A New Classification System for Facial Paralysis in the Clinical Setting

Assessing Adult Patients with Facial Deformities for Injectable Treatment: Do Current Classification Systems and Methodologies Meet Important Patient Needs?

BACKGROUND

Many individuals are affected by facial deformities. Injectable aesthetic treatments can often be used to improve appearance and/or dynamic function. However, to best meet the needs of these patients, broadly applicable methodologies are required for classifying the deformity, assessing severity, and developing a treatment strategy.

OBJECTIVE

To assess whether any published systems could be used for this purpose.

METHODS

Thirty-eight searches were conducted in PubMed (1999-2019; in English). Forty-two publications were identified describing novel classification systems for adult facial deformity. They were analyzed against a checklist of 10 characteristics defining an "optimal" system-based on appropriate anatomical coverage, wide usability across types of deformity, user-friendliness, applicable underlying methodology, and ability to guide treatment with injectables.

RESULTS

None of the systems met more than 7 of the 10 checklist criteria; none were usable across multiple types of deformity or provided a recommendation for treatment with injectables.

CONCLUSION

There remains a need for a broadly applicable system for classifying adult facial deformities ahead of injectable therapy. The checklist provides a developmental framework. With the increasing popularity and accessibility of injectables, this diverse and complex demographic is at risk of mismanagement without superior methods for devising treatment strategies.

Facial paralysis and the role of free muscle transplantation

Facial paralysis can have significant functional, psychological and aesthetic concerns that alter the lives of our patients. These effects can be functional, affecting the eye, nose and mouth, or aesthetic, affecting the symmetry of the face and particularly the mimetic function of smile. Several reanimation procedures have been described to address this. In this chapter, we will outline our technique for reanimation utilizing segmental gracilis muscle transplants to the face. These are innervated either by the contralateral normal 7th nerve via a cross face nerve graft, or a different ipsilateral motor where no 7th nerve is available or would not produce the required result. The other ipsilateral motor that we have found extremely effective is the motor nerve to masseter. This can power a segmental gracilis muscle transplant and lead to excursion that is near normal. These techniques will be described in detail.

Dynamic reanimation for facial palsy: an overview

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. The symptoms depend on which branch of the nerve has been damaged and the severity of the injury. The purpose of this paper is to review currently available treatments for dynamic reanimation of a damaged facial nerve, and the goals are a symmetrical and coordinated smile. Careful selection of patients and use of the appropriate surgical technique can have excellent results.

Facial nerve palsy in childhood

Facial nerve palsy in children is usually idiopathic but can also result from many conditions such as neoplasias, systemic diseases, or congenital anomalies with poor prognosis. Children with idiopathic facial palsy (Bell's palsy) have a very good prognosis, while treatment with prednisone does not certainly improve the outcome. The causes of facial nerve palsy in childhood differ from those in adults. A detailed investigation and differential diagnosis are recommended for facial palsy in children.

Successful salvage surgery after treatment failures with cross graft and free muscle transplant in facial reanimation

BACKGROUND

The microneurovascular transfer of a free-muscle transplant is the procedure of choice for facial animation, It is characterized by low morbidity in both adult and paediatric patients. In spite of the improvements in microsurgical techniques, failures due to absent revascularization or reinnervation of the transplanted muscle or infections causing flap necrosis are observed. We propose a second surgical procedure based on the gracilis muscle transplant reinnervated by the masseteric nerve as a solution for these cases.

METHODS

We analyzed and report on two patients treated in our department after the failure of a previous cross-facial nerve graft and free muscle transplant. They were treated with a new facial reanimation using the contralateral gracilis muscle and the masseteric nerve as the donor nerve.

RESULTS AND DISCUSSION

We did not observe any postoperative complications, and all of the flaps survived. Reinnervation and contraction of the muscle appeared 3-4 months postoperatively, with good functional and aesthetic results.

CONCLUSIONS

This technique is a one-step procedure characterized by reliable flap harvesting, low donor site morbidity and good activity of the masseteric nerve. We consider it as a good option for treatment of facial animation failures.

Modern concepts in facial nerve reconstruction

Background

Reconstructive surgery of the facial nerve is not daily routine for most head and neck surgeons. The published experience on strategies to ensure optimal functional results for the patients are based on small case series with a large variety of surgical techniques. On this background it is worthwhile to develop a standardized approach for diagnosis and treatment of patients asking for facial rehabilitation.

Conclusion

A standardized approach is feasible: Patients with chronic facial palsy first need an exact classification of the palsy's aetiology. A step-by-step clinical examination, if necessary MRI imaging and electromyographic examination allow a classification of the palsy's aetiology as well as the determination of the severity of the palsy and the functional deficits. Considering the patient's desire, age and life expectancy, an individual surgical concept is applicable using three main approaches: a) early extratemporal reconstruction, b) early reconstruction of proximal lesions if extratemporal reconstruction is not possible, c) late reconstruction or in cases of congenital palsy. Twelve to 24 months after the last step of surgical reconstruction a standardized evaluation of the therapeutic results is recommended to evaluate the necessity for adjuvant surgical procedures or other adjuvant procedures, e.g. botulinum toxin application. Up to now controlled trials on the value of physiotherapy and other adjuvant measures are missing to give recommendation for optimal application of adjuvant therapies.

Facial animation in children with Moebius and Moebius-like syndromes

BACKGROUND

Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterized predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. The paralysis of the VI and VII cranial nerves leads to a lack of function in the muscles they supply. Facial paralysis often causes bilabial incompetence with speech difficulties, oral incompetence, problems with eating and drinking, including pocketing of food in the cheek and dribbling, as well as severe drooling.

METHODS

In this study, we report on pediatric patients with Moebius and Moebius-like syndromes seen and treated surgically from 2003 to September 2007 at the Operative Unit of Maxillofacial Surgery, Head and Neck Department, University of Parma, Italy.

RESULTS

Twelve patients underwent microsurgical reconstruction for restoration of facial movement. The contralateral facial nerve was used as a motor donor nerve in 4 procedures, the motor nerve to the masseter muscle was used in 8 patients, and the gracilis muscle was used in all operations, with a total of 17 free-muscle transplantations. All free-muscle transplantations survived transfer, and no flap was lost. We observed a significant improvement in drooling, drinking, speech, and facial animation with a high degree of patient satisfaction.

CONCLUSIONS

The gracilis muscle free transfer is a surgical procedure well tolerated by the young patients and well accepted by their families. We consider it a safe and reliable technique for facial reanimation with good aesthetical and functional results in children with Moebius and Moebius-like syndromes.