Facial Reanimation

Barry M. Schaitkin

Rehabilitation of the patient with chronic facial paralysis must take into account the losses of form and function. Although each individual presents unique challenges, experience has led to guidelines in caring for this group of patients.

The patient with facial paralysis must be treated by the physician on an individual basis, and only after extensive evaluation of the patient’s deficits and desires. The assessment should include evaluation of the:

• Cause of the facial paralysis
  
• Extent of paralysis and functional deficit(s)
  
• Likelihood and time course to recovery from facial paralysis
  
• Presence of other cranial nerve deficits
  
• Patient’s life expectancy
  
• Duration of paralysis
  
• Patient’s needs and expectations

Past experience gained by careful evaluation of postoperative results suggests the following key points:

Dynamic procedures can be divided into three broad categories. The facial nerve nucleus (proximal system) and the facial nerve musculature (distal system) are thought of as two structures, which ideally are in continuity. The procedures are then dictated by the integrity of those systems:

• Proximal system intact and distal system intact
  
• Proximal system intact and distal system unavailable
  
• Distal and proximal systems unavailable
  
• Proximal system not available and distal system intact

• This situation can be illustrated by the patient with an iatrogenic facial nerve deficit caused during a mastoidectomy. With both systems intact, the ideal procedure reconstitutes the deficit with a primary neurorraphy, or more likely a nerve graft.
  
• Key point: The ideal reanimation procedure reconstitutes the facial nerve nucleus with the facial nerve musculature.
  
• Technical points on nerve grafting:
  
  
  
  • Choose the appropriate nerve graft for length and axon volume.
    
  • Minimal number of 9–0 monofilament sutures to approximate endoneurial surfaces
    
  • Do repair under microscope; high power to place sutures, low power to tie them.
    
  • No suture required within the temporal bone
    
  • No tension along nerve course