Facial Paralysis Restoration Center

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 cobine their 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.

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

Contact us at 410.502.2145 or email for a facial paralysis consultation

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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 2010.

Book chapters, Scientific journal articles

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	After

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

Before and After photos : facial paralysis surgery

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.

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,

after extensive trauma, radical parotid surgery for ccancer.

ABOVE: 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.

Facial Plastic And Reconstructive Surgery Specialist

Washington DC, Virginia, Maryland 410. 502 .2145