• "The human face is the organic seat of
beauty. It is the register of value in
development, a record of Experience,
whose legitimate office is to perfect the
life, a legible language to those who will
study it, of the majestic mistress, the
• Farnham, Eliza
• Facial function plays an integral part in our
– Smile; nonverbal communication, etc.
• Facial paralysis is devastating on many levels
• Fortunately, a plethora of techniques are
available to treat the paralyzed face.
NERVE FIBER COMPONENTS
– Surrounds each axon
– Adherent to Schwann cell
– Vital for regeneration
– Encases endoneural tubules
– Tensile strength
– Barrier to infection
• Epineurium (nerve sheath)
– Outermost layer
– Houses vasa nervosum for
• Two acceptable classification schemes used
to describe the histologic changes that occur
following nerve injury.
SEDDON CLASSIFICATION (1943)
• Neurapraxia-a conduction block from
transient anoxia owing to acute
epineurial/endoneurial vascular interruption
resulting from mild nerve manipulation with
rapid and complete recovery of sensation.
• Axonotmesis- This damage extends through
and includes the endoneurium with no
significant axonal disorganization.
Recovery is slow and may take weeks to
months, and it may not be complete.
• Neurotmesis- injuries result from complete
or near complete transection of the nerve
with epineurial discontinuity and likely
neuroma formation. Spontaneous
neurosensory recovery is unlikely.
7th Cranial nerve
Nerve of the 2nd branchial
Has two roots. A large
motor and a smaller mixed
• Brancial motor(special visceral efferent)-
Supplies; Stapedius , Stylohyoid,
posterior belly of digastric muscle and the
muscles of facial expression.
• Visceral motor(general visceral efferent)
Parasympathetic innervations of the
lacrimal, submandibular, and sublingual
glands, as well as mucous membranes of
nasopharynx, hard and soft palate.
•Special sensory(special afferent)-Taste sensation from the anterior 2/3 of tongue;
hard and soft palates.
•General sensory(general somatic afferent)-General sensation from the skin of the
concha of the auricle and from a small area behind the ear.
The facial nerve is
I. Contraction of the
muscles of the face
II. Production of tears from a
gland (Lacrimal gland)
III. Conveying the sense of
taste from the front part
of the tongue (via the
Chorda tympani nerve)
IV. The sense of touch at
destruction of the
Central or cerebral or
Peripheral- from a lesion
of the nerve
usually a part of hemiplegia,
only the lower part of the
face is paralysed. The upper
part (frontalis and part of
orbicularis oculi)escapes due
to bilateral representation in
the cerebral cortex.
Infranuclear lesions- entire
face is paralysed, as seen in
ETIOLOGIC CLASSIFICATON OF FACIAL
Various classification have been suggested in this
Course of the nerve
Various etiologic causes
Degree of dysfunction observed
CNS degenerative diseases
Tumours of the intracranial cavity
Trauma to the brain
Congenital abnormalities and agenesis
INTRACRANIAL (CENTRAL) CAUSES
Bacterial and Viral infection
Trauma- blunt temporal bone trauma,
longitudinal and horizontal fractures of the
temporal bone and gunshot wounds.
Tumours invading the middle ear, mastoid and
Malignant tumours of the parotid gland
Primary tumours of the facial nerve
Malignant tumours of the ascending ramus of the
mandible, pterygoid region and skin.
• Grade I-normal function without weakness.
• Grade II-mild dysfunction with sligth facial asymmetry
with a minor degree of synkinesis.
• Grade III-moderate dysfunctions-obvious, but not
disfiguring, asymmetry with contracture and/or
hemifacial spasm, but residual forehead motion and
incomplete eye closure.
• Grade IV-moderately severe dysfunction- obvious,
disfiguring asymmetry with lack of forehead motion and
incomplete eye closure.
• Grade V-severe dysfunction-asymmetry at rest and only
slight facial movement.
• Grade VI-total paralysis-complete absence of tone or
• It is defined as an idiopathic
paresis or paralysis of the facial
nerve of sudden onset.
• The name was ascribed to SIR
CHARLES BELL, who in 1821
demonstrated the separation of
motor and sensory innervation of
• INCIDENCE-15-40 cases per 1 lakh cases
• SEX PREDILECTION- women more affected
than men.3.3 more times common in
pregnancy and in the third trimester.
• AGE- can occur at any age, common in middle
• SIDE INVOLVMENT- can be equally seen,
• There is sudden onset, usually pt gives h/o
occurrence after awakening early morning.
• Unilateral involvement of entire side of the
• Abrupt loss of muscular on one side of face.
• Inability to smile, close the eye or raise the
eyebrow on affected side.
• Whistling is not possible.
• In an attempt to close eyelid, the eyeball
• Inability to wrinkle forehead or elevate
upper or lower lip.
• Obliteration of nasolabial fold.
Face appears distorted and mask like
appearance to the facial features.
Speech becomes slurred.
Occasionally there is loss or alternative of
Partial paralysis always resolves completely within a few
Recovery from complete paralysis takes longer (months)
and is complete in only about 60-70% of cases.
Approximately 15% of patients are left with troublesome
residual palsy and or synkinesis.
COMPLICATIONS OF FACIAL PARALYSIS
Facial paralysis severely hinders:
• Normal facial expressions
• Speech production
• Eye protection.
• The most significant complication is the social
isolation these patients often succumb to.
The most serious complication is corneal damage.
One of the greatest problems with Bell's palsy is the involvement of
the eye if the lid fissure remains open.
In this case, eye care focuses on protecting the cornea from
dehydration, drying, or abrasions due to insufficient lid closure or
ASSESSMENT AND PLANNING
Cause of facial paralysis
Functional deficit/extent of paralysis
Time course/duration of paralysis
Likelihood of recovery
Other cranial nerve deficits
Patient’s life expectancy
EVALUATIONS OF NERVE FUNCTION
• HISTORY is of vital importance to establish the
onset characteristics,duration and degree of
• Previous trauma, surgery or infection may help in
arriving at a diagnosis
• Examination of the face at rest and movement.
• Radiolologic evaluations
• Nerve excitability tests.
• TEAR TEST: (Schirmer’s test)
• Semiquantitative method for comparing lacrimal
secretion on normal & affected side.
• 0.5×5cm strip of filter paper.
• If moistened length in affected side <25% of
normal: significant hyposecretion is present.
• Subjective loss of sensation: unreliable symptom.
• Swab sides of tongue by a cotton applicator dipped in lemon juice.
• Threshold measured with electrogustometer (measured electric
current). N:30gk microamp
• Patient percieves this as sour or metallic.
• Cannulate wharton duct on each side with no.50 polyethylene tube
• Stimulate saliva with lemon juice
• Output of saliva measured in each tube
• 25% reduction is significant
• Indicates interruption of chorda tympani or facial nerve to this branch.
• LIMITATIONS- Unequal penetration of cannula, assymetry of glands.
ELECTRICAL TESTING OF FACIAL NERVE
MAXIMUM STIMULATION TEST
• Pulsed electric current is delivered through a cutaneous
• Short pulse will stimulate an intact nerve & elicit a
• In paralysed facial nerve, this indicates that lesion is
neuropraxia & distal neurons have not undergone
• Hence differentiates between neuropraxia & axonotmesis:
NERVE EXCITABILITY TEST:
• Current required for stimulation on normal side is compared with
• Disadv: even few intact fibres can elicit a response when rest in
Muscle twitch response is subjective
Requires patient co-operation
• Measures compound action potential in facial muscles in response to
facial nerve stimulation.
• Similar to MST, except instead of visually ration the muscle
contraction, the muscle action potential is measured on EEG- more
• Best test to predict & follow facial nerve recovery.
• Compare & represent it as percentage of normal side.
• Oral antivirals - Acyclovir
• Eye protection
• Follow progression with serial exams
• If the patient is seen within 2 to 3 weeks of onset
of symptoms-tab. Prednisolone in doses of
1mg/kg/d for 10 to 14 days has been
recommended with a gradual tapering.
• Vitamins B1, B6, B12 may be administered.
• If pt is seen after 3-4 weeks, then steroid therapy
is of no use.
A. Acute (< 3 wks)
1. Nerve exploration/decompression
2. Nerve repair
a. Primary anastomosis
b. Cable grafting
i. Great auricular nerve
ii. Sural nerve
B. Intermediate (3 wks- 2 yrs)
1. Nerve transfer
b. Spinal accessory-facial
2. Cross face nerve grafting using sural nerve
C. Chronic (>2 yrs)
1. Muscle transfers
2. Free muscle flaps/
b. Latissimus dorsi
c. Serratus anterior
d. Pectoralis minor
D. Static procedures/ancillary procedures
(can be performed at any time period
1. Gold weight/spring implants
3. Lid procedures
Ryan Ridley. Facial Reanimation .Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
SURGICAL TREATMENT MODALITIES
• Facial nerve repair is the most effective
procedure to restore facial function in patients
who have suffered nerve damage from an
accident or during surgery.
• It involves microscopic repair of a nerve that
has been cut.
PRIMARY NERVE REPAIR
performed < 72 hrs of
Most common methods
Group fascicular repair
Epineural repair Group fascicular repair
Primary Nerve Repair
Severed ends of nerve
removed with fine scalpel
Small bites of epineurium
approximated with 9-0
Epineural repair recommended
for injury proximal to pes
anserinus and intratemporal
EPINEURAL REPAIR TECHNIQUE
Used when defect > 17mm; nerve cannot be
reapproximated without tension
Greater Auricular Nerve
Sensory nerves from superficial cervical plexus
INTERPOSITION GRAFTING GREATER AURICULAR
Located on lateral surface of
SCM at the midpoint of a
line drawn between mastoid
tip and mandibular angle
May extend postauricular
incision or use separate neck
Proximity to facial nerve
Reconstruction of long defects
Ideal for defects < 6cm in length
– Formed by union of medial
sural cutaneous nerve and
lateral sural cutaneous branch
of peroneal nerve.
Length : >12cm
Low morbidity associated with
Often too large
Difficult to make graft approximation
NERVE TRANSPOSITION/ CROSSOVER
• Nerve transposition is also known as facial-
• Restores movement to the side of the face that
has been paralyzed.
• With the stump of the 12th nerve hooked up to
the end of the 7th nerve, the face will move
when the tongue is moved.
Irreversible facial nerve injury
Intact facial musculature/distal facial nerve
Intact proximal donor nerve
Prior to distal muscle/facial nerve atrophy
Ideal if performed within a year of facial paralysis
Time interval until movement
Avoid multiple sites of anastomosis
Mimetic-like function achievable with practice
Donor site morbidity
Some degree of synkinesis
1. Parotidectomy incision extended
into cervical crease ~ 2-3 cm below
inferior border of mandible
2. Facial nerve identified and
dissected distal to pes anserinus
3. Identify hypoglossal nerve
a. SCM retracted posteriorly
b. Dissect superiorly until
posterior belly of digastic is
c. Retract digastric superiorly
and CN XII is found
d. Hypoglossal is within
2-3 c m of main trunk of the
4. Hypoglossal nerve is dissected
anteriorly and medially into the
1. Transect distal to ansa
5. Facial nerve transected at the
6. Anastomose nerves using 9-0
Hypoglossal Facial Nerve Transfer
Entire hypoglossal nerve
40% segment of nerve secured to
Hypoglossal Facial Nerve Transfer
Jump graft modification
Reflection of the facial nerve
out of the mastoid bone.
CROSS-FACIAL NERVE GRAFTING
• Contralateral Facial nerve used to reinnervate
paralyzed side using a nerve graft
– Sural nerve often employed
– ~25-30cm of graft needed
• Restitution of smile and eye blinking obtained.
– 2nd surgical site
– Violation of the normal facial nerve
CROSS-FACIAL NERVE GRAFTING
Sural nerve graft routed from buccal
branch of normal VII to stump of
Zygomaticus and buccal branch of
normal VII used to reinnervate
zygomatic and marginal mandibular
4 separate grafts from temporal,
zygomatic, buccal and marginal
mandibular divisions of normal CN
VII to corresponding divisions on
Entire lower division of normal side
grafted to main trunk on paralyzed
– Congenital facial paralysis
– Facial nerve interruption of at least 3 years
• Loss of motor endplates
– Crossover techniques not possible due to donor
Often used for reanimation of
the oral commisure.
Middle 1/3 of muscle is best for
transfer (Sherris, 2004)
1. Incision in preauricular crease
extending to superior temporal
2. Obtain wide exposure of
temporalis muscle by dissecting
above the SMAS
3. Incise down on periosteum to
elevate muscle fibers
-Harvest middle 1/3
4. Large tunnel created over
5. Orbicularis oris muscle exposed
via vermilion border incision at
6. Large tunnel over zygomatic arch
used to connect oral commisure to
zygomatic arch/superior incision.
7. Temporalis flap detached and
elevated from its origin and
tunneled to the oral commissure.
8. 3-0 prolene used to suture
orbicularis to temporalis at oral
9. Overcorrection of nasolabial fold
and oral commissure
• Used when temporalis muscle is not opted.
• May be preferred due to avoidance of large facial
– Less available muscle compared to temporalis
– Vector of pull on oral commisure is more horizontal
than superior/oblique like temporalis
1. Expose muscle with gingival
incision along mandibular sulcus
2. Dissection carried out in a plane
between mucosa and muscle.
3. Muscle freed off of mandible
medially and from the
inferiolateral edge of mandible.
4. Vertical incision made in inferior
portion of muscle
5. Anterior half of muscle is split
into 2 divisions.
6. The 2 anterior slips of muscle are
tunneled anteriorly to reach the
oral commisure via external
vermillion border incisions
7. Muscle slips are attached to lips
and oral commisure in the deep
dermal layer using suture
FREE MUSCLE FLAPS
• They have potential of achieving individual
– Reduction of synkinesis
• Muscle flaps used are:
– Latissimus dorsi
– Inferior rectus abdominus
FREE MUSCLE FLAPS
Requires viable muscle and nerve innervation
Traditionally done in 2 stages
1st: Cross-face nerve graft ~ 1 yr prior to muscle transfer
2nd: Muscle transfer performed after neural ingrowth of graft
1. “Workhorse” for free muscle
2. Long, thin muscle in medial
-Good neurovasular pedicle
1. Adductor artery and
2. Anterior obturator
3. 2 stages involved:
1. Sural nerve employed for
2. Gracilis muscle transferred
after 6-12 months
4. Vascular anastomosis to the
facial artery and vein or to
superficial temporal vessels.
5. Obturator nerve of gracilis
connected to distal end of sural
Anterior Obturator nerve
Adductor a. & v.
ADDRESSING PARALYTIC EYELIDS
Complications of orbicularis oculi paresis
Impairment of nasolacrimal system
Risk of exposure keratitis, corneal ulceration and
Goal of treatment is to maintain cornea
Gold weight/spring implants
Open / endoscopic brow lifts for significant brow ptosis
1. Small incision
the upper eyelid
2. Tarsal plate
exposed with sharp
3. Gold weight
secured to tarsus
using 8-0 nylon.
4. Wound closed in 2
Horizontal mattress 5-0 nylon
Begin 3mm medial to lateral canthus,
6mm from lid margin
Stitch travels through gray line to
5mm below lower lid margin
Bolster with 3mm, 4-french rubber
Cosmetically unappealing, visual field
Surgical management of LAGOPHTHALMOS
• F. Stagno d’Alcontres, G. Cuccia*, F. Lupo, G. Delia, M. RomeoThe
orbicularis oculi muscle flap: Its use for treatment of lagophthalmos. Journal
of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 416e422
Debilitated individuals; poor prognosis
Nerve or muscle not available for dynamic procedures
Adjuct procedure with dynamic techniques to
provide immediate benefit
Immediate restoration of facial symmetry at rest
No oral commisure ptosis
Drooling, disarticulation, mastication difficulties
Relief of nasal obstruction caused by alar collapse
• Static Facial Suspension is used to lift the corner
of the mouth so that balance is restored to the face
and drooling out of the mouth is helped.
Variety of materials
• PTFE (Gor-Tex)
• Fascia lata
Gor-Tex and alloderm
have advantage of no
donor site morbidity
but higher risk of
STATIC FACIAL SLING TECHNIQUE
1. Preauricular, temporal or nasolabial
fold incision may be used
2. Additional incisions made adjacent
to oral commisure at vermillion
border of upper and lower lip
3. Subcutaneous tunnel dissected to
connect temporal to oral
4. Dissection may be carried out in
midface adjacent to nasal ala, if
needed (for alar collapse)
5. Implant strip is split distally to
connect to the upper/lower lips
6. Implant secured to orbicularis
oris/commisure using permanent
7. Implant is suspended and anchored
superiorly to superficial layer of
deep temporal fascia, or zygomatic
arch periosteum, using permanent
8. May also secure to malar eminence
using small miniplate or bone
• Cranial nerves-Functional Anatomy – Stanley Monkhouse
• Anatomy for Surgeons: Hollinshead
• Maxillofacial surgery: Peter Ward Booth Vol 1 & 2
• Peterson’s Principles of Oral & Maxillofacial Surgery, 2nd edition.
• Oral pathology- Regezi.
• Textbook of oral surgery – Neelima Malik
• Gray’s anatomy.
• Text of Anatomy by Roylce.