Facial Paralysis

Facial Paralysis Surgery

Facial Paralysis | Johns Hopkins Medicine

Nerve damage due to trauma or other conditions, such as Bell’s palsy, can lead to an inability to move the muscles of the face, on one side or both. Facial paralysis can make it difficult to speak, blink, swallow or smile. When facial paralysis does not resolve on its own, surgery can address the problem.

Facial Paralysis Treatment: Before and After Pictures

Facial Reanimation

Result after two stage cross facial nerve graft and Gracilis flap for smile restoration to correct right sided facial paralysis resulting from resection of acoustic neuroma.

To produce an engaging smile the procedure is tailored to lift the upper lip to show teeth, define the smile lines to match the unaffected side, raise the Malay fat pads to reflect light and raise the corners of the mouth evenly.

Right eyelid procedures were also performed to match the size of the unaffected side. The first and second procedures were performed 6 months apart.

Facial Reanimation

​Result of smile restoring surgery for complete left sided facial paralysis.

Treatment : Dual innervation with a combination of cross facial nerve graft and hypoglossal nerve transfer. The cross facial nerve graft recruits facial nerve function from the normal right face to allow a spontaneous smile and movement on the left side. The hypoglossal nerve restores tone to the left face and keep the lips symmetric when she talks.

Facial Reanimation

​Diagnosis: Right facial paralysis.

Treatment: Temporal Tendon Transfer (T3); browlift; lower eye lid surgery; reconstruction of right lower lid with a medical and lateral eyelid lift surgery.

Facial Reanimation

Diagnosis: left facial paralysis.

Treatment: Temporal Tendon Transfer (T3) surgery, left brow lift, left face lift and placement of gold weight implant.

Facial Reanimation

Diagnosis: facial paralysis after a parotidectomy

Treatment: Temporal Tendon Transfer (T3) surgery, which doesn't cause any noticeable swelling or deformity of the face.

Facial Reanimation

Result after two stage cross facial nerve graft and Gracilis flap for smile restoration to correct right sided facial paralysis resulting from resection of acoustic neuroma.

To produce an engaging smile the procedure is tailored to lift the upper lip to show teeth, define the smile lines to match the unaffected side, raise the Malay fat pads to reflect light and raise the corners of the mouth evenly.

Right eyelid procedures were also performed to match the size of the unaffected side. The first and second procedures were performed 6 months apart.

Facial Reanimation

​Result of smile restoring surgery for complete left sided facial paralysis.

Treatment : Dual innervation with a combination of cross facial nerve graft and hypoglossal nerve transfer. The cross facial nerve graft recruits facial nerve function from the normal right face to allow a spontaneous smile and movement on the left side. The hypoglossal nerve restores tone to the left face and keep the lips symmetric when she talks.

Facial Reanimation

​Diagnosis: Right facial paralysis.

Treatment: Temporal Tendon Transfer (T3); browlift; lower eye lid surgery; reconstruction of right lower lid with a medical and lateral eyelid lift surgery.

Facial Reanimation

Diagnosis: left facial paralysis.

Treatment: Temporal Tendon Transfer (T3) surgery, left brow lift, left face lift and placement of gold weight implant.

Facial Reanimation

Diagnosis: facial paralysis after a parotidectomy

Treatment: Temporal Tendon Transfer (T3) surgery, which doesn't cause any noticeable swelling or deformity of the face.

Facial Paralysis: Why Choose Johns Hopkins Facial Plastic Surgery?

  • Our surgeons are internationally renowned, including two of the most highly regarded in the world for the treatment of facial paralysis.
  • With the large number of patients we see and our faculty’s experience, which includes specific training in the structure of the head and neck region, we offer a rare degree of skill and expertise even in the most complex procedures.
  • The team’s unique skills in surgical reanimation techniques can address paralysis of the face, including nerve and tendon transfers, microvascular surgery and oculoplastics.
  • Our experts at Johns Hopkins have contributed many innovations to the field of facial reanimation, including the recent advancement of powering the gracilis muscle with multiple nerve sources including the cross face nerve and the masseteric nerve. This facilitates the spontaneous smile of the cross facial nerve graft with added power from the masseteric nerve. 

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Facial Paralysis Surgical Options: What You Need to Know from a Johns Hopkins Expert

What you need to know about three options for facial reanimation surgery: masseteric nerve transfer, temporalis tendon transfer and gracilis free tissue flap from Johns Hopkins facial plastic and reconstructive surgeon Patrick Byrne.

A number of surgical procedures can restore movement to the lower part of the face. Some of these procedures involve moving facial nerves, tendons and muscles (or parts of them) from other areas of the body to the face.

Surgery to transplant muscle tissue may involve more than one procedure and hospital stays of several days for each stage.

Your individualized treatment plan may involve one or more of these procedures:

Temporalis Tendon Transfer (T3): This is a relatively simple procedure that moves the temporalis muscle and tendon from one location in the face to another.

Gracilis Muscle Transplant (Gracilis Free Flap): The surgeon transfers a small portion of a thin muscle of the inner thigh to replace facial muscles.

Cross-Facial Nerve Graft: The surgeon moves a nerve from one side of the face to the other to supply a transplanted muscle with the ability to contract.

Masseteric Muscle Transfer: One branch of the muscle that helps people chew is re-routed to a new area in the face.

Hypoglossal Nerve Transfer: The surgeon can relocate a portion of the facial nerve that moves the tongue to a position that enables a transplanted muscle to function.

Facial Paralysis Patient Smiles Again

Follow Anthony’s journey as he has a masseter nerve transfer and eyelid surgery and experiences an improved quality of life.

Meet Drs. Kofi Boahene and Patrick Byrne

Our doctors are board certified in both otolaryngology—head and neck surgery and facial plastic and reconstructive surgery, which gives our team a unique and comprehensive level of expertise.

Meet Dr. ByrneMeet Dr. Boahene

Source: https://www.hopkinsmedicine.org/otolaryngology/specialty_areas/facial-plastic-reconstructive/reconstructive/facial-paryalsis/

Facial Paralysis

Facial Paralysis | Johns Hopkins Medicine

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An inability to move the muscles of the face on one or both sides is known as facial paralysis. Facial paralysis can result from nerve damage due to congenital (present at birth) conditions, trauma or disease, such as stroke, brain tumor or Bell’s palsy.

The problem can affect one or both sides of the face, with noticeable drooping of the features and problems with speaking, blinking, swallowing saliva, eating or communicating through natural facial expressions.  

Treatment for Facial Paralysis

Paralysis of the face may be temporary or permanent. The facial plastic surgery team determines the best treatment how long the paralysis has been present, the cause and whether it is a complete paralysis, or an incomplete (or partial) paralysis.

Two surgical techniques that are used for long-standing facial paralysis—the temporalis tendon transfer (T3) and gracilis free flap. Hear from patients who have had these procedures.

Facial paralysis surgery is also called facial reanimation surgery. A facial plastic surgeon can use all or parts of muscles, nerves or both from other parts of the body to restore motion to the lower half of the face.

Because of the importance of facial mobility in creating recognizable facial expressions and communicating with others, addressing paralysis of the face is more than a cosmetic concern, especially in children.

Nerve Transfers

When a facial nerve is injured, there is a period of time during which it may be possible to restore lost nerve function to (reinnervate) the muscles of the face by transferring another nerve to that area.

For example, a branch of the nerve responsible for chewing can be released and attached to one or more branches of the facial nerve. If this is done soon enough after an injury, it is usually successful.

If nerve function is lost, as time goes on the muscles of the face weaken and degrade. When a year or more has passed, the opportunity to reinnervate the facial muscles may be lost. Even if this happens, there are options to restore movement and expression to the face.

Temporalis Tendon Transfer (T3)

The temporalis muscle and tendon are located in the face. The muscle’s purpose is to help with chewing. The plastic surgeon can move these structures to another position, a relatively simple operation that takes less than an hour.

This technique is extremely effective at lifting the sagging or droopy mouth. It can restore symmetry, reduce drooling and even allow a patient to smile again.

One drawback to this procedure is that the person must clench the teeth to smile, which takes practice. With work, over time, most patients can achieve an almost effortless smile. Although there is a theoretical risk of trouble chewing following this surgery, that risk is minimal.

Gracilis Muscle Transplant (Free Flap)

The gracilis muscle is located in the inner thigh. A small portion of this muscle, called a flap, along with its corresponding nerve and blood supply (artery and vein), can replace the facial muscles that allow the person to smile.

Using highly specialized microsurgical techniques, the surgeon transplants the gracilis muscle’s artery and vein and attaches them to a corresponding artery and vein in the head and neck region. This connection is critical for the muscle to survive in its new environment in the face.

There are stronger muscles in the leg that perform the same function as the gracilis muscle, so even after the surgeon removes this muscle to use in the person’s face, the person is not ly to have any long-term problems in moving or walking after the procedure.

Though the gracilis transplant takes longer, involves two surgeries and a two-day hospital stay, it has certain advantages over the T3 procedure. The smile produced by a gracilis transplant does not require teeth clenching and is more natural looking, involving the whole face rather than just the corner of the mouth.

Maggie Whittum suffered a life-threatening stroke that left half her face paralyzed, a devastating loss for a talented actress. Today, she's back to performing.

Muscles require nerves in order to function, and so muscle transfers such as the gracilis transfer require two separate surgeries.

The first procedure involves moving a nerve to the facial area. Once this surgery heals, the surgeon can perform the second procedure: the transplantation of the gracilis muscle itself.

The surgeon has several different nerve-grafting options for facilitating motion and sensation to the transplanted muscle and empowering it to work in its new location.

Cross-Facial Nerve Graft

Because this nerve graft crosses the face from the normal side to the paralyzed side, it is called a cross-facial nerve graft or CFNG.

First Surgery: The surgeon removes a sensory nerve from the lower leg (the sural nerve) and attaches it to a facial nerve branch on the person’s normal side, tunneling the other end of this nerve underneath the skin to position it in the paralyzed portion of the person’s face. Removal of the nerve may result in some numbness around the little toe and the outer edge of the foot.

There is a six- to nine-month wait after this procedure to allow the nerve signal to grow across the nerve graft, from the patient’s normal side to the paralyzed side.

Second Surgery: The surgeon then connects the cross-facial nerve graft to the nerve that moves the gracilis muscle at the time of the gracilis muscle transfer.

Masseteric Muscle Transfer

The masseter muscle is one of many muscles that help people chew. One of the branches of the nerve that moves this muscle can be rerouted to power the gracilis muscle. The masseter nerve is a strong nerve that is easily accessible during surgery.

Hypoglossal Nerve

The hypoglossal nerve moves half of the tongue, and the surgeon can move a portion of this nerve to power the transferred gracilis muscle. the masseteric nerve, the hypoglossal nerve is a very strong nerve that is fairly easy to reach in surgery.

People undergoing this procedure have a small risk of tongue weakness that can result in difficulty speaking and eating. Some people may experience an inadvertent facial twitch when moving the tongue, such as during eating. Practice and exercise are also required to coordinate tongue movement to create a smile.

Dual Innervation

A recent innovation in the field of facial reanimation involves powering the gracilis muscle with multiple nerve sources, such as both the CFNG and the masseteric nerve, which boosts the spontaneous smile of the CFNG with added power from the masseteric nerve.

Follow Anthony’s journey as he has a masseter nerve transfer and eyelid surgery and experiences an improved quality of life.

The goal of surgery to correct facial paralysis is to achieve the best possible function and appearance of the lower part of the face. A person with facial paralysis should meet with an experienced surgeon who has experience and skill in addressing this problem. The surgeon will consider:

  • The cause of the paralysis and the areas of the face that are affected
  • The person’s general physical and emotional health
  • The type of procedure(s) most appropriate for the person
  • The results that the person expects and hopes for from the procedure

Facial Paralysis Surgery: Procedure and Care

Muscle transplantation surgery is an inpatient procedure that takes place at the hospital. Surgery itself takes an average of six to eight hours. Most patients can go home after three or four days in the hospital.

The person spends the first 24 hours after surgery in the intensive care unit, because the team must monitor the gracilis flap every hour for the first 24 hours, every two hours for the following 24 hours, and every four hours after that.

Gracilis Muscle Transplant: Special Considerations

If the surgeon places a drain in the thigh where the gracilis muscle tissue was removed, the person will get detailed instructions on caring for the drain at home. When the patient returns for the first postoperative visit the week after surgery, the surgeon will ly remove the sutures (stitches) and the drain.

Most patients return to school or work two to three weeks after surgery. The surgeon will provide instructions on avoiding strenuous activity such as lifting.

After surgery, it will take several months for the return of the smile function with movement of the transplanted gracilis muscle. Recovery will vary the nerve option(s) chosen. It is important for patients to focus on recovery and maintain a positive outlook.

Swelling After Gracilis Flap Surgery

There will be quite a bit of facial swelling right after surgery, but it will improve over the first couple of weeks. A certain amount of fullness in the face will persist until the transplanted gracilis muscle begins to move. Up to 20 percent of patients need a revision procedure to reduce the volume of the flap.

Follow Up for Facial Paralysis Surgery

Follow-up care is vital to ensure optimal healing. It is extremely important to follow the surgeon’s postsurgery instructions carefully, especially:

  • Avoiding strenuous activity or lifting according to the surgeon’s instructions
  • Alerting the surgery team immediately in the event of any problem or unexpected change
  • Keeping follow-up appointments, one day, one week and one month after surgery.

Johns Hopkins facial plastic and reconstruction surgeon Patrick Byrne answers questions about facial paralysis surgical techniques.

Source: https://www.hopkinsmedicine.org/health/conditions-and-diseases/facial-paralysis

Facial Pain and Facial Paralysis | Johns Hopkins Department of Plastic & Reconstructive Surgery

Facial Paralysis | Johns Hopkins Medicine

If you suffer from facial paralysis or chronic facial pain, there are several options to consider when searching for treatment including surgery, pain management, and rehabilitation therapies.

Our patients are all ages and experience facial pain or paralysis due to trauma, illness, surgery, strokes or congenital conditions.

We also treat chronic facial pain patients and are on the forefront of new methods in treating these devastating conditions.

Why choose Johns Hopkins?

Often sufferers of these conditions feel there is no hope.

We provide a comprehensive approach to treating patients with facial paralysis and/or chronic facial pain that can include pain management, rehabilitation therapies, or surgery to help relieve symptoms.

Our experts consult with each other often, are leaders in their field and conduct research in the treatment of chronic facial pain. Over years of practice, they have built a reputation as being among the best facial reconstruction surgeons in the country. 

Request an appointment phone443-997-9466

Conditions We Treat

  • Facial paralysis, an inability to move the muscles of the face on one or both sides.
  • Trigeminal neuralgia, a condition characterized by pain coming from the trigeminal nerve, which affects the face — most commonly one side of the jaw or cheek.
  • Trigeminal neuroma, rare tumors that may involve any part of the nerves of the face.
  • Moebius syndrome, a rare congenital (present at birth) condition that results from underdevelopment of the facial nerves that control some of the eye movements and facial expressions.

Pain Management

Non-trigeminal neuralgia patients are typically suffering from facial pain due to injury or surgical trauma to the face.  For these patients we offer a combination of medications, nerve blocks, rehabilitation therapies, and ​surgical release.

Rehabilitation Therapies

1. Neuromuscular rehabilitation.  These include a range of motion exercises, teaching and strengthening the muscles. The goal of neuromuscular rehabilitation is to facilitate the ones we want to work and inhibit the ones that are not operating efficiently.

Within this category are two popular forms of therapy:

  • Mirror therapy.  Patients look in mirror as they perform certain exercises in order to receive visual cues and feedback from their movements
  • Biofeedback.  Surface electrodes are placed on a patients’ face.  These electrodes only sense what the muscles are doing and provide feedback as to their motor activity.  As patients practice their exercises, the feedback assists them in learning to efficiently use their muscles.  The machine also picks up when muscles are overactive and helps in teaching patients the proper way to do an exercise.

​​​2. Massage. By gently manipulating the muscles and nerves in the face, the therapist can provide another form of stimulation and help the patient to identify certain feelings and patterns.

Surgery

These surgeries are tailored to your individual needs. There are two kinds of surgeries our reconstructive experts perform to treat facial paralysis:

  • The goal of dynamic restoration of facial paralysis is to reanimate the face by performing nerve grafts and muscle transfers. These procedures can be used to restore your smile and improve facial movement and symmetry.​ 
  • Static surgeries are performed to improve facial symmetry without restoring movement.  Facial slings can be inserted to correct facial drooping. Other static operations include brow lifts, upper and lower eyelid surgery and facelifts. These operations are often used in mild forms of facial paralysis or in patients who are elderly or otherwise cannot tolerate a more lengthy, complex surgery.

Our Facial Pain and Paralysis Surgeons

Assistant Professor of Plastic and Reconstructive Surgery

Assistant Professor of Plastic and Reconstructive Surgery Clinical Director, Face Transplant Program, Johns Hopkins Comprehensive Transplant Center Clinical Co-Director, Penile Transplantation, Johns Hopkins Comprehensive Transplant Center Assistant Professor of Plastic and Reconstructive Surgery Medical Director, Johns Hopkins Technology Ventures Johns Hopkins University Professor of Plastic and Reconstructive Surgery Professor of Pediatrics Interim Director, Plastic and Reconstructive Surgery Director, Pediatric Plastic Surgery Director, Cleft Lip and Palate Center Clinical Director, Genitourinary Transplant Program Co-Director, Brachial Plexus Clinic, Kennedy Krieger Institute Associate Director, Pediatric Burn Program Associate Professor of Plastic and Reconstructive Surgery Associate Professor of Oncology Co-Director, Johns Hopkins Facial Palsy Center Director of Breast Reconstruction

Assistant Professor of Plastic and Reconstructive Surgery

  

Source: https://www.hopkinsmedicine.org/plastic_reconstructive_surgery/services-appts/Facial-Pain-and-Facial-Paralysis

Facial Paralysis Treatment for Children

Facial Paralysis | Johns Hopkins Medicine

Children occasionally may be born with complete, or more commonly partial, facial paralysis as a fetal anomaly.

In addition, head trauma, birth injuries, Bell’s palsy and other conditions can cause facial paralysis in children, affecting their ability to speak, blink, eat or express emotions through facial expressions.

A number of nonsurgical treatments can be effective; however, if the condition persists, surgical procedures can help restore form and function to the facial muscles.

Facial Paralysis in Children: Why Choose Johns Hopkins Facial Plastic Surgery?

  • With the large number of patients we see and the experience of our faculty, we offer a rare degree of skill and expertise even in the most complex procedures.
  • Surgeons Patrick Byrne, M.D., M.B.A., and Kofi Boahene, M.D.

    , have unique skills in surgical reanimation techniques that can address paralysis of the face, including nerve and tendon transfers, microvascular surgery and oculoplastics.

  • Our staff and environment provide our patients’ families with clear communication and compassionate support throughout treatment.

  • We are dedicated to restoring children’s health and confidence, helping them recover from facial paralysis and regain both form and function.

Contact Us

Sam’s Story: Facial Reanimation Surgery to Correct Facial Paralysis

Born with Moebius syndrome that left him with a crooked smile, Sam, a high school student, and his mother traveled from Syracuse, New York, to seek facial reanimation surgery from Johns Hopkins facial plastic and reconstructive surgeon Patrick Byrne.

Facial Paralysis Treatment for Children: What to Expect

Our experts will take a detailed history of your child’s facial paralysis, and may use video analysis to better assess the range of motion. Imaging studies such as X-rays, MRI or computed tomography scans of the child’s head can help identify any underlying issues.

Depending on the cause and severity of your child’s facial paralysis, Boahene and Byrne may be able to resolve the problem through nonsurgical therapies such as physical therapy, botulinum or steroid medication. A speech pathologist may be part of the child’s care team.

For severe or persistent facial paralysis in children, specialized surgical procedures can include:

Muscle transfers: The surgeon removes one or more tendon or muscle and relocates them to areas of the face where they can restore more natural movement. These procedures include:

  • Temporalis tendon transfer (T3) relocates one end of the temporalis tendon connected to the jaw and moves it closer to the mouth, which allows the child to smile by clenching the jaw. The T3 procedure takes about an hour and may be performed in an outpatient setting.
  • Digastric tendon transfer relocates a tendon connected to a muscle located under the jaw. 
  • Gracilis transfer relocates fibers from a slender muscle located on the inside of the leg. This surgery may require more than one procedure and several months of recovery, but enables a more natural-looking smile response that involves the entire face. 

Nerve grafting involves moving nerves from different parts of the body to the face. Grafting can restore both movement and sensation, increasing muscle control. Some examples of this technique involve moving the hypoglossal nerve in the tongue, facial grafting and cross-facial grafting.

Protecting the Child’s Eyes

Facial paralysis can affect a child’s ability to blink, resulting in dryness and potential damage to the eye. One treatment your doctor may recommend is the insertion of a tiny platinum weight in the upper eyelid, which enables the child to blink and lubricate the eye with natural tears.

In addition to addressing the paralysis itself, the surgeon may suggest other facial plastic surgical procedures such as lifting the eyelid or the brow, which can help restore the child’s visual field, function and appearance