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Clinical Review & Education Special Communication

A Contemporary Approach to Facial Reanimation

Figure 1. Acute Flaccid and Long-standing Nonflaccid Facial Palsy in Ramsay Hunt Syndrome (Varicella-Zoster Virus Facial Palsy)

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days of symptom onset. 17,21 Lyme disease–associated FP is treated with a prolonged course of oral doxycycline hyclate or intravenous ceftriaxonesodium. 22 Otitismedia–associatedFP is treatedwithwide myringotomywith or withoutmastoidectomy, corticosteroids, and topical andparenteral antibiotics. 23 Delayed-onset or incomplete FP following trauma or iatrogenic insult warrants corticosteroids and observation. Iatrogenic injury resulting in immediate and complete paralysis of 1 or more FN branches warrants urgent surgical exploration. Transection or resection of the FN warrants direct end-to end repair, and an autologous nerve graft should be used if tension-free apposition cannot be achieved. Although stimulation of distal nerve segments is only possible up to 72 hours following neurotmesis, exploration with the goal of primary repair is indi cated until the period of denervated muscle viability has expired ( Figure 2 ). Neurorrhaphy may be achieved using only two or three 10-0 nylon epineurial sutures and fibrin glue. Sensory donor nerves (eg, the sural, medial antebrachial cutaneous, or great auricular) are preferred due to their low morbidity, and the ipsilat eral great auricular nerve is contraindicated when the possibility of malignant infiltration exists. Although no firm evidence dem onstrates improved outcomes based on graft polarity, 24 most sur geons favor inlaying of sensory grafts in reverse orientation, and antidromic positioning has been shown to prevent axonal loss through side branches of sensory grafts. 25 In the setting of an FN defect that extends from themain trunk to involve distal branches, options for repair include a single branching interpositiongraft,multiple interpositiongrafts, or a com bination of interposition grafting and nerve transfer. An emerging technique involves immediate masseteric nerve transfer to pro vide volitional control to selective distal midfacial branches control ling blink, smile, or both combined with interposition grafting from adequate (K and L). Smile symmetry is improved with light effort (M); commissure restriction is noted with full-effort smile. Near normal return to function of the orbicularis oris muscle is noted (O). Lip depressor function remains weak on the affected side (P). Periocular, mentalis, and platysmal synkinesis is worsened by smile, pucker, and lip depression (N-P). elevation remains impaired (J), while marked brow synkinesis is present with eye closure (K and L). As is usual in nonflaccid facial palsy, eye closure is

presentation, symptomevolution lasting longer than 72 hours, and presence of other cranial neuropathies. 2 Electroneuronography is indicated between 3 and 14 days of symptomonset in patientswho are seen with delayed traumatic or idiopathic complete FFP. A-H, Acute facial palsy. Complete flaccid paralysis on the affected side (asterisk) is demonstrated at rest (A), and with brow elevation (B), gentle eye closure (C), full-effort eye closure (D), gentle smile (E), full-effort smile (F), lip pucker (G), and lower lip depression (H). The patient lacks Bell’s phenomenon (C and D). I-P, Long-standing nonflaccid facial palsy. One year following symptom onset, the affected brow remains depressed, while hyperactivity has developed in the orbicularis oculi, mentalis, and platysma muscles at rest (I). Volitional brow Acute Setting Intervention Facial nerve insult leads initially to FFP, and acute interventionsmay includemedical therapy, physical therapy, and surgery (eTable in the Supplement).Daytimeeyedrops, nighttime lubricatingointment, and eyelid taping are used to prevent corneal desiccation and subse quent exposure keratopathy. Patient education and upper eyelid stretching to prevent contracture and ease passive closure are use ful physical therapy adjuncts. In the setting of acute idiopathic FP, administrationof high-dose corticosteroidswithin72hours of symp tomonset shortens recovery time. 16 Combined use of antivirals and corticosteroids in idiopathic FP may be of additional clinical ben efit, especially for those with severe to complete paralysis, 17,18 and good evidence supports combination therapy in varicella-zoster virus, 19 with valacyclovir hydrochloride (1 g 3 times daily orally for 7-14days) demonstratingaccelerated time to resolutionof acuteneu ritis compared with acyclovir (800 mg 5 times daily orally for 7 days). 20 Many otolaryngologists routinely prescribeprednisone (60 mg bymouth for 5 days, followed by a taper of 10mg/d over 5 days) in combinationwith valacyclovir hydrochloride (1 g bymouth twice daily for 7-14 days) to all patients with idiopathic or varicella-zoster virus FP up to 2 weeks from symptom onset. Patients with com plete idiopathic or posttraumatic paralysiswith anelectroneuronog raphy response demonstrating more than 90% degeneration and absent voluntary motor units on electromyography are referred to neurotology for consideration of surgical decompression within 14

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

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