Facial reanimation: discussion and debate

Dynamic eyelid reconstruction in facial nerve palsy

The consequences of facial nerve palsy and the secondary inability of eyelid closure and blink may lead to devastating complications for the patient, including blindness. Reconstruction techniques to improve eyelid position and function can be broadly classified into 'static' and 'dynamic' techniques. Generally, ophthalmologists have been familiar with static procedures such as upper eyelid loading, tarsorrhaphy, canthoplasty, and lower eyelid suspension. Recently, dynamic techniques are being increasingly described for patients who require definitive strategies to improve eyelid function, once the initial critical goals of corneal protection and vision preservation have been achieved. The choice of technique(s) is dependent upon the status of the main protractor of the eyelid region, as well as the age of the patient, the patient's morbidities and expectations, and surgeon preference. This review shall first describe the clinical and surgical anatomy relevant to the ophthalmic consequences of facial paralysis and discuss methods of defining function and outcomes. A comprehensive review of dynamic eyelid reconstruction is then presented with a discussion of the literature. These various techniques may not be familiar to all clinicians. It is important that ophthalmic surgeons are aware of all options available for their patients. Furthermore, eye care providers must have an understanding of when referral may be appropriate to provide timely intervention and optimal chances of recovery.

Reducing Risk in Facial Reanimation Surgery

Facial reanimation surgery can greatly improve quality of life, but these procedures are not without risk. Important considerations for risk reduction in facial reanimation surgery include preoperative risk-stratification, protecting patients' clinical media, clearly and thoroughly setting expectations, and intraoperative strategies to maximize technical success and minimize operative time.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

Controversies in Contemporary Facial Reanimation

Facial palsy is a devastating condition with profound functional, aesthetic, and psychosocial implications. Although the complexity of facial expression and intricate synergy of facial mimetic muscles are difficult to restore, the goal of management is to reestablish facial symmetry and movement. Facial reanimation surgery requires an individualized treatment approach based on the cause, pattern, and duration of facial palsy while considering patient age, comorbidities, motivation, and goals. Contemporary reconstructive options include a spectrum of static and dynamic procedures. Controversies in the evaluation of patients with facial palsy, timing of intervention, and management decisions for dynamic smile reanimation are discussed.

Adipose-Derived Stem Cells Enhance Axonal Regeneration through Cross-Facial Nerve Grafting in a Rat Model of Facial Paralysis

BACKGROUND

Cross-face nerve grafting combined with functional muscle transplantation has become the standard in reconstructing an emotionally controlled smile in complete irreversible facial palsy. However, the efficacy of this procedure depends on the ability of regenerating axons to breach two nerve coaptations and reinnervate endplates in denervated muscle. The current study tested the hypothesis that adipose-derived stem cells would enhance axonal regeneration through a cross-facial nerve graft and thereby enhance recovery of the facial nerve function.

METHODS

Twelve rats underwent transection of the right facial nerve, and cross-facial nerve grafting using the sciatic nerve as an interpositional graft, with coaptations to the ipsilateral and contralateral buccal branches, was carried out. Rats were divided equally into two groups: a grafted but nontreated control group and a grafted and adipose-derived stem cell-treated group. Three months after surgery, biometric and electrophysiologic assessments of vibrissae movements were performed. Histologically, the spectra of fiber density, myelin sheath thickness, fiber diameter, and g ratio of the nerve were analyzed. Immunohistochemical staining was performed for the evaluation of acetylcholine in the neuromuscular junctions.

RESULTS

The data from the biometric and electrophysiologic analysis of vibrissae movements, immunohistochemical analysis, and histologic assessment of the nerve showed that adipose-derived stem cells significantly enhanced axonal regeneration through the graft.

CONCLUSION

These observations suggest that adipose-derived stem cells could be a clinically translatable route toward new methods to enhance recovery after cross-facial nerve grafting.

Evaluation of short-term surgical outcomes in facial paralysis patients treated by trigeminal neurotization

The management of patients with facial nerve palsy is a challenge of modern neurosurgery. The study purpose was to evaluate the degree of facial nerve function recovery, following trigeminal neurotization. Trigeminal neurotization was performed in 23 patients within 1 to 10 months after the development of facial paralysis. In most cases, the cause of facial paralysis was surgery for space-occupying lesions of the cerebellopontine angle (95.6%). Outcomes of trigeminal neurotization were evaluated in 17 (73.9%) patients who were followed-up for more than 6 months. In 16 (94.1%) patients, the facial nerve function was recovered to a House-Brackmann grade III-IV. Given the surgery

RESULTS

we can say that trigeminal neurotization is one of the effective treatments for facial paralysis. In most cases, this technique has provided good outcomes without additional complications, which is important for this group of patients.

Reanimating the paralyzed face

Facial animation is an essential part of human communication and one of the main means of expressing emotions, indexing our physiologic state and providing nonverbal cues. The loss of this important human quality due to facial paralysis can be devastating and is often associated with depression, social isolation and poor quality of life. Interruption of the neuromuscular pathway from the facial motor cortex to the facial muscles is the common causative factor in facial paralysis resulting from various etiologies. Restoring tone, symmetry and movement to the paralyzed face requires timely nerve grafting intervention in cases of reversible paralysis and the transfer of functional muscle units in irreversible paralysis. We review recent advances in these techniques.