Download PDF
Facial Plast Surg 2023; 39(02): 190-200
DOI: 10.1055/a-1950-4483
Original Research

Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review

Meryam Shikara 
1   Department of Otorhinolaryngology- Head and Neck Surgery, University of Maryland Medical System, Baltimore, Maryland
,
Kelly Bridgham
2   Department of Otorhinolaryngology- Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
3   University of Maryland School of Medicine, Baltimore, Maryland
,
Emilie Ludeman
4   Health Sciences and Human Services Library, University of Maryland Graduate School, Baltimore, Maryland
,
Kalpesh Vakharia
1   Department of Otorhinolaryngology- Head and Neck Surgery, University of Maryland Medical System, Baltimore, Maryland
3   University of Maryland School of Medicine, Baltimore, Maryland
,
Natalie Justicz
1   Department of Otorhinolaryngology- Head and Neck Surgery, University of Maryland Medical System, Baltimore, Maryland
3   University of Maryland School of Medicine, Baltimore, Maryland
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Background Synkinesis is commonly encountered after flaccid facial paralysis and can have a detrimental impact on a patient's life. First-line treatment of synkinesis is chemodenervation with botulinum toxin (Botox) and neuromuscular retraining. Surgical options include selective myectomy, selective neurectomy (SN), cross-facial nerve grafting, nerve substitution, and free gracilis muscle transfer. Data on surgical management of synkinesis using SN is limited.

Evidence Review PubMed, Embase, Cochrane CENTRAL, Cochrane Neuromuscular Register, Clinicaltrials.gov, and World Health Organization International Clinical Trials Registry Platform were searched using a comprehensive keyword strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-only texts published in the past 20 years were included. Two independent investigators reviewed 906 abstracts and 7 studies met inclusion criteria. Demographics, etiology of paralysis, time to surgery, and primary outcomes studied were collected.

Findings A total of 250 patients were included across 7 studies. In 6 out of 7 studies, Botox was used prior to surgical intervention. Two studies showed significant reduction in Botox dosage postoperatively, while one study showed no difference. Other primary outcomes included the House–Brackmann Score, palpebral fissure width, electronic clinician-graded facial function scale (eFACE) score, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Three studies showed significant improvement in the eFACE score, two studies showed significant improvement in the FaCE scale, while one study showed improvement in quality of life measured by the SAQ.

Conclusion SN can be considered as an adjunct to other management options including neuromuscular retraining, Botox, selective myectomy, and reanimation procedures. While there is great heterogeneity of study design in the studies included, many cohorts showed improvement in facial symmetry, facial function, and quality of life. There remains a great gap in knowledge in this subject matter and a need for large well-designed prospective studies comparing this technique to other management options.

Keywords

nonflaccid facial paralysis - facial synkinesis - post-facial paralysis synkinesis - selective neurectomy - modified selective neurectomy

Note

This abstract was accepted for poster presentation at the AAFPRS International Symposium of Facial Plastic Surgery, National Harbor, MD, 10/20/22–10/23/22.


Author Disclosure Statement

The authors whose names are listed certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this manuscript.




Publication History

Accepted Manuscript online:
25 September 2022

Article published online:
03 December 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Dey JK, Ishii LE, Nellis JC, Boahene KDO, Byrne PJ, Ishii M. Comparing patient, casual observer, and expert perception of permanent unilateral facial paralysis. JAMA Facial Plast Surg 2017; 19 (06) 476-483
    CrossrefPubMedGoogle Scholar
  • 2 Goines JB, Ishii LE, Dey JK. et al. Association of facial paralysis-related disability with patient- and observer-perceived quality of life. JAMA Facial Plast Surg 2016; 18 (05) 363-369
    CrossrefPubMedGoogle Scholar
  • 3 Parsa KM, Hancock M, Nguy PL. et al. Association of facial paralysis with perceptions of personality and physical traits. JAMA Netw Open 2020; 3 (06) e205495
    CrossrefPubMedGoogle Scholar
  • 4 Nellis JC, Ishii M, Byrne PJ, Boahene KDO, Dey JK, Ishii LE. Association among facial paralysis, depression, and quality of life in facial plastic surgery patients. JAMA Facial Plast Surg 2017; 19 (03) 190-196
    CrossrefPubMedGoogle Scholar
  • 5 Ishii L, Godoy A, Encarnacion CO, Byrne PJ, Boahene KDO, Ishii M. Not just another face in the crowd: society's perceptions of facial paralysis. Laryngoscope 2012; 122 (03) 533-538
    CrossrefPubMedGoogle Scholar
  • 6 Dey JK, Ishii M, Boahene KDO, Byrne PJ, Ishii LE. Changing perception: facial reanimation surgery improves attractiveness and decreases negative facial perception. Laryngoscope 2014; 124 (01) 84-90
    CrossrefPubMedGoogle Scholar
  • 7 Kleiss IJ, Hohman MH, Susarla SM, Marres HAM, Hadlock TA. Health-related quality of life in 794 patients with a peripheral facial palsy using the FaCE Scale: a retrospective cohort study. Clin Otolaryngol 2015; 40 (06) 651-656
    CrossrefPubMedGoogle Scholar
  • 8 Ho AL, Scott AM, Klassen AF, Cano SJ, Pusic AL, Van Laeken N. Measuring quality of life and patient satisfaction in facial paralysis patients: a systematic review of patient-reported outcome measures. Plast Reconstr Surg 2012; 130 (01) 91-99
    CrossrefPubMedGoogle Scholar
  • 9 Krane NA, Genther D, Weierich K. et al. Degree of self-reported facial impairment correlates with social impairment in individuals with facial paralysis and synkinesis. Facial Plast Surg Aesthet Med 2020; 22 (05) 362-369
    CrossrefPubMedGoogle Scholar
  • 10 Fu L, Bundy C, Sadiq SA. Psychological distress in people with disfigurement from facial palsy. Eye (Lond) 2011; 25 (10) 1322-1326
    CrossrefPubMedGoogle Scholar
  • 11 Lee J, Fung K, Lownie SP, Parnes LS. Assessing impairment and disability of facial paralysis in patients with vestibular schwannoma. Arch Otolaryngol Head Neck Surg 2007; 133 (01) 56-60
    CrossrefPubMedGoogle Scholar
  • 12 Yamamoto E, Nishimura H, Hirono Y. Occurrence of sequelae in Bell's palsy. Acta Otolaryngol Suppl 1988; 446 (S446): 93-96
    PubMedGoogle Scholar
  • 13 Nash JJ, Friedland DR, Boorsma KJ, Rhee JS. Management and outcomes of facial paralysis from intratemporal blunt trauma: a systematic review. Laryngoscope 2010; 120 (07) 1397-1404
    CrossrefPubMedGoogle Scholar
  • 14 Hohman MH, Hadlock TA. Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope 2014; 124 (07) E283-E293
    CrossrefPubMedGoogle Scholar
  • 15 Takeda T, Takeda S, Okada T, Kakigi A, Yamasoba T. Experimental studies on the recovery processes from severe facial palsy and the development of its sequelae. Otol Neurotol 2015; 36 (05) 896-903
    CrossrefPubMedGoogle Scholar
  • 16 Moran CJ, Neely JG. Patterns of facial nerve synkinesis. Laryngoscope 1996; 106 (12 Pt 1): 1491-1496
    CrossrefPubMedGoogle Scholar
  • 17 Brach JS, VanSwearingen J, Delitto A, Johnson PC. Impairment and disability in patients with facial neuromuscular dysfunction. Otolaryngol Head Neck Surg 1997; 117 (04) 315-321
    CrossrefPubMedGoogle Scholar
  • 18 Çelik M, Forta H, Vural C. The development of synkinesis after facial nerve paralysis. Eur Neurol 2000; 43 (03) 147-151
    CrossrefPubMedGoogle Scholar
  • 19 Mehta RP, WernickRobinson M, Hadlock TA. Validation of the Synkinesis Assessment Questionnaire. Laryngoscope 2007; 117 (05) 923-926
    CrossrefPubMedGoogle Scholar
  • 20 Shtraks JP, Mirocha J, Azizzadeh B. Quality of life outcomes after modified selective neurectomy for postfacial paralysis synkinesis. Facial Plast Surg Aesthet Med 2021; 23 (06) 443-448
    CrossrefPubMedGoogle Scholar
  • 21 Azizzadeh B, Irvine LE, Diels J. et al. Modified selective neurectomy for the treatment of post-facial paralysis synkinesis. Plast Reconstr Surg 2019; 143 (05) 1483-1496
    CrossrefPubMedGoogle Scholar
  • 22 Schmidt KL, Cohn JF. Human facial expressions as adaptations: evolutionary questions in facial expression research. Am J Phys Anthropol 2001; (Suppl. 33) 3-24
    CrossrefPubMedGoogle Scholar
  • 23 Otta E, Folladore Abrosio F, Hoshino RL. Reading a smiling face: messages conveyed by various forms of smiling. Percept Mot Skills 1996; 82 (3 Pt 2): 1111-1121
    CrossrefPubMedGoogle Scholar
  • 24 Helwig NE, Sohre NE, Ruprecht MR, Guy SJ, Lyford-Pike S. Dynamic properties of successful smiles. PLoS One 2017; 12 (06) e0179708
    CrossrefPubMedGoogle Scholar
  • 25 Miller MQ, Hadlock TA. Deep dive into denervation: institutional experience with selective denervation in nonflaccid facial palsy. Facial Plast Surg Aesthet Med 2021; 23 (04) 241-247
    CrossrefPubMedGoogle Scholar
  • 26 Cabin JA, Massry GG, Azizzadeh B. Botulinum toxin in the management of facial paralysis. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (04) 272-280
    CrossrefPubMedGoogle Scholar
  • 27 Terzis JK, Karypidis D. Therapeutic strategies in post-facial paralysis synkinesis in adult patients. Plast Reconstr Surg 2012; 129 (06) 925e-939e
    CrossrefPubMedGoogle Scholar
  • 28 Lindsay RW, Robinson M, Hadlock TA. Comprehensive facial rehabilitation improves function in people with facial paralysis: a 5-year experience at the Massachusetts Eye and Ear Infirmary. Phys Ther 2010; 90 (03) 391-397
    CrossrefPubMedGoogle Scholar
  • 29 Miller MQ, Hadlock TA. Beyond Botox: contemporary management of nonflaccid facial palsy. Facial Plast Surg Aesthet Med 2020; 22 (02) 65-70
    CrossrefPubMedGoogle Scholar
  • 30 Jowett N, Malka R, Hadlock TA. Effect of weakening of ipsilateral depressor anguli oris on smile symmetry in postparalysis facial palsy. JAMA Facial Plast Surg 2017; 19 (01) 29-33
    CrossrefPubMedGoogle Scholar
  • 31 Jowett N, Hadlock TA. An evidence-based approach to facial reanimation. Facial Plast Surg Clin North Am 2015; 23 (03) 313-334
    CrossrefPubMedGoogle Scholar
  • 32 Filipo R, Spahiu I, Covelli E, Nicastri M, Bertoli GA. Botulinum toxin in the treatment of facial synkinesis and hyperkinesis. Laryngoscope 2012; 122 (02) 266-270
    CrossrefPubMedGoogle Scholar
  • 33 Biglioli F, Kutanovaite O, Rabbiosi D. et al. Surgical treatment of synkinesis between smiling and eyelid closure. J Craniomaxillofac Surg 2017; 45 (12) 1996-2001
    CrossrefPubMedGoogle Scholar
  • 34 Lindsay RW, Bhama P, Hadlock TA. Quality-of-life improvement after free gracilis muscle transfer for smile restoration in patients with facial paralysis. JAMA Facial Plast Surg 2014; 16 (06) 419-424
    CrossrefPubMedGoogle Scholar
  • 35 Henstrom DK, Malo JS, Cheney ML, Hadlock TA. Platysmectomy: an effective intervention for facial synkinesis and hypertonicity. Arch Facial Plast Surg 2011; 13 (04) 239-243
    CrossrefPubMedGoogle Scholar
  • 36 Azizzadeh B, Hjelm N. Modified selective neurectomy: a new paradigm in the management of facial palsy with synkinesis. Facial Plast Surg Clin North Am 2021; 29 (03) 453-457
    CrossrefPubMedGoogle Scholar
  • 37 Azizzadeh B, Frisenda JL. Surgical management of postparalysis facial palsy and synkinesis. Otolaryngol Clin North Am 2018; 51 (06) 1169-1178
    CrossrefPubMedGoogle Scholar
  • 38 Vincent AG, Bevans SE, Robitschek JM, Wind GG, Hohman MH. Masseteric-to-facial nerve transfer and selective neurectomy for rehabilitation of the synkinetic smile. JAMA Facial Plast Surg 2019; 21 (06) 504-510
    CrossrefPubMedGoogle Scholar
  • 39 Coleman CC. Surgical treatment of facial spasm. Ann Surg 1937; 105 (05) 647-657
    CrossrefPubMedGoogle Scholar
  • 40 Greenwood Jr J. The surgical treatment of hemifacial spasm. J Neurosurg 1946; 3 (06) 506-510
    CrossrefPubMedGoogle Scholar
  • 41 Marino H, Alurralde A. Spastic facial palsy; peripheral selective neurotomy. Br J Plast Surg 1950; 3 (01) 56-59
    CrossrefPubMedGoogle Scholar
  • 42 Chuang DCC, Chang TNJ, Lu JCY. Postparalysis facial synkinesis: clinical classification and surgical strategies. Plast Reconstr Surg Glob Open 2015; 3 (03) e320
    CrossrefPubMedGoogle Scholar
  • 43 Hohman MH, Lee LN, Hadlock TA. Two-step highly selective neurectomy for refractory periocular synkinesis. Laryngoscope 2013; 123 (06) 1385-1388
    CrossrefPubMedGoogle Scholar
  • 44 Yang SF, Xie Y, Kim JC. Use of local anesthetic injections in the evaluation of facial synkinesis. Facial Plast Surg Aesthet Med 2022; 24 (01) 60
    CrossrefPubMedGoogle Scholar
  • 45 Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological Index for Non-Randomized Studies (MINORS): development and validation of a new instrument. ANZ J Surg 2003; 73 (09) 712-716
    CrossrefPubMedGoogle Scholar
  • 46 Marvin K, Coulter M, Johnson C, Friesen T, Morris K, Brigger MT. Dysphagia outcomes following surgical management of unilateral vocal fold immobility in children: a systematic review. Otolaryngol Head Neck Surg 2022; 1945998221084891
    PubMedGoogle Scholar
  • 47 Fattah AY, Gurusinghe ADR, Gavilan J. et al; Sir Charles Bell Society. Facial nerve grading instruments: systematic review of the literature and suggestion for uniformity. Plast Reconstr Surg 2015; 135 (02) 569-579
    CrossrefPubMedGoogle Scholar
  • 48 Banks CA, Bhama PK, Park J, Hadlock CR, Hadlock TA. Clinician-graded electronic facial paralysis assessment: the eFACE. Plast Reconstr Surg 2015; 136 (02) 223e-230e
    CrossrefPubMedGoogle Scholar
  • 49 Banks CA, Jowett N, Hadlock TA. Test-retest reliability and agreement between in-person and video assessment of facial mimetic function using the eFACE facial grading system. JAMA Facial Plast Surg 2017; 19 (03) 206-211
    CrossrefPubMedGoogle Scholar
  • 50 Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB, McKenna MJ. Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale. Laryngoscope 2001; 111 (03) 387-398
    CrossrefPubMedGoogle Scholar
  • 51 van Veen MM, Dusseldorp JR, Hadlock TA. Long-term outcome of selective neurectomy for refractory periocular synkinesis. Laryngoscope 2018; 128 (10) 2291-2295
    CrossrefPubMedGoogle Scholar
  • 52 Hjelm N, Crippen M, Azizzadeh B. Long-term changes in the treatment pattern of botulinum toxin A injections for postfacial paralysis synkinesis following modified selective neurectomy. Facial Plast Surg Aesthet Med 2021; 23 (03) 234-235
    CrossrefPubMedGoogle Scholar
  • 53 Salles AG, da Costa EF, Ferreira MC, do Nascimento Remigio AF, Moraes LB, Gemperli R. Epidemiologic overview of synkinesis in 353 patients with longstanding facial paralysis under treatment with botulinum toxin for 11 years. Plast Reconstr Surg 2015; 136 (06) 1289-1298
    CrossrefPubMedGoogle Scholar
  • 54 Li MKK, Niles N, Gore S, Ebrahimi A, McGuinness J, Clark JR. Social perception of morbidity in facial nerve paralysis. Head Neck 2016; 38 (08) 1158-1163
    CrossrefPubMedGoogle Scholar