Facelift and Facial nerve injury: how to deal with?
Ritidoplastia e paralisia facial: como lidar?

Diagnostic

In a majority of cases the surgeon will face the onset of paralysis during post-op. Whenever possible, evaluating the facial mimetic muscles at the end of the surgery is a good way to differentiate surgical trauma from other post-op causes such as Bell’s palsy. It is important to have a very strict follow-up and take pictures at every single contact with the patient.

To clinically assess the severity of peripheral facial nerve palsy various scoring systems are available. In our opinion, the most suitable facial nerve grading system is the Muscle testing of Freyss (Chart 1). This scale allows each muscle function to be evaluated separately, which is different from other grade systems, such as the House-Brackmann Grading System, which assesses groups of facial muscles. The system relies on evaluation of the degree of voluntary excursion of the facial muscles, evaluating ten muscles groups and attributing scores from 0 to 3 for each muscle, for a total score ranging from 0 to 30¹⁶. Evaluation is usually limited to two or three muscles, according to the injured nerve branch.

Chart 1 - Muscle testing of Freyss¹⁶.

Facial nerve palsy can be categorized as complete if there is inability to voluntarily contract the facial muscles, or incomplete (partial). The degree of nerve damage can also be assessed by nerve conduction studies (electromiography-EMG) of the facial nerve. Reduction of the compound muscle action potential suggests axonal degeneration whereas increase in latency suggests demyelination of the nerve¹⁷.

Facial nerve palsy is an extremely frightening situation for the patient. The most frequently asked questions by these patients are whether their facial function will return to normal and how long it will take.

Among the wide variety of available prognostic tests, as discussed by Hughes¹⁸, the EMG seems to be the most reliable test to predict a patient’s prognosis¹⁹. To evaluate the lesion, an EMG is done early in the post-op, between day 4 and 6, although there is no rule ordering this first exam, because at this early stage, electromyography is used to detect any remaining voluntary activity. If voluntary potentials are detected, the palsy is labeled incomplete. The paralysis is considered complete only in the case of a totally silent electromyography¹⁹.

A diagnosis according to Sunderland and Seddon classifications (Chart 2) cannot be made at this stage, because pathologic spontaneous activity as a sign of neural degeneration does not occur earlier than 10 to 14 days after the onset of palsy. This early test is mainly intended to categorize the severity of an individual palsy and does not yield reliable prognostic information^20,21.

Chart 2 - Sunderland and Seddon classifications²¹.

A second examination should be performed not earlier than 10 to 14 days after the onset of palsy. After this period, all diagnostic criteria may have developed to establish a diagnosis according to Seddon, which predicts a prognosis on the expected clinical course^19,20.

Steinner published that a fibrillation detected in EMG studies later than 10 to 14 days predicts that a patient has an 80% chance of an unfavorable result, but on the other hand, the absence of these signs implies an approximately 93% chance of total recovery²⁰.

Eye protection

One of the biggest problems with upper face facial palsy is the involvement of the eye if the lid commissure remains open. In this situation, eye care focuses on protection of the cornea from dehydration, drying or abrasions due to insufficient lid closure or tears. Eye ointments are recommended during day and night with protective glasses during the day²².

Physiotherapy

There are only a few controlled trials available on the effectiveness of physical therapy for facial palsies. In a randomized trial on 50 patients with Bell’s palsy and a House Brackmann scale grade of IV, mime therapy, speech therapy, including automassage, relaxation exercises, inhibition of synkinesis, coordination exercises, or emotional expression exercises, resulted in improvement of facial stiffness, lip motility, and the physical and social indices of the facial disability index²³. A simple and reproducible technique has been used and advised by us: the mirror feedback therapy. It involves training the paralyzed side to reproduce symmetrical movements of the unaffected side in front of a mirror. Blanchin et al.²⁴, in 2013, presented a paper proving that when the mirror therapy is applied to patients with long standing facial palsy and submitted to Labbe’s technique of facial reanimation it is more effective in recovering a spontaneous smile when compared to conventional therapies.

Corticosteroids

Till date to our knowledge, no study has discussed facial nerve trauma and the use of steroids for treatment. But since it is known that inflammation (particularly edema) of the facial nerve plays a key role in the pathogenesis of other types of facial paralysis, such as Bell’s palsy, we can extrapolate the concept to surgical trauma,. given the fact that a vast majority of cases are partial lesions.

Corticosteroids have been used due to its powerful anti-inflammatory effects in Bell’s palsy and this has recently been supported by a growing and well-designed evidence base. A Cochrane review included 1569 patients from 8 randomized controlled trials of adequate quality, and showed a benefit in improving the facial recovery, and a significant reduction in motor synkinesis in the steroid group²⁵. Another high level systematic review published in the Journal of the American Medical Association (JAMA) concluded that corticosteroids used alone produced a reduced risk of unsatisfactory recovery²⁶.

Even though the reviews support the use of steroids in facial palsy, there is no consensus on the prescription pattern. There are many authors who have suggested different protocols. We recommend the ones with the largest reviews:

- The Sullivan protocol²⁷: Prednisolone 25 mg, by mouth (PO), twice daily, for 10 days, starting at a maximum of 72 h from the onset of palsy.

- The Engström protocol²⁸: Prednisolone 60 mg PO for 5 days, then the dose is reduced by 10 mg per day for 5 days, also starting before 72 h of the onset.

- The Lagalla Protocol²⁹: Prednisone 1 g, intravenous (IV), for 3 days, than 0.5 g IV for 3 days.

- The Stennert protocol (Table 1)³⁰.

Table 1 - Stennert protocol³⁰.

Stennert³⁰ proposed a protocol based on an assumption that nerve damage is caused by edema and primary and secondary ischemia. To reduce the phlogistic and edematous reaction, he introduced steroids. Secondly he tried to increase the peripheral nerve perfusion, by adding pentoxifyline and dextrane to the IV infusion.

The effect of pentoxifylline on the recovery of Bell’s palsy has only been tested in association with other drugs, particularly steroids and low-molecular dextran. The studies showed a beneficial effect of a combination therapy, but it is not known which of these drugs is responsible for the beneficial effect^16,28.

Botulinum toxin

When injected into facial muscles, botulinum toxin has been found to reduce the facial asymmetry in patients suffering from facial paralysis and has being used to treat synkinesis, hyperlacrimation, and hyperkinesis⁹. Most people have neglected the “physiotherapeutic” effect of the toxin. When applied to the healthy side, the toxin moderates movements, forcing the patient to exercise the affected side, which helps the muscle recover, and stimulates new neural connections. Therefore we recommend that it should be utilized even in the absence of hyperkinesia after confirmation of the diagnosis, around 12 days after the surgery (assumed facial palsy onset) and the EMG.