Medical Case Studies

Facial Paralysis Surgery Restores Facial Movement in Acoustic Neuroma Patient

Dr. Azizzadeh feels that giving a patient the ability to smile is one of the best parts of his job. Earlier this year, Dr. Azizzadeh had the opportunity to begin stage 1 of a 2-stage procedure to give one patient her smile back after she suffered facial paralysis from an acoustic neuroma.

The Patient’s Journey

Dr. Azizzadeh’s patient, Hela, was in medical school when she discovered she had an acoustic neuroma, or benign brain tumor, in June of 2011. She underwent two surgeries and radiation to get rid of the acoustic neuroma, but was left with facial paralysis in this medical case study. Facial paralysis is a common side effect of acoustic neuroma treatment as the tumor is in close proximity to the facial nerve.

Depending on the individual, there are a number of surgical options for restoring facial movement in patients who have undergone acoustic neuroma surgery. This particular patient was a candidate for a masseteric-facial nerve transfer combined with a cross facial nerve graft and gracilis muscle transplant, a two-step procedure in which Dr. Azizzadeh first attaches the masseteric nerve to the problematic facial nerve to give nerve input to all the paralyzed facial muscles. In this medical case study, a nerve from the lower leg is attached to the facial nerve on the normal side. This nerve can later transmit normal spontaneous signal to a new muscle (gracilis), which is transplanted from the leg into the face.

About 7 months after Hela’s first procedure, the patient is already experiencing improvement in facial muscle movement. She says that she can finally make her mouth smile and her eyes close, something she couldn’t do for almost 2 years. She will have the second and final stage of the surgery in December and is hopeful about the results in this medical case study.

Why Dr. Azizzadeh?

Hela was considering undergoing surgery with another doctor when her sister caught a rerun of the Oprah Winfrey Show in which Dr. Azizzadeh appeared with Mary Jo Buttafuoco to discuss how he helped her regain facial movement and improved her appearance after a traumatic injury left her with permanent facial paralysis. After learning about Dr. Azizzadeh on TV, her sister called her saying, “You have to check him out!” So, she called Dr. Azizzadeh’s office, was very pleased with everyone she spoke to, and scheduled her appointment. In this medical case study, it was important that the procedure be performed before the 2-year mark for best results, so they got her in quickly, and guided her through every step.

She loved how Dr. Azizzadeh made sure she understood every step of the process. She said that if he was ever running late, she never would have known because he always took his time and made sure all of her questions were answered.

Contact Dr. Azizzadeh at the Facial Paralysis Institute Today

If you or someone you love is living with permanent facial paralysis, there may be a surgical treatment that can restore facial animation and improve appearance. Dr. Azizzadeh is a world-renowned facial nerve expert who is known for his facial paralysis acumen. Call the Facial Paralysis Institute at (310) 657-2203 today to schedule a consultation!

Case Studies of Facial Paralysis and Bells Palsy

Case No. 1

6 year old girl developed facial paralysis at age of one following an upper respiratory tract infection. She presented with complete left sided facial paralysis.

The family was extremely concerned about her appearance and the fact that she would be entering school with this appearance. A treatment plan was created with the family after lengthy discussion about all of the patient’s options. Young patients who have had long-term paralysis are able to undergo advanced facial reanimation procedures to re-create dynamic spontaneous smile mechanism. Cross-facial nerve grafts gives patients the ability to utilize the facial nerve in the normal side of the face to drive the facial movement in the paralyzed side. Patients with long-term paralysis (> 2 years) have non-functional muscles; therefore, new vascularized muscle needs to be attached to the cross-facial nerve grafts. The nerve grafts also need to be activated for 8-12 months before the muscle in transferred.

Treatment Plan- Two stage procedure

Stage 1: Cross facial nerve grafts are harvested from sural nerve and attached to the normal facial nerve (photo of sural nerve)
Stage 2: Gracilis muscle free flap is harvested from the inner thigh and attached to the cross-facial nerve graft and artery/vein in the neck

Physical therapy is continued for the next 18 months. Facial movements can be gradually seen at 8 months following the second stage of surgery and continued for 2 years. The chances of facial movement are better with younger patients.

Case No. 2

48 year old woman
developed Bell’s Palsy 4 years earlier. She was devastated
emotionally and physically.

She could not close her eyes completely or smile. Her face was asymmetric. She drooled constantly and was unable to chew well on the affected side. All of her physicians had told her that she should live with these problems. She finally presented to Dr. Azizzadeh and a special surgical treatment was tailored for her after lengthy discussion.

Treatment Plan

1. Asymmetric facelift
2. Endoscopic brow lift
3. Gold weight placement upper eyelid
4. Lower eyelid canthoplasty
5. Static suspension of face with tensor fascia lata
6. Radiesse injection to the normal laugh line
7. BOTOX injection to the normal forehead to reduce its activity

Case No. 3

A 42 year old man presented following removal of acoustic neuroma 12 months earlier. He had developed complete facial paralysis following surgery without any return of facial nerve function.

MRI testing showed that the tumor was completely removed. Dr. Azizzadeh devised a plan to reconstruct the facial nerve using the hypoglossal nerve (cranial nerve 12). The hypoglossal nerve is responsible for moving the tongue muscle and by attaching a partial portion of the nerve to the facial nerve, the patient has the ability to move the face voluntarily by tongue thrusting. More importantly, the nerve allows the facial muscles to stay alive and thereby giving excellent tone to the face that is extremely important in preventing long-term facial asymmetry. Furthermore, in younger patients, there is potential for plasticity of the brain to naturally move the face. The patient also had additional procedures for eyes and brows. Furthermore, the patient underwent simultaneous static suspension to restore facial symmetry and improve his drooling.

Treatment plan:

1. Hypoglossal to facial nerve transfer (12-7 cranial nerve substitution)
2. Static suspension of face with tensor fascia lata
3. Endoscopic brow lift
4. Eyelid spring placement
5. Lower eyelid canthoplasty
6. Aggressive facial nerve rehabilitation

Case No. 4

Facial Paralysis Reconstruction

Gracie, a 12-year-old girl, faced paralysis after a cavernous hemangioma (CH) in her brain began to bleed. The bleeding caused paralysis to the right side of her body, making her unable to control her face and limbs.

After the initial surgery to stabilize her condition, Gracie and her parents began their search for a facial paralysis specialist. Aside from Dr. Azizzadeh’s expertise with facial paralysis surgery, the family also found comfort in the fact that he has worked with several other children, something very few surgeons have experience with.

To date, Gracie has had several surgeries and gone through countless hours of therapy to restore movement and function to the right side of her face. She has had 3 surgeries with Dr. Azizzadeh over the past two years. The overall goal of her surgeries is to restore more normal facial movements and expressions and to create the best possible facial symmetry.

During the first surgery, Dr. Azizzadeh took a piece of nerve from her leg and attached it to her non-paralyzed facial nerve.

Several months later, Dr. Azizzadeh performed a second surgery in which he brought in a brand new muscle from her inner thigh, the gracilis muscle. The gracilis muscle and it’s artery, vein and nerve were hooked up to the nerve that was transplanted in the original surgery and to the artery and vein on the left side of her face.

In the third surgery, Dr. Azizzadeh checked on the muscle that was previously transplanted to make sure it was healthy and functioning properly. He also repositioned some of Gracie’s tissue to create more symmetry with the other side of her face and to redefine her cheeks.

Today, Gracie is able to smile and make facial expressions that are much closer to her normal facial movements prior to paralysis.

CASE NO. 5

A young minor league baseball player developed facial paralysis following a traumatic injury after being struck by a car in 2008. The patient was left with severe damage to the facial nerve, resulting in complete paralysis on one side of his face as well as brain trauma, a collapsed lung, broken bones, and a fractured skull.

The patient was extremely eager to get back on with his life and continue his career as a professional baseball player. Neither facial paralysis surgeries performed jeopardized his playing ability.

Treatment Plan

Surgery 1: The patient and family initially decided to undergo a hypoglossal facial nerve transfer due to the general quicker recovery to accommodate his athletic training and baseball schedule. A hypoglossal facial nerve transfer involves surgically suturing the paralyzed facial nerve to another working nerve to allow neural input, therefore improving facial reanimation. The patient saw a tremendous improvement, though he decided that continuing with a second surgery would bring the best results.

Surgery 2: The patient, his family, and Dr. Azizzadeh decided upon a Gracilis free flap surgery for the best chance of full facial reanimation and improved symmetry. The Gracilis free flap surgery involves harvesting the gracilis muscle, artery, and nerve from the patients leg and transplanting it to the paralyzed facial nerve. This procedure was extremely successful in restoring the patients smile and creating a more balanced facial appearance.

The patient went on to make an excellent recovery and was able to continue with his athletic career. Physical therapy and neuromuscular retraining was completed to bring optimal results in facial reanimation.