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Reconstruction of the paralyzed face.


Facial nerve paralysis can result in significant functional, cosmetic, and social disability. Patients may experience disturbances in oral competence, eye protection, and lacrimation, as well as in their ability to convey voluntary and emotional facial expressions. The disfigurement caused by facial nerve paralysis may have serious consequences in terms of a patient's self-esteem and well-being. (1) Indeed, many affected patients avoid social interaction and relationships, and they may even change jobs. (3) Depression is a common sequela of facial paralysis. (3)

The goals of facial reanimation include the restoration of facial symmetry, oral competence, eye closure, voluntary facial movement, and spontaneous facial expression in the absence of synkinesis. Two types of surgical procedures have been designed to achieve these objectives; they are categorized as dynamic and static.

* Dynamic procedures are those that restore movement to the face. They are generally more successful than static procedures in achieving the goals of reconstruction.

* Static procedures support and stabilize the soft-tissue structures of the face. However, they do not provide animation.

Both types of procedures are useful as adjunctive measures to enhance facial symmetry. Static procedures are often considered to be the procedures of choice for the management of the eye in facial paralysis. Moreover, static measures can be important as a primary option for debilitated or older patients and for patients who are not otherwise candidates for dynamic reconstruction.

Facial nerve paralysis can be a difficult problem to treat as it presents with functional, aesthetic, and psychosocial challenges. Optimal reconstruction of the paralyzed face usually requires multiple dynamic and static surgical procedures. The figure presents an algorithm for the management of facial nerve paralysis.

Pertinent anatomy

Impulses from the motor cortex travel along axons of the corticobulbar tracts and internal capsule toward the contralateral VIIth cranial nerve nucleus. Those impulses that are intended for projection to the frontal branch of the facial nerve are sent to bilateral nuclei, which explains why central lesions result in frontal sparing.

The facial nerve exits the brainstem at the level of the pons. (4) The branchial motor fibers constitute the largest portion of this nerve; the nervus intermedius comprises the remaining three components, which include the visceral motor fibers, the general sensory fibers, and the special sensory fibers. The facial nerve travels in the anterosuperior quadrant of the internal auditory canal before entering the fallopian canal, which is the pathwaythrough the temporal bone. The 3- to 5-mm labyrinthine segment includes the geniculate ganglion, which is the most common intratemporal site of facial nerve injury. (5) The nerve then makes a sharp turn (genu) and enters the tympanic segment, giving off the greater, lesser, and external petrosal nerves. The facial nerve travels 8 to 11 mm horizontally before it reaches a second genu, where it turns vertically and travels 10 to 14 mm through the mastoid segment. The facial nerve gives off branches to the stapedius muscle and the chorda tympani prior to its extratemporal course. The facial nerve exits the temporal bone at the stylomastoid foramen and enters the parenchyma of the parotid gland after it gives off the posterior auricular, posterior digastric, and stylohyoid muscle branches. At the pes anserinus (parotid plexus), the facial nerve typically divides into two main trunks: the frontozygomatic trunk and the cervicofacial trunk. These trunks then divide into five main branches: temporal (frontal), zygomatic, buccal, marginal mandibular, and cervical. (6)


The parasympathetic division of cranial nerve VII supplies fibers that contribute to the greater petrosal nerve (which supplies the lacrimal gland), the lesser petrosal nerve (which supplies the parotid gland), and the chorda tympani (which supplies the submandibular and sublingual glands). The general sensory component of cranial nerve VII supplies sensation to the conchal skin, and the special sensory component supplies the taste sensation to the anterior two-thirds of the tongue via the chorda tympani. (4) The facial nerve innervates 23 paired muscles in addition to the unpaired orbicularis oris. (5)

Evaluation of the patient

A detailed history and physical examination must precede any type of intervention in the evaluation of the patient with facial paralysis. Key elements of the history include the onset and duration of paralysis, the general medical history and overall medical condition, and anyprevious surgical procedures. The general health and life expectancy of the patient must be taken into consideration; for example, a procedure that requires 2 years for results to manifest is obviously inappropriate for a patient with a terminal illness. As part of the patient's education, realistic expectations need to be established early, and the patient should be motivated to expend the time and financial resources required for a successful result.

Etiology is the most important factor in determining the timing and choice of a reconstructive technique, and so intervention should not begin until the cause of the paralysis has been identified. The cause of facial nerve palsy can be idiopathic, traumatic, infectious, neoplastic, neurologic, or systemic/metabolic in nature (table 1). (5,7)

The history of the onset can provide valuable information on etiology. For example, an abrupt onset may indicate a Bell palsy, in which spontaneous recovery is possible. In such a patient, an irreversible technique to reanimate the face is not the optimal choice. On the other hand, an insidious onset may represent an undiagnosed malignancy that requires further workup. After the etiology is identified, the potential for recovery can be estimated and planning for reconstruction can begin.

The duration of paralysis is also an important factor in surgical planning. The method of reanimation depends on the availability of proximal and distal nerve stumps and viable facial musculature. Facial musculature undergoes fibrosis after denervation, and it therefore might not be available for reinnervation in a patient with long-standing paralysis. (4)

The physical examination should include a determination as to whether the paralysis is total or partial, unilateral or bilateral, and symmetric or asymmetric at rest. An assessment of facial asymmetry should include brow ptosis, dermatochalasis, skin laxity, oral commissure incompetence, and ocular exposure. Other key factors are the degree of synkinesis if present, the presence of other cranial nerve deficits, and the condition of the eye. Isolated region-specific facial motion such as brow elevation, eye closure, smile, pucker, and frown with the remainder of the face at rest should be observed and recorded.

Objective measures of facial motion can be documented with still photographs, video recordings, and digital imaging. (8,9) No standardized and universally accepted system for grading facial movement and facial nerve dysfunction has been devised, but the House-Brackmann facial grading system is widely used (table 2). (10)

In identifying the etiology of facial palsy secondary to retrocochlear pathology or mass lesions of the middle ear, it may be useful to perform audiometric testing, including tympanometry and a determination of acoustic reflexes. Radiologic testing with high-resolution computed tomography and magnetic resonance imaging should be considered in the evaluation of a patient with a suspected tumor of the parotid gland, internal auditory canal, cerebellopontine angle, or skull base, as well as in a patient with idiopathic or traumatic facial palsy. (11) Electrodiagnostic tests such as nerve excitability testing (NET), (7) electroneuronography (ENoG), (12) and electromyography (EMG) (13) can provide additional information regarding the facial nerve and the integrity of the muscles that the facial nerve innervates.

Dynamic reconstructive techniques

The three basic procedures for dynamic rehabilitation of the paralyzed face are nerve repair (with primary or interpositional grafts), nerve transposition, and muscle transfer (regional or free).

Nerve repair. Repair of the facial nerve is the most effective procedure to restore normal function. (2) It is indicated for patients in whom both the proximal and distal nerve stumps are available and the facial musculature is viable. Nerve continuity may be achieved by either direct repair or interpositional grafting, although direct repair is associated with better recovery. (2,14) In general, the sooner the grafting is performed, the better the results will be. (15)

Early repair of facial nerve injury makes it easier to identify nerve ends with a stimulator. (16) A nerve that is transected during surgery should be immediately repaired with an end-to-end anastomosis. In the event that the facial nerve is transected because of tumor involvement, frozen sections of both ends of the nerve should be sent for histopathologic examination to exclude microscopic invasion before the repair is attempted. In cases of grossly contaminated wounds, the nerve ends should be identified, tagged, and then repaired once the wound stabilizes. Severely traumatized stumps should be debrided and grafted. In cases of delayed nerve repair, each end of the potentially damaged nerve should be resected back to normal tissue. (17) Maximal voluntary facial muscle movement is typically obtained between 9 and 18 months following direct end-to-end neural repair, as regenerating motor axons grow at an estimated rate of 1 mm/day. (18)

If the two ends of the nerve fail to lie together unsecured without pulling apart, a nerve graft can be used to bridge the two ends together. Tension on the ends after repair can result in the formation of scar tissue, poor neural regeneration, increased pain, and/or decreased function. Extensive mastoid and extratemporal mobilization of the nerve may add up to 2 cm of relative length, but it also may result in devascularization and further neural injury. (9) Malik et al found no difference in outcomes between patients who had undergone cable grafting and nerve mobilization with direct anastomosis. (2) Interpositional grafts of autologous, nonessential sensory nerve can be used to bridge the gap between the proximal and distal nerve stumps. Grafts for repair of the facial nerve can be harvested from any superficial sensory nerve; the most commonly used are the sural, great auricular, medial, and lateral antebrachial cutaneous nerves. (4,19) Interpositional grafts function as conduits in which sprouting axons from the proximal nerve stump travel to the motor endplates, providing cellular and humoral neural growth promotion.

Matching the endoneurial surfaces is essential to promoting neural regeneration. In fact, it is more important than matching the entire nerve diameter. Occasionally, a significant mismatch between proximal and distal nerve ends requires a double cable graft--for example, when a graft is placed from the main facial nerve trunk to the segmental branches. Nerve repair may be carried out with an epineural or perineural technique; a minimal number of monofilament sutures under the operating microscope remains the current standard for either technique of neurorrhaphy. Tissue adhesives, laser neurorrhaphy, tubulization, and trophic factors have been investigated in an attempt to improve neural regeneration. (20, 21) One should anastomose only to the functionally important branches to optimize the number of nerve fibers that will reach the desired endpoint.

Nerve transposition. Nerve transposition (substitution) is performed if the patient has complete and irreversible facial paralysis, the proximal facial nerve stump is not available, and the extracranial distal facial nerve stump and the facial musculature are intact. (22) Most patients achieve voluntary facial movement with tone and symmetry at rest. (23) Common nerve transposition options include the hypoglossal nerve-facial nerve transposition graft, the hypoglossal nerve-facial nerve interpositional jump graft, the cross-face nerve graft, and the spinal accessory nerve-facial nerve transposition graft. (23)

Hypoglossal nerve-facial nerve graft. The classic hypoglossal nerve-facial nerve transposition graft is an end-to-end neurorrhaphy between the proximal end of the ligated ipsilateral hypoglossal nerve and the distal facial nerve trunk. The hypoglossal nerve-facial nerve interpositional jump graft is a variation of the classic transposition graft that involves longitudinal splits of a proximal segment of the ipsilateral hypoglossal nerve with end-to-side grafting of an interpositional graft to the distal facial nerve trunk. (2) The jump graft avoids the ipsilateral hemitongue paralysis that is associated with the classic transposition.

Both types of hypoglossal nerve-facial nerve grafts are associated with an extensive relearning period, and intensive rehabilitation with facial nerve physical therapy is recommended for optimal results. (24) Improved facial tone and symmetry at rest are seen in most patients about 4 to 6 months after a hypoglossal nerve-facial nerve anastomosis. Voluntary facial movement typically occurs in 6 to 18 months. Spontaneous facial movement or emotional expression is rare, and synkinesis and mass movement are common sequelae.

Transposition grafts are also used to prevent facial muscle atrophy during multistep reconstructions. Performing a nerve transposition can provide tone to the affected side of the face in order to prevent end motor plate degeneration while axons from the contralateral face via cross-face nerve grafting slowly traverse the distance. The hypoglossal nerve-facial nerve jump graft can be employed as a "babysitter" because the short distance of neural regeneration results in relatively fast facial muscle reinnervation, which can prevent muscular atrophy. (6)

Cross-face nerve graft. Cross-face nerve grafting involves sacrificing a large buccal branch on the nonparalyzed side. A nerve graft (e.g., sural nerve) is then harvested and used to reinnervate the affected side. The disadvantage of the cross-face nerve graft is that branches of the contralateral facial nerve are sacrificed for the potential benefit of the paralyzed side of the face. Kumar and Hassan reported that approximately half of the facial nerve branches can be divided without weakening the donor side of the face. (25) A nerve graft is anastomosed to the donor branches, and then it is tunneled under the chin to the contralateral pretragal area. The interpositional graft is typically reinnervated in about 4 to 8 months. The onset of voluntary facial muscle activity typically occurs between 1.5 and 5.5 months, and spontaneous activity occurs between 5 and 7 months. (26)

In a retrospective study of 53 patients, Guntinas-Lichius et al found no significant difference in facial function between patients who had undergone facial nerve interpositional grafts, facial nerve-facial nerve grafts, and hypoglossal nerve-facial nerve transpositional grafts. (26) May concluded that the cross-face nerve graft should not be used as a primary facial reanimation procedure because a branch of the contralateral facial nerve can provide only a limited number of axons. (23) The cross-face nerve graft is optimal for powering a free muscle transfer or as an adjunctive procedure.

Spinal accessory nerve-facial nerve crossover graft. Initially described in 1879, the spinal accessory nerve-facial nerve crossover graft never gained popularity because of its associated shoulder deformity and unnatural facial aesthetic results. (23) In general, patients should not expect a House-Brackmann score better than III following any reanimation procedure. (3)

Muscle transfer. A period of facial denervation that exceeds 1 year is associated with irreversible loss of muscle motor end plates and subsequent muscle atrophy. In these patients, reinnervation alone cannot restore facial motion. (4) Therefore, regional muscle transposition or free neurovascular muscle transfer should be considered.

The temporalis muscle, the masseter muscle, and the anterior belly of the digastric muscle have all been used to produce voluntary facial movement in patients with facial nerve paralysis. (27) Frey et al described a technique for temporalis muscle transposition to reanimate the upper and lower eyelids. (28) A strip of temporalis muscle is elevated, split in two at its free edge, and elongated with strips of temporalis fascia. The two strips are then tunneled through the upper and lower eyelid and sutured under appropriate tension to the medial palpebral ligament with nonabsorbable suture. The temporalis muscle can also be used to animate the corner of the mouth by fixation to the modiolus. Masseter muscle transfer involves elevation of the inferior periosteal attachments to the mandible with fixation of muscle/ periosteum strips to the orbicularis oris or orbicularis oculi; it is rarely used secondary to long-term mastication difficulties. (3)

In patients with isolated marginal mandibular nerve weakness, a lack of depressor labii inferioris function can be quite noticeable because an affected patient is unable to evert, depress, or lateralize the lower lip. (29) Terzis and Kalantarian advocated dynamic restoration of lip depressor function with a digastric and/or platysma muscle transfer. (30) The anterior belly of the digastric muscle is elongated with a strip of fascia or by releasing the posterior belly. The digastric muscle is then tunneled to the lower lip and sutured to the orbicularis oris near the vermilion and inferiorly at the chin-lip groove. (31) In patients with complete unilateral facial paralysis, one must weigh the improvement in appearance against the potential decrease in oral competence.

Like nonfacial nerve transpositions, regional muscle transfers require extensive retraining to produce the desired facial movements, such as tensing the temporalis muscle to smile or close the eyes. (32) Disadvantages of regional muscle transfer include eye and facial movement with mastication and aesthetic changes at the donor site.

Free microneurovascular muscle transfer can result in spontaneous facial movement, and it is considered the procedure of choice for long-standing facial paralysis. (33) Free muscle transplantation can be performed as either a one- or two-stage procedure. Mathes and Hentz reported that a two-stage reconstruction with facial nerve mapping and cross-face nerve grafting followed by microneurovascular muscle transplantation is preferable. (29) The facial nerve is commonly employed to innervate these muscles, but the trigeminal nerve, spinal accessory nerve, and hypoglossal nerve have also been used. In the preoperative evaluation of candidates for this transfer, one must consider the substantial size of the operation, the impact of patient comorbidities on flap survival, and the lengthy amount of time required before full movement of the flap is achieved--usually 18 months. (29)

When a two-stage reconstruction is selected, the cross-face nerve graft is performed first. This involves dissection of the contralateral facial nerve with identification of the zygomaticobuccal branches medial to the parotid. Harvested sural nerve is then coapted to the distal ends of selected zygomaticobuccal branches; the sural nerve can be split longitudinally for a better size match. The sural nerve graft is tunneled subcutaneously across the face or below the chin and then banked in the upper buccal sulcus. (29) The second stage is typically performed 6 to 12 months later, depending on the length of the sural nerve graft. The Tinel sign can be used to assess axonal growth; percussion over the nerve graft in a distal-to-proximal fashion should produce a tingling sensation at the site of active growth.

Multiple muscles are available for microneurovascular transplantation, including the gracilis, latissimus dorsi, pectoralis, rectus abdominis, rectus femoris, abductor hallicus, extensor carpi radialis brevis, and serratus anterior muscles. (27,29) Regardless of which muscle is selected, the principles of insetting the muscle flap are the same. The muscle is oriented so that the vessels are positioned on the deep surface. The distal muscle ends are anchored to the area to be reanimated with nonabsorbable sutures; the proximal muscle ends are usually anchored to the zygomatic arch or temporal region. The microneurovascular anastomoses are performed after the distal muscle belly is anchored. (27)

Free gracilis muscle transposition is a reconstructive option that can address both the paralyzed eyelids and lips. In a two-stage reconstruction, a cross-face nerve graft is performed first. The 6- to 12-month staging interval can be avoided by harvesting long donor nerve branches for a single-stage reconstruction. Functional territories of two branches of the obturator nerve are determined with the gracilis in situ to allocate the muscular slips for use in reanimation of the lip or eye. The origin of the gracilis free flap is attached to the temporalis fascia. The medial circumflex femoral artery (the vascular supply to the gracilis) is anastomosed to the recipient superficial temporal or facial vessels. Finally, the crossface nerves are coapted to the two nerves supplying the functional units of the gracilis muscle. (28,34)

Koshima et al described a single-stage facial reanimation procedure that involved a rectus abdominis free muscle transfer along with a long intercostal nerve that could reach the contralateral facial nerve branches. (35) While one- and two-stage procedures generally yield comparable results (good to fair), a study by Kumar and Hassan found that 67% of patients who had undergone a two-stage procedure had good symmetry at rest, compared with only 20% of those who had undergone a single-stage procedure. (25) The serratus anterior muscle--which uses branches of the thoracodorsal artery and vein, as well as the long thoracic nerve--has five muscle belly slips that can be oriented in different vectors for facial reanimation. (9) The latissimus dorsi flap is based off the thoracodorsal artery, vein, and nerve. (36) Terzis and Noah reported that the onset of transplanted muscle function occurred an average of 20 to 22 weeks after second-stage surgery. (33)

Artificial muscles, such as the electroactive polymer artificial muscle (EPAM), have been designed for use in eyelid closure. This technology uses an inner core of dielectric elastomer film sandwiched between compliant electrodes; the polymer expands and contracts, using the contralateral face as an actuator. (37) Movement of the paralyzed unilateral face with EMG has been performed with aesthetically acceptable results; implantation of acceptable biocompatible devices may be an option for patients in the future. (38)

Static reconstructive techniques

Static suspension of the face with autologous or alloplastic materials can provide symmetry at rest, and it may improve commissure competence for patients who are not candidates for a dynamic procedure. Static procedures to improve symmetry and cosmesis can be performed alone or in conjunction with other reanimation procedures. Adjunctive cosmetic procedures include brow lift, blepharoplasty, and rhytidectomy. (39) The use of these techniques depends on the degree of facial asymmetry, brow ptosis, dermatochalasis, and skin laxity.

Management of the eye. One of the most important issues in treating a patient with facial paralysis is management of the eye and protecting the cornea from complications that would affect the patient's vision. Ocular sequelae of facial palsy include incomplete closure of the eye (lagophthalmos) with corneal exposure, loss of the corneal "squeegee effect" lower-lid ectropion with epiphora, browptosis, and decreased tear production. (28,40) These sequelae can lead to exposure keratitis, corneal ulceration, and blindness. Immediate care of the exposed cornea includes the administration of a lubricating ointment and the placement of a protective eye shield. Ophthalmologic consultation should be obtained if the condition of the eye is concerning.

Tarsorrhaphy had been the mainstay surgical treatment of eyelid dysfunction secondary to facial palsy since its original description by von Walther in 1826. (41) Temporary tarsorrhaphy involves the placement of sutures through the upper and lower lids to narrow the palpebral fissure; permanent tarsorrhaphy involves sewing the upper and lower lids together after the lid margins are de-epithelialized at the point of upper- and lower-lid contact. While tarsorrhaphy may decrease corneal exposure, it does not allow for active eyelid closure, and cosmetic results are less than ideal.

Lid dysfunction secondary to paralysis affects both the upper and lower eyelids. The upper lid is often unable to completely descend in facial paralysis secondary to poor orbicularis oculi muscle tone. (42) Gold implants or eyelid-loading devices move the upper eyelid in a gravitational vector for corneal protection. The implanted weight should be placed just above the pupil in forward gaze in a pocket superficial to the tarsal plate yet deep to the orbicularis oculi. (43) The selection of implant size and weight should be based on the lightest weight (affixed with adhesive) that consistently closes the eye during repetitive blinking. (44,45) Implants can be removed with ease, and they are therefore very useful in preventing exposure keratitis for patients in whom facial nerve function is expected to return.

Lower-eyelid dysfunction can be evaluated on the basis of location: medial vs. lateral lid ectropion. Medial ectropion is associated with retraction of the inferior punctum away from the surface of the globe, which results in disruption of the lacrimal drainage system, epiphora, keratitis, and scleral show. Medial canthallaxity can be addressed with static slings and/or horizontal lid shortening. Static slings can be made of alloplastic (e.g., polytetrafluoroethylene [Teflon]), allogeneic (e.g., AlloDerm; LifeCell Corp.; Branchburg, N.J.), or harvested fascia. The sling is fashioned so that it is approximately 3 mm wide and 5 cm long. A subcutaneous tunnel is dissected from the lateral canthus above the pretarsal orbicularis oculi to the medial aspect of the eye. A medial Lynch incision is made anterior to the medial canthus; care should be taken to avoid disruption of the canaliculi and lacrimal sac. The medial aspect of the sling is secured with a permanent suture or a 1.5-mm screw. The sling is then passed through the subcutaneous tunnel, and its lateral aspect is secured in a similar fashion so that the eyelid rests about 1 mm above the inferior limbus. (42)

Correction of paralytic medial ectropion can also be accomplished via horizontal lid shortening with a deliberate transection of the inferior canaliculus. The remainder of the partially resected tarsal plate is then plicated under tension to the medial canthal tendon, and the inferior canalicular stump is marsupialized. (46)

Lateral ectropion is associated with scleral show and keratitis. Lateral lower-lid laxity and ectropion may be addressed with a lid-shortening procedure via a tarsal strip/lateral canthoplasty technique. A lateral canthotomy is performed with sharp dissection down to the periosteum of the lateral orbital rim. The lower division of the lateral canthal tendon is severed at its insertion into the Whitnall tubercle. The amount of lower lid to excise is determined by pulling the lid superolaterally so that it rests just above the inferior limbus. After a wedge of lower lid is excised, a small portion of the lateral tarsal strip is de-epithelialized and sutured to the medial aspect of the lateral orbital rim with a permanent suture. (44)

Other static procedures. Most techniques for static facial reconstruction involve suspension of parts of the face by a sling. Static facial slings are commonly used to suspend the oral commissure, which results in improved facial symmetry and oral competence. (47) Surgical exposure for the placement of a static sling can be obtained via a preauricular rhytidectomy incision and incisions at the vermilion border of the upper lip, lower lip, and oral commissure. A cheek-temple flap is elevated medially to the level of the nasolabial fold and orbicularis oris muscle, which is dissected circumferentially from the surrounding skin and mucosa. (18) Temporalis fascia, tensor fascia lata, or tendon can be harvested if autogenous tissue is desired; autogenous tissue is preferred over polytetrafluoroethylene for immediate reconstruction in patients with a history of radiation therapy. (48) The grafts selected are sutured laterally to the temporal fascia or zygoma and medially to the corner of the lip, and tension is adjusted to achieve the ideal amount of elevation.

Multiple-vector suspension is a procedure in which the lateral canthus, melolabial crease, and lower lip are suspended with nonabsorbable sutures and/or polytetrafluoroethylene through several small stab incisions. (49,50) Slings can also be used to suspend a collapsed nostril by pulling the lateral alar base to the ascending maxillary buttress. (51) Subperiosteal midfacial suspension--including a suborbicularis oculi fat lift (SOOF) via a temporal, lower-lid, and buccal approach--allows for suspension of stretched and atrophied facial muscles for improved static facial symmetry. (52)

Brow ptosis can be addressed with a direct brow lift, a midforehead lift, a coronal brow lift, or a pretrichial or endoscopic technique. (53) A study by Ducic and Adelson of 31 patients who underwent endoscopic brow lift for facial paralysis found that all 31 had much improved brow positions and no major complications. (54)

Cheiloplasty is a static reconstruction technique used to address lip paralysis, oral incompetence, drooling, and cheek biting. It entails surgical excision of the paralyzed ipsilateral lip muscles with stretching of the innervated contralateral lips across the defect to create a new commissure. This results in a smaller oral aperture (a 33% reduction of both the upper and lower lips) with some dynamic sphincteric contribution from the contralateral side. (55)

Resection of the depressor labii inferioris muscle on the contralateral side can improve facial symmetry at rest and with smiling. (56) Botulinum toxin injection also improves facial symmetry by paralyzing contralateral hyperfunctioning facial muscles. (3,57) In patients with hyperkinetic facial movements secondary to aberrant nerve regeneration, selective myectomies can achieve a permanent resolution of abnormal muscle movement or spasm. (58)


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Ashley B. Robey, MD; Mary C. Snyder, MD

From the Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology/Head & Neck Surgery, Oregon Health & Science University, Portland (Dr. Robey); and Monument Plastic Surgery, Scottsbluff, Neb. (Dr. Snyder).

Corresponding author: Ashley B. Robey, MD, Division of Facial Plastic & Reconstructive Surgery, Oregon Health & Science University, 3181 SW Sam jackson Blvd., L352A, Portland, OR 97239. Email:
Table 1. Causes of facial nerve paralysis (5,7)

Type of cause   Prevalence   Example

Idiopathic      49 to 51%    Bell palsy, Melkersson-Rosenthal

Traumatic       8 to 22%     Birth/delivery trauma, temporal or
                             facial bone fractures, iatrogenic
                             surgical trauma, barotrauma

Infectious      5 to 15.3%   Bacterial: Otitis media, otitis externa
                             Viral: Poliomyelitis, influenza, Coxsackie
                             disease, mononucleosis, varicella zoster
                             (Ramsay Hunt syndrome), herpes zoster,
                             human immunodeficiency virus infection
                             Fungal: Various

Neoplastic      5 to 13%     Parotid tumors, cholesteatoma, acoustic
                             neuroma/vestibular schwannoma, glomus
                             jugulare/tympanicum tumors

Neurologic      5 to 13%     Multiple sclerosis, myasthenia gravis,
                             Guillain-Barre syndrome, stroke, Mobius

Systemic/       ~2%          Diabetes mellitus, hyper/hypothyroidism,
metabolic                    pregnancy, autoimmune syndromes, acute

Table 2. Summary of the House-Brackmann facial nerve grading
system (10)

Grade   Degree of function   Characteristics

I       Normal function      Facial function is normal in all areas.

II      Mild dysfunction     Gross: Slight weakness is noticeable only
                             on close inspection.
                             Repose: Symmetry and tone are normal.
                             Motion: Eye completely closes with
                             minimal effort; mouth movement is slightly
                             asymmetric; forehead movement is
                             moderate to good.

III     Moderate             Gross: Muscle weakness is obvious
        dysfunction          but not disfiguring.
                             Repose: Symmetry and tone are normal.
                             Motion: Eye closes completely with
                             effort; mouth is slightly weak with
                             maximal effort; lifting of the eyebrow
                             may not be possible.

IV      Moderately severe    Gross: Weakness or asymmetry is
        dysfunction          disfiguring.
                             Repose: Symmetry and tone are normal.
                             Motion: Eye does not completely close;
                             mouth is asymmetric with maximum effort;
                             forehead does not move.

V       Severe dysfunction   Gross: Motion is barely perceptible.
                             Repose: Facial features are asymmetric.
                             Motion: Eye does not completely close;
                             mouth moves slightly at the corner;
                             forehead does not move.

VI      Total paralysis      No movement.
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Author:Robey, Ashley B.; Snyder, Mary C.
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:1USA
Date:Jun 1, 2011
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