Facial Disfigurement: Restoration of Facial Dynamics in a Patient with Concomitant Facial Paralysis and Blindness

Individuals with facial palsy experience physical, psychological, and social disability every single day.

The treatment of unilateral established facial paralysis requires transplantation of new musculature to reach symmetry at rest, and to partially restore facial movement.[1] [2] [3] [4]

Effective rehabilitation after muscle transfer requires training and physical therapy to achieve optimal function. The concept of neural plasticity supports that there is central plasticity and reorganization. After a certain training period, patients with gracilis transfers driven by the masseteric branch of the trigeminal nerve are able to achieve movement without initiating clenching of teeth.[5] [6] [7]

The rehabilitation in blind patients is one of the greatest challenge that a reconstructive surgeon can face, and to date, there is no previous report of facial reanimation in these particular cases. However, it may have an important functional role in social interaction.

A 37-year-old woman with established facial paralysis as sequelae of surgery for eighth nerve neuroma ([Fig. 1] [left panel]), undergone right suboccipital craniectomy, removal of the tumor in 2005 and radiosurgery as an adjunct treatment, which was complicated with bilateral blindness secondary to optic atrophy, paralysis of the right oculomotor nerve, right facial palsy, and hydrocephalus managed with ventriculoperitoneal shunt. A year after the removal of the tumor, she was submitted to a cross-face graft with the sural nerve, retaining obvious asymmetry at rest (grade V of the House-Brackmann scale), without frontal function, no function of the orbicularis oculi and minimal excursion of the oral commissure. In 2012, she underwent facial reanimation with gracilis free transfer; microneurovascular anastomosis was performed to the facial vessels, and to the motor nerve of masseter muscle. Time of contraction onset (reinnervation) was 3 months.

Fig. 1 (Left panel) Established right-side facial paralysis in a blind patient following acoustic neuroma surgery and radiotherapy (preoperatively 6 years from the onset of paralysis). (Right panel) Full contraction with a symmetrical smile.

The patient then initiated a rehabilitation program that was designed to reinforce the desired facial movement patterns; the first stage of exercises included individualized muscle contractions of the contralateral part of the face only, then with the transferred gracilis contracting. The program consisted of 5 to 20 repetitions of 3 to 5 exercises to be done three times daily. Her mother was used for acoustic feedback during exercise, helping to coordinate facial movements for the construction of different facial expressions. Further, other tasks were added, such as sucking, and saying words containing “f,” “p,” or “b,” which facilitates lip movements. The patient was also educated to evaluate the degree of muscle contraction through the tactile sense, that is, through a sensory feedback.

The patient was further evaluated with a novel quantitative method, called the facegram, which accurately assesses the fundamental aspects of the facial excursion. To reliably capture the dynamics of the smile movements, we developed specialized software capable of tracking simultaneously the position over time of several anatomical points (commissures, midpoints, and Cupid). This is accomplished using video recordings of the subject while controlling the process of smiling. The programing environment MATLAB (R2011a, MathWorks, Natick, MA) was used to develop the tracking software, and for computing the facegrams. The video sequences are not analyzed frame by frame with manual point selection by the user on each frame. The user only identifies the markers' locations in the first frame. The algorithm then tracks automatically the markers independently in (x, y, t) coordinates for the entire video sequence. The process thus takes a few seconds, is reproducible, and reliable, since variability in the point selection of the markers (as long as within its central area) is not translated in variability in the markers trajectories.

The main element in the facegram is the plot, in scale, of the paths followed by each anatomical landmark, and includes four additional elements for analysis: the absolute horizontal (and vertical) displacements and the differential horizontal (and vertical) displacements of each landmark as a function of time. The fact that this plot is on scale also allows direct measurements such as maximal extensions.

In this patient we observe that Cupid mark does not exactly intersects the vertical axis of the face, despite improved symmetry of the face at rest after surgery ([Fig. 2]).

Fig. 2 Some imbalance between contraction and relaxation. However, good vertical excursion of commissure marks is noted (4.8 mm). There is symmetry of the commissures at rest.LC, left commissure; LMP, left midpoint; RC, right commissure; RMP, right midpoint.

Some imbalance between contraction and relaxation is observed. Horizontal movements are abrupt at the right side and less coordinated. However, good vertical excursion of the commissure marks is noted (4.8 mm) and there is symmetry of the commissures at rest.

Drooling decreased and speech was improved. Both her self-esteem as well as intellectual performance increased with a more symmetric face at rest and during animation ([Fig. 1][right panel]). She could develop social skills to start and carry on conversations, to play games effectively, and to join in and feel part of a group.

The impact of facial disfigurement on social interactions includes psychological and physical fatigue.[8]

Visually-impaired patients suffer from reduced social interaction in part due to reliance upon others to initiate social contact, and they have smaller social circles.[9] The isolation and emotional pain that a blind and visual impaired person experience in association with facial paralysis can be distressing and constrictive in regular public interaction and may also elevate the risk for depression.[10]

In addition to the disfiguring condition that takes away facial expressiveness, facial paralysis is associated to functional problems such as speech impairment, drooling, problems with eating, drinking or rinsing the mouth, and closing or sustaining eye closure for moistening and protection.

Therefore, all efforts should be taken to enhance the recovery of facial expression by means of neuromuscular reeducation, or facial reanimation surgery.

In this article, we describe for the first time the treatment of facial paralysis in a blind patient. The facial reanimation program combined microsurgical facial reanimation, acoustic, and sensorial rehabilitation. A quantitative spatial-temporal analysis (facegram) was performed, and revealed good vertical excursion of the commissure marks (4.8 mm) and symmetry of the commissures at rest.

On the functional aspect, drooling and fluid loss with drinking were eliminated. Speech was significantly improved.

After successful facial reanimation she could develop social skills to start and carry on conversations, to play games effectively, and to join in and feel part of a group. This patient lives in an institution of support/solidarity. The difficult relationship with the children, who do not understand the nature of such deformity, also comes out strongly enhanced, and was one of the great achievements reported by the patient.

Microsurgical muscle-free transplantation in association with acoustic and sensorial feedback rehabilitation achieves good results in blind patients, improving their levels of self-esteem and expectations, and allowing greater social interaction by means of the ability to smile.

• References

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