Dr. Roy Xiao is determined to reshape facial paralysis care

Facial plastic and reconstructive surgeon Roy Xiao, MD, is exploring multiple approaches to restore spontaneous symmetric facial motion, including a targeted injectable drug, an engineered nerve graft, and a neuroprosthetic.

Dr. Xiao, an assistant professor of Otorhinolaryngology - Head and Neck Surgery at the Hospital of the University of Pennsylvania (HUP), believes surgery has entered an exciting but challenging phase.

“Challenging in that there have been so many amazing innovations in surgery, technology, et cetera, so it can seem like so much has already been solved,” says Dr. Xiao. “As a result, a lot of effort is being invested in incremental advancements.”

Dr. Xiao is striving for more, and he’s positioned himself accordingly. He is one of a handful of surgeons in the United States with his particular skillset. During a fellowship at Massachusetts Eye and Ear, Dr. Xiao trained under Theresa “Tessa” Hadlock, MD, one of the world’s most accomplished facial plastic and reconstructive surgeons. He credits her with informing his “ability to do everything I do now.”

Dr. Xiao says his passion lies in treating patients with facial motion disorders or facial paralysis, for which he says there is a wide range of options, including nerve repair, nerve transfers, and microneurovascular gracilis free flap reconstruction.

To ensure that patient care is provided in a comprehensive and multifaceted manner, Dr. Xiao is working toward establishing a facial nerve center at HUP involving experts from various related fields such as microvascular surgeons, neurosurgeons, neurotologists, and physical therapists.

A targeted therapy for acute facial paralysis

The lab is where Dr. Xiao may ultimately reshape the landscape for facial paralysis care. Among his targets is Bell’s palsy, the treatment of which, he says, has been unchanged and non-specific for decades.

“This is the exciting part for me, because I see the real possibility of developing a very meaningful alteration to how these patients ultimately are taken care of,” he says.

Dr. Xiao envisions a targeted therapy administered at the onset of paralysis, not just for patients with Bell’s palsy, but for those diagnosed with acute facial paralysis of any kind. The concept remains theoretical, but he’s begun collaborating with D. Kacy Cullen, PhD, a Professor of Neurosurgery at the Perelman School of Medicine. Dr. Cullen's lab focuses, in part, on the development of cutting-edge neural tissue engineering-based treatments to promote regeneration and restore function. Drs. Xiao and Cullen are also working together to develop an engineered nerve graft.

Currently, to bridge a nerve deficit, surgeons create a graft from the great auricular nerve, a major sensory nerve of the neck, or the sural nerve, a sensory nerve in the lower leg. An engineered nerve graft, Dr. Xiao says, would not only decrease morbidity compared to these existing techniques but also potentially outperform the body's own nerve supply.

A neuroprosthetic for chronic facial paralysis

The most mature research project is a neuroprosthetic that restores spontaneous symmetric facial motion in patients with chronic facial paralysis. Dr. Xiao calls it the Bionic Face. He began working on it three years ago and developed the prototype in collaboration with Dr. Hadlock in Boston and researchers and engineers at Cornell University.

Dr. Xiao says the current standard of care for patients with chronic facial paralysis involves physical therapy, Botox injections to weaken the parts of the face that are overly tense, and an assortment of minor procedures to remove antagonistic muscle or nerves. Although each is effective to a certain degree, rarely have they fully restored spontaneous symmetric facial motion like the Bionic Face has.

The Bionic face involves two components, something that can sense the face and something that can stimulate distal nerve branches to electrically cause the muscle to move again, Dr. Xiao says. The concept, he adds, is similar to a cochlear implant in that it can restore motion in real time. However, there is no residual effect. In other words, without the Bionic Face, the paralysis immediately returns.

While the name hints at something from science fiction, the Bionic Face is a pair of typical eyeglasses outfitted with a small printed circuit board and two pairs of tiny microphones and speakers. The speakers bounce sound waves off the wearer’s face and the microphones pick up the echoes, not unlike the echolocation used by bats to navigate in the dark. This system, Dr. Xiao says, has been shown to detect asymmetry in facial motion and quantify it in real time.

As the device reads the healthy side of the face, it stimulates the paralyzed side at the same time, recreating symmetric eye elevation and eye closure. “Essentially, your healthy side is informing and driving the stimulation and motion of your paralyzed side,” Dr. Xiao says.

According to Dr. Xiao, he Bionic Face has been most effective so far at restoring eyebrow elevation and eye closure in patients who can’t do these things for themselves. With proof of concept for the Bionic Face’s two components, detection and facial tracking and stimulation, the next step is creating a “truly wearable device,” a process he anticipates taking several years.

Clinical consult and patient referral

Roy Xiao, MD, sees patients at Penn Otorhinolaryngology - Head and Neck Surgery in Philadelphia, PA.

For a provider-to-provider consultation with Dr. Xiao, please call 877-937-7366, or refer a patient online.