Health and Disease informationParalysis

Facial Paralysis and Restoring Movement

Thank you very much. It’s my honor to join you. Thank you all for coming. I’m very excited to share with you something I’m very passionate about, which is the treatment of facial paralysis. And as was already stated in abundance, this is something that I was brought here to launch. And we’ve made incredible progress with a very strong, multi-disciplinary team. And I’m going to tell you all about that. As in any academic talk, we state our disclosures or conflicts of interest. I have none. Before embarking on a discussion of the basics of facial paralysis, what I treat, what treatments we offer as a team, I would just like to start with a heartfelt thank you to our patients.

Our patients are our ambassadors, and some of them were kind enough to allow me to share images of their face so that you can understand the disorder of facial paralysis and also the treatment of it. So we owe them thanks. So the basics of facial paralysis. This is something that you can understand quite simply with a visual image, and I have a nice illustration here of it. When I am talking about facial paralysis today, what I am referring to is mostly a single side of the face affected, although one can have bilateral, or both sides of the face, affected. Most commonly, this is affecting one side of the face. The most common cause, fortunately, is something called Bell’s palsy. Bell’s palsy is due to a virus that inflames the nerve and the tissues around it. And Bell’s palsy most often resolves. That’s why I said it’s fortunately the most common cause.

But there are a subset, a small group, of patients that don’t recover from Bell’s palsy that may seek treatment with someone like me. So surgeons like myself may evaluate a patient with paralysis or weakness usually from something aside from Bell’s palsy, maybe for a tumor, trauma, something else that has caused maybe a more significant injury to the facial nerve from which it cannot recover. The nerve that moves the muscles of our face does regenerate. It does regrow. But it may not do so completely or effectively, and that may prompt someone to see a facial reanimation surgeon like myself. So facial paralysis, just to completely set the table for our chat, is a really fundamental impact on a patient’s quality of life. So you can imagine that not moving one side of your face would profoundly impact how you express emotion and how people interact with you.

But it actually goes far, far beyond that. It impairs some really critical functions of the face that are not just about appearance. You cannot properly close your eye. That can lead to drying of the outer layer of the eye, which is called the cornea. The lower eyelid can droop and sag, further drying the outer layers of the eye. The eyebrow can droop such that it can obstruct the vision of the patient. Of course, kind of the telltale sign that’s being shown in the illustration here is that when fully smiling, the smile is very asymmetric. But beyond that, food and drink may leak from the corner of the mouth. So there are appearance issues, communication issues, but also just issues of normal, daily function that are profoundly impacted by facial paralysis. And some portions of our speech require that our lips come together in certain ways.

We call that bilabial speech. Those sounds are very much affected by facial paralysis. So the treatment of a facial paralysis, just in terms of the conceptual treatments of what is offered, really go into two broad categories. And I’ll go into a lot of detail about what these specifically are. But on the one hand, we have rehabilitative treatments and non-surgical treatments. These are ways of relearning or retraining some movement that persists in the face. Alternatively, there are some non-surgical treatments that can be offered in clinic that can be very helpful as well.

The other arm of treatment is surgical. And that’s when needed, when appropriate. That’s sought out by surgeons like myself, people who specialize in surgical treatment of the face and then, in my case, in the treatment of the paralyzed face. So before we launch into a description of the treatments and acknowledgment of the problem, which is dependent upon the setting in which it occurs– and so I would argue to you and all the attendees as residents, most likely, of Silicon Valley– the face has never been in this type of situation before.

Images of our face are more broadly and widely shared than ever. So I like to tell my patients that the impact of this disease is very much an evolving concept. We use images of our face more broadly than ever than any point in history. And so that makes, I think, effective, multi-disciplinary treatment a particularly important aspect of what we offer here. And so who is this team? And so I’m going to show you some names, and then I’ll show you some faces. But broadly stated, we are the Stanford Facial Nerve Center, and we are here to provide comprehensive, multi-disciplinary care for facial paralysis. There’s facial reanimation surgery provided by myself.

But there’s much more than just surgical treatment. We have a world-class rehabilitation specialist who is also a speech and language pathologist. Her name is Sarah Strandberg. Critically, we offer some dedicated nursing care to help coordinate what can be a multipoint, kind of sequenced and nuance and sometimes frustrating– if someone has to see a lot of practitioners, having a nurse coordinator to help tie together all of the components of care is critical to what we offer. We have world-class neurotologists, such as Dr. Rob Jackler. They are surgical partners that enable us to do some very unique things in terms of surgery but also diagnostic partners, helping us to figure out and craft excellent treatment plans for our patients. We have dedicated eye surgeons, such as my colleague, Dr. Andrea Kossler, and then specialized neurologists, such as Dr. Sakamuri, who perform neurodiagnostic testing as well as performing some functions as a neurologist, helping us sort through diagnoses that may be neurologically kind of rare. She also performs some specialized testing that allows us to give prognosis as to the likelihood of recovery, which is critical.

And these are not things that happen all in necessarily disparate parts and places. We convene together once a month for a facial nerve conference, which we join together and discuss new cases, discuss our ongoing patients, and work together as a team to really craft a treatment plan that I think is world class. And I think this is a testament to everyone’s personal investment in treating patients with facial paralysis that we actually physically work together. So you can see in the top left, Sarah Strandberg there is doing some rehabilitation with our patients. Andrea Kossler is shown in the top right. And then we get together around a big table, as you might imagine. And we review images. We review video of patients, clinical histories, and craft a multi-disciplinary treatment plan, which is really something that distinguishes what we do here at Stanford. And because of that, we are excited, for the first time, in August of 2019, to host the first ever symposium dedicated to facial nerve treatment here at Stanford.

And so we’ll be in a way that faces community practitioners and other people who treat facial nerve disorders, allowing them to come in and learn along with us and share knowledge. And so we’re very much looking forward to that. If we were to pick, I think, as a group– and I know for me, personally, as both an otolaryngologist and a facial plastic surgeon, what is kind of the soul of this problem, what is the core issue? It is this. In one sentence, it is that facial paralysis is a disorder of communication.

And that is because communication is not just the sounds of speech, although facial paralysis does affect some of those. It is because communication relies on so many nonverbal cues. So many of the ways that we posture and frame the things that we say are directly dependent upon the obedient movement of the muscles of our face. And when we lose that, we lose the ability to, quite frankly, communicate normally. So how have we assessed this and proven this? And so I’m just going to take a quick segue into some data, and then we’ll go back to some pictures. And it will be something I think that you will all enjoy. But we actually give our patients a survey of how willing they are to communicate in different public settings in light of the fact that they have facial paralysis. You can have any disorder or disease and have it impact your willingness to communicate. So this is not specific for facial paralysis. It just measures, how much are you impacted in terms of your willingness to publicly communicate because of any diagnosis that you carry? So when we have looked at large groups of our patients– I know this is a bit of a busy slide, but we can compare the impact of facial paralysis to other diseases.

Pardon a little bit of the abbreviations and whatnot. But the scores that you see are better the higher they are in the chart, and the worse they are, they’re lower on the chart. So our patients with facial paralysis, they actually score as impaired as people who have cancer of the head and neck, even equivalently to people who have had their voice box surgically removed. And that’s a fundamental and eye-opening fact that, of course, the impact on communication is subjective. But it is so potent, and it is such a powerful impact on our patients. And I think these types of assessments really underscore that that original statement of the communication aspect of this disease is quite real. And so without further ado, I would like to quickly transition into, what are some surgical treatments that we offer? Because as a surgeon, that is really my role.

That is why I was brought here. And so the broad title for surgical treatments that are used to restore symmetry and improve the movement of the face is facial reanimation surgery, meaning that we are going to be, as our goal, making the face move again. Before discussing the specific techniques– and we’ll do them kind of broadly and conceptually– I have to give a nod to the fact that I am trained as an aesthetic surgeon. So a portion of my practice is and always will be doing some aesthetic surgery– rhinoplasties, blepharoplasty, and facelifts. But those principles are actually a very important foundation for facial reanimation surgery insofar as everything is geared towards being as minimally invasive as possible. We try to hide incisions for facial reanimation surgery exactly as we would hide incisions for facelift surgery. So those principles are really the core kind of bedrock that we use to reach out and to reanimate the face. So the very simplified treatment plan for someone who comes to see me with complete facial paralysis– this is someone who has no movement on the side of their face and, after appropriate assessment, is deemed to be highly unlikely or will not recover movement.

Perhaps the nerve is definitively injured or definitively cut. So then the branch point of what type of treatment I recommend depends wholly upon how long it has been, the duration of paralysis. So in general, if it has been less than two years, I find a treatment modality that is called nerve transfer surgery to be the most effective means of reanimating the face. And so now, we’ll talk a little bit about what it means to perform a nerve transfer surgery, and what are those? Nerve transfer surgery is, in essence, sacrificing a donor nerve in the head and neck region to resupply the paralyzed facial nerve. So what you’re doing is you’re either partially or completely cutting a nerve that performs a different function, connecting it to the facial nerve so that the patient can use that other function to initiate a smile or to restore some symmetry to the face. So this is a patient who underwent something called a dual nerve transfer. This is a surgery that is unique and performed kind of in a unique way here at Stanford.

And this is her six-month post-operative result. It’s about 6 and 1/2 months after surgery. As always, the video is much more revealing than a still photo. And I think this is where it’s kind of pausing. There is no perfect treatment for facial paralysis. There is no treatment that completely restores perfect symmetry and perfect movement. But we can make it better and improve upon that. This is another patient who had a similar procedure, a nerve transfer. These patients are initiating a very nice smile. They are doing so by biting down. And I’ll show you exactly which nerve is used to do that, but we are sacrificing a bit of function. And when the patients want to smile, they bite.

So it does require some rehabilitation and retraining. But overall, at least in my hands, it leads to the best results in terms of smile. So in general, I find it helpful to look at the images first but then to diagram it out. What are we doing in this case? So we are, in a very targeted fashion, using a facelift surgery, retrieving a nerve that innervates your masseter muscle, which is the bulky chewing muscle that when you bite down, it pops out kind of at the corner of your jaw. There’s a very fine nerve that goes just over the jawbone and into the muscle and enervates it.

With a facelift approach, we can identify it, cut a branch of the muscle, move it over towards the portion of the face that is paralyzed, and we connect it to the portion of the facial nerve that initiates a smile. So that is the essence of how the surgery works is we are partially sacrificing the masseteric nerve or the nerve that goes to this masseter muscle. We’re connecting it to the portion of the face that produces a smile so that patients can bite down and then initiate a smile. And in my opinion, it is the most effective and most natural-looking smile. The clear disadvantage of this is you have to think about it. You have to think, I’m going to bite now, in order to smile. It requires retraining and practice. But because it provides new nerve input to the facial nerve and, thereby, the actual muscles of the face, the smile can be the most impressive of the reanimation surgeries. And this is another patient of mine who has a right-sided, from his perspective, facial paralysis and has undergone a nerve to masseter surgery and is then biting and using that as a means of initiating a smile.

So as you can see, it doesn’t make for perfect symmetry. But it does make for significant improvement. There are a variety of other means. And so I’ll just talk about one. There’s another nerve that is in the neighborhood, if you will. It is the hypoglossal nerve, or the nerve that helps you protrude your tongue. And so with my heavy emphasis on the importance of communication, causing any potential damage to something that moves your tongue would be a huge issue for someone who, like me, is an otolaryngologist. And so this surgery must be done in a very specific way. It is done with, under a microscope, a partial cut in the side of the nerve such that there is no tongue weakness– no permanent tongue weakness. This allows nerve fibers to regrow into the facial nerve. And this is a good source of, if you will, tone to the face. This is not a good means of getting someone to smile again.

It’s proven to be relatively ineffective for that. But it can be something that gives the face a more general kind of symmetric tone. And so this is a patient of mine who has had this procedure done. You can see, on your left, she has facial paralysis on her left side. And this is about 13 months after a hypoglossal nerve transfer. It makes for nice symmetry at rest but, really, no smile. So one of the things that we’ve done and been kind of on the leading edge is to take a reasonable step forward and find a means of combining these two surgeries together. And so working as a multi-disciplinary team with skull-based surgeons and myself as a facial plastic surgeon, we offer these types of procedures together to try to give patients the benefits of both.

And so as I said, everything, the emphasis is on minimally invasive. So we want to be able to access all of these nerves with minimal incisions or incisions that are extremely well hidden. So we use the ear and the hairline and the shadows of the jaw as means of camouflaging incisions and giving them an easy spot where they can heal up but not show easily to the front of the face. From that point– yeah, question? Are you going through the skull to do that? Through the mastoid bone, which is the bone that’s right behind the ears. So the incisions are actually very accurately drawn here.

This limb, that dotted line, is going behind the ear. That’s right. And it can be successfully used in somebody who has had a prior skull-based surgery. But depending on the surgery, it might not be something that we would employ. But it has been successfully used in that situation. So that incision behind the ear allows my neurotology colleagues to essentially fish out the facial nerve within the base of the skull to give me adequate length to connect it to the nerve to the tongue to supply some tone at rest.

And then I go on through a dissection area that’s about the size of a nickel, using a microscope to get down to the nerve to masseter to retrieve it in a very targeted fashion and connect it to a portion of the facial nerve to restore a smile. And that, in fact, is what this patient has had done previously. So I think, in my opinion, this does offer some pretty impressive results. And so I think that nerve transfer for facial paralysis, at least in my hands, offers a superior result compared to some other treatments. And we’ve looked at her video just recently. And that was when she was just 6 and 1/2 months post-op, and she’s returned at about a year post-op. This is a photograph of her and I in clinic. And so I have been satisfied with the results of that surgery, but it is a little bit early.

It is a new procedure relative to others. So what about patients that present and are greater than two years from paralysis? We have to think about the treatments differently. The reason for that is very complex. But if a nerve in any part of the body is injured, it can be a recipient for new nerve fibers to regrow.

The facial nerve, like other nerves in the periphery of the body– not so much like the brain, but like other nerves in kind of our peripheral nervous system– it will regrow. With time, however, the nerve begins to scar shut. And so you cannot connect it to a donor nerve no matter how viable that nerve may be. A nerve transfer will no longer work or will be incompletely effective. So in that case, we have to have a substitute procedure. And there are ready and well-described procedures that can resuspend the corner of the mouth even in this case, if it’s been more than two years since the onset of paralysis.

The general theme here is that we need to bring either new muscle or new muscle and new nerve together up to the face. We cannot just directly connect into the facial nerve any longer. It has essentially scarred shut. But there are still treatments that we can offer. And so one of the workhorse procedures for this that has been around for a long time and was invented in the 1970s, actually, is something called the gracilis free muscle transfer. And in this procedure, a muscle is harvested from the inner thigh. It is used because it’s a muscle that’s familiar to reconstructive surgeons. It also can be sacrificed with very little to no deficit. I just talked to one of my patients this past week who is a professional mixed martial artist, and he was reporting that, I think, now, four months after surgery, he ran six miles. But he didn’t tell me that.

He told me after he did it. So people actually can train quite heavily after losing a little segment of muscle in the leg, partially because we have a lot of redundant musculature in this area that helps with leg stabilization. But it is still a loss of a small slip of muscle from the inner thigh. This is then transplanted, if you will, meaning disconnected from its blood vessels and its nerve supply, and brought up into the face and used to suspend the corner of the mouth. So this is a gracilis free tissue transfer for facial paralysis. It then needs to be connected to a new nerve supply. And in my hands, in my opinion, I usually use the masseteric nerve– so again, using a biting means of initiating a smile. And that can reliably restore elevation to the corner of the mouth. The chief downside, in my opinion, is the additional bulk that the muscle requires. You are bringing up a muscle that’s from the thigh. And I do, these days, thin it quite aggressively to make for a little bit less bulk than that.

But the reality is you’re bringing mass into the face where there was none before, and so it does add some bulk to the face. And that is its kind of chief Achilles’ heel. But you can see a pretty prominent cheek bowl right there and then also a little bit of regularity when the dimpling that occurs during a smile– it doesn’t have a perfect vector of movement, meaning the direction of movement.

It’s a slightly bulkier muscle. All of those, I think, being somewhat downsides of the procedure. However, they can be mitigated through a really careful surgical technique. That surgery does take roughly seven or eight hours to complete. It can take six, seven, eight hours. And it may require a hospital stay afterwards. So for some patients, they’re not very enthusiastic about that. Many patients with facial paralysis are going about their business of their daily life with the exception being the facial paralysis. So sometimes, something that they may deem more of a major surgery does not really resonate with them. So they want to know if there are any shorter surgical procedures that can accomplish a similar goal. And there are. There are, again, well-described procedures. This is something called a temporalis tendon transfer.

And this is the same concept of essentially taking something that can be sacrificed and using it to move the corner of the mouth. This is harnessing the muscle on the side of the head that you can feel when you chew, such as when you chew gum. This is a muscle called the temporalis muscle. It goes from broadly originating on the side of your head to inserting on the very tip of the jawbone, which you can see right here. And it can be gently separated from the jawbone and then used to resuspend the corner of the mouth. That gives the corner of the mouth better positioning. It also enables the patient to chew to smile, very similar to biting to smile. But you’re initiating another muscle group in the efforts to elevate the corner of the mouth to produce a smile. So this is a sample of a patient of mine who had that procedure. Play. And this is her with paralysis on your left, and this is her actually just three weeks after the surgery.

She doesn’t have a lot of swelling at this point. Sometimes, people have a little bit more swelling. But it can give you a little bit more of an immediate improvement. But I think the Achilles heel of this procedure, at least in my hands, is it does not adequately address the lower lip. As you can see, there’s still some asymmetry of the lower lip, and you have to address that through other means. So I tell my patients that there’s either things that we can try to add to the surgery to make it a bit better. But in my hands, this is the Achilles’ heel of this procedure but still can give someone some meaningful correction with a surgery that is not as long of duration in comparison to a gracilis, or inner thigh muscle, free tissue transfer. OK. I’m going to shift gears and talk about something that is not outright facial paralysis. But this is something that affects a majority of people who have facial paralysis, because many people are going to recover some function.

So broadly, if you take the number of patients in the United States who experience facial paralysis in a given year, more of them will end up with this than complete immobile facial paralysis. They will end up with sort of a mismatch of movement of the face. And it’s a disorder called synkinesis. And what this means is you’re trying to move one specific part of your face. And when you make that effort, other parts of your face move at the same time. So synkinesis is movement simultaneously. But it is unwanted, and it can be quite troublesome and quite bothersome. So patients who come to see me sometimes carry a diagnosis of facial paralysis. But in fact, that’s not true anymore. They have something that is more of a discoordinated or uncoordinated movements of the muscles of the face. And the reason for it is essentially a cross wiring of the nerve itself. So the nerve sustained some type of injury, and then it regrew.

But it regrew to the wrong targets. So what I will explain to my patients is that a portion of the nerve used to go to the corner of the mouth to help you elevate the corner of the mouth. After injury, there was regrowth. And now, that same nerve fiber goes to the eye and forcefully closes the eye when you attempt to smile. But it is not just that pattern. It can be any pattern of any pair of muscles on the face. So it is quite a nuanced disorder to treat. It’s something that has to be, I think, treated in a very orderly, stepwise fashion. And this is where I think we really shine as a multi-disciplinary treatment team, because we offer something, I think, on every step of the potential treatment ladder. There is an option of high quality for our patients here.

So what exactly is that? So for treatment of facial paralysis, the first step for most patients is intensive work with a specialized rehabilitation specialist. And so that’s someone who can offer facial retraining exercises to help mitigate or lessen unwanted movements of the face. Because the face is showing a tendency to spasm, patients can sometimes develop patterns of trying to overcome the spasm that actually can make it a bit worse.

So by trying to work through it, they try harder and make some of the spasms even more profound and even more strong. And so working with somebody like Sarah Strandberg, who’s shown here, can yield an immense benefit and an immense improvement. And so that’s usually first-line treatment. Second-line treatment are things that would fall under my domain, which is treatment with botulinum toxin to temporarily eliminate contraction from muscles that are contracting in an unwanted fashion and then using other treatment techniques, such as hyaluronic filler, which is a non-FDA-approved use of the filler for some of these products but adding volume to some areas where it may be lacking.

It can be actually a very helpful thing, for instance, helping people close their lips together more effectively. We’ll talk more about that. And then, really, time-tested, age-old techniques, such as facelifts and brow lifts, can be very helpful not only for resuspending a face that maybe is drooping from paralysis but also using that as a means of accessing the muscles that are functioning poorly and then perhaps diminishing their function in a targeted fashion. I’ll discuss that more. But again, rehabilitation is really the core and the first step. It’s not only the appropriate initial treatment. It offers me, as a surgeon, invaluable information about exactly where the dysfunction is. And it also tells me, how good can the patient get with no surgery at all, which is, I think, the first thing that people want when they come and seek treatment. They don’t necessarily come in wanting to undergo a surgery. So just a bit about this, and this is from the perspective of Sarah, my partner, who sees patients along with me.

We have some dedicated combination clinics so that we can really provide an amazing multi-disciplinary experience for patients. So these are her words that I’m sharing with you. This is a highly individualized form of rehabilitation, and there’s really an intensive focus on education, trying to identify patterns of movement that just aren’t working and trying to dampen those or extinguish those so that the patient can have more functional facial movement but also maybe a little bit more facial comfort. Some of these spasms can be a little bit uncomfortable, can make the face feel extremely tight. And so adequate rehabilitation is actually helpful not only for the appearance of the face, but for the patients’ subjective experience of their own facial movement. There are other, I think, really helpful critical additions that Sarah adds on, particularly with her expertise as a speech pathologist.

Because many patients suffer, as I showed you, from disorders of communication and even difficulty keeping liquids or solids in the mouth. And she can offer them strategies on how to work around that and work around it quite effectively. So her expertise is really critical in handling what is a very stubborn problem of synkinesis. So then the patient may, if needed, transition to treatment with me for botulinum toxin. So that’s an injection of a medication that is designed over a three-month period to temporarily paralyze a muscle. But it can do so in a therapeutic fashion, and I’ll show you what I mean by that.

This is from a publication from a few years ago I published with my one of my mentors, Dr. Jennifer Kim. And so this is showing a patient who has undergone injections of botulinum toxin in certain muscles of the face that, when she’s attempting to smile, are causing unwanted contractions and unwanted movement of the face. You can see it before on the left.

And then after, by temporarily paralyzing through the use of botulinum toxin, it can actually offer a really great relief not only in terms of improving the symmetric smile or improving the overall symmetry of the face, but just dampening down what can be very powerful contractions of the muscles of the face. There is an additional, very important benefit to this treatment. It’s a treatment, but it is also powerful diagnosis.

It tells us turning off certain groups of muscles is therapeutic for this patient. So it is proof positive that if we turn off this muscle, it helps this patient. So it’s very instructive to me as a surgeon. And why is that? That is because some of the time-tested, age-old techniques, like a facelift, can be used for a unique dual purpose. During a facelift, really, the general thrust of a facelift is repositioning this broad muscle on the neck. It’s called the platysma muscle. But it’s responsible for some of the redundancy that we’ll see underneath our chins, and so repositioning this muscle is just a fundamental part of a routine facelift. We can use that as a point of access for a targeted cut in the muscle, also clipping the nerve that goes to the muscle, so permanently Botoxing, if you will, the muscle through a facelift approach.

So these are things that we can add in multidisciplinary fashion, finding the right kind of offending muscle, identifying that this is therapeutic when we turn it off, and then transitioning that to a surgical treatment to hopefully give patients a little bit more long-lasting effect. If people are satisfied with Botox every three months, they’re more than welcome to keep doing it. But this is a nice kind of endpoint for patients who want to know, well, what else could be offered here? Because coming in every three months for injections, it obviously can be a bit of a drag. It demands quite a lot of medical care visits, et cetera. So that’s an example of something that we can offer.

And this is an example of one of my patients who kindly agreed to let me share her pictures with you and some video. But you can see that as she’s attempting to smile, she’s experiencing contractions in other regions of the face. So as you analyze the corner of the mouth on her right side, your left, you will notice that there’s an excessive amount of eye closure.

There’s also, if you look down at the neck, a kind of thick band of muscle there that she’s certainly not trying to contract, but it is doing so. When we do a facelift approach and a targeted and safe cut of the muscle in that area with a clip and cut of the nerve, that allows that muscle to relax. Some of the side benefits of that is she does not necessarily have to try as hard with her whole face for a given degree of movement. That can allow the face to feel a bit more comfortable, have less spasm, but also can diminish some of the other symptoms of synkinesis in other parts of the face. You can see that there is a little bit less of the eye closure and things of that nature just because less effort has to be exerted to overcome that spasmodic muscle.

And these patients, when we go to surgery, the thickness of that muscle is two or three times the thickness of a normal neck muscle. So it really has gotten too much nerve input. It is big. Just like a weightlifter’s muscle gets big from repetitive use, it gets large. And so it is a testament that this is a neuromuscular problem. And so you have to approach it in a way that respects that, that is a neuromuscular solution for a neuromuscular problem.

And this is just a bit of her video showing some of the movements on the left and on the right. Similarly, an endoscopic brow lift is a very commonly applied treatment for brows that begin to droop over the eyes. It’s endoscopic, because small access incisions that are all hidden in the hairline are used to insert an endoscope so that the surgeon can visualize the field of surgery, the field of dissection, and to release some of the muscles and ligaments that hold down the brow.

So just as I showed you the patient with synkinesis, that can be another means of access to provide some relief of synkinetic movement of the face. So this is a patient of mine who, in addition to noticing that synkinesis was tethering her brow down in a way that she didn’t like, we also identified muscles around the center of the eyebrow– this is a region of the face called the glabella. But these are kind of the frowning muscles. These are muscles that people will treat sometimes with botulinum toxin. However, during an endoscopic brow lift, these muscles are visualized and can be safely cut, just in the same way that I described with a facelift approach on the previous slide. And that can give that patient less frowning when she’s attempting to move completely disparate, completely different muscles of the face and also, of course, gives her a bit of a brow lift, as well, which is a good relief for their visual field and then gives better symmetry, because of course, we do the lift on both sides to try to leave the brows as symmetric as possible and also give a muscle release in the center of the brow area to diminish frowning when she’s trying to activate other muscles.

So one additional treatment that may also, on its surface, seem like an odd pairing for a facial paralysis or synkinesis treatment is the use of hyaluronic acid filler as a means of improving facial symmetry but also, critically, facial function. This is a study that was published by a Stanford practitioner, Heather Starmer, but it was published while she was at another institution. But it surprisingly shows that the injection of filler– so increasing the volume of the lips in patients with facial paralysis– actually improves the strength of the lip closure. So just by bulking up the lip, we’re actually able to get patients to close their lips more strongly, more effectively– and this is proven by increased strength as measured on something called the tensometer– but also improve their speech as assessed by both the patient and by the speech pathologist. So some of these treatments that may seem like they’re more aesthetic, to me, have a very profound functional impact on patients.

And so we pull out all of these tools in the armamentarium for patients as they deem fit and we deem fit to offer them through our consultations. But what I like to tell patients is that we have a lot of things to offer, and not all of them are reanimation surgery per se. There are a lot of minor modifications that can be made that, in my opinion, significantly increase patient quality of life. These techniques do rely heavily on aesthetic approaches and making things symmetric, making things minimally invasive. But I think that that is an excellent foundation from which to treat this disease in addition to the powerful nerve transfer surgeries and reanimation techniques that we offer. So I will close with that. I’m just going to leave the slide up of our symposium that we’re very, very much looking forward to.

I do have our website listed on the bottom right. Many of the treatments that I discussed are described in detail on our website, so please do feel free to visit it. It is a very helpful thing to review prior to a consultation for facial paralysis, whomever you may see. Also, if you did want to contact our clinic, the phone number is there on the bottom left. And so with that, I thank you very much for your time. It was my pleasure, and it would also be my pleasure to answer any questions that you may have.

[APPLAUSE] Yes? For the rehabilitation, I know you were talking about the synkinesis. Is there any point in doing any rehabilitation before there’s any movement or anything like acupuncture or some sort of workout for the face? That’s a great question and a very common one. And it has a long answer. So I’m going to apologize in advance. I’ll repeat the question, and it was, during complete paralysis, while waiting for recovery, is there any utility to doing facial retraining exercises or other treatments, such as acupuncture? Is that a pretty reasonable restating? So in general– I said it was going to be a long answer– but we like to start the retraining once there’s some movement. There are some things that can be offered, but I find that they’re not as impactful until there is some movement.

And then we can identify some abnormal movement. And that’s the clay that can be molded with an expert like Sarah. Also, the reality in which we live is that health care is a finite resource. And so many of our patients can get approved for rehabilitation but a certain number of visits, say, per year. That is a common thing faced by some of our patients. I don’t like to waste any of those very valuable visits until the impact is quite high.

There’s a second question that’s very important. What can I do to increase my odds of regenerating this nerve, right, of recuperating this function? So some things that you will see are acupuncture. You will also see electrical stimulation, amongst other types of treatments. You will see regenerative medicine type treatments, perhaps, even, offered for this. The reality is that none of those treatments has been able to stand up to a randomized, controlled trial confidently. So I usually tell that to patients first. I say, look, we don’t have definitive evidence that any of this stuff works. Particularly with acupuncture, though, some patients derive some other forms of benefit. They think that it improves their blood flow. There can be some symptom management with acupuncture application.

The reality is that things that we know work for facial paralysis, such as steroids given to a patient with Bell’s palsy– it took us studies of thousands of patients to definitively prove that. And so it’s a high bar, right? And so I add that in by saying there may be some benefit. We just can’t identify it. Electrical stimulation, which I know you didn’t ask about, but just to add my own, because I am asked that fairly frequently– that’s a bit more controversial, because there is some potential and some thought that it may be able to cause some harm. There are some animal studies that demonstrate that certain forms of electrical stimulation applied to the muscles of the face in the setting of facial paralysis in animals actually inhibits regeneration to those sites.

I think that electrical stimulation is actually a very broad form of potential therapy. It can depend on how much, in what fashion. And so it is not one thing. It is actually a very potentially variable treatment. So I usually tell people I don’t have good evidence that that works. Great question. Yes? Thanks for your excellent presentation. I’m curious about where computer simulation may offer help in the future. I’m very interested in the physical and the digital, the actual and the virtual.

Is there an avenue forward for photogrammetry, digital representations which take you to the cellular as well as the sort of street-view levels that offer more avenues on the actual surgery or vice versa? Yeah. And I think, to restate the question, it is that, is there some type of additional technological advance, such as simulation of surgery or simulation of the process of regeneration? Is that a fair restatement of it? We can certainly do a photoshopping to try to help someone understand what their face may look like after a reanimation surgery.

But fortunately, that job is mostly done by them looking at similar patients– patients who maybe have similar physical characteristics to them– and looking at some outcomes and then having a good, honest discussion with the surgeon about, what are reasonable expectations from a given surgery? I think that’s kind of where we’re at as far as that’s concerned. This is a problem that lends itself very well towards biomedical engineering applications.

The ideal source of movement is only 14 centimeters away, right? It’s the other side of the face and, sometimes, not even that. Sometimes it’s 10 centimeters or 8, depending on which muscle you’re talking about. And so there have been a lot of efforts to develop, for instance, an implantable electrode that could take signals in some fashion from the non-paralyzed side of the face and translate that into an electrical signal on the paralyzed side of the face. That is a bit of a Mount Everest still at this point, with some unsuccessful attempts on the side of the trail. I do think that there is a future for that. One of the things that we have to overcome is that making a chronically denervated muscle move is different than one that has just been acutely denervated. So if your muscle hasn’t been moving for two years, the electrode might not be able to overcome that. But there might be some workarounds that with technological advance, we can kind of overcome it. It seems as something that’s kind of right at our grasp, but it’s been that way for the past 10 years– at least, for me.

So I think we may have just a little bit of time still to wait on that. But exciting, for sure. Next question. Do you have any experience doing these muscle transfer surgeries in children, whether they’ve just never recovered from their Bell’s palsy or they were born with a facial paralysis? And if so, what are some special considerations for a pediatric patient versus an adult patient? The vast majority of my patients are adults. Oh, thank you– is to describe what nuances, what differences there may be in cases of pediatric facial paralysis.

Pediatric facial process can be quite different, particularly if it is something that’s congenital. There may be other nerves that are affected. That may affect your choice of what nerve you want to use to power the face. There are size considerations. The age at which someone should undergo this type of surgery when what we call the cranial facial region, meaning the skull and the face and all of that anatomy, still has so much time to grow, that is another variable. It’s much more likely to have bilateral paralysis because of the congenital nature. So there can be a multitude of differences in terms of treatments. However, in a one-sentence summary, the treatments are oftentimes very similar with a heavier reliance on muscle transfer, doing a free flap of muscle transfer from the inner thigh.

Usually, we don’t want to intervene in kids in the first two years, say, of life. And I kind of laid out a two-year window, although kids can sometimes wait longer. So usually, the children are given time to grow to where their face reaches a reasonable size. And then we want to intervene before it becomes a social impediment for them, so ages 6 to 10 are sometimes how it’s done. So yeah, the treatment algorithm can be different. Some of the treatments, though, are very much the same, if not identical. But their timing and sequencing may be unique. Yes? Do you think Dr. Strandberg– is that her name? Yeah, Sarah Strandberg. –she could do the rehab without surgery, or do you always work together? The question is, can rehabilitation for the face be applied without surgery? And it most certainly can.

And so oftentimes, it is a consultation first, where we decide that, yeah, rehabilitation would be the best means of treating it. And certainly, I think most people’s goal is to avoid surgery. And that is completely understandable. What we need to, though, as a treatment team, is to really give you an honest assessment of what would lead to the best outcome. Because what we don’t want is someone to work fruitlessly over a long course of rehabilitation. We want improvement. But that said, yeah. There are definitely cases where rehabilitation alone is the treatment modality of choice. Yes? What about eyelids? Certainly. I didn’t talk about eyelid reanimation. I perform those surgeries, as do my colleagues in ocular plastic surgery. One of the reasons that I didn’t present it is it is, at this point, not really reanimation. But we do use thin profile platinum weights or gold weights to help the eye close. And I do eyelid-tightening procedures, such as a lower lid tightening, to help the lower eyelid sit at a better position. So those are treatments that are done.

There is, though, not yet really effective and useful reanimation surgeries that restore blink. You can connect to any of the nerves I talked about, in theory, to restore someone’s blink. But it is much less useful to have to think about blinking, so biting to blink. That’s certainly a possible thing. It’s just less useful, because the frequency of blinking is so extraordinarily high. Would you recommend those eyelid weights? Yes, definitely. I think that eyelid weights can be very helpful not only for just helping the eye close, but they can help prevent sort of a cycle of drying and some of these– once the eye begins to dry, if it’s not closing normally, some of the glands that help lubricate the eye start to kind of shut down.

And so an important component of this is care for the cornea. And so for all my patients, I recommend that they see an ophthalmologist to make sure that we get regular exams of the cornea and make sure that it’s not becoming too dry. That’s oftentimes a front-line treatment. The reason I didn’t discuss it is it’s kind of not reanimation surgery, but it’s very important nonetheless.

So thank you for asking about it. How do you measure your success rate? Is it– Great question. –the level of recovery and the level of reanimation versus you get a hit every time that it works? Right. So the question was, how do you measure success? That really strikes at the heart of this field. And I think that one of the real problems in facial paralysis is that this is a low frequency. It is a rare disease overall. And that has hampered good outcomes, assessments. And so something that I did not show you is the regular use of disease-specific quality of life metrics, which I give every patient every time they come to clinic so that they score their level of facial function or dysfunction.

I did show you a measure of their willingness to communicate in public. And we also have both software and observer score programs that we use to score the movement of the face. We essentially grade it from a 0 to 100 scale on how good or bad it is in different components of the face. There is no denying, however, that there is a heavy dose of right-brain analysis that goes into, did that work or not, right? You can show movement in centimeters in a table. But I think we all know what looks good when we see it.

And so we really have to acknowledge that there’s both. There’s before and after videos that are critical to showing people what they can expect from a surgery. There are patient testimonials. What was it like to go through this? That’s a critical element. But then also, in the era of evidence-based medicine, we use disease-specific quality of life metrics and then disease-specific assessment metrics. So then how do I tell patients what’s likely for them, right? What I will tell patients is it depends upon what they define as success or failure. And I tell them what the surgery can do. And I don’t like to choose a procedure that has less than an 80% or 90% chance of working. And that’s kind of baked into what I recommend to patients. It’s part of my surgical philosophy. I just don’t like coin tosses. And so I usually want to choose a procedure that has a success rate of somewhere in the neighborhood of 80% or 90% as long as I’ve helped them understand what I define as success, helped them really internalize that. There are exceptions to that based on certain people’s clinical history, maybe lack of a better option.

But that’s what I aim for, and that’s what we get with the appropriately selected treatment. Yes? I’m wondering. It seems that you said that with one of the crooked smiles, you can lessen the side that works to make it more equal. Does that mean you can’t smile? So the question was that one of the strategies I discussed was lessening the contraction of some muscles to improve symmetry, and does that also include weakening the smile on the intact side? That can be done, but it does not work. Because when people become completely non-expressive, they may have better symmetry at rest. But they’re completely unhappy with that, because they’re unable to express themselves. And they’ll also have more difficulty keeping food and liquid in their mouth.

So that’s not a strategy that is oftentimes used. It can be used, though, on the muscles that pull the lips down. That is something that can be used and used effectively. The good side of the face can be paralyzed but not the muscles that elevate the corner of the mouth. Yeah. Yeah, it’s just ineffective. And people simply don’t like it. Sure. I think there may be one other question. I’m trying to figure out how to phrase this, because we talked a little about Kaiser earlier. But is this a very unusual thing to be able to do? Or are there surgeons all across the country and many in the Bay Area that do reanimation if we can’t get into Stanford? The question is, is this a common treatment, or is it a more routine treatment? And so I think that it is an obtainable treatment in most major metropolitan areas.

And then you have to take with a grain of salt that I’m extremely biased that this is the best treatment center in the country. Because I think that the surgical approaches and techniques– they are not confined to a single person, a single practitioner. I think the thing that distinguishes the really, really high-performing centers is just a dogged determination and focus on this disease. All of the extra work that goes into the multi-disciplinary management to make this the best experience possible, it’s not so much, can you do the surgery? It’s, what is the total care package like? So that’s one thing I would say is a very important consideration. And there are some other very strong centers in the United States. OK. Thank you. [APPLAUSE] Thank you all..

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