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Facial Reanimation Surgery

The facial nerve, also known as the cranial nerve seven, controls the muscles of the face. Some parts of the facial nerve are also responsible for controlling tearing, nasal secretions, some saliva production and some parts of taste.

The facial nerve starts in the brain, goes through the inner ear and middle ear and exits the skull just behind the ear at the stylomastoid foramen. Once it exits the skull, it has a number of branches that control different muscles responsible for moving the muscles of facial expression. Within the parotid gland, the facial nerve divides into multiple branches, each controlling a different part of the upper, mid and lower face. Therefore, cancers of the parotid gland are the most common cancers that invade and cause damage to the facial nerve.

Injury to and/or removal of branches of the facial nerve will result in limited mobility of all or part of one side of your face, depending on where the injury occurs. Aside from the cosmetic problems associated with being unable to move half of your face, being unable to move your face can result in problems with the eyes and with drooling. For example, blinking and closing your eyes are important for lubrication and protection of the cornea from drying out. Closing the corners of your mouth is important to keep saliva, food and drinks from spilling.

For these reasons, if your facial nerve is resected or damaged as a part of your cancer removal surgery, your surgeon might recommend you undergo a facial reanimation procedure. Facial reanimation can be divided into two groups—static suspension and dynamic reanimation.

Static suspension: This involves performing procedures that do not include reinnervation of muscles. The goal of static reanimation is not to give muscles of the face a new nerve supply but to move and/or suspend muscles to improve the way you look at rest. Examples of static suspension include static slings, eyelid weights, brow lifts and face-lifts.

  • Static sling:  Static sling is considered when one side of your face, including the corner of the mouth, is drooping and there is obvious asymmetry at rest. A piece of tissue taken from the side of the leg, or synthetic tissue, is attached from the cheekbone to the corner of the mouth for a lift. The goal is to pull the corner of the mouth upward and outward, resulting in a more symmetric look at rest.

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  • Lip wedge excision: A lip wedge excision is considered when the corner of your mouth does not close completely, resulting in drooling of saliva, food and liquids when you eat.  A wedge of the lip is removed, and the remaining tissue is sewn together to lift and tighten the corner of the mouth.

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  • Eyelid weights:  Eyelid weights are considered when the upper division of the facial nerve is affected, resulting in incomplete eye closure.  Instead of using artificial tears and lubricants to keep your eye lubricated and prevent corneal drying, your doctor might recommend placement of a gold or platinum weight into your upper eyelid to help it close completely and protect your cornea from drying out. This can be done in the office with local anesthesia or in the operating room with general anesthesia.

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  • Brow/face-lifts: Brow lifts or face-lifts are considered when there is major asymmetry of part of the face at rest. The midface, brow or lower face can be targeted. A hidden incision is made either in front of your ear, in your hairline or near your eyebrow.  In all of these lifting procedures, the skin is pulled up and back, and any excess skin is removed. The location of the incisions vary, depending on what part of the face needs lifting. The purpose of these techniques is to improve the appearance of a drooping face or brow, which can result when the facial nerve no longer works.

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  • Botulinum toxin injections:  Botulinum toxin injections (Botox) are considered when the upper branch of the facial nerve is damaged, resulting in disappearance of wrinkles on one side of the forehead. By having Botox injected into the opposite side of the forehead, you might achieve a more symmetrical appearance.

Dynamic reanimation

This involves bringing in a new nerve supply to select muscles of the face. When a muscles loses its nerve supply, the muscle shrinks over time, which results in further cosmetic deformity. While the ultimate goal of dynamic reanimation is for you to have some movement in the injured side of your face, another worthy goal is to prevent the muscles from shrinking and to preserve facial tone.

  • Nerve grafting: This involves suturing the ends of nerves together. There are a number of ways to do this:
    • Primary nerve repair: If the cut ends of the facial nerve are close together, they can be stitched back together, called primary nerve repair.
    • Cable graft: Cable grafts involve taking a less important nerve from one part of the body and using it as a cable to join two cut ends of the facial nerve, which can achieve dynamic reanimation.
    • Jump graft: Taking a motor nerve from one area and moving it to connect the cut end to the facial nerve cut end can achieve dynamic reanimation. Potential jump grafts can be obtained from the masseter nerve or hypoglossal nerve.

If a jump graft is used, you will have to reprogram how you move your face. That is, if the masseter nerve is used to connect to the facial nerve, then in order to move your face you need to think about biting down (the normal function of the masseter muscle).  Similarly, if the hypoglossal nerve is used, then you need to think about moving your tongue in order to get facial movement. This requires practice! If the cut ends of the facial nerve are close together, they can be stitched back together, called primary nerve repair.Cable grafts involve taking a less important nerve from one part of the body and using it as a cable to join two cut ends of the facial nerve, which can achieve dynamic reanimation.Taking a motor nerve from one area and moving it to connect the cut end to the facial nerve cut end can achieve dynamic reanimation. Potential jump grafts can be obtained from the masseter nerve or hypoglossal nerve.

  • Muscle transfer techniques: This involves sewing a muscle that has a nerve supply to the corner of the mouth to achieve movement of the mouth. This can be done with local muscles or as a free flap.
  • Local muscle transfers: Local muscle transfers are considered in cases of facial paralysis to achieve immediate movement of the face.The temporalis muscle and the masseter muscle are two common muscles that are transferred to the corner of the mouth. Then, when you clench your teeth together, you can get movement of the mouth. This takes practice and training on your part.
  • Cross facial nerve graft with free muscle transfer:  A cross facial nerve graft with free muscle transfer is considered in cases of facial paralysis to achieve movement of the face to create an effortless smile. This procedure is done in two stages, separated by at least six to nine months. First, a nerve graft is taken from somewhere in your body (typically a sensory nerve in your leg). One end of this nerve is connected to a small branch of the facial nerve on the “normal” side of the face, and the other end is placed just under the skin on the other side of the face. In the second stage, a free muscle graft (usually the gracilis muscle in the inner thigh) is removed along with a nerve, artery and vein and placed into position in the paralyzed side of the face so that when the muscle moves, it will create a smile. The artery and vein of the flap are sewn to an artery and vein in the neck to give the muscle life again, and the nerve from the flap is sewn to the other end of the nerve that was placed in the previous operation.