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Patients who experienced these symptoms often have a lot of psychological strain that goes along with it. They are anxious over the way they look on a day to day basis, the inability to move the face or even maintain symmetry in the resting state. These are very important features that we all take for granted when we don’t have paralysis. But when we do have paralysis, this is when the true value of the facial nerve and the facial muscles of expression come out.
In Bell’s palsy, patients can typically recover facial nerve function on their own. However, in some cases, this can be a longer process. In those patients that take a longer time to recover, sometimes they phenomenon occurs called synkinesis. And what is synkinesis? This is a problem of reinnervation. In other words, there’s a miswiring of the various facial nerve branches during the recovery phase of Bell’s Palsy. In other words, when a nerve shuts down, it really has to start over again. The facial nerve has to regenerate from the point of the injury or the inflammation all the way down the channels into the facial muscles again. During this process, because of the thousands of interconnected networks of little nerves that constitute the facial nerve further downstream, you can get a miswiring or a redirection of that signal into another part of the face. For example, when patients try to smile, they can trigger the closure of the eye or a spasm of the eye and vice versa. There’s all sorts of combinations and patterns of synkinesis that can be very distressing to a patient. And the treatment for these can be quite challenging.
Depending upon the reason for facial paralysis, the condition can be curable. In the setting of Bell’s Palsy, recovery curves mostly in a spontaneous fashion or on its own. Sometimes recovery is prolonged, sometimes the recovery is and complete. The residual weakness that results can be a permanent fixture. In those patients, we then analyze them a little bit differently. We may recommend additional surgical options or therapy options that we wouldn’t necessarily do for the person who is actually recovering on their own.
The difference between Bell’s Palsy and some of the other causes is really in the history of that particular problem. So for example, Bell’s palsy occurs out of the blue. It can be associated with the common cold. It can be associated with climatic changes. There are a number of reasons why the facial nerve might become inflamed and swollen, but it is a very quick process. The symptoms of Bell’s Palsy can be very similar to other causes of facial paralysis. So it’s very important to differentiate Bell’s Palsy from what else can cause facial paralysis. Some of those other causes can be quite severe and serious. Things like brain tumors or stroke. These have a very similar clinical appearance, but they’re treated in a much different way.
Within facial paralysis there are numerous causes. One of the reasons of facial paralysis is something called Bell’s Palsy. What Bell’s Palsy is, is the actual inflammation of the facial nerve, and it could occur from a variety of causes, but it’s most notably associated with a viral infection such as that which occurs with a common cold. it is sort of a widely used term for facial paralysis, but it really should be used as a focus term for that particular condition where we just don’t know why the paralysis has occurred. The causes of facial paralysis can be many. Patients can be born with it or have the congenital types and there are various syndromes and conditions that go along with that such as Moebius Syndrome. Or they can have a traumatic incident later in life, such as in a car accident or an injury of or laceration to the nerve itself. Other causes can include more rare phenomenon such as a brain tumor or an arterial venous malformation in the brain that can compress a very critical part of the brainstem itself where the nerve originates. There are many more causes of facial paralysis, and it’s important for the clinician to diagnose and differentiate what it is that’s causing the actual paralysis because the treatments are then, tailored based on that particular diagnosis.
Bell’s Palsy is the most common cause of facial paralysis. It can affect virtually anyone, but typically tends to cluster around, patients roughly in their early twenties, thirties, and sometimes up to 60 years of age. There is no predilection for male or female, young or old, healthy or not. And, this is a very important feature of bell’s Palsy. It can happen in virtually anyone.
There are a number of risks associated with facial paralysis. It’s not just limited to the cosmetic appearance of an individual who’s been affected. Many times when people are unable to control the facial nerve or the facial muscles, they have an inability, for example, to close their eyes. When an individual cannot close their eyes, they’re at risk of drying the eye or causing an irreversible scarring of the eye itself. And this can lead to blindness. Some of the other risks of facial paralysis include the quality of speech. So if an individual is affected by facial paralysis, they can potentially slur their speech, their articulation is affected, they may be difficult to understand, and this can cause a lot of psychological distress for a patient.
Early intervention is critical for facial paralysis. It’s important that patients seek medical attention right away. More so for the reason of distinguishing the source of the facial paralysis from a benign cause to something such as a stroke or a tumor that can have more life threatening consequences.
Once diagnosed with facial paralysis and the appropriate tests have been done to rule out any of the other life threatening causes of the condition, your next step will be to seek counseling by facial nerve or facial paralysis specialist. The main role of the facial paralysis specialist is to establish the time course of treatment. In other words, when did the facial paralysis first occur? Is it getting better? Is it getting worse? And then to decide whether or not someone has not achieved maximal recovery and is thus a candidate for surgery. Sometimes the early medical advice given to patients is to simply wait out the facial paralysis, let it recover on its own. Although that might be true in the majority of cases, it’s very important to seek counseling by a facial paralysis specialist. And the reason for that is that there are certain early lines of treatment that can be instituted to get facial nerve recovery in a much more expedient fashion.
When someone presents with facial paralysis, it’s not always necessary to get a battery of tests. It is important, however, to get the tests that are responsible for removing certain diagnoses from the list, such as a stroke or a brain tumor. These are very important things to rule out. However, when someone is trying to figure out, well, is this a patient who will benefit from one type of surgery versus another, then certain tests are possible to help determine if that patient is a good candidate. Things such as a nerve conduction study or an electromyogram, also known as an EMG can be performed to really assess what is it that’s going on between the facial nerve and its input into the facial muscles and how well that relationship exists.
It’s important for the clinician or the specialist to really focus in on that patient and follow the trajectory down the road. In other words, do we see a continued improvement? Do we plateau on our improvement? Or is it just getting worse? And in those each have a bearing on what type of treatment is required, what type of prognosis is involved and more specifically, when is it the time to do surgery? When monitoring a person for facial paralysis, it’s important to understand when that facial paralysis occurred. Is it in the early period, which is somewhere between 12 to 18 months since the time of the paralysis? Or does it fall into the later category, which is sometimes 18 months or longer? Depending on what category that patient presents in, will determine whether surgery is required or not. When patients start experiencing the symptoms of facial paralysis, it’s important that they seek medical attention right away, whether it’s the emergency room or their primary care doctor. There are a series of tests that may need to be run to understand what is the cause of the facial paralysis to rule out more of the life threatening problems. And then based upon that, they can then present to a specialist who can then further refine their treatment.
If someone presents with facial paralysis, it’s important that they get to the clinician right away. There are certain early treatments that are possible in those instances to correct the problem. If someone has missed that opportunity, then problems can arise in terms of protecting the, for instance, with the inability to close the eyes. So drying of the eyes is a very big problem. If someone does not get to a clinician in time, you can miss a potentially more life threatening problem, such as a stroke or a brain tumor. When a patient experiences facial paralysis, it’s important to get in to the specialist right away. The reason for that is that there are some interventions that can be done early to correct the problem or sometimes late. So, for example, in the setting of Bell’s Palsy, much of the early treatment involves administering oral steroids and antiviral medications to overcome, the inflammatory source of the problem.
When someone comes in for a consultation in our office, they are typically greeted by our patient coordinator and the consultation then takes place. The consultation can be anywhere from 45 minutes to over an hour in the typical case. And the reason for that is to really understand what the problem is at hand. I very much believe in spending the time to not only get to know my patients because that is a very important part of establishing trust, but also to really understand what the patient’s desires are, whether it’s a cosmetic patient or if it’s something related to a complex reconstructive problem, which I also do see. We, then, go through a proper exam at that time and, uh, come up with an extensive and comprehensive plan in terms of what it is that treatment will require. Sometimes that requires surgery, sometimes it requires different treatments or therapies that don’t necessarily require a trip to the operating room.
When patients come to my office, they can expect a very custom approach to their treatment. I never reapply one treatment across the board for a similar problem. Everyone is an individual and everyone deserves a custom made plan. With that said, it’s very important to be able to execute the plan or plastic surgical procedure to the highest degree. And that is one thing that I always pride myself on in terms of the skill required to achieve that result. In on another level, and similarly speaking, we always want to make sure that we’re at the cutting edge, we’re offering the state of the art treatments available. I participate frequently in research activities and in constantly refining the techniques are available currently in plastic surgery and building upon the fundamentals that drive the practice of plastic surgery.
In some instances of your facial paralysis specialist may recommend physical therapy or something called occupational therapy to help strengthen the innovation and the muscles of the face. That can include mostly things such as mirror exercises or something called mime therapy to really try to force certain facial expressions to take place and strengthen that connection in the brain.
Although many cases of facial paralysis are curable, there’s a subset that will need intervention down the road. For those patients, we categorize them as early or late, and that really has to do with the time from which that paralysis set in. So for example, if a paralysis has been ongoing for a year or more, we may be out of the early period and entering a later phase. That has a large bearing on what type of treatments that we’re going to offer that particular patient. The longer you wait, the more surgery is going to be an option for you.
One of the techniques for reanimating someone’s smile after facial paralysis is using a muscle from the thigh called the Gracilis. We transplant that muscle into the face and reconnect it to the structures that were initially used for smiling.
One of the surgical procedures that I perform for the purposes of smile reanimation is something called the Lengthening Temporalis Myoplasty. What that involves is moving one of the biting muscles or chewing muscles, which is located on the side of the head, down through the face and reconnecting it to the corner of the mouth. And by way of that, we are really sort of repurposing the temporalis muscle itself to trigger it only for the purposes of smiling. The effect of the procedure is that smiling is restored when someone goes to bite initially. And that’s an important aspect of the expectations of the patient postoperatively. They need to know that when they actually want to bite, they will trigger their smile on that side of the face. The physical therapist’s role in this setting is to retrain that muscle for the purposes of only smiling, and that may take several weeks or that may take several months to accomplish that.
In the procedure, we’re actually taking a biting muscle and we’re using it for the purposes of smiling. The reason for that is because the facial nerve that’s responsible for smiling is no longer working. The secondary question is, is that going to affect my bite? And the answer is no. There’s typically three other muscles that do essentially the same biting function. So basically what we’re doing is retraining a muscle that’s used for biting for the purposes of smiling. Depending upon the type of procedure being performed, it can take anywhere between six to eight hours to perform the procedure. And in many cases, for example, with the lengthening Temporalis Myoplasty, you can expect to go home the same day.
When patients are deemed candidates for facial reanimation surgery, there’s really no other preparation that is required. They simply will show up on the day of surgery and will proceed with one of the surgical options that was discussed during the consultation.
In many instances, facial paralysis, will take care of itself. However, in some instances where a person is deemed for surgery, we don’t categorize that as a curable condition. We are trying to fix the problem instead and that involves a surgical procedure of some type, whether it’s a nerve transfer or a muscle transfer to achieve that goal. There are many options for surgery available for facial paralysis patients and a lot of it has to do with where that patient falls. Are they in the early boat, which is up to 12 to 18 months after paralysis or sometime later than that, In individuals who are in the late category, which many are when they present to a facial paralysis specialist, it’s usually a movement of muscle that is required. In other words, we have to borrow a piece of muscle from one part of the body and move it into the location for the purposes of reanimating the face. One of the areas that we focus in on and facial reanimation surgery is the smile. The smile is an incredibly important function of the muscles of facial expression. And when we lose it is when we really see some of the psychological stigmata of facial paralysis. When we decide that a patient is a candidate for surgery, there’s really no other preparation that is needed. Patients are expected to fast the night before. The surgery itself, it requires a general anesthetic and in many cases, the surgery’s an outpatient procedure. On the day of surgery, you’ll arrive at the surgery center and you will have been fasting the night before. The anesthesiologist will interview you and you will be taken to the operating room where you will receive general anesthesia. The surgery can be expected to last anywhere between six to eight hours, depending on the actual procedure being performed. In some cases, you’ll be allowed to go home the same day. And in other cases, you may need to stay in the hospital for anywhere between one to three nights.
The post-operative expectations are actually a very important part of any plastic surgical procedure. It’s important that patients understand what it is that they’re getting into when they agree to having a procedure done. In other words, what do things look like is a very big question in plastic surgery. And I spent a lot of time talking to patients about that to help them understand that there are certain things that are possible with plastic surgery, but within reason. And I find that many patients lack that ability to discern what it is that they see out there in the press and in the media and what is actually medically possible. So it is important part that I always emphasize during the consultation preoperatively as to what is the possibilities and expectations afterwards. And in most cases, we meet those expectations. And that’s a very important part of plastic surgery is to actually hit the point and make patients happy.
Every surgery is different and you really should consult with your facial paralysis specialist regarding the recovery involved. In many cases, facial nerve recovery happens on its own and it’s very quick. However, in a certain subset of patients that can be a very prolonged process. Unfortunately, there’s no early intervention that is going to expedite the process of reinnervation or regeneration of that facial nerve. The recovery after surgery can vary depending on the procedure that was performed. For instance, the Temporalis myoplasty, patients typically have some swelling afterwards that usually resolves in one to two weeks, and then therapy is initiated at about three weeks following the surgery. Every patient with facial paralysis is going to have a different recovery period. Some may take one to two weeks, others can take up to a year or longer. The decision to proceed with any line of treatment is really guided by the facial paralysis specialist. That can include things like therapy or surgery, and the timing of that will be determined by that specialist.
My name is Dr. Andre Panossian and I’m a board certified plastic surgeon practicing in Los Angeles, California. One of the expertise that I have is in the treatment of facial paralysis patients. In our office we see everything from the typical cosmetic patient from rhinoplasties to body contouring, all the way up to the very complex reconstructive problems such as patients dealing with facial paralysis another condition called neurofibromatosis. And in more and in more specific terms, we also focus in on pediatric patients quite a bit. Patients with cleft lips and palates, patients with vascular anomalies, or vascular birthmarks that can be quite disfiguring. So there’s a variety of conditions that I treat in my particular practice that distinguishes my practice from others in this particular area.
My expertise of plastic surgery is not just limited to the traditional cosmetic patient, although that is a big part of what I do. One of the areas in plastic surgery that drove me to the profession was actual complex reconstructive problems that come up. Most specifically I treat patients with facial paralysis. This can be a very troubling problem in many patients and it’s often and historically been an incurable problem. So patients have often been told to just live with it. And this is an important area that I focused my particular practice and direction in terms of trying to really get at the cutting edge, really refined techniques to help people return to some level of symmetry of the face. And this is a dynamic symmetry. In other words, smiling is not in one position. It occurs in rest and in activation. Same with eye closure or forehead elevation. These are the things that are affected in facial paralysis. Other areas of expertise include the relatively unknown condition known as neurofibromatosis. And neurofibromatosis is a genetic disorder that can affect patients at birth. And what happens in neurofibromatosis is that nerve tumors develop around virtually any nerve in the body, and some of these can be quite disfiguring. What my practice focuses in on is the removal of these tumors and also in the reconstruction of the physical disfigurement that some of these tumors can cause. One of my other focuses is the area of pediatric reconstructive surgery. This is an area that is quite challenging and can include everything from birth defects, things like cleft lip and palate to really rare tumors. And in fact, other things such as large birthmarks, vascular birthmarks, which can be quite difficult to address in any other way, but with surgery.
Moebius Syndrome is one of the conditions that can result in facial paralysis. Now, this is a rare condition that can affect virtually anyone and there’s no real genetic source for why this ever happens. However, when it happens, there is a distinct set of features that occur. One of the features is actually facial paralysis. The facial nerve never develops from the brainstem along with another nerve called the sixth cranial nerve responsible for some eye movements. What results is a person who has no facial nerve and it’s usually occurring on both sides of the face. So these patients have no movement whatsoever in the face. They look as though they have a mask-like appearance.
Bell’s Palsy occurs in roughly 40,000 Americans every year. This is the result of an inflammatory process that affects the facial nerve, which causes a shutdown of the facial muscles. Many times Bell’s Palsy recovers on its own, and this is a fortunate side of this particular condition. However, roughly one third of patients will continue to suffer some level of facial weakness, asymmetry or full blown paralysis, and that can be sustained down the road.
Facial paralysis involves the loss of movement of the muscles of facial expression. So what that means is that a person cannot smile, the face droops, there’s an asymmetry that results, and this all stems from an inflammation or a dysfunction of the facial nerve itself. So if the facial nerves dot working, it’s not sending a signal to those muscles of facial expression, and then you get the paralysis or drooping of the face.
Sometimes Bell’s Palsy is a term used to describe facial paralysis in general, but it most specifically refers to this condition that involves the inflammation of the facial nerve. That inflammation is sometimes centered on some sort of a viral illness such as the common cold.
If patients are experiencing symptoms of facial paralysis, whether it’s Bell’s Palsy or another source, it is imperative that they seek medical attention right away. Whether it’s through the emergency room or their primary care doctor, it is important to work that up further because the symptoms do in fact overlap on other more serious conditions such as a stroke or a brain tumor. Symptoms of facial paralysis result from the inability of the muscles of facial expression to do their job. Things such as raising your eyebrows, closing your eyes and protecting the eyes themselves. Smiling. These are very critical functions of the facial muscles of expression. When they are lost other symptoms can occur. Things such as drooling, slurred speech, facial drooping, asymmetry, the cosmetic problems that go along with it and the inability to smile. These have a profound effect on patients. They have a very strong underlying psychosocial strain that results. Facial paralysis can present in a number of ways. Most often it’s a pretty sudden or a very specific time point when that occurs. However, in certain cases, for example, if there’s a tumor gradually growing and pressing on the facial nerve itself, this can result in initial weakness and ultimately a full blown paralysis if it is severe enough or not caught in time.
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