After reviewing this article on facial paralysis, the reader should be able to do the following:. The loss of facial expression and the disfigurement of facial paralysis have serious implications for a patient's physical and psychological well being [ 1 ]. Numerous aetiologies of facial paralysis exist but once nerve recovery has been static for two years, interventional surgery is required to improve the situation [ 2 ]. Facial paralysis is often treated as an aesthetic problem but can also have real physical and psychological problems. These include difficulty with speech, low self-esteem, poor social interaction, oral incontinence, and dental problems; caries may develop due to the lack of food progression through the oral cavity and repeated trauma and ulceration caused by biting of the inside of the paralysed cheek.
Injury to the facial nerve may cause imbalance of the face at rest as well as distorted, imbalanced facial expressions and an asymmetrical smile. Jump to navigation. Labbe D, Huault M. Cross-Facial Nerve Graft : The surgeon moves a nerve from one side of the pwlsey to the other to supply a transplanted Facial surgery for bells palsey with the ability to contract. There is only very low quality evidence from randomised controlled trials and this is insufficient to decide whether surgical intervention is beneficial or harmful in the management of Bell's palsy.
Diaper free portland group. What Should I Expect at My Initial Consultation?
Additional delay in surgical evaluation however, can lead to the loss of certain treatment options that are time dependant. In general, decompression surgery for Bell's palsy -- to relieve pressure on the nerve -- is controversial and is seldom recommended. Bell's palsy causes sudden, temporary weakness in your facial muscles. Read more. Submit Search. Mayo Clinic does not endorse companies or products. Acute facial paralysis. Facial weakness or paralysis may cause one corner Jacking off increase penis size your mouth to droop, and you may have trouble retaining saliva on that side of your mouth. For most people, Bell's Facial surgery for bells palsey is temporary. Take care to insist that the surgeon fully explains the procedure, recovery, and risks. Videotapes of you engaged in normal conversation and facial expressions are helpful in monitoring patterns of muscle use and smile configuration before and after your surgery. For Bells Palsy it remains highly controversial, even when nerve degeneration is severe. A handy set of questions for researching different procedures.
A Loyola University Medical Center surgeon is using electrical stimulation as part of an advanced surgical technique to treat Bell's palsy.
- Injury to the facial nerve may cause imbalance of the face at rest as well as distorted, imbalanced facial expressions and an asymmetrical smile.
- Various surgeries may be offered to people with facial palsy.
- What is Bell's Palsy?
Jump to navigation. The symptoms probably occur when a nerve in the face is trapped and swollen. People with Bell's palsy generally recover but there is a small group who do not. Some surgeons have thought that an operation to free the nerve could improve recovery.
We did this review to assess the effects of surgery for Bell's palsy compared with no treatment, other types of surgery, sham fake treatment or treatment with medicines. After a wide search for randomised controlled trials, we found two studies to include in our review , which together involved 69 people with Bell's palsy. Our main measure of the effects of surgery was to be the recovery of paralysis at 12 months. The first study compared surgery with a steroid medicine and the second study compared surgery with no treatment.
In the first study the surgery and no surgery groups appeared to have similar facial nerve recovery at nine months. The second study found no differences in recovery of the facial paralysis after one year, between the participants who had an operation and those who had no treatment. One participant who had surgery in the first study had mild hearing loss and vertigo dizziness afterwards. Both studies had limitations that could have affected the results.
This review was first published in We updated the searches in October and found no new relevant studies. The review found that there was only very low quality evidence and that this was insufficient to decide whether an operation would be helpful or harmful for people with Bell's palsy. There is unlikely to be further research into the role of an operation because Bell's palsy usually recovers without treatment.
There is only very low quality evidence from randomised controlled trials and this is insufficient to decide whether surgical intervention is beneficial or harmful in the management of Bell's palsy. Further research into the role of surgical intervention is unlikely to be performed because spontaneous recovery occurs in most cases. Bell's palsy is an acute paralysis of one side of the face of unknown aetiology.
Bell's palsy should only be used as a diagnosis in the absence of all other pathology. As the proposed pathophysiology is swelling and entrapment of the nerve, some surgeons suggest surgical decompression of the nerve as a possible management option. This is an update of a review first published in We also handsearched selected conference abstracts for the original version of the review.
We included all randomised or quasi-randomised controlled trials involving any surgical intervention for Bell's palsy. We compared surgical interventions to no treatment, sham treatment, other surgical treatments or medical treatment. Two review authors independently assessed whether trials identified from the searches were eligible for inclusion. Two review authors independently assessed the risk of bias and extracted data. Two trials with a total of 69 participants met the inclusion criteria.
The first study considered the treatment of people but only included 44 participants in the surgical trial , who were randomised into surgical and non-surgical groups. However, the report did not provide information on the method of randomisation.
The second study randomly allocated 25 participants into surgical or control groups using statistical charts. There was no attempt in either study to conceal allocation. Neither participants nor outcome assessors were blind to the interventions, in either study. The first study lost seven participants to follow-up and there were no losses to follow-up in the second study.
Surgeons in both studies decompressed the nerves of all the surgical group participants using a retroauricular approach. The primary outcome was recovery of facial palsy at 12 months. The first study showed that the operated group and the non-operated group who received oral prednisolone had comparable facial nerve recovery at nine months. This study did not statistically compare the groups but the scores and size of the groups suggested that statistically significant differences are unlikely.
The second study reported no statistically significant differences between the operated and control no treatment groups. One operated participant in the first study had 20 dB sensorineural hearing loss and persistent vertigo. We identified no new studies when we updated the searches in October Authors' conclusions:. To assess the effects of surgery in the management of Bell's palsy. Search strategy:. Selection criteria:. Data collection and analysis:.
Main results:. You may also be interested in: Interventions for Bell's Palsy idiopathic facial paralysis Physical treatments for idiopathic facial paralysis Corticosteroids for Bell's palsy Antiviral treatment for Bell's palsy Acupuncture for Bell's palsy. Health topics:.
Bell's palsy: Pathogenesis, clinical features, and diagnosis in adults. Loyola University Health System. Facial reanimation is usually covered all or in part by insurance because it is medically necessary surgery. There is not likely to be any benefit over prompt treatment by standard meds, and there are serious risks involved. Nerve and muscle grafts or transpositions can offer functional improvement as well as improve appearance. The surgeon removes the bony covering of the facial nerve, then slits open the outer covering of the nerve. NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency.
Facial surgery for bells palsey. Center for Facial Paralysis Surgery and Functional Restoration
Facial Paralysis Surgery | Johns Hopkins Medicine
After reviewing this article on facial paralysis, the reader should be able to do the following:. The loss of facial expression and the disfigurement of facial paralysis have serious implications for a patient's physical and psychological well being [ 1 ].
Numerous aetiologies of facial paralysis exist but once nerve recovery has been static for two years, interventional surgery is required to improve the situation [ 2 ].
Facial paralysis is often treated as an aesthetic problem but can also have real physical and psychological problems. These include difficulty with speech, low self-esteem, poor social interaction, oral incontinence, and dental problems; caries may develop due to the lack of food progression through the oral cavity and repeated trauma and ulceration caused by biting of the inside of the paralysed cheek.
Poor understanding of the treatment modalities available and an element of 'postcode lottery' have an impact on the service a patient may receive in the UK. Facial palsy is a condition that affects the facial nerve, one of twelve cranial nerves. Its main function is to control all 17 muscles of facial expression [ 3 ]. This involves the ability to express emotion by controlling the position of the mouth, eyebrows, and nostrils, and control eye closure, drooling, speech, and dental hygiene.
A spontaneous facial palsy can present at any age but is most frequently seen at age 20 to 50 years, affecting both sexes equally. Incidence is around 30 cases per , per year and is slightly higher in pregnant women 45 per , [ 4 ] and an incidence of 1. There are discreet patient groups that can best be broadly classified into children and adults; this is the most important criteria for determining the treatment options available.
In children, the majority of cases of facial palsy are of an idiopathic aetiology; however, congenital and obstetric injuries are also important causes. In adults, Bell's palsy is by far the most common cause. This is typically transient and spontaneously recovers; however, a small proportion will have persistent palsy to varying degrees.
Direct trauma to the facial nerve and neoplasia are the other main causes. During parotid surgery, the facial nerve is particularly vulnerable and may also be disrupted by parotid gland tumours or acoustic neuromas. In rare cases, iatrogenic injury can be incurred during other types of surgery. A detailed history and thorough clinical neurological examination must be performed. In children, a detailed obstetric history is important, identifying concerns the parents have regarding the child and determining any functional problems that may be present.
Examining the child may be difficult, but an overall impression can be made of the static position of the face at rest and when the child is smiling. It is crucial to determine if the contralateral side is also functioning normally. Performing a full neurological assessment in adults is somewhat easier. Again, assessing the position of the face at rest and whilst smiling is important.
Examination of the main branches of the facial nerve is obligatory, and it is also prudent to determine the functioning of the trigeminal and hypoglossal nerves; these are important surgical 'donor' nerves, which may be used in future surgical procedures. The remaining cranial nerves should be assessed, especially if there is concern that the palsy is part of a congenital syndrome. A full medical history is mandatory, as medical co-morbidities may impact on the available treatment options. The most useful form of investigation for assessing the function of the facial nerve or any possible donor nerves is electromyography EMG.
It is also prudent to assess a patient's preoperative psychological status. This can initially be part of the consultation process but formal psychological referral may play a role in the care pathway of the patient [ 1 ]. This helps to manage the expectations of the patient and address what the outcome may be. It is important to provide a support network before, during, and after surgery, which potentially may be over a significant period of life.
The parents of affected children often require reassurance, and this provides the ideal setting for an open discussion and prepares the family for the surgical process. The aetiology may influence the choice of reconstruction, and generally the most important factors depend on the degree of smile impairment and the general condition of the patient. The desire to regain active motion peri-orally versus just improving the static position of the mouth will influence the choice of surgery.
Since the first description of a vascularised, innervated functional muscle transfer by Harii [ 6 ] in , a two-stage reconstruction has become the gold standard, especially in children [ 7 ].
In the first stage, a cross facial nerve graft is connected to a functioning terminal branch of the facial nerve, typically a buccal branch, on the unaffected side and tunnelled subcutaneously under the upper lip to the affected side Fig.
The donor nerve ideally should leave a minimal deficit; therefore, a pure sensory nerve is used, usually the sural nerve from the leg.
This leaves a small patch of numbness on the outside of the ankle and foot. The nerve graft is then allowed to regenerate across the face, which normally takes around 3 to 6 months and is monitored clinically by Tinel's sign.
This may be unreliable in young children, as they may not fully understand the test. In addition, Tinel's sign is a more sensitive indicator of sensory nerve than motor nerve regrowth; therefore, it is important educate the parents that this is not necessarily a sign of surgical failure. In the second stage of the surgery, the patient then receives a vascularised muscle flap that will be innervated by the cross facial nerve graft over a 6 to 12 month period Fig.
The typical muscles used are the pectoralis minor, gracilis, and latissimus dorsi, as these leave as little donor morbidity as possible. At this stage, the patient will slowly regain movement on the affected side of the face [ 8 - 10 ]. In bilateral congenital facial paralysis, the facial nerve is not available as a motor to drive the new muscle; therefore, another branch of a cranial nerve may be used, such as the V, IX, or XII [ 11 ].
Neurophysiological studies e. Stage 1 and 2 facial reanimation. A A cross facial nerve graft CFNG , usually a harvested sural nerve, is joined to a functioning buccal branch of the facial nerve FN on the contralateral side and tunnelled subcutaneous to the preauricular area on the affected side. The nerve regeneration can be monitored clinically using Tinel's sign. B A free functional pectoralis minor flap is raised through an axillary approach with its neurovascular pedicle. The flap is inset on the affected side where the thoraco-acromial artery and vein are anastomosed to the facial artery and vein, and the medial pectoral nerve is connected to the CFNG.
Reinnervation of the muscle typically takes 6 months, at which stage the muscle can be seen to start twitching. When considering facial reanimation in children, it is important to consider the impact the surgery and hospital appointments will have on the family and the child. The average time taken to complete the treatment is around two years, and this should ideally be completed before educational commitments become affected and before the child becomes fully aware of his or her palsy and the psychological implications begin to take hold.
Surgery can be started from the age of four years, and it is beneficial to allow time for the family to consider the surgical options in detail; therefore, early referral is prudent. The nerve regeneration potential of a patient is inversely proportional to their age; the older the patient, the less likely they are to experience a good result from nerve grafting.
It is currently accepted that one-stage reconstruction yields the most favourable results in the older age group [ 14 ]. A muscle flap with a long nerve is used to directly reach the opposite side of the face and allow the surgeon to do a direct neurorrhaphy i. After the age of 60, it is probably prudent to choose the shortest innervation route of the functional muscle transfer by joining the nerve of the muscle to a branch of ipsilateral cranial nerve V, most commonly to a branch of the masseteric nerve; this gives the patient the best possibility, even with slow nerve regeneration, of gaining some active motion [ 16 ].
It is important to realize that this will require a certain amount of re-learning or 'plasticity' in order to smile spontaneously. There are other treatment modalities available, which can be broadly grouped into static or dynamic options. Simple unilateral skin tightening procedures can be performed, but these are normally of little long-term value; the lack of muscle activity as well as the elasticity of the skin cannot sustain a corrective result.
More permanent sling procedures offer an improved static position of the mouth [ 17 ]. In this type of surgery, a portion of the tensor fascia lata is harvested and inset in a fixed position to give the face a more symmetrical posture at rest.
More complex local muscle transfers exist, such as the Labbe temporalis slide [ 18 , 19 ], the Gilles conventional temporalis transfer, and the masseteric transfer [ 20 ]. It is often difficult for patients to learn how to effectively utilize these muscles, as the plasticity of the brain also decreases with age and often multiple revisions are required over time [ 21 ].
The most common isolated branch palsy is that of the marginal mandibular branch; this results in uncontrolled excessive retraction of the lower lip on the normal side, as it is unopposed. There are both medical and surgical treatments. Botulinum toxin A Botox can be injected into the healthy side of the face every 3 to 6 months in order to restore symmetry. Botox may also be used to improve involuntary twitching and fasciculation or synkinesis, which is often experienced during a patient's recovery from a Bell's palsy, but it may also be a permanent symptom [ 22 ].
Equally, the healthy muscle can be resected to improve posture [ 23 - 25 ]. The position of the lower lip can be corrected with a local muscle transfer of the anterior belly of the digastrics, as described by Conley [ 23 ] in Various other midface techniques such as the suborbicularis oculi fat SOOF lift can be used to correct the minimally displaced corner of the mouth of the affected side [ 26 - 28 ].
Small adjustments around the nasolabial fold or the corner of the mouth may also improve symmetry. Various methods have been used to judge the outcomes of reanimation surgery, and opinions differ on the matter. Most authors agree that video assessment and panel judgment is important [ 9 , 10 , 29 - 32 ]; however, multiple outcome scales have been proposed [ 33 ]. All surgery involves a certain amount of scarring, and for patients who suffer from problematic wound healing, such as with hypertrophic or keloid scarring, the cosmetic outcome may be a disaster.
The most important outcome is patient satisfaction following surgical intervention, as it is not uncommon for perspectives to differ between surgeons and their patients [ 34 ]. Bulkiness and asymmetry in the shape and volume of the paralyzed cheek compared to the unaffected side is almost an inevitable consequence of the disease and surgery. The results of surgery are not entirely predictable and may require some revision surgery over time [ 35 - 37 ].
A patient following facial reanimation. A A patient with an incomplete right-sided facial paralysis caused by an unresolved Bell's palsy. Predominantly, the buccal and mandibular branches were affected the most, leading to the loss of smile and symmetry of the mid- and lower face. B Two years after completion of facial reanimation, the patient shows good excursion of the modiolus of the mouth and symmetry of the mid- and lower face.
There is minimal bulkiness of the right side of the face, and the position of the mouth is restored to being symmetrical. C Twenty years following surgery, the patient continues to have a functioning muscle transfer with no loss in excursion or symmetry. There are multiple treatment modalities available to offer an individual with facial paralysis.
The delivery of these is dependent on patient awareness and primary care physician education to ensure early referral to specialist units. The treatment methods of children and adults with facial paralysis follow different algorithms based on similar principles and must be considered separately.
Answers: Click here to view. No potential conflict of interest relevant to this article was reported. National Center for Biotechnology Information , U.
Journal List Arch Plast Surg v. Arch Plast Surg. Published online Sep Jonathan Leckenby and Adriaan Grobbelaar. Find articles by Jonathan Leckenby. Find articles by Adriaan Grobbelaar.