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Facial Plastic And Reconstructive Surgery Specialist

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

 FPRC                              with innovative techniques






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.


Evaluating a facial paralysis patient for reanimation

Depending on the status of the facial muscles, a patients with facial paralysis can be classified into one of 3 clinical categories. The clinical category helps us determine what treatment option is likely to achieve the best outcome.

Longstanding facial paralysis and paralysis present at birth such as Mobius syndrome  are examples of irreversible complete paralysis. In this category, functional facial muscle are absent either from atrophy, trauma or developmentally. Patients in this category often require functional muscle transfer procedures to restore symmetry and smile. Examples of functional muscle transfer procedures are the temporalis muscle tendon unit transfer, gracilis muscle transfer, pectorals minor muscle transfer , etc.

Paralysis present up to 12 months with intact facial muscles are often reversible.Reversing the muscle paralysis usually require nerve grafting procedures that allow new nerve axons to grow into the facial muscle.The new nerve is usually a healthy substitute cranial nerve whose function can be spared without functional compromise. Commonly used substitute nerves are the masseteric, hypoglossal and cross facial nerves. These nerve each have their unique features and may be used alone or in combination to optimize the desired outcome.

Beyond 12 months, reversibility is determined on a case by case basis.

Some patient present with incomplete paralysis  or partial recovery. Treatment options for patient is this category may include nerve grafting or muscle transfer procedures.

Timing reanimation procedures

One of the most important factors that determines the outcome of most facial reinnervation procedures in the duration of paralysis. Facial muscles that have been denervated for shorter periods respond better to reinnervation than those that have been denervated for longer periods. It is not always obvious when to intervene in a completely paralyzed face when there is  hope for spontaneous recovery. However, hope for recovery may unnecessarily delay timely intervention and negatively impact the quality of recovery that will ultimately result. It is commonly recommended that patients with complete paralysis , especially after removal of acoustic neuromas, should wait for one year to see if their faces will recover. We find this 12 month waiting period too long . Our current recommendation is to wait no longer than 6 months. This is based on our extensive study of hundreds of patients. Patients who are likely to recover good facial function show clinical signs of facial improvement within 6 months. Patients who show no signs of recovery within the first 6 months are unlikely to recover satisfactory facial function even after waiting 18 months if no nerve grafting is performed. The reluctance in intervening early is the obvious risk of disturbing any recovering facial nerve or prematurely performing an unnecessary surgery a patient who may otherwise recover spontaneously if given time. The clinician and patient should weigh all factors when making the decision when to intervene. In our published experience, patients who showed no signs of recovery after 6 months and were taken to surgery for facial nerve exploration also had no EMG response when their exposed facial nerve was directly stimulated. We design our nerve grafting surgery to preserve continuity of the main facial nerve branch which ensures that any facial nerve axons regenerating from the brainstem still has a pathway to reach their target facial muscles. Click to read Dr Boahene's publication on the timing of facial nerve grafting in facial paralysis after acoustic neuroma surgery.

Neuromuscular Retraining

As injured nerves recover, there is almost always so aberrancy in their regeneration. This aberrancy  may manifest as too much much function in one area, not enough function in other areas or groups of the innervated muscles moving together  when not desired. Two different muscles ( for example eyelid and smile muscles ) moving unwantedly together is termed synkinesis. The causes of these abberant nerve regeneration and their clinical manifestations vary and include changes occurring within the brain, the facial nerve branches and facial muscles. Reeducating the facial nerve - muscle network is an important aspect of rehabilitating the face after facial paralysis surgery.

Our patients work with our specially trained physical therapist using specific facial exercises to improve their facial balance.  By suppressing unwanted movements, patients learn to enhance desired ones. 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 of Botulinum toxin

Botulinum toxin is a neuropeptide that blocks nerve impulse from activating muscle fibers. The effect of botulinum on muscles are temporary since muscles recover from this near blockade. 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 branch or branches that appear to strongly cause synkinetic movement are identified.The nerve branches are then tagged through tiny incision in the skin.The patient then wakes up from anesthesia.  In the  early recovery period, the previously tagged nerve branches are sequentially blocked with micro injections of lidocaine to see if the synkinesis will resolve without negatively affecting eyelid closure or smile. The responsible  nerve branch is then tied off and divided.

Highlyselective neurectomy is an important technique in the management of difficult to control ocular synkinesis. It is however the last resort procedure after we have exhausted less-invasive procedures.


Highly selective neurectomy is usually performed as an outpatient procedure under general anesthesia. The success of the procedure depends on identifying potential candidate nerve branches  for division while maintaining adequate innervation to allow eyelid function and smile. We sometimes combine  selective neurectomy with selective myectomy (muscle resection) to optimize the outcome.

Selective myectomy

Selective myectomy is the division of an overactive facial muscle that is causing unbalanced facial movement. This is seen in extreme forms of synkinesis. In our practice, the  most commonly divided muscle for facial  balance is the platysma muscle. The platysma muscle is a broad paper thin muscle that starts over the lower face and extends to the clavicle. It is the muscle that tightens up in the neck when one tries to grimace. It acts to pull down the lower face and lip. When hyperactive, a tight platysma muscle tends to pull the lips down and counters the effects of the upper lip elevators needed for a smile. This tug of war between a depressor muscle ( platysma ) and an elevator muscle ( smile muscle ) can result in a strained appearance. Platysma resection is performed through a 2 to 3 cm neck incision and has the potential of relieving part of the facial tightness and imbalance common after Bells Palsy or synkinesis resulting from other causes of facial paralysis. 

Another form of myectomy is the division of the lower lip depressor 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 balanced symmetric lower lip when smiling. 

The hyperactive orbicularis oculi muscle may also be partially resected to partly control the effects of ocular synkinesis and extreme cases of blepharospasm  

We often consider selective myectomy after a trial period of selective 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.

Types of nerve transposition for facial paralysis. 12  hypoglossal nerve, 7 facial nerve, 5 masseteric nerve, 7 to 7 cross facial nerve. While each example of the above nerve transposition can be done alone, occasionally we recommend a combination of nerve transpositions to take advantage of the unique features of each donor nerve.

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


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 

 Hypoglossal nerve transfer

Combination of masseteric nerve graft and interposition facial nerve graft following 
complete resection of the facial nerve with complete reversible paralysis. Recovery
from the masseteric nerve was noted first with restoration of tone and symmetry. This was 
followed by recovery of the interposition facial nerve grafts which restored spontaneous
movement when laughing and smiling.

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 functional muscle transfer. 

( gracilis 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. 


Example of a gracilis flap in a young boy for reanimation of a left facial paralysis. Notice before surgery( left image) there was asymmetry at rest, the lips were uneven and no smile crease defined on the left cheek. After the gracilis flap ( center and right images)  there is excellent symmetry, even lips, no excessive bulk from the muscle flap and restored smile crease and movement of the lip. The gracilis flap was innervated by a cross-facial and masseteric nerves.



Example of a gracilis flap reanimation of a left facial paralysis. Notice smile asymmetry before the gracilis flap ( left images) with unequal teeth exposure (dental show) . After the gracilis flap ( right images)  there is excellent symmetry, even lips, no excessive bulk from the muscle flap and restored smile with equal teeth showing. The gracilis flap was innervated with masseteric nerve only as a single stage procedure.

Gracilis flap innervated by mastered nerve for right-sided congenital facial paralysis in a young boy.

Note result at rest with restore symmetry ( left ), symmetric Mona Lisa smile ( middle ) and

spontaneous smile showing nearly symmetric lip elevation and dental ( teeth) show.


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 eyelid 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.


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.


Neck and facial tightness  from 
Relaxed face and resolved neck
tightness after platysma resection 

 Smile recovery scale

We grade our procedure outcomes  both subjectively and objectively. Our smile recovery scale is based on measures of symmetry, lip elevation and dental show. An abbreviated version of the smile recovery scale is shown here.

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. 

Facelift many be used to improve the neckline, midface  and  the overall facial symmetry. 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, they are usually invisble where they are implanted. Lower 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. Combinations of spacer grafts( tissue grafts placed within the lower eyelid) and eyelid suspension techniques ( medial and lateral canthopxey) are key in protecting the eye from irritation, drying and ulceration.

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.


After  After   Before  After 

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.




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



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. 



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.


Speech and swallowing difficulties are common after facial paralysis involving the lip. Click below to find out about a simple solution we have developed to solve speech and swallowing problems associated with Bells palsy and other forms of facial paralysis .Read more


Coming soon, a personal memoir


Case sample: Facial to hypoglossal nerve grafting 

performed 16 months after primary surgery for acoustic 





Contact us at 410.502.2145 or email for a facial

paralysis consultation



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.



*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.


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.