Photo: Courtesy of Science Photo Library
With current advances in treatment for facial paralysis, most patients can benefit from one of the many diverse approaches that now are available, says UCLA facial plastic and reconstructive surgeon Irene Kim, MD.
“In the past, many patients with facial paralysis were told that they were going to have to live with it, but that should no longer be the case,” says Dr. Kim, who helped to establish a multidisciplinary facial reanimation center at UCLA. “There are many options now offered that can help these patients regain function as well as confidence regarding their appearance.”
While the manifestations of facial paralysis differ depending on the cause, the impact on quality of life is almost always substantial. Dr. Kim notes that studies have documented that people with a paralyzed face can be viewed as less healthy, less agreeable and less approachable than others, hindering their ability to obtain jobs or find suitable mates. “Facial reanimation surgery isn’t just a cosmetic procedure to make people feel better about themselves,” Dr. Kim says. “Facial paralysis has an impact both on patients’ self-esteem and, given the social stigma, on the way they are perceived.”
The inability to fully smile or otherwise express the emotions they feel on the inside is the biggest complaint that Dr. Kim hears from patients with facial paralysis. But she points out that there are often significant functional issues as well. “People might see an asymmetric face, but there can exist deeper pain from struggles to do daily activities like brushing one’s teeth or drinking water from a cup,” she says. When the muscles around the mouth are weakened, many patients have difficulty eating food without spilling or drooling. Some patients can’t close an eye, leading to dryness of the cornea, which can impair vision.
Facial nerve surgery has to be tailored to the individual patient, taking into account the cause of the paralysis, the timeline of events and the health of the facial nerve and muscles. In patients with Bell’s palsy, an idiopathic form of paralysis that tends to affect one side of the face and is usually temporary, there is a tendency to treat medically and wait since a majority of patients regain their facial function without intervention. But in most other cases, Dr. Kim says, the UCLA team looks to be proactive with treatment to ensure that patients meet their facial-functioning potential. “The traditional thinking has been to wait two years before you do anything to see if there is some improvement,” Dr. Kim explains. “Most of us don’t think that way anymore. We don’t want to let the muscles atrophy.”
Left: This patient had a left-sided temporal bone tumor that caused her to have dense facial paralysis. Right: Five months after tumor resection, eyelid weight, lower eyelid tightening and two nerve (hypoglossal and masseteric) transfers, there is increased symmetry at rest and the ability to smile. Photos: Courtesy of Dr. Irene Kim
When, for example, a patient has an acoustic neuroma — a benign growth on the acoustic nerve in the brain also known as vestibular schwannoma — removal of the tumor can weaken the facial nerve. Traditionally, surgeons have waited to see signs of improvement; this can unfortunately lead to further weakening of facial muscles and poorer long-term outcomes, Dr. Kim says. There usually are options that can be implemented earlier on. For example, various nerve transfers that connect a portion of the masseteric, hypoglossal or facial nerve from the other side of the face to the weakened facial nerve can help “power” and instruct the paretic facial muscles to move.
Some patients may not be candidates for dynamic facial reanimation surgery, given their other health issues or inability to tolerate long periods of general anesthesia. They may benefit from more static procedures during which various tissues can be used as slings to suspend the patient’s face into a better position. They can help restore lip position and help with drooling and speech. Still, other surgeons are using minimally invasive temporalis tendon transfers to restore smile function. In this procedure, a small incision is made along the nasolabial fold or within the mouth itself. The temporalis tendon is secured to the tissues around the mouth, ultimately allowing patients to voluntarily smile when they bite down or clench.
