Reanimation surgery for facial motion disorders at Penn Medicine

Surgeons at Penn Facial Plastic Surgery are performing a sophisticated collection of nerve and muscle reanimation procedures to restore movement and symmetry to the faces of individuals affected by facial paralysis.

Facial paralysis and sense of self

Because normal facial responses to social stimuli and emotion are lost in the absence of functional nerves that animate the face, patients with facial paralysis endure the profound social stigma and isolation associated with disfigurement.

In particular, when the eyes are affected, dramatic asymmetry can result due to loss of eyebrow height, inability to close the eye, and lower eyelid sagging. This can increase the risk of corneal exposure, which may result in dryness, corneal abrasions or ulcerations, and in severe cases even blindness. Moreover, loss of facial tone can also obstruct normal breathing through the nose.

“It’s like having your face taken away,” says plastic and reconstructive surgeon Roy Xiao, MD, lead facial plastic and reconstructive surgeon at Penn Otorhinolaryngology - Head and Neck Surgery. “The inability to use the muscles surrounding your mouth eliminates your ability to smile or express yourself non-verbally.”

Facial reanimation at Penn Facial Plastic Surgery

At Penn Facial Plastic Surgery, the treatment goal for patients with facial paralysis is to reintroduce form and function to the affected face, restore patient quality of life, renew a sense of self-confidence, and produce a return to premorbid social activities and the workplace.

According to Dr. Xiao, these goals are achieved through a combination of dynamic facial reanimation and static interventions.

“Reanimation procedures can restore innervation and motion to the affected regions of the face with emphasis on the smile,” he says. “Surgeries have the potential to re-establish eyelid closure and, in many cases, voluntary animation of the facial muscles.”

At Penn Facial Plastic Surgery, these dynamic procedures include facial nerve interposition grafting, nerve transfer procedures (masseteric and/or hypoglossal), cross-facial nerve grafting, and vascularized free gracilis muscle flap transfer.

The static interventions are a natural complement to these procedures, he adds, in that they restore harmony to the facial features at rest. Static procedures include facial suspension (which restores facial symmetry using strong connective tissue grafts), low-profile eyelid weight implants to assist with eye closure, brow lift surgery, and lower eyelid tightening procedures.

Free Gracilis muscle flap transfer for facial reanimation

Reanimation of the paralyzed face often involves replacing atrophied muscle and damaged nerves with a free flap of healthy tissue. Dr. Xiao notes that the gracilis muscle is preferred for free flap transfer procedures in facial reanimation for its ability to accept new neural input for post-transfer function, as well as its thin character, which can recreate a smile without adding excessive bulk to the face.

“Gracilis muscle transfer surgery resembles that of other free-flap surgeries in that you have an artery and a vein that you transfer from one part of the body to another,” he observes. “But the gracilis free flap is unique in that you’re also connecting its controlling nerve, which allows the muscle to function.”

The nerve and blood vessels of the transplanted gracilis muscle are anastomosed through microsurgery to donor nerves and blood vessels in the face. The muscle is then carefully positioned to replicate the movement vector of the patient’s smile, which can begin to re-emerge nine-to-twelve months following transfer, Dr. Xiao says.

Additional options for facial paralysis

Cross-facial nerve grafting, hypoglossal-facial transfer, facial nerve interpositional jump graft surgery, and temporalis muscle transposition are also offered at Penn Facial Plastic Surgery for very specific circumstances.

In addition, Dr. Xiao performs a number of procedures for patients with chronic non-flaccid facial paralysis (NFFP) as a result of aberrant nerve regeneration.

“NFFP occurs after previous facial paralysis due to disorganized over-recovery, a sort of confusion between the nerve branches,” says Dr. Xiao.

Among the defining symptoms of the condition is synkinesis, wherein voluntary muscle movement causes the simultaneous involuntary contraction of other muscles. In NFFP, this manifests as cheek twitching or involuntary eye closure.

The treatments for NFFP at Penn Medicine include Botox, small, muscle-based procedures to remove the frown muscles, and selective neurectomy.

“Selective neurectomy relieves severe synkinesis by selectively ablating the specific nerve fibers involved in undesirable involuntary motion while carefully protecting those that supply desirable motions,” Dr. Xiao explains.

About Penn Otorhinolaryngology - Head and Neck Surgery

Penn's Department of Otorhinolaryngology – Head and Neck Surgery's team of board-certified physicians specializes in the evaluation, diagnosis, and treatment of a full spectrum of ear, nose, and throat disorders, as well as areas within the head and neck. With a commitment to providing the highest quality care and the most advanced treatments, our otorhinolaryngologists are uniquely qualified to treat each condition individually.

The Department is also actively involved in clinical research, including investigations of the efficacy and safety of TransOral Robotic Surgery (TORS) in a variety of indications.