Facial paralysis and Bell palsy are challenges for the plastic surgeon because of the complex nerve and muscle work involved to correct these conditions. Babak Azizzadeh, MD, an assistant clinical professor at University of California at Los Angeles, is one of a small number of surgeons in the United States who performs repair of facial paralysis. Dr. Azizzadeh is board certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology-Head and Neck Surgery. He is founder of the Facial Paralysis and Bell's Palsy Foundation. Dr. Azizzadeh spoke to Medscape's Pippa Wysong about what plastic surgeons need to know when it comes to working with patients who have facial paralysis.
Medscape: How common is facial paralysis?
Babak Azizzadeh, MD: The true incidence of facial paralysis is not known because of the lack of physician understanding of the disorder and its various causes. Bell palsy, the most common cause of facial paralysis, affects about 40,000 people in the United States annually. Approximately 1 in 65 people will be affected by Bell palsy.
Medscape: What are the causes of facial paralysis?
Dr. Azizzadeh: Facial paralysis has a variety of causes. Bell palsy is the most common cause. This disorder is thought to be a result of herpes virus reactivation -- similar to how chickenpox zoster virus can reactivate, causing shingles. Incidentally, pregnant women are at a higher risk for Bell palsy developing.
Other common causes of facial paralysis include trauma (congenital, fractures, surgery, iatrogenic), acoustic neuroma, parotid tumors, head and neck tumors, and Lyme disease. Of interest, stroke is not a very common cause of facial paralysis.
Medscape: Which parts of the face are typically affected?
Dr. Azizzadeh: All muscles that are involved in facial expression can be affected by this disorder, including those that lift the eyebrows, close the eyes, produce a smile,, keep nostril valves open, and prevent drooling.
Medscape: Where do people go for treatment?
Dr. Azizzadeh: Facial paralysis has traditionally been undertreated [because there is] a paucity of treatment knowledge among medical professionals. Very few centers around the world have a dedicated team of specialists who are solely focused on this disease process. I have been fortunate to be involved with one of these centers in Los Angeles (Facial Paralysis Institute), which has world class experts dedicated to the treatment of facial paralysis in specialties such as facial plastic surgery, physical therapy, oculoplastic surgery, neuro-otology, ear-nose-throat, head and neck surgery, neurology, and neurosurgery. Treating these patients requires a multidisciplinary approach.
Medscape: How are these patients typically treated?
Dr. Azizzadeh: The treatment of facial paralysis has significant variations, depending on the cause, severity, duration, and age of the patient. Bell palsy, when initially diagnosed, must be treated immediately with high-dose steroids and antiviral medications (valacyclovir [Valtrex®] or famcyclovir [Famvir®]). However, it is paramount that the clinician who diagnoses "Bell palsy" rule out more serious conditions such as brain tumors, stroke, and head and neck cancer. Eye protection is also a key factor because most patients in early phases of the disease are unable to close their eyes and run a high risk for the development of long-term corneal ulceration and blindness. Patients are encouraged to use a special tape to close the eyelids at night and to use artificial tears and lubricate their eyes regularly.
Patients who present with long-standing facial palsy will require a more graduated treatment algorithm. We use 3 main treatment arms: neuromuscular retraining, botulinum toxin (BOTOX® Cosmetic, Dysport®), and surgery. These options should be tailored to each patient depending on various individual factors.
Medscape: What are the key investigations that should be performed prior to surgery?
Dr. Azizzadeh: The underlying cause of facial paralysis must be uncovered. In my practice, I've seen many patients who had been misdiagnosed with "Bell palsy" but turned out to have other, more serious underlying conditions such as acoustic neuroma or parotid tumors. Imaging studies should be done to make sure there are no tumors or growths, and electromyopathy [should be done] to evaluate the nerve input and the muscle action. You want to see what's really going on. You also want to see if there is any underlying tone to the facial muscles, which will help determine the appropriate operation for the patient.
Medscape: What are some of the key surgical challenges?
Dr. Azizzadeh: Every surgery is different. We customize the procedure depending on the patient's desires as well as [the person's] age, and the cause, duration, and severity of the paralysis. Most people have similar desires -- to improve functional deficits, create facial symmetry, restore the smile mechanism, and allow good closure of the eyes. In many patients who have fairly good facial movement, we [can create facial symmetry] using tendon transfers and facelift procedures. In other cases -- in patients who have no movement -- we will employ advanced surgical procedures using nerve and muscle transfers.
Two key surgical procedures truly benefit patients when used appropriately: hypoglossal-facial nerve transfer and cross-facial nerve grafting with gracilis free muscle graft. If patients are candidates for these procedures, they have the best opportunity to obtain tone and a spontaneous smile mechanism.
Medscape: Can you walk through some of the issues involved in nerve repair of the face?
Dr. Azizzadeh: A labyrinth of issues must be dealt with when a patient has nerve injury. When nerves are repaired or spontaneously regenerated (as is often the case in Bell palsy), they often have no clue which muscle they innervate or activate. As a result, even under the best circumstances, patients will have uncoordinated facial movement with a very limited functional smile mechanism.
My research laboratory at Cedars Sinai Regenerative Medical Institute is focused on studying growth factors and stem cells and seeing how we could force the nerve to grow to the appropriate locations; however, that's a glimpse of the future, not what we can do now.
Medscape: What special considerations are involved in transplanting nerves vs muscle when working on the face?
Dr. Azizzadeh: Nerve and muscle transfers from other parts of the body to the face are now common procedures for restoring a spontaneous smile mechanism. In patients who have no movement and no chance of nerve or muscle regeneration, we perform a 2-stage operation. The first stage is a cross-facial sural nerve graft, the second stage is a gracilis free flap.
Medscape: How are those stages performed?
Dr. Azizzadeh: In the first stage, we harvest sural nerve tissue from the ankle area and connect it to the normal facial nerve on the unaffected side. We allow the nerve to [undergo neurotization] or activated for 6 to 12 months. In the second stage, free muscle graft is used. The gracilis muscle with its nerve, artery, and vein is harvested and anchored to the paralyzed side. The sural nerve is connected to the gracilis nerve (obturator nerve) and the artery and veins are hooked up to the facial artery and veins to allow blood supply to the muscle. When the patient smiles on the normal side, the gracilis muscle on the paralyzed side is activated and moves, thereby restoring the patient's smile.
Medscape: That's an interesting "work-around." Are there others?
Dr. Azizzadeh: Many patients require just modified/customized facelifts to [make the face more symmetrical] and create more balance to the overall structure. We often combine this with blepharoplasty and browlifts to further improve symmetry.
Medscape: It sounds like there is a certain amount of puzzle-solving when planning the surgery.
Dr. Azizzadeh: The human face is a very special and unique part of our livelihood. It allows us to express emotions, communicate, develop relationships, and interact with others in complex manners. Loss of facial expressions truly reduces our ability to socialize and advance in life. That is the true puzzle that we need to address.
Medscape: Are there differences in how you deal with young vs old patients?
Dr. Azizzadeh: Absolutely. Younger patients are better candidates for advanced surgical options such as cross-facial nerve grafting with gracilis free flap. They have a higher success rate with these procedures and better nerve regeneration ability.
Medscape: Is extra training available for plastic surgeons who wish to learn how to surgically repair facial paralysis?
Dr. Azizzadeh: I am a co-director of the American Academy of Facial Plastic & Reconstructive Surgery fellowship program, and there are 2 or 3 other programs in the United States that have in-depth training for facial plastic surgeons and plastic surgeons in this arena. My doors are always open for residents and visitors as well. Surgeons can also get more information from the Facial Paralysis Institute in Beverly Hills, California.
Medscape: Thanks for discussing this topic with Medscape today.
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Cite this: Facing the Truth About Bell Palsy - Medscape - Mar 28, 2011.