Restoring facial movement & balance

FPRC with innovative techniques

FACIAL

PARALYSIS

RESTORATION

CENTER

At the facial paralysis restoration center, experts who specialize on the face and the facial nerve combine years of experience to treat individuals who have suffered injury to their facial nerve. Injury to the facial nerve is a common problem that can result from causes including Bell's palsy, trauma and cancer. It may also be present at birth. Regardless of the cause, the movement impairment that follows may affect the eye, smile, nasal breathing and speech. The psychological toll can be severe. Dr. Boahene and colleagues at the facial paralysis restoration center have years of experience treating facial paralysis patients with state of the art techiqnues that they have helped refine. Dr. Boahene has written several book chapters and scientific articles on facial paralysis. He has given lecturers around the country and at international conferences on methods of restoring the paralyzed face."Our goal for all patients with facial paralysis is to restore movement to the face that is controlled, symmetric and spontaneous".

TREATMENT OPTIONS FOR FACIAL PARALYSIS:

Neuromuscular Retraining

Neuromuscular reeducation (therapy): working with our specially trained physical therapist, specific facial exercises one can relearn to cmove the face by suppressing unwanted movement while enhancing desired facial movement. This therapy is aided by video recording of desired facial movements such as a learned smile in a system known as self-modeling and social implementation.

Targeted chemodenervation with injection

The botulinum toxin neuropeptide can be injected into specific muscle groups to help correct assymetry, muscle spasms, over contraction, synkinesis and is also used to facilitate the results of physical therapy.

Static reanimation ( facelift, eyelid sling, midfacelift, Fascia lata slings)

The droopiness seen in the paralyzed face can be corrected with various procedures that even out the face and actually helps the face look younger. Brow lift procedures even out the droopy brow correcting the angry look. it also releave strain of the eyelids

Facelift tighthens the paralyzed muscles and improves symmetry of the face. The droopy cheek is sometimes lifted ( midface lift) to help support and suspend the lower eyelid which improves eye closure.

Platinum chain eyelid implants are flexible low profile implants that we place within the upper eyelid to aid in eye closure. Because of their low profile nature, they are usually invisble where they are implanted Eyelid suspension using free fascia slings or temporalis muscle slings helps suspend the retracted eyelids up which aids in eye closure, tear distribution and thus reducing excessive tearing. Combines with spacer graft( tissue grafts placed within the lower eyelid), eyelid suspension techniques ( medial and lateral canthopxey) are key in protecting the eye from irritation, drying and ulceration.

Dynamic muscle and tendon transfer procedures ( temporalis tendon transfer, diagastric muscle tendon transfer).

Tendon transfer procedures are common in hand surgery. We have used the same principles to design minimally invasive techniques from transposing the temporalis tendon toacheive immediate improvemnt in smile.With this special and minimally invasive technique that we have helped advance, we are able to restore movement to the face and allow one to relearn the ability to smile. This is one of the most rewarding procedures we perform for facial paralysis because the result is almost immediate. Infact, with muscle stimulators, we can record movement of the face minutes after the procedure is completed. The patient then learns to harness the power of the transfered muscle for smiling.

Nerve grafting ( facial nerve-hypoglossal nerve, cross facial nerve grafting).

Whenever feasible, we try to reconnect the injured nerve either directly or by using nerve grafts harvested from the neck or leg. It usually takes 6 months to see results but the outcome continues to improve over several years.

Upgrading partially recovered facial nerves

An important concept in facial paralysis treatment is the ability to improve nerve and muscle function in individuals who have incomplete facial nerve recovery or paralysis. The typical case is a patient who developes Bells palsy and recovers only partially. They have improved symmetry but an assymetric smile. The challenge is to improve their smile without disturbing the partial recovery they regained. We use a technique called "supercharging" whereby through nerve grafting more movement is restored to the smile muscles while preserving the recovery gained.

Free muscle transfer. ( gracillis muscle, vastus lateralis muscle, pectoralis muscle, serratus muscle transfer)

When nerve repair or muscle transfer is not feasible, we have the option of transferring muscle and nerve from other parts of the body to the face, connect the nerves to other nerves in the face to allow facial movement. The muscle being transfered does not leave a noticeable deficit. Common sites for transferring muscle includes the thigh, chest wall or back.

Synkinesis

One of the most bothersome sequelae of facial paralysis ( Bells palsy) is synkinesis. Synkinesis is the unwanted movement the accompanies a desired movement and it usually a sign of abberrent regrowth of the facial nerve. A common example is eye closure when one smiles or laughs.The explanation for why this happens to a recovering nerve following injury varies and includes; nerve fibers reaching the wrong target, changes in the sheath that covers a regenerating nerve and alteraltion of the facial nucleus at the level of the brain stem. Treatment options for facial synkinesis include nerve-muscle retraining aided by biofeedback techniques, selective disruption of nerve signals to the muscle group one desires to supress either by injections ( chemodenervation with botulinum neuropeptide ) , nerve division ( neurectomy) or selective removal of muscle (myectomy). The most distressing evidence of synkinesis usually involves the eye muscles and can be severe enough to obstruct ones vision. The involved eye looks smaller and cosmetically unappealing. We use a combination of the above methods to acjieve long-lasting improvement. See before and after photos of surgical correction of synkinesis and blepharosm of the eye after Bells palsy.

Platysmoplasty

The platysma muscle is a broad thin muscle which is by development, an extension of the facial muscle into the neck. It is innervated by the facial nerve and acts to pull down the lower face. During recovery of an injured or repaired facial nerve, precious fibers of the regenerating nerve may end up in the platysma muscle diverting nerve fibers from desired targets in the upper face. In addition to this, cross talk between these platysma fibers and nerves to the midfacial and eye muscles may contribute to diminished lip evelation during smile and synkinesis. This may also result in tightness in the face and can occasionally be painful. Dividing the offending platysma fibers ( platysmoplasty) has the potential of immediately relieving the facial tightness, improving lip movement and minimizing synkinesis. Platysmoplasty for facial paralysis can be done under local anesthesia and is usually well tolerated.

Book chapters, Scientific journal articles

Minimally Invasive Temporalis Tendon Transposition

Boahene and colleagues describe a minimally invasive version of the temporalis tendon transposition, which is used for immediate dynamic reanimation in patients with longstanding facial paralysis. They present the surgical technique and analyze their results. Full Text » Video Supplement

A Model for Early Prediction of Facial Nerve Recovery After Vestibular Schwannoma Surgery.

Rivas A, Boahene KD, Bravo HC, Tan M, Tamargo RJ, Francis HW.

Source

*Department of Otolaryngology - Head and Neck Surgery, †Department of Biostatistics, Bloomberg School of Public Health, and ‡Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, U.S.A.

E: To identify early predictors of long-term facial nerve function after vestibular schwannoma resection.

PATIENTS: Subjects with facial nerve weakness despite anatomic preservation of the nerve after removal of vestibular schwannoma.

Abstract

OBJECTIVE: To identify early predictors of long-term facial nerve function after vestibular schwannoma resection.

STUDY DESIGN: Retrospective chart review.

SETTING: Tertiary referral center.

PATIENTS: Subjects with facial nerve weakness despite anatomic preservation of the nerve after removal of vestibular schwannoma.

INTERVENTION: Surgical resection of vestibular schwannoma.

MAIN OUTCOME MEASURE: Facial function after 1 postoperative year. Independent variables included patient demographics, presenting symptoms, tumor size and location, and serial postoperative function within the first year.

RESULTS: Among 281 patients with postoperative facial weakness, 81% improved to a House-Brackmann (HB) III or better (good outcome) after 12 months of recovery, whereas 12% remained HB IV or worse (poor outcome). For patients starting with HB V or VI function, recovery rate was the most reliable predictor of poor outcome after 1 year. The resulting predictive model using rate of functional improvement as the independent variable was found to anticipate poor outcome before 1 year in more than 50% of cases with 97% sensitivity and 97% specificity. Although associated with facial nerve outcome, tumor size, tumor vascularity, preoperative facial function, age at surgery, and ability to stimulate the nerve intraoperatively did not contribute significantly to the predictive model.

ONCLUSION: The rate of recovery within the first postoperative year serves as a useful early predictor of long-term facial nerve function. We present a novel predictive model using rate of recovery that can be used to select candidates for reanimation surgery sooner than the traditional waiting period of 1 year, potentially improving the outcome of this intervention.

Dynamic muscle transfer in facial reanimation.
Kofi Boahene, MD, FACS

Dynamic muscle transfers offer the hope of improved facial support and symmetry, with volitional movement. These are most commonly employed for reanimation of the oral commissure to produce a smile. In addition, muscle transfers have been used successfully to reestablish eye closure. Facial paralysis of long-standing duration presents challenges quite distinct from paralysis that is managed early after onset. It is in this situation, most commonly, that dynamic muscle transfers are used. In this respect, the alternative is free tissue transfer. Each of these two options have advantages and disadvantages.

Temporalis tendon transfer as part of a comprehensive approach to facial reanimation.
Byrne P, Kim, M, and Boahene K, Millar, J and Moe C

OBJECTIVE: To report an approach to facial paralysis in patients for whom dynamic adjacent muscle transfer is determined to be the best treatment option. METHODS: Retrospective review of 7 consecutive patients who underwent orthodromic transfer of the temporalis muscle insertion for the treatment of long-standing facial paralysis. Patients underwent facial-retraining physical therapy before and shortly after the procedure. Outcomes measured included patient satisfaction, objective measurements of oral commissure elevation with smiling, and physician grading of preoperative and postoperative patient photographs. Medical records were reviewed for complications. RESULTS: Patient satisfaction was high, with a mean score of 8.5 (possible score of 10). Four patients were physician graded as excellent to superb. The other 3 patients were rated as having good postoperative results. Movement was identified in every patient and ranged from 1.6 to 8.5 mm, with mean movement of the oral commissure of 4.2 mm. One patient developed postoperative salivary fluid collection that required drainage. CONCLUSIONS: Temporalis tendon transfer is a relatively easy procedure to perform that has distinct advantages compared with other forms of facial reanimation and provides very good results. This procedure results in improved form and function, may often be performed in a minimally invasive manner, and eliminates the facial asymmetry typically produced by temporalis transfer.

Facial nerve paralysis secondary to occult malignant neoplasms.
Kofi Boahene, MD FACS et al.
OBJECTIVE: This study reviewed patients with unilateral facial paralysis and normal clinical and imaging findings who underwent diagnostic facial nerve exploration.Study design and setting Fifteen patients with facial paralysis and normal findings were seen in the Mayo Clinic Department of Otorhinolaryngology. RESULTS: Eleven patients were misdiagnosed as having Bell palsy or idiopathic paralysis. Progressive facial paralysis with sequential involvement of adjacent facial nerve branches occurred in all 15 patients. Seven patients had a history of regional skin squamous cell carcinoma, 13 patients had surgical exploration to rule out a neoplastic process, and 2 patients had negative exploration. At last follow-up, 5 patients were alive. CONCLUSIONS: Patients with facial paralysis and normal clinical and imaging findings should be considered for facial nerve exploration when the patient has a history of pain or regional skin cancer, involvement of other cranial nerves, and prolonged facial paralysis. SIGNIFICANCE: Occult malignancy of the facial nerve may cause unilateral facial paralysis in patients with normal clinical and imaging findings.

Before and After photos : facial paralysis surgery
Before Before After

8 months after redirecting the injured facial nerve from behind the ear into the neck with side grafting into the hypoglossal nerve ( facial to hypoglossal transposition) using a single anastomisis. Notice the restored facial tone, symmetry and smile. Upper blepharoplasties were performed at the same time.

Before After After

One year results after hypoglossal nerve grafting of a completely
paralyzed facial nerve occuring 16 following brain surgery.
Before After

Surgical correction of blepharospasm and eyelid droop resulting from synkinesis after Bells palsy. Note the improve eye symmetry.

Before After After

After successful removal of acoustic neuroma , complete facial paralysis may occur. In a majority of cases, the face recovers spontaneously if the facial nerve was kept intact. In some cases , the nerve does not recover and alternative measures have to be pursued in a timely manner to restore facial movement. In this patient, the injured facial nerve did not recover after a waiting for almost a year. An electromyogram (EMG) was used to detect any electrical signs of facial muscle recover. With the confirmed absence of recovery, the injured facial nerve was re-routed and conneected to the side of the hypoglossal nerve in a single procedure. Facial movement was restored within 5 months and became stronger over time.
The hypoglossal nerve normally moves the muscles of the tongue. Similar to facial muscles, tongue muscles are capable of multiple movements in various directions and can be adapted to help power the paralyzed face. In addition, the hypoglossal nerve has neural connections with the facial nerve network at the level of the brain making it a reasonable substitute or helper to a weak or injured facial nerve. Dr. Boahene commonly combines the facial - hypoglossal nerve connection procedures with a crossfacial nerve graft which recruits facial nerve axons from the normal face resulting in dual innervation of the paralyzed face and a synchronized spontaneous smile. These procedures are performed with minimal to no morbidity to the normal face and tongue. The timing of these surgeries are essential since the longer one waits to intervene the less predictable the outcome. Above, read the published abstract of our study on this subject above based on our experience at the Johns Hopkins hospital.
A Model for Early Prediction of Facial Nerve Recovery After Vestibular Schwannoma Surgery.
Rivas A, Boahene KD, Bravo HC, Tan M, Tamargo RJ, Francis HW.

Before After After

Right sided congenital facial paralysis. Note the asymmetric smile. A temporalis tendon transfer procedure was perfored in a minimally invasive manner (minimally invasive temporalis tendon transfer MIT3) through a small 2 cm incision hidden under the cheek. During surgery, I use a muscle stimulation techinque I developed to help guide and set the transfered musle at the appropriate length and tension in order to gain the desired movement. At the end of the surgery , we stimulate the transferred muscle and detect facial movement, simulating a smile. This is one of the most rewarding procedures I perform since a patient walks in without a smile and wakes up with one. Physical therapy to adopt and master the newly acquire smile is very important for success. Click to read more about our published paper on temporalis tendon transfer

Before After

Results after temporalis tendon transfer using a minimally
invasive approach. Notice how smile is restored to the paralyzed
face. When facial paralysis has been present for a long time and
nerve grafting is not possible the temporalis tendon transfer
procedure is able to restore movement and a smile almost
immediately after the surgery. Other patients who will benefit from
this procedure include Mobius syndrome patient, congenital
facial paralysis, paralysis after extensive trauma, radical parotid
surgery for cancer.

Patient with a history of acoustic neuroma surgery. She had no return of facial nerve function after 18 months of observation. She underwent facial nerve to hypoglossal nerve grafting using a greater auricular nerve graft. The temporalis muscle tendon transfer procedure was performed in a minimally invasive approach. Nine and 12 month post-operative pictures are shown here. Notice the improved brow symmetry. A browlift was not performed. She also has improved eye closure and lower eyelid position after a lower eyelid fascia sling procedure. Her nasal breathing has improved. Also notice the enhanced symmetry of the lower face at rest and during a controlled smile. She now has a more defined neck line with no jowling. She has excellent tongue movement. Patient directed neuromuscular re-training (physical therapy) is an important part of our facial paralysis rehabilitation protocol.
Before After

Results after facial nerve to hypoglossal nerve grafting. In this procedure nerve fibers from the hypoglossal nerve which usually supplies the tongue fibers are re-routed to grow into the facial nerve. This results with improve tone in the facial muscles which then gradual pull up the paralyzed face to provide a symmetric face. With practice a symmetric smile is acquired. I sometime with connect a nerve graft from the nrmal side of the face to the paralyzed . These two source of nerve helps even out the face and makes it easy to control both sides of the face. Because we preserve the bulk of the tongue nerve, tongue movement is not affected.

Results following facial nerve grafting. This patient with recurrent parotid
cancer had the entire right sided facial nerve removed resulting in complete
facial paralysis. His facial nerve were grafted at the time of the cancer surgery
Movement was restored within 3 months and has continued to improve.
Before After

This Middle Eastern male had a brain stem surgery which resulted in complete paralysis of the right face. 14 months after the surgery, there was no recovery. He travelled from the Middle East to see Dr. Boahene who designed a facial reanimation surgery that was performed in two stages. Durging the first stage, the injured facial nerve on the right side was dissected from behind his ear (mastoid) and re-routed to his hypoglossal nerve. A sensory nerve (sural nerve) graft measuring 15 cm was borrowed from his leg and connected to a branch of the normal facial nerve on his left face (crossfacial nerve) and tunnel into the paralyzed right face. After 5 months, he noticed movement of the paralyzed face which improved overtime. One year after the first stage surgery, a small second stage surgery was performed where the crossfacial nerve graft was connected to branches of the recovering right face. This second stage procedure was performed such that the movement he had already recovered was preserved . The crossfacial nerve graft provided move neural input and synchronized both sides of his face when he smiles. Besides the improved smile, recovery of the eyelid muscles allowed him to close his eyes better.

Case sample: Facial to hypoglossal nerve grafting performed 16 months after primary surgery for acoustic neuroma.

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Out-of-state and international patients

We encourage patients living close to our offices in Baltimore and the Johns Hopkins hospital to come in for an in-person consultation. Patients residing out-of- state and international patients can start this process with a virtual consultation with Dr. Boahene. For a virtual consultation, please submit a brief history of your paralysis, any treatment you have had and the specific improvements you are seeking. Also submit photos of your face only, showing your face at rest, with eyes closed, smiling and grimacing. A short video clip showing these facial movement, if available, is very helpful. Once Dr. Boahene reviews your information, an onilne consultation will be arranged.

Dr. Boahene presented a course on current techniques in reanimatng the paralyzed face. Dr. Boahene will be presenting updated techniques in correction of facialparalysis in 2011.

Minimally InvasiveTechnique Appears Helpful to Reanimate Facial Paralysis ScienceDaily(Jan. 18, 2011) — A procedure involving only one small incision and no major modifications to bone can be used to transpose a tendon and appears helpful in reanimating the lower face after paralysis, according to a report in the January/February issue of Archives of Facial Plastic Surgery, one of the JAMA/Archives journals.Read more

Fixing the crooked smile. Read about one young child's journey to achieving the perfect smile.

Facial Plastic And Reconstructive Surgery Specialist

Washington DC, Virginia, Maryland 410. 502 .2145

A Model for Early Prediction of Facial Nerve Recovery After Vestibular Schwannoma Surgery.