xRead - May 2023

Clinical Review& Education

Special Communication

A Contemporary Approach to Facial Reanimation

Nate Jowett, MD; Tessa A. Hadlock, MD

Journal Club Slides and Supplemental content at jamafacialplasticsurgery.com CME Quiz at jamanetworkcme.com and CME Questions page 316

The management of acute facial nerve insult may entail medical therapy, surgical exploration, decompression, or repair depending on the etiology. When recovery is not complete, facial mimetic function lies on a spectrum ranging from flaccid paralysis to hyperkinesis resulting in facial immobility. Through systematic assessment of the face at rest and with movement, one may tailor the management to the particular pattern of dysfunction. Interventions for long-standing facial palsy include physical therapy, injectables, and surgical reanimation procedures. The goal of the management is to restore facial balance and movement. This article summarizes a contemporary approach to the management of facial nerve insults.

Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Nate Jowett, MD, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, 243 Charles St, Boston, MA 02114 (nathan _jowett@meei.harvard.edu).

JAMA Facial Plast Surg . 2015;17(4):293-300. doi:10.1001/jamafacial.2015.0399 Published online June 4, 2015. Corrected on August 17, 2015.

T he importance of facial movement is epitomizedby its con servation and increasing complexity in higher-order ani mals through natural selection. 1 In addition to their pivotal role innonverbal communication,muscles drivenby the facial nerve (FN) are important in corneal and hair cell protection, respiration, mastication, and articulation. Injury to the FN results in functional, communicative, and social impairment, with profound negative im pact on quality of life and emotional well-being. Ul t imate funct ional outcomes fol lowing FN insul t l ie on a spectrum ranging from complete flaccid facial palsy (FFP) to return of normal function. In between exist zonal permutations of varying degrees of static and kinetic hypoactivity and hyperac tivity and synkinesis, collectively referred to as nonflaccid facial palsy (NFFP). The role of clinicians is to identify and tai lor the management to the patient’s unique pattern of dysfunction. Etiology and Presentation The etiology, symptoms, and time course of the facial palsy (FP) are elucidated. Common causes include idiopathic (Bell palsy), postsur gical insult, benign or malignant tumors, Ramsay Hunt syndrome (varicella-zoster virus), Lyme disease, otic infections, and trauma. 2 Symptoms vary according to the degree of recovery. Flaccid facial palsy results in paralytic lagophthalmos and ocular irritation, loss of symmetry at rest, collapse of the external nasal valve, and oral in competence, while symptoms in NFFP are dictated by the specific pattern of dysfunction. Platysmal synkinesis results in neck discom fort and facial fatigue. Periocular synkinesis results inanarrowedpal pebral fissure width, and excessive tearing is common. Lack of meaningful smile occurs in severe NFFP. To gauge progress, an FN-specific quality-of-life survey (the Facial Clinimetric Evaluation [FaCE] Scale) is administered to all patients on presentation and fol lowing interventions. 3-8 The time course of FFPdictates reconstruc tive options. Use of native facial musculature for dynamic reanima tion is contraindicated when the time from injury to reinnervation

exceeds 18 to 24months, owing to fibrosis and loss of electrical ac tivity in chronically denervated facial muscle. 9-11 A thorough zonal assessment of facial function at rest andwith movement is essential ( Figure 1 ). The brow position together with its effect on the periocular complex is noted. The degree of para lytic lagophthalmos, presenceor absenceof Bell phenomenon,width of the palpebral fissure, and position of the lower lid are noted, and laxity is assessed using distraction and snapback tests. The depth andorientationof thenasolabial fold (NLF), positionof the oral com missure, andpresence anddegree of ocular,midfacial,mentalis, and platysmal synkinesis are evaluated. Attention is paid to the contra lateral side with regard to whether weakening of a given paired muscle group (eg, the hemibrowor lip depressors) is likely to result in improved symmetry. The status of themasseteric and deep tem poral branches of themandibular division of the trigeminal nerve is assessed by palpation of the bulk and tone of the masseter and temporalis muscles. Documentation Photography and videography to document appearance at rest and with 7 volitional facial movements (browelevation, light-effort and full-effort eye closure and smile, lip pucker, and lower lip depres sion) on presentation and follow-up are essential (Figure 1). Spon taneous smilemaybeelicitedusinghumorous videoclips, anda stan dardized video assay has recently been validated. 12 A protocol for documentation of outcomes data has been described. 13 Investigations When the history and physical examination are consistent with idiopathic FP, further investigation is not required except in Lyme disease–endemic areas, where serology is prudent. 14,15 Red flags ne cessitating further workup include persistent FFP at 3 to 4months, recurrence, bilaterality, asymmetricweakness across facial zones on

Downloaded by Ucsf Library University of California San Francisco from www.liebertpub.com at 08/19/21. For personal use only.

(Reprinted) JAMA Facial Plastic Surgery July/August 2015 Volume 17, Number 4

293

jamafacialplasticsurgery.com

Copyright 2015 American Medical Association. All rights reserved.