Diagnosis and treatment

Brow-lift

Paralysis of the forehead muscles often causes the height of the eyebrow to drop. This descent causes an obvious asymmetry and can cause problems with vision and a feeling of "heaviness" of the eyelids. A brow-lift procedure aims to restore the symmetry at rest and alleviate the eyelid problems associated with a drop in the eyebrow level.

Static slings

Facial paralysis causes a loss of tone and descent of the tissues of the mid and lower face. This can cause problems with the nasal airway on the affected side, drooping of the corner of the mouth and often a marked asymmetry as the unaffected muscles on the opposite side of the face pull all the tissues over to the unaffected side. This causes problems with speech and eating. A static sling uses a fibrous sheet of tissue from the side of the thigh to help re-suspend the soft tissues vertically and also to pull them back across the midline in order to provide a more balanced position at rest. The operation is carried out through a facelift incision so that it is barely noticeable.

Dynamic slings

Dynamic slings utilise the action of one of the muscles of mastication i.e. one of the muscles that is attached to the jaw. The pull and action of this muscle is redirected or sometimes extended so that the muscle action helps to not only re-suspend the tissues as in a static sling but also aims to recreate the smile as the muscle is re-inserted into the corner of the mouth and pulls upwards and outwards.

Free tissue transfer

This technique aims to re-create the smile by harvesting muscle from the inner aspect of the thigh. The muscle is taken with its artery, vein and nerve and re-attached to vessels in the facial region and the nerve is joined either to a nerve which supplies a jaw muscle or into a nerve graft that has been placed some months prior to the procedure. The advantage of using a nerve graft from the opposite facial nerve means that the smile produced is spontaneous. This type of surgery is staged and is more complex than the other procedures described.

Specialists from the Wessex facial nerve centre are routinely called upon in the treatment of complex conditions causing facial weakness. In addition to the treatment of the underlying cause, the specialists will make plans to decompress, repair or graft the facial nerve to maximise the potential for facial nerve recovery. These techniques can either be performed at the time of surgery or at a later date.

Decompression of the facial nerve

Surgical decompression of the facial nerve is sometimes needed in cases of trauma to the facial nerve when electrical tests show the nerve function has significantly deteriorated. Here, the rigid bone around the swollen nerve is removed, relieving the pressure around the nerve. The degree and speed of recovery of facial nerve function depends on the amount of damage sustained by the nerve. Recovery may take three to 12 months and may not be complete. Hearing loss can sometimes follow surgery, but this depends on the extent of surgery needed.

Facial nerve graft

A facial nerve graft is used if a segment of the facial nerve is so severely damaged that it cannot be saved. A sensory nerve is removed from the neck and used to replace the diseased or damaged portion of the facial nerve. It is interposed between the two portions of the remaining normal nerve. Total paralysis will be present until the nerve regrows through the graft. This usually takes six to 15 months. Some facial weakness is permanent.

Split hypoglossal-facial nerve jump graft

When it is not possible for a facial nerve repair by other means, it is possible to connect some of the fibres of the nerve which move the muscles of one side of the tongue (hypoglossal nerve) to the facial nerve. This is usually performed under general anaesthetic nine to 12 months after the tumour removal. If present, previous incisions behind the ear are used and extended slightly into the neck, where a sensory nerve is removed. The hypoglossal nerve is partially cut and then connected to the sensory nerve. The other end of this sensory nerve is connected to the facial nerve.

In six to 12 months, when tongue nerves grow into the facial nerve, via the sensory nerve, a variable degree of facial movement returns. The facial appearance at rest is usually restored to near normal. However, there is always some persistent weakness of the face after surgery. On speaking or moving the face to smile, all of the muscles tend to contract at once, which results in a noticeable visual difference from the other half of the face. Weakness and wasting of one half of the tongue can sometimes develop, however in this technique where only part of the tongue nerve is divided this is rare.

The majority of patients with a facial nerve disorder will experience difficulty in closing the eye and therefore difficulty in protecting the surface of the eye, which may impair vision. The eye unit provides a comprehensive range of  services which include monitoring the health of the eye, advice to medical teams and the patient on how to look after the eye and a range surgical procedures to address some of  these problems, for example insertion of a lid weight  to assist eye closure.

Botulinum toxin can be used at different times during your recovery. If, despite training, you continue to have difficulty in producing a wanted movement or in controlling an unwanted movement because of hyperactivity in some of the facial muscles, botulinum can be used to temporarily reduce the activity in those muscles. This gives the patient time to strengthen the weak muscles which were being over powered by the hyperactivity in other muscle groups or improve or establish movement patterns that had become difficult because of synkinesis.

This is a tailor made approach which recognises and addresses the individual needs of each patient throughout the course of their recovery. The elements of facial rehabilitation are education, relearning and controlling facial movement so normal patterns of facial movement are regained.

Examples of areas where seeing a psychologist could help include:

• adjustment to living with symptoms of facial palsy
• anxiety around diagnosis or treatment
• depression
• managing trauma
• relationship difficulties exacerbated by others’ responses to difference
• self esteem and appearance issues
• sense of loss
• social anxiety or avoidant behaviour
• preparation for medical procedures.

Fortunately in the more common conditions, such as Bell’s palsy, most patients will make a full recovery. However, these patients will benefit from advice and instruction on how to protect their eye and maintain good oral hygiene so as to avoid any unnecessary complications.