BACKGROUND:Disorders of the facial neuromuscular system result in significant functional impact on expression, speech impairment, and oral competency, which can be particularly challenging to the reconstructive surgeon. Recovery is age-related with only 37% full-recovery in patients over 65. Therapy for facial nerve paralysis is similarly age-related, and dependent upon the magnitude of deficit and time from injury as motor end units only retain their ability to recover during a finite 24 month period. Currently accepted treatment regimens include a reconstructive ladder of neurotoxins, gold weights, static slings, nerve grafts, dynamic flaps and muscle transfers. Planning the ideal therapeutic option is more complicated than simply picking from a list of acceptable procedures for facial reanimation. Fractionated and uncoordinated treatment is detrimental to optimal care. Negative factors affecting facial nerve reanimation therapy such as the wrong procedure at the wrong time can be as injurious as a delay in care, especially for physical therapy. This leads to average national rates of recovery of only 30% on the Facial Grading System for delayed presentations. The purpose of this study was to implement a new algorithm for facial paralysis reconstruction combined with techniques in physical rehabilitation in order to improve and expedite functional recovery. We present a reconstructive “Rubik’s Cube” based upon three criteria, age which reflects the potential for regeneration, the level of deficit, and time from injury which indicates the window for recovery.
METHODS: This was a prospective study of a consecutive forty-five facial nerve palsy reconstruction patients between 2005 and 2009 from the senior author’s practice. Patients were evaluated for functional disability and deficit using both the House-Brackman Classification and the Facial Grading System (FGS) by evaluating resting symmetry, symmetry of voluntary movement, and synkinesis. Following a systematic algorithm of reconstruction, patients were then reevaluated at weekly intervals. Novel rehabilitative techniques included manual therapy, cranial release, PENS, mirror box, and double-dime therapy.
RESULTS:Patient ages ranged from 9 to 78, mean of 50.2. Most common etiologies at presentation included Bell's Palsy (64%), neoplastic sequelae (13%), traumatic (11%), and iatrogenic causes (4%), and time from injury ranged from one month to 23 years with a mean of 14 months. Patients required an average of 2.4 surgical interventions and an average of 16 (5-68) weekly physical therapy sessions. Patients demonstrated an average recovery of 62.5% (pre 44, post 71.5) in functional improvement of FGS with a 27% decrease in disability score.
CONCLUSIONS:We report improvements in the functional recovery of facial paralysis. Age of the patient and timing from injury are critical in surgical decision-making. Acute and intermediate (12 months), or late presentation (24 months) are significant indicators of potential for recovery. The window for physical therapy may have ceased when significant muscle atrophy has occurred. Facial nerve reanimation patients benefit from physical rehabilitation at all phases of their therapy. Physical therapy has a significant and lasting benefit to facial paralysis.