Annual Report

General Editor: Daniel Buchbinder

Authors: Damir Matic, John Yoo

Facial nerve - Reversible paralysis

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Glossary

Observation
Main indication Skill Equipment
When return of function is likely or during the course of recovery (e.g. Bell's palsy, post-surgical trauma) Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Clinical deficit without laceration
  • Geriatric patients
  • Comorbidities affecting nerve regeneration
  • Patients who cannot be examined (e.g. severe head injury)
Lateral tarsorrhaphy
Main indication Skill Equipment
Corneal exposure Basic surgical experience, no specialized skills Basic equipment only

Further indications

  • Temporary and/or preemptive measure prior to definitive procedure to improve eyelid function and ensure corneal protection
  • Emergency measure when definitive treatment is delayed or there is possibility of imminent visual loss due to exposure
  • Salvage procedure when other treatments have failed
  • Poor or absent Bell's phenomenon

Advantages

  • Simple
  • Quick
  • Immediate result
  • Local anesthetic
  • Adjustable
  • Reversible

Disadvantages

  • Not dynamic
  • Poor cosmesis
  • Reduced visual field
Direct nerve repair
Main indication Skill Equipment
When a tension free coaptation is possible. This applies to the main trunk or the distal branches Basic surgical experience, no specialized skills Simple surgical and imaging resources

Further indications

  • Open laceration
  • Suspected/known iatrogenic injury
  • For midface branches (smile, pucker, and blink) no signs of recovery after 3-6 months
  • For frontal and marginal branches (forehead elevation and lip depression) no signs of recovery after 6-9 months

Contraindication

  • Lacerations distal (anterior) to the lateral canthus
Interpositional nerve graft
Main indication Skill Equipment
Tension free direct repair not possible Basic surgical experience, no specialized skills Simple surgical and imaging resources

Further indications

  • Nerve defect (from trauma/resection)
  • Crush injury
  • Neuroma in-continuity
  • For midface branches (smile, pucker, and blink) no signs of recovery after 3-6 months
  • For frontal and marginal branches (forehead elevation and lip depression) no signs of recovery after 6-9 months

Relative contraindications

  • Geriatric patients
  • Comorbidities affecting nerve regeneration
Reinnervation with masseteric nerve transposition
Main indication Skill Equipment
Proximal facial nerve not available. Functioning masseteric nerve Some specialized surgical experience Simple surgical and imaging resources

Contraindication

  • Donor nerve (masseteric) not functioning

Advantages

  • Voluntary movement
  • Strong motor nerve input
  • Early recovery
  • Easier for patients to coordinate smiling and biting

Disadvantages

  • Not spontaneous movement
  • Synkinesis
  • Potential loss of donor (masseter) muscle function
Reinnervation with hypoglossal nerve
Main indication Skill Equipment
Proximal facial nerve not available. Functioning hypoglossal nerve Some specialized surgical experience Simple surgical and imaging resources

Further indication

  • Non-functioning masseteric nerve

Contraindication

  • Donor nerve (hypoglossal) not functioning

Advantages

  • Voluntary movement
  • Strong motor nerve input
  • Early recovery

Disadvantages

  • No spontaneous movement
  • Potential loss of donor (tongue) muscle function
  • Difficulty for patients to coordinate face movement with tongue movement
  • Synkinesis
Selective reinnervation with proximal facial nerve and masseteric nerve
Main indication Skill Equipment
To limit synkinesis by separating eye closure and smile movements when proximal nerve available Some specialized surgical experience Simple surgical and imaging resources

Advantages

  • Spontaneous eye closure
  • Potential to reduce synkinesis
  • No contralateral scar
  • Early reinnervation of smile

Disadvantages

  • Difficult to achieve spontaneous smile
  • Less lower facial tone
Reinnervation with cross facial nerve graft
Main indication Skill Equipment
Proximal facial nerve not available Highly experienced and skilled surgeon Simple surgical and imaging resources

Further indication

  • To limit synkinesis

Relative contraindications

  • Proximal facial nerve available
  • Older patients

Advantage

  • Spontaneous mimetic movement

Disadvantages

  • Muscle power may be weak
  • Donor site scar
  • Risk of contralateral facial weakness
  • Longer time to reinnervation
Selective reinnervation with contralateral facial nerve and masseteric nerve
Main indication Skill Equipment
To limit synkinesis by separating eye closure and smile movements. When the ipsilateral proximal facial nerve is not available Some specialized surgical experience Simple surgical and imaging resources

Contraindication

  • Older patients

Advantages

  • Spontaneous eye closure
  • Potential to reduce synkinesis

Disadvantages

  • Difficult to achieve spontaneous smile
  • Less lower facial tone
  • Contralateral scar
  • Risk of injury to the contralateral facial nerve
Static suspension with tendons
Main indication Skill Equipment
Augmentation of reinnervation procedures Some specialized surgical experience Simple surgical and imaging resources

Further indication

  • Augmentation of reinnervation procedures, in order to improve facial symmetry at rest, especially during the period of facial nerve recovery

Advantages

  • Simple and quick
  • Reliable
  • Immediate results

Disadvantages

  • Not dynamic
  • Relapse over time
  • Require donor site
  • Additional scar
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources