Facial Reanimation Lights The Way
January 19, 2021
Patients find help, hope and personalized care through the new program
Innovations in Ear, Nose & Throat | Winter 2021
People with facial paralysis can feel lost when seeking help for their condition, even long after experiencing facial nerve damage or trauma.
“Patients will come to me who have been treated for many months, but they have very little understanding of their condition and what options they have for treatment,” explains Cyrus Rabbani, MD, who is leading the new facial reanimation program at University Hospitals Ear, Nose & Throat Institute.
The most common cause of facial paralysis is Bell’s Palsy, a sudden weakness or paralysis of the facial muscles on one side of the face. Though other causes include infection, surgery, trauma, tumors or other diseases, and congenital conditions.
For Dr. Rabbani and team, treating facial paralysis is a highly personal process that involves team decision-making and multidisciplinary care. A patient’s treatment team may include an oculoplastic surgeon, ophthalmologist, neurotologist, plastic surgeons, speech therapists and physical therapists, depending on their needs.
“Everyone carries a component of the care for a patient, so it is a true team approach to ensure patients receive every possible option in their care,” says Dr. Rabbani, a facial plastic and reconstructive surgeon in the Department of Otolaryngology – Head and Neck Surgery at University Hospitals, and Assistant Professor at Case Western Reserve University School of Medicine.
Dr. Rabbani completed his fellowship in facial plastic surgery at Johns Hopkins University before he was recruited by the UH ENT Institute this year. The department also added three new otologists with expertise in facial nerve surgery in the last six months — part of its plan to offer a comprehensive facial reanimation program for patients throughout the greater Cleveland area.
The newly formalized program treats people of all ages with different facial nerve limitations, using medical and/or surgical therapies to restore movement and function of the patient’s face — including their ability to smile.
“Our program sees a lot of patients with facial paralysis with different functional and aesthetic concerns,” he says. “We treat each patient differently based on presentation, the cause and effects of the paralysis, and other factors.”
Patients who have recovered from their facial paralysis but are left with some abnormal facial movement can often be treated with a less invasive chemical denervation, such as botulinum toxin, or Botox®, to gain temporary relief from muscles that are moving abnormally.
“Once patients find that they like these results, we may continue to inject Botox®, as necessary every 3-4 months,” Dr. Rabbani explains.
Other interventions can help patients achieve similar results to Botox®, with more permanent results. In a myectomy procedure, doctors identify which muscles in the face are most severely affected and remove the ones that aren’t functioning properly. A similar procedure, called selective neurolysis, is used to cut the nerves that are moving the facial muscles abnormally, rather than temporarily paralyzing them.
Current surgical therapies for facial reanimation include nerve grafts and muscle transfers. Patients that have new or recent facial paralysis may be candidates for facial nerve decompression surgery to alleviate pressure on pinched nerves as well as reanimation techniques such as reinnervation. With reinnervation, surgeons perform a nerve graft to transfer nerves that move neck or other muscles and restore facial movement.
If none of the patient’s facial muscles is functioning, they may require a muscle transfer surgery to restore muscle movement. Candidates for this surgery are usually patients with a long-standing history of facial paralysis but incomplete recovery.
The most common muscle transfer for facial reanimation uses the gracilis muscle, located along the inner thigh. Gracilis muscle transfers are performed in children as well as adults and usually consist of two stages: a priming stage where surgeons perform a cross-face nerve graft, and a second surgery, where they remove muscle from the patient’s leg, including an artery and vein to resupply the blood when the muscle is transferred.
“This technique has have evolved substantially over the last decade to improve results tremendously,” Dr. Rabbani says. “The nerve is then hooked up to the banked, cross-face nerve graft, so those two nerves together can power the gracilis muscle, and we reestablish blood flow through the vessels in the neck into the muscle.”
Having a multidisciplinary facial reanimation program is critical to offering patients the latest therapies — and also advancing new ones.
Although most individuals with Bell’s Palsy will recover well or completely without much treatment, for example, a subset of patients will experience the opposite. “Those patients who end up with abnormal facial movement will generally continue to get worse about one to two years after it starts,” Dr. Rabbani says.
He and his team are interested in how clinicians can better predict outcomes in Bell’s Palsy and how earlier intervention could aid in the patient’s recovery. That could include having a dermatologist perform facial nerve decompression surgery or other techniques sooner and meeting with patients earlier in the disease process to discuss their options, he says.
Also, because Bell’s Palsy is often a diagnosis of exclusion, some patients with a Bell’s Palsy diagnosis may have another condition that is causing their paralysis. Earlier evaluation with the facial reanimation team could help them understand the true root cause of their facial paralysis to see improvement sooner.
“My goal is to make sure that every person with facial paralysis understands what they're going through, whether it's early on in their facial paralysis or late, and what options they have for potential treatments,” Dr. Rabbani says. “I want our patients to feel like they have a good resource to get care — and they're never left in the dark.”