facial plastic and reconstructive surgery in Winston Salem North carolina
Facial Paralysis before and after photos The nerve that works the muscles of the face comes out of the skull through the ear and then distributes evenly to approximately five branches that work the muscles of the face. The branches go to the forehead, to the eye, to the nose, to the mouth, and to the neck. If you look closely at people's faces you can see that we all have asymmetry. Some of the most obvious places that you can notice this symmetry are in the evenness of our smile and the shape of our upper eyelids. You probably recognize that it is easier to wink with one eye than it is with the other eye. In the same way that you right-handed or left-handed you have a dominant side of your face. This leads to preference and strength of one side of your facial muscles in comparison with the other.
Injuries to these muscles can also cause asymmetries of the face. The most common cause of an asymmetry in our practice is due to cancer or tumors that affect the nerve or one of the branches of the facial nerve. There are many causes of facial paralysis.
It is quite difficult to ever completely match an injured side to a normal side. We have techniques that we use mostly to camouflage a facial paralysis rather than actually repair the cause of it. In the upper third of the face, the forehead branch, patients will be unable to wrinkle one side of their forehead. For this type of problem we try to do a brow lift. Often we don't do the usual brow lift that we do for cosmetic procedures, which is an endoscopic forehead lift, since patients with facial paralysis have no muscle tone and need more direct positioning of their brows including the layers that contain the muscles. We often will do a brow lift, therefore, through an incision hidden in a wrinkle in the forehead rather than behind the hairline. In younger patients with good skin tone and some muscle tone our endoscopic forehead lift is still a procedure of choice. The brow lift tends to reposition the droopy eyebrow and droopy forehead at a more even position with the other side. This is not something that will change with facial expression but a very droopy eyelid will start blocking the vision because of the droopy brow. This causes a reflex elevation of the brow that accentuates the difference between the healthy side and the injured side. Doing the brow lift therefore allows some of our reflex to create even more asymmetry to be reduced. The downfall is that we can't create an active muscle through this technique but try to even the positioning of the muscle with the functional side.
Rather than elevating one side of the brow another option is to use Botox and even the two brows. If there isn't too much sagging of the upper eyelid tissue that is blocking the vision on the injured side then the other side can be paralyzed temporarily with Botox (botulinum toxin) to match the injured side. The downside of this is that this side of the forehead will lose its ability to function but the truth is that our faces register asymmetry and as long as this does not cause a functional problem such as obstructed vision, then this an easy yet temporary solution to a problem with minimal side effects, no downtime, and no need for surgery. It is reversible with time.
The most important concern we have with facial paralysis is not the cosmetic appearance but the functional protective actions of our facial muscles. For us, the first thing we think of is protecting the eye from exposure. With a facial paralysis you can still open your eye since a different nerve is used to open the eye. Closing the eye is done with the facial muscles through a muscle called the orbicularis oculi. This muscle allows us to close our eye and distribute tears evenly across the cornea and clear small particles from the surface of the eye. Without this blink reflex and the ability to close the eye the cornea can become dried out and injured from exposure. This can significantly damage vision.
There solutions to treatment of the eye, which are temporary and more permanent. Most of these procedures are reversible. The simplest way to protect the eye is to use natural tears frequently. This doesn't require surgery but will require attention on the part of the patient. If there is any sensory deficit as well in the area then it is particularly dangerous to try to use this technique since the patients won't know when they are being irritated. Still, conscientious patients can protect themselves and avoid surgery using good conservative care such as frequent eyedrops and ointment in the eye at nighttime.
Another technique for protecting the eye is called a tarsorrhaphy. With a tarsorrhaphy suture the corner of the eyelids are sutured together to help bring them closer together even they are opened. This procedure, by bringing the eyelids closer together, helps allow the eyes to be lubricated by the eyelid and tears. There still may not be complete closure but patients can roll their eyelids underneath the eyelids more easily in order to use the eyelid to wash the cornea with tears. The downside of this is that it changes the shape of the eyelids to a more rounded shape at the outside corner of the eye. The method we prefer is called a gold weight. A gold weight can be placed in the upper eyelid through a blepharoplasty (eyelid surgery) incision. With a gold weight, when you rest your eyelids the weight will close the eyelid for you. Since a different nerve opens the eye the ability to open the eye is still present. We use gold because it is very dense and we can use a smaller weight. It is also not very reactive and tolerated well by our bodies. It is such a straight-forward procedure that we feel comfortable doing this even temporarily in patients for whom we have any concern about exposure.
In the lower third of the face, the mouth and neck, things get more difficult for us. Our mouths are so diversely functional. It is extremely difficult for us or any physician to recreate the abilities and functions of the mouth. The mouth must be able to close in order to talk, prevent drooling, whistle, pucker, and open in order to communicate, smile, display emotion, etc. The very subtle interplay of the many muscles that work the mouth is beyond the technology that our generation if surgeons has. We have a few methods for repairing facial nerve paralysis around the mouth but these only help camouflage the asymmetry and with our limited technology, in my opinion, don't camouflage it very well. In order to stop the droop at the corner of the mouth we use facial slings. We can suspend the corner of the mouth and the upper lip higher with natural tissues or with grafts such as Gore-Tex to the cheek bone. This can even the level of the mouth at rest but when smiling the other side of the mouth still elevates higher than this side creating asymmetry although it is markedly different than the asymmetry with a mouth that is drooping. This also can help people from biting on the inside of their lip as they chew and can't lift their lip out of the way. The active method of doing this is to transfer a muscle from the chewing muscles of the side of the face down to help elevate the corner of the mouth. The problem with this is where the muscle is transferred there is a small bulge on the cheek, which creates another asymmetry. The asymmetry is not completely corrected since the nerve that works the chewing muscle is different than the nerve that works the facial muscles. The smile muscle, which is triggered by a reflex, triggered by the brains, triggered by emotion, will not ever lean how to match contraction of the chewing muscles that we transfer to correct this problem. Still, for some people having some control of their mouth seems worthwhile enough that this method rather than a passive sling becomes the method they choose for reconstruction.
Patients who feel young and have active vibrant lives often have a tired appearance as tissues around their eyes and face fall. Our best opportunities to help patients with this are to address each of the issues individually. |
