Facial Nerve Reanimation and rehabilitation
That’s a big deal and we are here to help!
This kind of rehab is a pretty unique part of what we do. We work in with all types of facial nerve static and active reanimation techniques.
Types of reanimation for facial nerve paralysis:
Dynamic/active lower face reanimation - aiming to get movement from another source.
Cross Face Nerve Graft
Masseteric to facial nerve graft
Temporalis transfer
Gracilis or other muscle free flaps
Hypoglossal nerve to facial nerve graft
Static techniques:
Slings to hold up the mouth and cheek
Eye brow and eye lid repositioning / lifts
eye lid weights, chains and lower lid repairs
Face lifts
Other surgeries we work with frequently:
For synkinesis we work with DAO myectomy, selective neurectomy and other selective myectomies.
… ok but what are they and how do you rehab them??
In summary:
A note on these surgeries. There are a lot of variables that your surgeon will consider to help select the best options. The likelihood of the graft taking/working given your unique health situation will be something that is discussed with you during the decision making process. As face physios we will often be involved in a person’s life for years after these surgeries, but most of what we do is amenable to self treating. So we don’t actually see people all that often once they are comfortable with how face rehabilitation works.
Cross Face Nerve Graft:
A sensory nerve (sural nerve) is harvested from the leg and is used to connect the working facial nerve to the paralysed side across the front of the top lip, under the nose. This is the only reanimation technique that gets true spontaneous movement, as it uses the uninjured side to set the timing for the inured side. It is great for timing but not known for power/size of movement and can often be done in conjunction with a technique designed for power like a masseteric nerve transfer.
This is big surgery! There are multiple surgical sites and often a couple of stages to this. There are incision sites on both sides of the head and one of the leg at the harvest site. I takes a couple of months (usually around 3) for the nerve axons to grow and find there way across the new nerve bridge so there is a flaccid period immediately post surgery. There are ways we can check to see how far along the nerve is.
Once movement starts, it is time for rehab! our mission is to help your brain work out how to use the graft using face exercises. We also use things like massage and stretching to help it feel comfortable through the process. It’s a little repetitive to start with but is very achievable. We tend to find with reanimation techniques they are a slow burn BUT with stimulus the graft just gets easier and easier to use with time and people find they are continuing to improve years down the track.
Masseteric to facial nerve graft
We work with this surgery a lot! It is known for power and can be done in conjunction with other surgeries like the cross face nerve graft or muscle transfers.
Part of the chewing nerve (masseteric nerve) on the same side as the paralysis is harvested and plumbed into trunk of the facial nerve. The intension is to give movement to the smile muscles innervated by the buccal (cheek) branch. It is amazing for power and size of movement. The really cool part about this is that you don’t loose any bite force! The masseteric nerve is just that strong.
Again this is a big surgery! All of the reanimations are. There is a waiting period of a couple of months for the graft to take and the axons to find the graft. Once movement starts, we are training people to activate their expression muscles via their biting nerve. So exercises can involve touching the teeth to turn on the face and training with the intention of making this as spontaneous and automatic as possible over time. If we get the opportunity to catch people before this surgery we can start introducing the concept pre op and this can help set people up for success.
This is another on we find continues to improve as time goes on if people have put in the work at the start. It is a long rehab! It can take months to years but is very rewarding.
Temporalis transfer
The front part of the clenching muscle is cut and flipped down and attached to the corner of the mouth. This lifts up the corner at rest into a more functional position and because it is a muscle we can sometimes get a little bit of contraction/lift out of it. Hence it is in the dynamic list.
Gracilis or other muscle (like TFL) free flaps
If there is concern about a lack of usable muscle in the cheek to plug new nerves into, then a free muscle flap may be considered. This can be dependant on the degree of paralysis and how long the tissue has been paralysed for. In short a bit of muscle and blood supply is pinched from usually the upper leg (gracilis or TFL) and is shaped into something that will fit in the cheek. This is placed in the cheek and usually a CFNG or master nerve graft can be attached. This is usually done in multiple stages as well.
The rehab is quite similar to CFNG and masseteric, rehab is very much exercise based and can take months to years for a full result.
Hypoglossal nerve to facial nerve graft
A less common surgery in Australia that involves taking part of the tongue nerve and connecting it to the facial nerve on teh same side as the paralysis. Depending on how much nerve is used this can result in some tongue weakness. We teach people how to move their expression muscles via tongue movements. Often we will work in with a speech pathologist for this rehab too.