Microsurgery for Facial Paralysis in Ankara, Turkey

Microsurgery in facial paralysis includes advanced surgical methods performed to restore the loss of facial expression caused by facial nerve (n. facialis) damage and to regain the functional and aesthetic structure of the face. Microsurgical techniques aim to restore muscle movements through nerve repair or transfer.

In the early period, if possible, the facial nerve can be sutured end-to-end or repaired with a nerve graft. In later stages, facial expression movements can be recreated with microsurgical methods such as cross-face nerve graft (CFNG), masseteric nerve transfer, or free muscle transfer.

In free muscle transfer, a muscle taken from another part of the body (for example, the gracilis) is transplanted to the facial region. Vascular and nerve connections are performed with microsurgery. In this way, both muscle movement and facial symmetry are achieved, and functions such as a natural smile are restored.

Treatment is planned individually and requires a multidisciplinary approach. Postoperative physiotherapy is of critical importance to support and retrain nerve activation. With microsurgery, aesthetic and functional losses due to facial paralysis can be largely corrected.

What is Microsurgery in Facial Paralysis?

Microsurgery in facial paralysis involves surgical interventions performed under a microscope to repair or reconstruct facial nerves that have been damaged or have lost their function. With this method, the aim is to restore movement to the facial muscles by applying nerve grafts, nerve transfers, or muscle transfers. Proper patient selection and early intervention play an important role in increasing the success of functional and aesthetic outcomes.

Why is facial nerve anatomy and structure so complex?

The facial nerve, medically known as the facial nerve, is one of the most fascinating yet delicate structures in the human body. Thinking of it as an ordinary electrical cable would do injustice to this complex structure. From the moment it exits the brainstem until it reaches the facial muscles, it takes an incredibly winding and challenging journey. The most critical part of this journey is the bony tunnel inside the temporal bone that we call the Fallopian canal.

This tunnel is tailor-made for the nerve, but there is no margin for error. As the nerve passes through this narrow bony canal, there is not even a millimetric space around it. This quirk of anatomy makes the nerve extremely vulnerable to external factors. The slightest edema, swelling caused by a viral infection, or a blow to that area can cause the nerve to become compressed between the bony walls.

This nerve does not only provide movement; it is also like a conductor directing many vital functions, from tear production to saliva secretion, and even taste sensation in the anterior part of the tongue. From a plastic surgery perspective, damage to this nerve does not simply mean one side does not move. The delicate balance of the face is disrupted, muscle tone that resists gravity is lost, and one half of the face droops downward. This affects not only the patient’s image in the mirror but also the way they communicate with people.

What are the causes of facial paralysis?

When our patients come to us in clinical practice, they are usually very anxious. Understanding the cause of facial paralysis is the first and most important step in treatment. The most common presentation we encounter is Bell’s palsy, which typically manifests as a sudden loss of movement on one side of the face upon waking in the morning. Although the cause is unknown, viral factors are thought to cause edema in that narrow canal. However, cases that require surgical intervention usually stem from more specific causes.

The main causes that may require microsurgical repair are:

• Traffic accidents
• Severe head trauma
• Penetrating or sharp object injuries
• Temporal bone fractures
• Salivary gland tumors
• Iatrogenic surgical injuries
• Congenital anomalies

When nerve continuity is disrupted or the nerve sheath is damaged due to one of these causes, the body’s self-repair mechanism becomes insufficient. Especially in traumatic cases, if it is seen on imaging that the fracture line has cut the nerve canal or if electrical tests reveal that the vast majority of nerve fibers have died, waiting is a waste of time.

What is timing and the critical window in treatment?

In the treatment of facial paralysis, the most vital topic that we have the hardest time explaining to our patients is timing. The thought “Let’s wait a bit, maybe it will pass” can, in some cases, lead to irreversible losses. Because what we are trying to protect here is not just the nerve but the “nerve-muscle unit.” The nerve is the electrical line that stimulates the muscle. If a muscle does not receive electrical stimulation for a long time, it begins to shrink as a biological rule, namely atrophy.

As time passes, muscle tissue wastes away and is replaced by nonfunctional fat and connective tissue. When this happens—when the muscle turns into hard tissue we call “fibrosis”—even if you perform the best nerve repair in the world, that muscle can never contract again. That is why timing must be managed very well. The first 3 weeks, which we call the acute period, are the golden time for relieving pressure on the nerve or immediately repairing a severed nerve.

In cases where we know nerve recovery will take time, we need to act quickly so that the muscles do not completely die during this waiting period. In cases that exceed 18 months, and at the latest 24 months, the facial expression muscles on the face are considered to have irreversibly lost their function. At this stage, trying to repair the nerve is a futile effort; a fresh, living muscle must now be brought to that area. Therefore, the earlier a patient presents to us, the more surgical options are available and the more natural the results.

What are microsurgical options in the early period?

In the early period, especially if severe compression is detected in the nerve after trauma or Bell’s palsy and there is no response to medical treatment, “decompression” surgery comes onto the agenda. In this procedure, working under a microscope, we open the bony canal in which the nerve is compressed and relieve the nerve sheath. You can think of this like loosening the laces of a shoe that is squeezing the foot. When the nerve is relieved, blood circulation within it improves and the healing process accelerates.

If the nerve has been cut during an accident or tumor surgery, the most ideal procedure to perform is “end-to-end repair.” We find the two ends of the nerve and bring them together under a microscope with sutures much thinner than a strand of hair. However, there is a very important rule here: The nerve must never be repaired under tension. Tension stops the healing traffic within the nerve. If the ends barely reach each other, adding a segment in between instead of pulling on the nerve yields much healthier results.

What is a nerve graft, and from which areas of the body is it taken?

Imagine an electrical cable has snapped and the two ends cannot reach each other. To complete the circuit, you need to add a new piece of cable in between. In plastic surgery, this is what we call a “nerve graft.” To fill the gap in the facial nerve, a sacrificable sensory nerve is taken from another part of the body and used as an interposition graft.

The donor nerves most commonly preferred for this procedure are:

• Sural nerve
• Greater auricular nerve
• Saphenous nerve

The “sural nerve,” which we use most frequently, is located on the posterolateral part of the leg. It provides us with a long and high-quality cable up to 30–40 centimeters. Harvesting this nerve never interferes with the patient’s walking or leg functions. There is only a small area of numbness on the outer edge of the foot, which our patients get used to very quickly.

Patience is very important in repairs performed using these interposition cables. Nerve fibers progress through this added cable at a speed of about 1 millimeter per day. This is a process as slow as an ant’s walk. Therefore, the onset of movement in the face after surgery may take months depending on the location of the nerve damage and the length of the added segment. In this process, the patient must not lose hope and must know that recovery is a marathon.

How is muscle preservation achieved with the babysitter procedure?

Sometimes, when we anticipate that nerve recovery will take a very long time or that the primary repair will reach the muscles too late, we apply the “Babysitter” procedure to prevent the muscles from wasting away during this waiting period. The logic is quite simple: until the main nerve heals and arrives, find another source that will temporarily look after those muscles and keep them nourished.

Usually, a small branch is taken from the nerve that activates the tongue muscles or from the nerve that activates the chewing muscle and is connected to the distal end of the facial nerve that enters the muscles. This “babysitter” nerve starts providing electrical input to the muscles and keeps them alive, full, and ready to move. When the primarily repaired facial nerve reaches the area months later, the muscles are still healthy and strong. This method is like an insurance policy that protects muscles against atrophy, especially in complex cases where the recovery process is uncertain:

How is masseteric nerve transfer performed?

In recent years, one of the most popular methods in facial paralysis surgery—and one that we also frequently use—is masseteric nerve transfer. The masseter muscle is the powerful chewing muscle in the cheek that allows us to close our jaw. The nerve that activates this muscle is an incredibly strong motor nerve. The number of motor fibers it contains is so high that it can easily activate the facial muscles on its own.

In this surgery, we find the masseteric nerve and connect its strong motor branches to the branches of the paralyzed facial nerve. The connection made to the zygomatic or buccal branches that enable smiling is particularly effective. The biggest advantage of this method is that the nerve source is very close to the target muscles. Since the nerve energy does not have to travel a long distance, recovery and the first visible movements can occur in as little as 3–4 months.

After surgery, patients begin to smile when they clench their teeth. At first, this movement is conscious and voluntary. The patient looks in the mirror, clenches the teeth, and smiles. However, the human brain has an incredible ability to adapt. As the patient exercises, the brain learns this new connection. Over time, our patients learn to activate this nerve unconsciously when they laugh, resulting in a quite strong and symmetrical smile.

How does cross-face nerve graft (CFNG) affect naturalness?

Masseteric nerve transfer provides a very strong smile, but it may sometimes be insufficient in providing what we call “emotional spontaneity,” that natural reflex that occurs without thinking when you laugh at a joke. This is where “Cross-Face Nerve Graft” (CFNG) comes into play for patients who seek a truly emotional smile.

The philosophy of this method is to take the natural command for smiling from the healthy side of the face and carry it to the paralyzed side with an “extension cable.” Small branches of the facial nerve on the healthy side are identified, and a long nerve graft taken from the leg is connected to these branches. This graft is then tunneled across the upper lip or subcutaneously to reach the paralyzed side.

The advantages of this procedure are:

• Provides natural smile symmetry
• Works with emotional triggers
• Makes involuntary smiling possible

However, the disadvantage of this method is that the nerve signals lose some of their strength while traveling such a long distance. That is why today we often use the concept of “Dual Innervation.” In other words, we get “power” from the masseteric nerve and “emotion” from the cross-face graft. Thus, we try to achieve a smile that is both strong and natural.

In which cases is free functional muscle transfer (FFMT) necessary?

If more than 2 years have passed since the onset of paralysis, unfortunately the original facial expression muscles of the face have atrophied irreversibly. No matter which nerve you connect to those muscles, you will not get a response. In this case, the most effective procedure a plastic surgeon can perform is “changing the engine.” That is, taking a living muscle from another part of the body together with its vessels and nerve and transplanting it to the face.

The muscles most commonly used for this procedure are:

• Gracilis muscle
• Latissimus dorsi muscle
• Rectus abdominis muscle

The gracilis muscle, which we most frequently prefer, is located on the inner part of the leg. With its thin and long structure, it is very suitable for the anatomy of the face. We take the muscle from the leg together with its vessels and nerve and place it in the facial region. We connect the muscle’s vessels to the vessels in the face, and its nerve to the masseteric nerve. This is one of the peak points of microsurgery. After successful healing, the patient can elevate the corner of the mouth and smile by using this newly transplanted muscle. These surgeries are a new beginning for patients who say “I am too late” in the treatment of facial paralysis.

How are eyelid problems and lagophthalmos managed?

In facial paralysis, there is a situation far more urgent and important than aesthetic concerns: inability to close the eye. In this condition, medically called lagophthalmos, the muscle that closes the eye does not work, so the eye remains open. This is not only an aesthetic problem but a serious health issue.

The risks of untreated eyelid problems are:

• Corneal dryness
• Permanent vision loss
• Corneal ulceration
• Recurrent infections

To correct this, the most common and most effective method we use is placing a “gold plate” inside the upper eyelid. Gold is extremely compatible with the body and is a heavy metal due to its density. With the effect of gravity, it allows the eyelid to descend when the patient wants to close the eye. It is not noticeable from the outside and dramatically increases the patient’s comfort. We also perform lateral canthal suspension procedures to correct laxity in the lower eyelid.

What are non-surgical aesthetic solutions?

Not every patient may want long and complex microsurgical surgeries, or the medical condition may not be suitable for these surgeries. Also, sometimes fine adjustments may be needed after surgery. In these cases, static suspension methods are used. By using thick fascial strips taken from the patient’s own leg or synthetic sutures, the corner of the mouth is suspended upward, at least correcting the drooping appearance at rest and providing symmetry.

In addition, Botulinum Toxin (Botox) applications are an indispensable part of our treatment. Surprisingly, we generally apply Botox not to the paralyzed side but to the “healthy” side. Because once the healthy side realizes the paralyzed side is not working, it begins to overwork to compensate. This pulls the face further toward the healthy side and increases asymmetry. Slowing down the healthy side a bit with Botox greatly improves facial balance and makes the patient feel the face is more centered.

What is the postoperative rehabilitation process like?

Microsurgical surgery is not the finale of the process but only the “starting whistle.” The newly connected nerves finding the muscles, the muscles strengthening, and most importantly the brain adapting to this new setup require serious rehabilitation. We surgeons install the hardware, but loading the software is the job of the patient and physiotherapists.

Methods applied during the rehabilitation process are:

• Exercises in front of a mirror
• Facial massages
• Electrical stimulation
• Biofeedback therapy
• Neuromuscular retraining

In the first stage, the goal is protection; edema is reduced and blood circulation is increased. In the second stage, when the first tremors in the muscles begin, small movement trials are performed in front of a mirror. The patient relearns “clenching the teeth and smiling” or “frowning.” With the method we call biofeedback, the patient reinforces performing the correct movement in front of a mirror and works with focus to prevent incorrect contractions. These short, repeated exercises performed several times a day increase the brain’s plasticity and strengthen the newly established neural networks.

Rehabilitation requires patience. Sometimes it can take months, even years. However, the patient’s participation in treatment is one of the most important factors determining the outcome. With good rehabilitation, surgical success can be doubled.