should be considered when electroneurography reveals >90%-95%
difference between sides within 2 to 3 weeks of symptom onset.
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Physiotherapy is effective in FFP (patient education, eyelid stretching) and
NFFP (patient education, soft-tissue mobilization, and biofeedback).
•
Botulinum toxin injection has been proven effective for management of
synkinesis in NFFP and may be used to weaken paired muscles to improve
facial balance in FFP (eg, brow, lip depressors).
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Controversies and Consensus
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Corneal protective measures are always indicated in acute FP and
long-standing FFP; they are rarely needed in NFFP.
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Dynamic reanimation of smile should be considered in all patients with
long-standing FFP and severe NFFP where oral commissure excursion
is severely limited.
– Options include regional muscle transfer (eg, temporalis muscle
transfer) and free muscle transfer (eg, gracilis).
– Direct nerve repair without tension, nerve grafting, or nerve transfer
to native facial musculature is indicated when the time from
denervation to reinnervation is less than 18 to 24 months.
•
Many static and dynamic surgical techniques have been described for
reanimation of various facial zones.
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Comment
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FFP results in loss of static and dynamic facial symmetry, brow ptosis that
obscures vision, paralytic lagophthalmos resulting in exposure keratitis,
collapse of the external nasal valve impairing nasal breathing, oral
incompetence, and articulation impairment.
– Management is focused on eye protection, restoration of symmetry at
rest, and dynamic reanimation.
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Synkinesis-related symptoms predominate in NFFP, with periocular
synkinesis resulting in a narrowed palpebral fissure width that impairs
peripheral vision, midfacial synkinesis restricting meaningful smile, and
platysmal synkinesis resulting in neck discomfort and facial fatigue.
– Management is concentrated on improving dynamic symmetry and
reducing symptoms of hyperactivity.
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Comment
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While strong evidence from well-designed studies exists for many of the
conservative options, surgical outcome studies are often biased owing to
lack of randomization, control arms, assessor blinding, long-term follow-up,
and use of validated tools to assess therapeutic impact on facial function
and quality of life.
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Although there is little doubt of the crucial role surgery plays in improving
the lives of patients with FP, higher-quality studies are necessary wherever
equipoise exists to advance the field.
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Conclusions
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Initial management of FP involves establishment of the correct diagnosis
followed by medical and/or surgical interventions in addition to physical
therapy.
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Management of long-standing FP entails physical therapy, injectables, and
surgical reanimation procedures.
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The facial reanimation surgeon, backed by a multidisciplinary team of
physical therapists, nurses, and assistants, is skilled in zonal assessment of
the paretic face and in procedures to protect the eye, reduce facial fatigue
and discomfort, optimize facial symmetry, and restore meaningful smile.
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Contact Information
•
If you have questions, please contact the corresponding author:
– Nate Jowett, MD, Department of Otolaryngology, Massachusetts Eye
and Ear Infirmary and Harvard Medical School, 243 Charles St, Boston,
MA 02114 (nathan_jowett@meei.harvard.edu).
Conflict of Interest Disclosures
•
None reported.
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