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Facial Plastic And Reconstructive Surgery Specialist

Baltimore, Lutherville, Maryland 410. 502 .2145
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                   Restoring facial movement & balance

 FPRC                              with innovative techniques

 FACIAL

 PARALYSIS

 RESTORATION

 CENTER

                                                                                                                                                                 

At the facial paralysis restoration center, experts who specialize on the face and the facial nerve combine years of experience to treat individuals who have injured their facial nerve. Injury to the facial nerve is a common problem that can result from various causes including Bell's palsy, trauma and cancer. It may also be present at birth. Regardless of the cause, the lost tone and  impaired movement  that follows may affect eye closure, smile, nasal breathing and speech. The psychological toll can be severe.  Dr. Boahene and colleagues at the facial paralysis restoration center have years of experience treating facial paralysis patients with state of the art techiqnues that they have  refined. Dr. Boahene has written several book chapters and scientific articles on facial paralysis. He has given lecturers at national and international conferences on methods of restoring the paralyzed face."Our goal for all patients with facial paralysis is to restore movement to the face that is controlled, symmetric and spontaneous". Recognized as an innovative surgeon, some of the contemporary techniques in facial reanimation were pioneered or refined by Dr. Boahene. Click below to learn more about Dr Boahene.

 

 

 

 TREATMENT OPTIONS FOR FACIAL PARALYSIS

 

Neuromuscular Retraining

Neuromuscular reeducation (therapy): working with our specially trained physical therapist using specific facial exercises, one can regain facial balance by suppressing unwanted movements while enhancing desired facial movements. This therapy is aided by video recordings of desired facial movements such as a learned smile in a system known as self-modeling and social implementation.

 

Targeted chemodenervation with injection

The botulinum toxin neuropeptide can be injected into specific muscle groups to help correct assymetry, muscle spasms, over contraction, synkinesis and is also used to facilitate the results of physical therapy.

 

Highly selective neurectomy

In selected cases, of synkinesis, nerve branches reponsible for the unwanted facial movement or spasm are resected. The facial nerve is first explored and isolated. The branches are stimulated and the associated movement recorded. The nerve branches are then tagged through tiny incision in the skin. With the patient awake, the nerve fibers resposible for the undesirable synkinetic movement of contaction are divided.

 

Static reanimation ( facelift, eyelid sling, midfacelift, Fascia lata slings)

The droopiness seen in the paralyzed face can be corrected with various procedures that even out the face and actually helps the face look younger. Brow lift procedures even out the droopy brow correcting the angry look. it also releave strain of the eyelids

Facelift tighthens the paralyzed muscles and improves symmetry of the face. The droopy cheek is sometimes lifted ( midface lift) to help support and suspend the lower eyelid which improves eye closure.

Platinum chain eyelid implants are flexible low profile implants that we place within the upper eyelid to aid in eye closure. Because of their low profile nature, they are usually invisble where they are implanted Eyelid suspension using free fascia slings or temporalis muscle slings helps suspend the retracted eyelids up which aids in eye closure, tear distribution and thus reducing excessive tearing. Combines with spacer graft( tissue grafts placed within the lower eyelid), eyelid suspension techniques ( medial and lateral canthopxey) are key in protecting the eye from irritation, drying and ulceration.

 

Selective myectomy

Commonly used to correct asymmetric movement of the paralyzed lower lip that results in a distorted sile. In this procedure, a small segment of the active lower lip muscle the pulls the lip down in an unbalanced manner is removed. This results in a more balance symmetric lower lip when smiling. We selective method after a trial of botulinum toxin injection.

 

Dynamic muscle and tendon transfer procedures ( temporalis tendon transfer, diagastric muscle  tendon transfer).

Tendon transfer procedures are common in hand surgery. We have used the same principles to design minimally invasive techniques from transposing the temporalis tendon to acheive immediate improvement in facail symmetry and to improve smile after facial paralysis.With this special and minimally invasive technique that we have helped advance, we are able to restore movement to the face and allow one to relearn the ability to smile. This is one of the most rewarding procedures we perform for facial paralysis because the result is almost immediate. Infact, with muscle stimulators, we can record movement of the face minutes after the procedure is completed. The patient then learns to harness the power of the transfered temporalis muscle for smiling. Read more about the minimally invasive temporalis tendon transfer by Dr. Boahene. There are important biomechanical principles that guide the successful transfer on muscle tendon units. These principles must be carefully adopted to ensure optimized movement after a T3 ( temporalis muscle tendon transfer procedure). Read more about Dr Boahene's publication on muscle transfer correction of facial paralysis.Nerve grafting ( facial nerve-hypoglossal nerve, masseter to facial nerve transfer, cross facial  nerve grafting).

In cases where the facial muscles are determined to be electrically viable, the facial paralysis may be reversed with a nerve graft procedure. The nerve graft supplies a new source of nerve fibers (axons) that grow through nerve channels to the facial muscle to restore tone and movement. Nerve sources include the hypoglossal nerve, the masseter nerve and the facial nerve on the unparalyzed side of the face. Excellent result may be obtained from each of these methods with timing of intervention being the most critical factor. We have been able to restore movement using nerve grafting techniques in partial paralysis cases that have been present for 2 to 20 years. In these longstanding paralysis cases, we were able to determine that, although the paralysis was old, some intact nerve fibers were able to keep the facial muscle alive leaving them electrically responsive and thus reversible. In complete paralysis of shorter duration, the results are predictable and we seen recovery as early as 4 months following the surgery. We select which donor nerve after carefully considering the goals and individual patient attributes.

 

Dr, Boahene has pioneered a minimally invasive method of transfering the masseter nerve to the facial nerve for facial reanimation.

    
The subzygomatic triangle by Dr. Boahene Through a small incision that leaves minimal scar, the masseter nerve is identified ( nerve seen under yellow band. Notice that the work area is very small which minimizes swelling and scar.  Using an endoscope through this small opening, we are able to trace a long segment of the masseter nerve (average 3cm). The masseter nerve is then transferred to the facial nerve under high magnification and carefully connected to the facial nerve using microsurgical techniques 

 BeforeAfter After 
   

3 months after complete facial

paralysis

4 months after masster nerve

transfer to the facial nerve showing

symmetry at rest. 

4 months after masster nerve

transfer to the facial nerve showing

excellent, natural and unstrained smile. 

 

 

 BeforeAfter  Before  After 
     
 Results after hypoglossal nerve transfer to the facial nerve for correction of facial paralysis Results after hypoglossal nerve transfer to the facial nerve for correction of facial paralysis 



Upgrading partially recovered facial nerves

An important concept in facial paralysis treatment is the ability to improve nerve and muscle function in individuals who have incomplete facial nerve recovery or paralysis. The typical case is a patient who develops Bells palsy and recovers only partially. They have improved symmetry but an asymmetric smile. The challenge is to improve their smile without disturbing the partial recovery they regained. We use a technique called "supercharging" whereby through nerve grafting techniques more movement is restored to the smile muscles while preserving the partial gains.

 

 

  
 

Improved smile following a nerve super charge procedure to correct incomplete recovery of facial paralysis. Facial paralysis resulting from Bells palsy or surgery can recover fully without residual asymmetry. Occasionally, the recovery is incomplete.  This young lady had surgery to remove a brain tumor (acoustic neuroma). She had complete paralysis of her face which recovered partially after one year.  At rest, her face was symmetric but  crooked when she smiles.  To improve her smile as well as eyelid closure a supercharge procedure was performed. The goal of a supercharge procedure is to upgrade the nerve signal to the partially recovered or paralyzed facial muscles without adversely affecting the  regenerated nerve fibers. The nerve transfer supercharge technique by Dr. Boahene preserves the partial recovery but upgrades the nerve signal to facial muscles resulting in improved movement, tone and a better smile. Results shown here is 3 months after the supercharge signal upgrading surgery. The surgery is done through a small incision placed in front of the ear crease. The procedure takes about 3 hours to perform and patients are usually discharged home the same day.


Free muscle transfer. ( gracillis muscle, vastus lateralis muscle, pectoralis muscle, serratus muscle transfer, latissimus musle transfer)

When nerve repair or muscle tendon transfer is not feasible, we have the option of transplanting a muscle and nerve from other parts of the body to the face; connect the nerves to other nerves in the face to restore facial movement. The muscle being transferred does not leave a noticeable deficit. Common donor sites for transferring muscle include the thigh, chest wall or back. Presently we commonly transfer the gracillis muscle to correct longstanding facial paralysis. This procedure has been refined over many years and can now yield predictable results. Specific techniques we use to improve results include transferring a small segment of the gracillis muscle to minimize bulk. We can perform this procedure in a single stage fashion using the masseter nerve to power the gracillis muscle. In a 2 stage fashion, we use a combination of a cross facial nerve graft that borrows nerve fibers from the normal face and the masseter nerve to produce a reliable result. There are other muscle besides the gracillis that may be transferred. We are constantly involved in research looking at other donor muscles and methods of enhancing results in facial muscle transfer.

 

   

The thin muscle segment is segment of the gracilis muscle can be harvested with its artery, veins (white arrow) and nerve (blue arrow). Guided by nerve stimulation, the muscle is carefully debulked. The thin muscle segment is transplanted to replace the smile muscles (large blue arrows) to restore symmetry and smile. In a single stage gracilis transfer, the nerve is connected to the masseter nerve. In a 2 stage gracilis transfer procedure; we first perform a cross facial nerve graft followed 6 months later by the muscle transfer.  In selected cases, we innervated the gracilis with both a cross facial nerve and masseter nerve. To achieve a nice result, it is important to apply the biomechanical principle of muscle tendon unit transfer. The vector of muscle contraction, site of muscle insertion, tension of muscle insertion and a bed of fat on both sides of the transplanted gracilis muscle are all important technical details essential in achieving a muscle that glides smoothly to restore a nice smile. 

 

Synkinesis

One of the most bothersome consequences of facial paralysis (Bells palsy) is synkinesis. Synkinesis is the unwanted movement that accompanies a desired movement and is usually a sign of aberrant regrowth of the facial nerve. A common example is eye closure when one smiles or laughs. The reason  why this occurs  following nerve injury varies and includes; nerve fibers reaching the wrong target, changes in the myelin sheath that covers a regenerating nerve and changes in nerve fiber connections in the facial nucleus within the brain stem.  Treatment options for facial synkinesis include nerve-muscle retraining aided by biofeedback techniques, selective disruption of nerve signals to the muscle group one desires to suppress either by injections (chemo denervation with botulinum neuropeptide), nerve division (neurectomy) or selective removal of muscle (myectomy). The most distressing form of synkinesis usually involves the eye muscles and can be severe enough to obstruct vision. The involved eye looks smaller and cosmetically unappealing. We use a combination of the above methods to achieve long-lasting improvement. See before and after photos of surgical correction of synkinesis and blepharospasm of the eye after Bells palsy.

 

 

Platysmoplasty

The platysma muscle is a broad thin muscle which is an extension of the facial muscles in the neck. It is innervated by the facial nerve and acts to pull down the lower face when grimacing. During recovery of an injured or repaired facial nerve, precious fibers of the regenerating nerve may end up in the platysma muscle diverting nerve fibers from desired targets in the upper face. In addition to this, cross talk between these platysma fibers and nerves to the midfacial and eyelid muscles may contribute to diminished lip evelation during smile and synkinesis. This  may also result in tightness in the face and can occasionally be painful. Dividing the offending platysma fibers ( platysmoplasty) has the potential of immediately relieving the facial tightness, improving lip movement and minimizing synkinesis. Platysmoplasty for facial paralysis can be done under local anesthesia and is usually well tolerated.

 

 

Facial weakness in FSH dystrophy 

Facioscapulohumeral (FSH) dystrophy is a common muscular dystrophy in which there is progressive weakness of the face, upper arms and shoulder regions as well as the legs. The symptoms of FSH dystrophy may appear during childhood with severe facial and limb weakness or develop slowly and gradually in adulthood with difficulty such as eye closure, lifting or tripping. The disease is caused by degeneration of muscle due to a specific chromosomal deletion. This deletion is inherited from one generation to the next. FSH dystrophy is the third most common dystrophy with an estimated prevalence of 1 in 20,000. In spite of this high prevalence, research and treatment options are at a suboptimal level.  We are collaborating with neurologists and therapist who focus in the care of this disease. We have focused on facial manifestation of FSH dystrophy and made several observations that have lead to treatment options for our patients.The muscles of facial animation are small skeletal muscles that mostly originate and insert on the soft tissues of the face. Facial expression is an important part of human communication allowing us to reflect emotions and project non-verbal cues. The facial muscles also support the facial skin and fat giving it shape and form.  Blinking, whistling, blowing out candles, drinking from a straw are simple day to day actions that depend of the fine action of the facial muscles. These functions are severely affected when the facial muscle become progressively weak as seen in FSH dystrophy.FSH dystrophy patient often complain of changes in their speech. They are unable to generate the intraoral pressure to pronounce plosive sounds such as "P" "B". As the facial muscle become weaker, midfacial fat descends the corner of the mouth turns downwards giving a falsely sad appearance. Read more.

 

 


Scientific articles, Book chapters 

 

Minimally Invasive Temporalis Tendon Transposition

Boahene and colleagues describe a minimally invasive version of the temporalis tendon transposition, which is used for immediate dynamic reanimation in patients with longstanding facial paralysis. They present the surgical technique and analyze their results. Full Text » Video Supplement

 

Dynamic muscle transfer in facial reanimation.

Kofi Boahene, MD, FACS

 

Dynamic muscle transfers offer the hope of improved facial support and symmetry, with volitional movement. These are most commonly employed for reanimation of the oral commissure to produce a smile. In addition, muscle transfers have been used successfully to reestablish eye closure. Facial paralysis of long-standing duration presents challenges quite distinct from paralysis that is managed early after onset. It is in this situation, most commonly, that dynamic muscle transfers are used. In this respect, the alternative is free tissue transfer. Each of these two options have advantages and disadvantages.

 

Temporalis tendon transfer as part of a comprehensive approach to facial reanimation.

Byrne P, Kim, M,  and Boahene K, Millar, J and Moe C 

 

OBJECTIVE: To report an approach to facial paralysis in patients for whom dynamic adjacent muscle transfer is determined to be the best treatment option. METHODS: Retrospective review of 7 consecutive patients who underwent orthodromic transfer of the temporalis muscle insertion for the treatment of long-standing facial paralysis. Patients underwent facial-retraining physical therapy before and shortly after the procedure. Outcomes measured included patient satisfaction, objective measurements of oral commissure elevation with smiling, and physician grading of preoperative and postoperative patient photographs. Medical records were reviewed for complications. RESULTS: Patient satisfaction was high, with a mean score of 8.5 (possible score of 10). Four patients were physician graded as excellent to superb. The other 3 patients were rated as having good postoperative results. Movement was identified in every patient and ranged from 1.6 to 8.5 mm, with mean movement of the oral commissure of 4.2 mm. One patient developed postoperative salivary fluid collection that required drainage. CONCLUSIONS: Temporalis tendon transfer is a relatively easy procedure to perform that has distinct advantages compared with other forms of facial reanimation and provides very good results. This procedure results in improved form and function, may often be performed in a minimally invasive manner, and eliminates the facial asymmetry typically produced by temporalis transfer.

 

 

Facial nerve paralysis secondary to occult malignant neoplasms.

Kofi Boahene, MD FACS et al.

OBJECTIVE: This study reviewed patients with unilateral facial paralysis and normal clinical and imaging findings who underwent diagnostic facial nerve exploration.Study design and setting Fifteen patients with facial paralysis and normal findings were seen in the Mayo Clinic Department of Otorhinolaryngology. RESULTS: Eleven patients were misdiagnosed as having Bell palsy or idiopathic paralysis. Progressive facial paralysis with sequential involvement of adjacent facial nerve branches occurred in all 15 patients. Seven patients had a history of regional skin squamous cell carcinoma, 13 patients had surgical exploration to rule out a neoplastic process, and 2 patients had negative exploration. At last follow-up, 5 patients were alive. CONCLUSIONS: Patients with facial paralysis and normal clinical and imaging findings should be considered for facial nerve exploration when the patient has a history of pain or regional skin cancer, involvement of other cranial nerves, and prolonged facial paralysis. SIGNIFICANCE: Occult malignancy of the facial nerve may cause unilateral facial paralysis in patients with normal clinical and imaging findings.

 

More publications on facial paralysis by Dr. Boahene
           Principles of muscle tendon unti transfer for facial reanimation

           Masseter nerve transfer in facial reanimation

           What faces reveal

Before and After photos : facial paralysis surgery 

 Before After  BeforeAfter 
    
 Hypoglossal nerve transfer

                            Hypoglossal nerve transfer

 

 BeforeBefore  After
   
 8 months after redirecting the injured facial nerve from behind the ear into the neck with side grafting into the hypoglossal nerve ( facial to hypoglossal transposition) using a single anastomisis. Notice the restored facial tone, symmetry and smile. Upper blepharoplasties were performed at the same time.

 

 BeforeAfter  After   Before  After 
      

 One year results after hypoglossal nerve grafting of a completely                               Results after trasfer of hypoglossal nerve for facial paralysis

paralyzed facial nerve occuring 16 following  brain surgery.

 BeforeAfter 
  
Surgical correction of blepharospasm and eyelid droop resulting from synkinesis after Bells palsy. Note the improve eye symmetry.  

 

 BeforeAfter After 
   

After successful removal of  acoustic neuroma , complete facial paralysis may occur.

In a majority of cases, the face recovers spontaneously if the facial nerve was kept intact.

In some cases , the nerve does not recover and alternative measures have to be pursued in

 a timely manner to restore facial movement. In this patient, the injured facial nerve did not

recover after waiting for almost a year. An electromyogram (EMG) was performed to detect

any electrical signs of facial muscle recover. With the confirmed absence of recovery, the

injured facial nerve was re-routed and conneected to the side of the hypoglossal nerve in a

single procedure. Facial movement was restored within 5 months and became stronger over

time. The hypoglossal nerve normally moves the muscles of the tongue. Similar to  facial

muscles, tongue muscles are capable of multiple movements in various directions and can

be adapted to help power the paralyzed face. In addition, the hypoglossal nerve has neural

connections with the facial nerve network at the level of the brain making it a reasonable

substitute or helper to an  injured facial nerve.  Dr. Boahene commonly combines the

 facial - hypoglossal nerve connection procedures with a crossfacial nerve graft which

recruits facial nerve axons from the normal face resulting in dual innervation of the paralyzed

 face  and a synchronized spontaneous smile. These procedures are performed with minimal to

no morbidity to the normal face and tongue. The timing of these surgeries are essential since

 the longer one waits to intervene the less predictable the outcome. Read the published abstract

of our study on this subject  on our experience at the Johns Hopkins hospital.

  

 
 BeforeAfter After 
   
Right sided congenital facial paralysis. Note the asymmetric smile. A temporalis tendon transfer procedure was perfored in a minimally invasive manner (minimally invasive temporalis tendon transfer MIT3) through a small 2 cm incision hidden under the cheek. During surgery, I use a muscle stimulation techinque I developed to help guide and set the transfered musle at the appropriate length and tension in order to gain the desired movement. At the end of the surgery , we stimulate the transferred muscle and detect facial movement, simulating a smile. This is one of the most rewarding procedures I perform since a patient walks in without a smile and wakes up with one. Physical therapy to adopt and master the newly acquire smile is very important for success. Click to read more about our published paper on temporalis tendon transfer

 

 BeforeAfter 
  

Results after temporalis tendon transfer using a minimally

invasive approach. Notice how smile is restored to the paralyzed

face. When facial paralysis has been present for a long time and

nerve grafting is not possible the temporalis tendon transfer

procedure is able to restore movement and a smile almost

immediately after the surgery. Other patients who will benefit from

this procedure include Mobius syndrome patient, congenital

facial paralysis, paralysis after extensive trauma, radical parotid

surgery  for cancer. 

 

   

 Patient with a history of acoustic neuroma surgery. She had no return of facial nerve function after 18 months of observation. She underwent facial nerve to hypoglossal nerve grafting using a greater auricular nerve graft. The temporalis muscle tendon transfer procedure was performed in  a minimally invasive approach. Nine  and 12 month post-operative pictures are shown here. Notice the improved brow symmetry. A browlift was not performed. She also has improved eye closure and lower eyelid position after a lower eyelid fascia sling procedure. Her nasal breathing has improved. Also notice the enhanced symmetry of the lower face at rest and during a controlled smile. She now has a more defined neck line with no jowling. She has excellent tongue movement. Patient directed neuromuscular re-training (physical therapy) is an important part of our facial paralysis rehabilitation protocol.

  
  
Results after facial nerve to hypoglossal nerve grafting. In this procedure nerve fibers from the hypoglossal nerve which usually supplies the tongue fibers are re-routed to grow into the facial nerve. This results with improve tone in the facial muscles which then gradual pull up the paralyzed face to provide a symmetric face. With practice a symmetric smile is acquired. I sometime with connect a nerve graft from the nrmal side of the face to the paralyzed . These two source of nerve helps even out the face and makes it easy to control both sides of the face. Because we preserve the bulk of the tongue nerve, tongue movement is not affected.

   

 Results following facial nerve grafting. This patient with recurrent parotid

cancer had the entire right sided facial nerve removed resulting in complete

facial paralysis. His facial nerve were grafted at the time of the cancer surgery

Movement was restored within 3 months and has continued to improve.

                                       
  
 This  Middle Eastern male had a brain stem surgery which resulted in complete paralysis of the right face. 14 months after the surgery, there was no recovery. He travelled from the Middle East to see Dr. Boahene who designed a facial reanimation surgery that was performed in two stages. Durging the first stage, the injured facial nerve on the right side was dissected from behind his ear (mastoid) and re-routed to his hypoglossal nerve. A sensory nerve (sural nerve) graft measuring 15 cm was borrowed from his leg and connected to a branch of the normal facial nerve on his left face (crossfacial nerve) and tunnel into the paralyzed right face. After 5 months, he noticed movement of the paralyzed face which improved overtime. One year after the first stage surgery, a small second stage surgery was performed where the crossfacial nerve graft was connected to branches of the recovering right face. This second stage procedure was performed such that the movement he had already recovered was preserved . The crossfacial nerve graft provided move neural input and synchronized both sides of his face when he smiles. Besides the improved smile, recovery of the eyelid muscles allowed him to  close his eyes better.

    

 

Case sample: Facial to hypoglossal nerve grafting performed 16 months after primary surgery for acoustic neuroma.

 

 

 

Contact us at 410.502.2145 or email for a facial

paralysis consultation









 

 Out-of-state and international patients

                                                                                  

 

 

 

 

 

 

 

 

 

 

We encourage patients living close to our offices in Baltimore and the Johns Hopkins hospital to come in for an in-person consultation. Patients residing out-of- state and international patients can start this process with a virtual consultation with Dr. Boahene. For a virtual consultation, please submit a brief history of your paralysis, any treatment you have had and the specific improvements you are seeking. Also submit photos of your face only, showing your face at rest, with eyes closed, smiling and grimacing. A short video clip showing these facial movement, if available, is very helpful. Once Dr. Boahene reviews your information, an onilne consultation will be arranged.

 

Dr. Boahene presented a course on current techniques in reanimatng the paralyzed face. Dr. Boahene will be presenting updated techniques in correction of facialparalysis in 2011.

 

 

 

 

 

 

 

 

 

 

 

 

Publications 

 

Minimally InvasiveTechnique Appears Helpful to Reanimate Facial Paralysis ScienceDaily(Jan. 18, 2011)A procedure involving only one small incision and no major modifications to bone can be used to transpose a tendon and appears helpful in reanimating the lower face after paralysis, according to a report in the January/February issue of Archives of Facial Plastic Surgery, one of the JAMA/Archives journals.Read more

 

Fixing the crooked smile.Read about one young child's journey to achieving the perfect smile.

what faces reveal.pdfHow facial paralysis affects how we are perceived. Read more

 

 

A Model for Early Prediction of Facial Nerve Recovery After Vestibular Schwannoma Surgery.

Rivas A, Boahene KD, Bravo HC, Tan M, Tamargo RJ, Francis HW.

 

Source

*Department of Otolaryngology - Head and Neck Surgery, †Department of Biostatistics, Bloomberg School of Public Health, and ‡Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, U.S.A.

E: To identify early predictors of long-term facial nerve function after vestibular schwannoma resection.

PATIENTS: Subjects with facial nerve weakness despite anatomic preservation of the nerve after removal of vestibular schwannoma.

Abstract

OBJECTIVE: To identify early predictors of long-term facial nerve function after vestibular schwannoma resection.

STUDY DESIGN: Retrospective chart review.

SETTING: Tertiary referral center.

PATIENTS: Subjects with facial nerve weakness despite anatomic preservation of the nerve after removal of vestibular schwannoma.

INTERVENTION: Surgical resection of vestibular schwannoma.

INTERVENTION: Surgical resection of vestibular schwannoma.

MAIN OUTCOME MEASURE: Facial function after 1 postoperative year. Independent variables included patient demographics, presenting symptoms, tumor size and location, and serial postoperative function within the first year.

RESULTS: Among 281 patients with postoperative facial weakness, 81% improved to a House-Brackmann (HB) III or better (good outcome) after 12 months of recovery, whereas 12% remained HB IV or worse (poor outcome). For patients starting with HB V or VI function, recovery rate was the most reliable predictor of poor outcome after 1 year. The resulting predictive model using rate of functional improvement as the independent variable was found to anticipate poor outcome before 1 year in more than 50% of cases with 97% sensitivity and 97% specificity. Although associated with facial nerve outcome, tumor size, tumor vascularity, preoperative facial function, age at surgery, and ability to stimulate the nerve intraoperatively did not contribute significantly to the predictive model.

CONCLUSION:  The rate of recovery within the first postoperative year serves as a useful early predictor of long-term facial nerve function. We present a novel predictive model using rate of recovery that can be used to select candidates for reanimation surgery sooner than the traditional waiting period of 1 year, potentially improving the outcome of this intervention.