Evolution of the Treatment of Facial Paralysis

The treatment of facial paralysis has always been a challenge for the plastic surgeon. Up to the seventies in the last century, the plastic surgeon had fewer options to treat the patient,who was usually referred only after years from the onset of the palsy. Other specialties involved in the treatment of facial palsy considered the severe cases as irreversible, and referred them only for minor “cosmetic procedures.”

In 1972, I was involved in a new project at the University of São Paulo to develop reconstructive microsurgery in Brazil. After a few visits abroad, namely to Vienna (H. Millesi) and San Francisco (H. Buncke), a training laboratory was opened in São Paulo in 1974. Replantations and some free flaps were already being performed. It was clear to me that this new field would be important for treating any condition that could benefit from techniques and sutures in small vessels and nerves. Working in the Division of Plastic Surgery, I saw a number of patients with facial palsy, mostly long-standing. These patients asked for improvement and rehabilitation of their faces, and many were already disappointed with the limited success after they had been submitted to other previous procedures. I thought microsurgery might have a place in the treatment of this condition.

I came across an article written by Hans Anderl on “cross-face nerve grafting” and I decided to visit him in Innsbruck, which was done in 1975 at the time of the International Congress of IPRS in Paris. From then on, cross-face nerve grafting was incorporated into our armentarium. Although not totally successful as expected, and actually dismissed as an option by many surgeons at that time, it proved to be an alternative with specific indications. For sure, it has never worked well for rehabilitation of eyelid paralysis.

Experience with microsurgery in small nerves proved to be essential to improve the results of facial nerve repair and grafting in the extratemporal area, as happens in injuries caused by trauma or tumor resection. It really changed the approach and introduced immediate reconstruction as the alternative of choice in those severe lesions.

Microvascular muscle transfer was the next step, introduced around 1980, after contributions from surgeons in Japan (Tamai experimentally, Harii, clinically). Microsurgery was essential for performing nerve and vessel suture.

Our next advance occurred only in the last decade when patients, who evolved with what we supposed were excellent results after muscle transplantation, still complained about some aesthetic deficiencies in their faces. Complementary procedures aiming to solve specific defects, like neurectomies and myectomies, were important, as well as non-surgical methods such as botulinum toxin and others. They are now incorporated into our integrated treatment and patients are much happier.

So, what have we learned in these past 30 years? First of all, that facial paralysis remains a complex problem. It is not so difficult to manage as it was before, but the results of the treatment are still elusive in some cases. Individual demands should be addressed, and there is no average treatment for each specific case. It is clear that we do not deal with a single entity but with a multi-variable problem to which we can offer many surgical and non-surgical options. The most important variables for the indication of procedures are the age of the patient, etiology, site and extent of the nerve injury, time elapsed since the onset of palsy, degree of the palsy,whether complete or incomplete, and if it is possible to restore the continuity of the facial nerve itself.

Techniques should be chosen depending on those variables. Often, several procedures must be combined in order to provide the best possible rehabilitation for the patient. Another problem we started to address almost a decade ago was how to reach a quantitative assessment of the result. What is a good result of a given procedure? How can we compare results and decide that this technique is superior to any other? What is the maximum we can offer our patients in terms of result? How to extract evidence-based conclusions from any treatment? In many ways, the difficulty is similar to what we encounter in most aesthetic procedures.

We are far from reaching the ideal method, but we have reviewed some assessment scales, mainly published in the ENT literature. For instance, the House scale is acceptable for evaluation of Bell's palsy but insufficient for complete palsies and we proposed a new method. The basis is to compare the paralyzed side with the non-affected side, giving to this one a score of 100%. In complete palsy, of course, the preoperative score is near 0%, and any improvement gained through treatment will appear as a percentage of the normal side. Evaluation includes voluntary and involuntary movements of different areas in the face. Altogether, the results of any treatment in severe cases have not been perfect, but we were able to achieve more symmetry and to improve the aesthetic balance of the face. The patients refer to increase in their self-esteem and psychological gain. Some degree of emotional control of the face is very important for the patient, as well as the overall aesthetic appearance.

Results are superior when dynamic techniques are used, such as the combination of cross-face nerve grafts with muscle transfers, either local (the Gillies transfer yields good results in our hands) or microvascular, or both. Sometimes reanimation of the paralyzed face reaches 60% of the healthy side. More important, those methods improve the face in a way that allows for a non-surgical method to achieve better results The surgeon must be prepared to use all methods for the benefit of the patient.

The gold standard result occurs only in injuries of the facial nerves if approached early and repaired by direct approximation or using short nerve grafts. In this situation, the outcome approaches the normal symmetry. It is unfortunate that, even today, a number of patients who might benefit from the modern treatment of facial paralysis are still not correctly referred to a plastic surgery center, and it our task to spread these ideas widely to more people.