Surgical Treatment of Facial Paralysis

The definition of plastic surgery is “the process of reconstructing or repairing parts of the body by the transfer of tissues, either in the treatment of injury or for cosmetic reasons”. There are two main categories that plastic surgery can be divided into, reconstructive surgery and cosmetic surgery. Reconstructive surgery can be defined as attempting to restore the function or anatomy of a body part. Cosmetic surgery can be defined as a type of surgery to improve a person’s appearance.

Some of the most common reconstructive procedures performed are breast reconstruction or reduction, wound care for severe burns, microsurgery or flap procedures, or facial surgeries to correct problems. The one I’m going to go into depth in is facial surgery. More specifically, facial paralysis procedures.

Facial nerve palsy, which was formerly called Bell palsy, is unilateral peripheral facial nerve palsy. Herpes simplex virus infection or Herpes zoster are possibly the most common viral causes of facial nerve palsy, recent evidence suggests.

The exact cause of facial nerve palsy is unknown, but it is believed to be either from inflammation of the nerve that controls one side of the face or a reaction from a viral infection. Pain behind the ear often comes before paralysis in idiopathic palsy, it usually develops within a few hours and can reach maximal within a few days. Patients have reported a heavy or numb feeling in the face. The side of the face affected becomes expressionless and flat; the ability to blink, grimace, or to wrinkle the forehead becomes absent or limited.

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Often in severe cases, the eye does not close affecting the surrounding areas. The examination of sensors are usually normal, but the external auditory canal and a small patch over the mastoid can be painful to the touch. In other situations; salvation, taste, and lacrimation may be impaired.

Diagnostic testing for facial nerve palsy starts with a clinical evaluation. A chest x-ray or a CT is done, and levels are checked for sarcoidosis. An MRI is performed if onset of symptoms was gradual or other neurologic deficits were present. Depending on what was found, additional testing may be indicated. Careful consideration must be taken into account when surgical intervention is considered. The patient’s age, medical history, segment of nerve injured, residual hearing, and the patients expectations and risk tolerance.

In cases of virally-induced facial paralysis, facial nerve decompression surgery may be the treatment option. Primary facial nerve repairing or grafting may be necessary in cases of resection or transection of the facial nerve. Facial nerve decompression has a couple different ways to be approached, one way is the transmastoid approach. This approach is used when the trauma is localized to the tympanic or mastoid segments of the facial nerve. Landmarks for this are the lateral semicircular canal, fossa incudis, and digastric ridge. The nerve is decompressed for 180 degrees of its circumference. The other approach is the middle fossa approach; this allows decompression of the nerve when the injury extends to the labyrinthine segment. This can also be used with the transmoid approach if there is further injury. Facial nerve repair provides the best return of facial nerve function, but the repair must be tension free. To make this possible, sometimes rerouting or mobilization of adjacent facial nerves may be necessary. Cable nerve grafts are used when tension-free is not possible, some nerves that are popular for this are the great auricular nerve, sural nerve, and the medial and lateral antebrachial cutaneous nerves. For intermediate duration, nerve transfers are usually the choice of treatment; for chronic facial paralysis, regional or free muscle transfer is required.

A few considerations for facial nerve palsy repair, one being that immediate complete paralysis and neural degeneration of 90 percent or higher is noted, constitutes surgical exploration. When the paralysis is delayed or incomplete, patients should be treated medically with high-dose steroids. Decompression is performed through the middle cranial fossa/transmastoid approach is done for a serviceable hearing, or the translabyrinthine approach is for cases of dead ear. Decompression surgery is often delayed for reasons such as treatment of life threatening injuries that were obtained during original trauma or neurological status. The treatment of facial paralysis must be altered to the patient, and the surgeon must select the appropriate course of action depending on the circumstances of the function of the nerve. The severity and the duration of the damage will play a significant role. The patient’s age is also a very important factor, because a lot of these procedures are lengthy and complex which makes it harder for elderly and frail individuals to handle, giving them a high risk of morbidity. The personal goals of the patient must be considered with the surgeon as well, to discuss expectations.

Complications for facial nerve decompression are to be considered too. Working close to the structures in the temporal bone, risks are to be expected. The most frequent injury during this procedure is auditory involvement. Some patients have experienced tinnitus following the surgery, and a few have required a hearing aid resulting from combined sensorineural and conductive hearing loss. Some of the less commonly injured structures are the facial nerve itself, the chorda tympani nerve, the balance function, the cochlea, the ossicles, the dura and the brain. Two serious complications of this surgery are the incidence of a cerebrospinal fluid leak and infection.

Recovery after facial nerve decompression surgery can be a long term process. Sutures are removed from the patients around 10 days after surgery, and after about 2 weeks, patients may return to their normal activities. Periodic checkups are done to make sure recovery stays on course.

Reconstructive surgery has come a long way and has many variations of treatment and success. Facial nerve decompression has helped to restore function of the face and has provided promising results. Surgical procedures are always evolving to find safer and more effective ways of treatment. Plastic surgery has helped many patients achieve expectations of reconstructive surgery as well as cosmetic surgery.

Works Cited

1. https://www.webmd.com/a-to-z-guides/qa/what-are-the-types-of-reconstructive-surgery
2. https://www.merckmanuals.com/professional/neurologic-disorders/neuro-ophthalmologic-and-cranial-nerve-disorders/facial-nerve-palsy
3. https://www.e-ceo.org/upload/pdf/ceo-2-1.pdf
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329040/
5. https://www.ncbi.nlm.nih.gov/pubmed/6834955
6. https://en.wikipedia.org/wiki/Reconstructive_surgery