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Journal of Neurologic Physical Therapy:
doi: 10.1097/NPT.0b013e3181cfc324
Case Study

Rehabilitation Postfacial Reanimation Surgery After Removal of Acoustic Neuroma: A Case Study

Wilson, Christopher M. PT, DPT, GCS; Ronan, Susan L. PT, DPT, PCS

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Author Information

Department of Physical and Occupational Therapy (C.M.W.), William Beaumont Hospital, Troy, Michigan; Department of Physical Therapy (C.M.W.), School of Health Sciences, Oakland University in Rochester, Michigan; and Department of Physical Therapy (S.R.), New York Medical College, School of Public Health, Valhalla, New York.

Address correspondence to: Christopher M. Wilson, E-mail: Christopher.Wilson@beaumonthospitals.com.

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Abstract

Background and Purpose: Facial paralysis can have a significant negative impact on an individual's social, physical, and emotional well-being; however, little information has been reported on the efficacy of physical therapy interventions for this condition. The purpose of this case study was to describe the details of a physical therapy evaluation and intervention for a patient who underwent facial muscle transfer after resection of acoustic neuroma.

Case Description: A 29-year-old woman underwent left-sided facial reanimation surgery, which included transplantation of the temporalis muscle and platysma muscle to the corner of the mouth.

Intervention: The patient received 30 sessions of physical therapy that included electrical stimulation, biofeedback, lymphatic drainage, home exercises and facial stretching, and scar management.

Outcomes: The patient exhibited an improvement in the Composite score of the Sunnybrook Facial Grading System from 17 to 41. She was able to regain function of the left side of her face with gains in expressions of smiling, frowning, and puckering, but symmetry was not completely restored. The patient had chronic difficulty with left-sided lymphedema, requiring frequent manual lymphatic drainage.

Discussion: Data from this case study suggest that physical therapy management improves functional outcomes for individuals with postoperative changes in facial motor function from facial reanimation surgery. Further research is required to explore factors that influence the rate and extent of recovery derived from physical therapy interventions.

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INTRODUCTION

Facial paralysis has been described as the loss of unilateral or bilateral motor function as a result of injury to the facial nerve. This leads to an inability to close the eye and paralysis of the muscles of facial expression.1 Facial nerve damage may also occur after acoustic neuroma resections, trauma, brain hemorrhage, birth trauma, and congenital causes, such as congenital bilateral facial paralysis (ie, Möbius syndrome).2,3 The incidence of acoustic neuroma (eg, vestibular schwannoma) is one to two per 100,000 persons, with the median age of diagnosis being 55 years.4,5 Tumor resections in the posterior fossa and at or near the distal branches of the facial nerve can result in the loss of facial nerve function secondary to surgical procedures to resect the tumor.6 Loss of facial motor function results in decreased facial muscle tone and paralysis.7 Other possible sequelae may also occur, such as temporomandibular joint (TMJ) dysfunction, decreased lacrimation, drooling, poor dentition (as a result of poor oral hygiene because of sensory loss), and lip or cheek trauma caused by malocclusion.8 Corneal damage may occur secondary to poor eyelid closure and impaired lubrication of the eye.

The physical and functional complications associated with facial paralysis can also affect an individual's social, psychological, emotional, and physical well-being. Facial paralysis can result in the reduction and inability to express emotions.1 The social and psychological sequelae reported after facial paralysis include guilt, anger, depression, rejection, and paranoia.1,9 Individuals often feel ostracized, and their facial asymmetry serves as a point of social discomfort.8 These emotions may be coupled with the stress of other diagnoses and the resulting treatments.

The treatment options for these individuals include surgical interventions and facial muscle rehabilitation. Surgical interventions, termed facial reanimation, are procedures used to improve cosmesis, resting facial symmetry, and functional recovery. The initial therapeutic approach used includes modalities of electrical stimulation and biofeedback. Oral motor stimulation and exercise are also incorporated.10

The goals of facial reanimation surgery are twofold: (1) to restore resting symmetry to the face and (2) to improve voluntary motor control for speaking and expression.11 The ideal candidate is someone with less than one year of facial paralysis. Facial reanimation surgery often consists of two stages. The first stage reinnervates the paralyzed side of the face by means of nerve grafting.12–14 In the second stage of the procedure, muscular connections are made to the grafted nerve. If the denervated muscles are not viable, it is possible to use a muscle transfer to restore movement to the face. The temporalis muscle is harvested and transferred to the zygomatic arch and temporal fascia. The muscle is also sutured to the dermis along the nasolabial crease. In cases of congenital paralysis or Möbius syndrome, split temporalis grafts have been used to restore movement to the upper lip and cheek area. The nerve supply to the temporalis muscle is from the fifth cranial nerve (trigeminal) and is usually not affected by trauma to the facial nerve. The temporalis transfer is performed without the nerve graft surgery.12,13 These patients will need to initiate some jaw clenching to accomplish any facial movement.

Physical therapy for individuals with facial nerve injuries has included facial exercise, electrical stimulation, oral motor stimulation, and biofeedback.15–18 Treatment can begin six weeks after facial reanimation surgery, that is, the muscle transfer stage. Byrne et al10 described physical therapy beginning once a week, progressing to once a month when the patient was able to be independent with a home program and was able to dissociate certain facial motions.

The initial presentation of the surgical site can be swollen, slightly discolored, and tender. Patients will report changes in their oral function secondary to the surgery and swelling. Their presurgical compensatory strategies for articulations, speech, and eating may not be as efficient with the improved nerve supply and muscular alignment. Patients may report biting on foods differently because there may be a new alignment of the teeth and facial structures.19

The new alignment of the musculature will change an individual's proprioceptive feedback for facial movement. Patients require a sensorimotor retraining program to improve their ability to control the transplanted muscle. Patients frequently have difficulty with bilabial sounds such as the “m” in “mother” and particularly in generating force behind phonations for plosive sounds such as the “b” in “boy.” VanSwearingen and Brach20 described facial neuromuscular re-education exercise programs that target facial movement patterns used to improve facial movement and decrease synkinesis. Synkinesis is defined as the presence of inadvertent motion in one area of the face produced during intentional movement in another region of the face.21

Two commonly used grading systems for facial paralysis are the House-Brackmann Facial Nerve Grading Scale and Sunnybrook Facial Grading System. The House-Brackmann Scale was introduced in 1983 and is endorsed by the Facial Nerve Disorders Committee of the American Academy of Otolaryngology.22 Based on the degree of facial function, the patient is placed into one of the six categories (Table 1).23 Although accepted as a standard for clinical practice, the House-Brackmann Scale has not been shown to have strong interobserver reliability.23,24 It has been noted by Croxson et al25 that this is a gross scale not useful for determining small, incremental changes in facial function.

Table 1
Table 1
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The Sunnybrook Facial Grading System has demonstrated sensitivity to changes in facial function with rehabilitation.26–28 This system grades facial Resting Symmetry on a zero to one- or two-point scale, with 0 representing normal symmetry. A five-point scale, where 1 is unable to initiate movement and 5 is a complete movement, is used to grade facial Voluntary Movements, such as forehead wrinkle, gentle eye closure, open mouth smile, snarl, and lip pucker. Synkinesis is graded on a scale of zero to three points, where 0 represents no synkinesis and 3 represents severe synkinesis. Once these category scores are determined, the Composite score is calculated by subtracting the weighted Resting Symmetry score and the Synkinesis score from the more heavily weighted Voluntary Movement score.29,30

The Sunnybrook System is frequently cited in the literature and has been considered to be reliable for this patient population, except for the grading of synkinesis, for which the reliability was rated as low by Coulson et al.30 Although the Sunnybrook System has been reported to be valid,29,31 no studies could be identified that have assessed the validity of the House-Brackmann Scale. The Sunnybrook System has been shown to have good to excellent repeatability, and the House-Brackmann Scale has fair to good repeatability.30,32

Balliet et al33 reported on patients after facial nerve anastomoses and noted functional progress made by the patients with feedback training, behavioral modification, and specific motor retraining, despite varying latencies of time to onset of rehabilitation after the surgical procedure. The authors attributed the progress to the improvement in sensory and motor awareness of the involved side. Mirror training was also used to improve motor control, increase facial awareness, and decrease synkinesis.

Although the use of electrical stimulation for patients after facial reanimation has not been studied, electrical stimulation has been used as an intervention for facial paralysis with the intent to improve motor recovery. Daily use of subsensory stimulation for patients with chronic facial nerve paralysis has been reported to improve motor nerve action potential distal latencies and to be associated with the gain of one grade in the House-Brackmann Scale.34 The application of subsensory electrical stimulation to the hand of individuals with an intact nervous system has been shown to change cerebral blood supply to the associated representational area of the motor and somatosensory cortex, suggesting increased cortex activity.35 Daily use of subsensory stimulation and progression to functional electrical stimulation of the hand may improve muscle tone and increase motor control in individuals who have had a stroke.36 Electrical stimulation, therefore, may aid in the retraining of muscles by facilitating activity in the cortical region representing the face. This may facilitate an alternative mechanism of recovery with electrical stimulation beyond the traditional use of local nerve and muscular stimulation, but further study is necessary. A Cochrane review of the literature related to Bell's palsy showed no significant improvement with the use of electrical stimulation over control or no treatment groups.37

Biofeedback has been used for facial retraining to encourage muscle activity and decrease synkinesis.12 It is particularly helpful to retrain facial movements like lip closure, puckering, and smiling in facial reanimation recovery secondary to the grafted neural supply and muscle transfers. The patient requires training to use these newly grafted muscles and nerves for facial function. Biofeedback has been used to encourage movement and relaxation in muscles. Mirror training has also been used to reinforce muscular control and encourage symmetry of movement in patients after facial reanimation surgery.38

The purpose of this case study was to describe the physical therapy examination, evaluation, and intervention of a patient who received facial reanimation surgery that included muscle transfers to compensate for denervated muscles after acoustic neuroma removal. At the time of writing of this manuscript, no other articles could be located to describe detailed physical therapy interventions and outcomes after facial muscle transplantation for facial reanimation. The patient completed an informed consent before submission of this article. Approval for a retrospective medical record review was sought from the Beaumont Hospitals Human Investigation Committee (Royal Oak, MI). The Human Investigation Committee determined that the study was exempt from full review, and a written Waiver of Review was provided.

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METHODS

Examination
Initial Observation

The patient was a 29-year-old woman referred to physical therapy by her facial reconstruction surgeon five weeks after muscle transfer for facial paralysis. The patient presented with significant swelling and bruising around the left mandibular area and extensive loss of motor function of the muscles on the left side of her face.

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History and Interview

The patient's chief complaint was limited left-sided facial movement and edema, bruising, and pain after facial reanimation surgery. She stated that 11 years before the initial evaluation, she had a diagnosis of hydrocephalus and a large left-sided acoustic neuroma. There is an established relationship between hydrocephalus and acoustic neuroma, with the incidence of hydrocephalus being between 3.7% and 42% in those with acoustic neuroma.39 Excision of the tumor resulted in complete left-sided facial paralysis because the facial nerve was transected near the brainstem. She also experienced complete left-sided hearing loss, slurring of speech, and inability to close the left eye completely. After surgery, the patient received limited speech and physical therapy and had minimal to no recovery of left facial function.

The patient described that five weeks before the current physical therapy initial evaluation, she underwent facial muscle grafting and tissue transplantation. Before facial reanimation surgery, the patient underwent electromyography testing and physical examination, which demonstrated “severe paralysis” of the facial nerve. The surgical report noted that surgery included lifting the left temporalis and platysma muscle origins and transposing the origins to the upper and lower left corners of the mouth, respectively, while attempting to preserve the muscles' innervation. The patient also had a portion of her left tensor fascia lata transplanted to provide an extension from the platysma to the inferior corner of the mouth. A segment of tensor fascia lata was grafted at her left nasolabial fold to improve symmetry of the nasolabial folds. A left hemilip elevation procedure and a left frontalis advancement procedure were performed to assist with restoring facial symmetry. Finally, a small gold weight was placed in the left eyelid to assist with eye closure. Her recovery from facial surgery was unremarkable; however, she was not instructed in any exercises or range of motion until starting formal physical therapy to allow for proper connective tissue healing. The patient stated that she was a bank manager for seven years, and her job involved a high degree of public interaction.

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Tests and Measures
Pain Assessment

The patient reported postoperative pain in her left lateral thigh donor site and left facial region. Pain was assessed with a zero to 10 numerical pain rating scale for ease of administration. Pain was reported to be 3/10 and 5/10 for the left thigh and the left facial region, respectively. Numbness was detected in the left mandibular area as assessed subjectively by light moving touch.

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Initial Observation

On initial observation, the patient displayed healing incisions of ∼2.0 cm along the left nasolabial fold, one crescent-shaped incision along the scalp at the origin of the temporalis muscle, a 2.5-cm incision along the underside of the left chin, and a circumferential incision along the outside border of the left upper and lower lip.

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Active Range of Motion

The patient displayed 20 mm of jaw opening; left jaw lateral deviation was 10 mm and right jaw lateral deviation was limited to 4 mm (normal ranges have been cited as 35–55 mm and 10–15 mm, respectively).40 Jaw active range of motion measurements were taken using a retractable cloth tape measure. Cervical range of motion into forward bending and right rotation was within 80% of normal limits, and right side bending was more limited at 60% of normal limits. Pain was not increased with any of the limited motions in the neck or the jaw; however, stiffness was reported for all of the limited movements. The patient was able to incompletely close the left eye gently, with a 3.0 to 4.0 mm opening remaining.

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Muscle Strength Testing

Muscle strength testing was performed using a 0 to 5 grading scale as described by Hislop and Montgomery.41 Typically, when describing facial muscle strength, specific muscle names would be cited, but because of the extensive denervation and facial muscle grafting, it was determined that a description of the direction of motion would be more meaningful. Grades for the tested facial movement were as follows:

* Closing and protruding the left inferior lip: 2/5

* Closing and protruding the left superior lip: 3/5

* Elevating the left upper lip: 2−/5

* Elevating and drawing the left commissure (corner of the mouth) laterally (smiling): 1+ to 2−/5

* Depressing the left commissure (frowning): 0 to 1/5

* Left forehead or eyebrow elevation: 0/5

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Anthropometric Measurements

To monitor edema, the left side of the face was measured and compared with the right side using the same standard retractable cloth measuring tape and consistent landmarks. No standardized anthropometric facial measurements could be found in the literature; therefore, the therapist devised a method using stable facial landmarks not determined to be affected by this patient's swelling, such as the superior and inferior seams of the earlobe, the nasolabial fold, and the cleft of the chin. The distance from the anterior earlobe to the cleft of the chin was 13.5 cm on the right and 14.5 cm on the left. The distance from the anterior earlobe to the corresponding nasolabial fold was 11.0 cm on the right and 12.0 cm on the left. The distance from the superior ear seam to the cleft of the chin was 16.5 cm on the right and 17.0 cm on the left.

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Palpation Assessment

The patient's left-side perioral skin and subcutaneous tissue were stiff and hypomobile when compared with the right side and initially did not have sufficient flexibility to allow full excursion for a balanced smile as determined by subjective examiner assessment.

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Functional Assessment

The patient reported that her main functional limitations were difficulty with smiling, eye closure, and lack of overall facial symmetry, all of which affected her interpersonal interactions with the public and her co-workers. She stated that she was just beginning to eat solid foods but was having difficulty because of biting the inside of her mouth and pocketing food on the inside of the left cheek. She also noted increased periods of wakefulness when attempting to sleep on her left side because of increased pain in her face and left thigh.

Two functional grading scales were used to assess function: the House-Brackmann Facial Nerve Grading Scale23 and the Sunnybrook Facial Grading System.29 According to the House-Brackmann Scale, the patient displayed a Grade V (severe) dysfunction, which is defined as only barely perceptible gross motion, asymmetry at rest, no forehead motion, incomplete eye closure, and slight mouth movement. The patient was also graded with the Sunnybrook Facial Grading System and was determined to have a Voluntary Movement score of 40 (normal = 100; range, 20–100), a Resting Symmetry score of 15 (normal = 0; range, 0–20), and a Synkinesis score of 8 (normal = 0; range, 0–15) for a Composite score of 17 (unimpaired facial movement = 100).

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Evaluation

Examination identified commonly expected postsurgical changes such as pain, edema, difficulty eliciting muscular contraction of the grafted muscles, and TMJ active motion limitations. The patient arrived in physical therapy with a prescribed home exercise program and recommendation for use of neuromuscular electrical stimulation (NMES) from the surgeon. To target the appropriate muscle groups and avoid synkinesis during exercise, facial exercise retraining augmented by biofeedback, including exercising in front of a mirror and surface electromyography (sEMG), was deemed to be an optimal approach. The patient had significant soft-tissue restriction to the left facial skin and subcutaneous tissue, which required restoration. Unless perioral tissue flexibility was restored, the patient's facial motion would be restricted despite underlying facial muscle strength. In addition, it was anticipated that the patient would have difficulty with chronic lymphedema because there are several lymphatic tracts around the mandible and anterior neck. It is likely that these tracts were disturbed during surgery, and the patient would possibly require manual lymphatic drainage (MLD) massage as described by Zuther.42

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Diagnosis

Based on the American Physical Therapy Association's Guide to Physical Therapist Practice, the patient was assigned to the Practice Pattern 5F: impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury.43

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Prognosis

It was anticipated that because of the short duration of TMJ immobilization postoperatively, joint mobility was likely to return during normal use without the need for joint manipulation. Because no facial nerve reconstruction was noted in the operative report, it was anticipated that there would be no further muscular recovery in the facial nerve innervation pattern (including the forehead and eyebrow region) beyond the patient's baseline status. Restoration of some left perioral motion and function was expected from the newly transplanted muscles around the left corner of the mouth.

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INTERVENTION

The patient received physical therapy for a total of 30 sessions spanning 14 weeks (labeled here as phase 1). Frequency was three times per week for sessions 1 to 18, decreased to two times per week for sessions 19 to 26, and finally decreased to once per week during the final four sessions, with increased emphasis on home treatment during these last sessions. Home treatment included self-MLD and home exercises previously introduced in the clinic. Re-evaluation was performed by the same physical therapist every six sessions to assess progress, including administration of the Sunnybrook Grading System. Each session lasted approximately one hour. A synopsis of the series of interventions is illustrated in Figure 1.

Figure 1
Figure 1
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During the first phase of physical therapy, the patient was instructed extensively in the home exercise program developed by her surgeon and one of the study authors (S.R.). The exercise protocol included word pronunciation and active range of motion exercises, including puckering lips, smiling, smirking, grimacing, eye closure, brow lifting, nostril flaring, wrinkling forehead, whistling, eyebrow elevation and lowering, wrinkling chin, mandibular protraction, winking, opening eyes wide, and platysma contraction for 10 to 20 repetitions performed three times daily. In addition to this home exercise instruction, the patient received MLD massage to the left facial region. Lymphatic fluid was guided in the direction of the thoracic duct to empty into the subclavian vein (Fig. 2). The patient performed active-assistive range of motion with the therapist's manual assistance in the direction of puckering, frowning, and smiling, which was continued for five sessions until the patient was independent in performing these movements.

Figure 2
Figure 2
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At the second session, the patient was provided an Empi 300 PV NMES unit (Empi, St. Paul, MN) and instructed on how to use the machine to electrically elicit muscle contraction with simultaneous volitional effort. Parameters for the NMES included a symmetric biphasic pulsatile current. Two 1.25-in self-adhering circular electrodes were used; one was placed under the left chin and the other over the left zygomatic arch. The placement of the electrodes was in accordance to the surgeon's specifications to stimulate the muscle that was both innervated and transferred for optimizing facial function (Fig. 2). The “on time” (time at peak current amplitude) was seven seconds and the “off time” was 45 seconds, with additional ramp-up and ramp-down times of three seconds each. The frequency was 50 pps and the pulse duration was 200 microseconds. The intensity of the stimulation was increased to the level at which a minimal muscle twitch was observed in the transposed temporalis muscle, which was able to contract because its original innervation was preserved. The patient was instructed to achieve an observable active contraction (1/5 on muscle strength testing) using electrical stimulation and volitionally attempt to smile during the “on” period of the stimulation. In this and subsequent NMES sessions, the stimulation intensity was adjusted to achieve motor activation. The patient was instructed to perform NMES for 20 minutes three times per day. The patient continued home NMES until she was able to elicit consistent volitional contractions of smiling without the assistance of NMES; this was achieved at session 17. At the third session, the patient's home program was modified to omit any eyebrow or forehead exercises because there was no further anticipation of forehead recovery.

By the sixth session, the patient displayed full, pain-free cervical range of motion without need for specific intervention. The patient was able to move the left commissure 1.2 to 1.5 cm into the direction of smiling. Commissure excursion measurements were performed as described by Manktelow et al.44 Also, all previously assessed edema measurements for the left face were within 0.5 cm of the right; therefore, MLD in the clinic was transitioned to the home program. At this time, sEMG biofeedback (Chattanooga Vectra Genisys unit; Chattanooga Group, Hixson, TN) was initiated to better allow the patient to relearn the smiling motion more effectively and efficiently. Three self-adhering circular sensor electrodes (3.17 cm) were placed superior and anterior to the left mandible (Fig. 2). Maximum voluntary contraction level was set according to the manufacturer's instructions. The device was set to elicit an audio tone when the patient was able to achieve a contraction of >80% of a maximum voluntary isometric contraction of the transplanted temporalis muscle. The patient was instructed to hold this contraction for 10 seconds, attempting to elicit the audio tone for the entire time. Initially, a rest time of 30 to 40 seconds was provided between sEMG contractions, but as the treatment progressed, the patient was able to hold a full contraction with only a 20-second rest. The patient completed three sets of 20 repetitions of sEMG isometric contractions each session. The patient performed sEMG in front of a mirror to emphasize symmetry of the smile to avoid synkinesis. The patient's maximum voluntary contraction strength gradually increased over time, and, accordingly, the 80% threshold was readjusted at each treatment to the patient's new maximum. Once the patient was able to elicit a voluntary smile contraction, focus was placed on reducing the effort required to smile. Blocked practice “rapid fire” smiling was initiated with visual feedback from a mirror for a high number of repetitions (50+) to help facilitate decreasing the conscious thought related to learning the new skill of smiling. This blocked practice was performed for three sessions and was phased into random practice interspersed throughout treatment once the skill was acquired, as indicated by Schmidt.45

By session 12, the patient was able to elicit an excursion of the left commissure in a smiling motion to 1.5 cm with maximal effort (according to patient's subjective report) and a trace frowning motion. As a measurement of progress, isometric contraction duration was assessed, and the patient was able to hold her smile for 30 to 45 seconds before fatigue. She continued to have difficulty coordinating a natural bilateral smile; consequently, blocked practice of “rapid fire” smiling was resumed and incorporated in conjunction with random practice of smiling for six more sessions. The patient's edema measurements continued to be stabilized; however, the patient indicated that home treatments were taking considerable time and effort. Thus, MLD massage was reintegrated into the clinic treatment plan at session 14. At this time, increased flexibility was noted in the left facial musculature and subcutaneous tissue, and no pain was noted in the left facial region.

At the session 18, treatment was decreased to twice per week. The patient reported stiffness and discomfort in the left shoulder with a loss of the last 20 degrees of flexion and abduction range of motion; therefore, gentle manual stretching was performed between sessions 20 and 24, at which point full, pain-free range of motion was restored. Glenohumeral stretching used both physiologic and accessory motions. Beginning at sessions 23 and 24, the patient began to report left-sided cervical discomfort and stiffness and occasional cervicogenic headaches for which soft-tissue massage and postural exercises (scapular retraction and cervical retraction) were performed during sessions 25 to 30. These exercises were also added to the home program. At the session 26, the patient's treatment was changed to once per week, with continued refinement and advancement of her home program. During sessions 29 and 30, the patient's facial mobility, function, and Sunnybrook score stabilized; the patient demonstrated independence in her home program, and it was, therefore, determined that she should be discharged from physical therapy. Throughout treatment, the patient cited strong adherence to the home exercises, NMES, self-stretching, and self-MLD; however, no formal tracking log or diary was kept.

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RESULTS

Patient Outcomes: Phase 1

On completion of 30 sessions of physical therapy, the patient reported no pain in any areas and no difficulty with speech, eating, sleeping, or drinking. She also displayed continued equalization of facial edema measurements concurrent with the MLD treatments and with soft-tissue healing and recovery after surgery. It was noted that if the patient missed an MLD home session, there was an associated increase in left facial edema, which reinforced the plan for continued daily MLD techniques. She was able to display a smiling motion of 1.5 to 1.7 cm excursion of the left corner of the mouth (normal range cited between 0.7 and 2.2 cm, average = 1.4 cm)46 and was able to do this motion easily without hesitation, but reported that it was not reflexive and spontaneous. In addition, she was able to display movements of puckering, which was a 1.0-cm medial excursion of the left commissure from its resting position, and a limited frowning motion of 0.3 to 0.5 cm on the left (no normative data available in the literature for these measurements). She reported continued difficulty with grimacing or showing her teeth, but she indicated that this did not frequently affect her daily life. She displayed full TMJ mobility, but continued to lack appreciable recovery of mobility in her left eyebrow or forehead region, which was anticipated, because there were no nerve or muscle transplants to this denervated area. Eyelid closure was described as “movement almost complete” on the Sunnybrook Grading System after this series of visits; however, the patient required eyedrops to prevent corneal dryness. Grades for the tested facial movement were as follows:

* Smiling, closing, and protruding the left side of the mouth: 3+/5

* Frowning: 1+/5

* Elevating the left upper lip: 2/5

On discharge evaluation for phase 1, the patient had a Sunnybrook Composite score of 41 compared with a score of 17 on initial evaluation, an improvement of 24 points. The Sunnybrook Voluntary Movement score improved from 40 to 52, Resting Symmetry score from 15 to 5, and Synkinesis score from 8 to 6. It should be noted that decreased scores in Resting Symmetry and Synkinesis indicate an improvement according to the Sunnybrook System (Fig. 3 and Table 2).

Figure 3
Figure 3
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Table 2
Table 2
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Finally, the patient's initial Grade V (severe) disability on the House-Brackmann Scale improved on discharge to Grade IV (moderately severe) dysfunction. The patient met all of the criteria for achieving Grade III (moderate function) except for “moderate to good forehead function.” One of the criticisms of the House-Brackmann Scale is that low scores in one criterion can unduly restrict the score.30

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Follow-Up and Continued Care

Four months after discharge, the patient returned to physical therapy (phase 2), which was initiated five weeks after undergoing a refinement surgery to her left facial region to enhance symmetry. The surgical procedure included tightening of a muscular sling at the left temple and zygomatic arch, liposuction to the left mandibular area, removal of some deep stitches near the left nasolabial fold, and microdermabrasion to the scars surrounding the left hemilip. The patient participated in physical therapy for nine sessions during one month, which included left perioral facial stretching, scar tissue mobilization, MLD, cervical stretching, and sEMG biofeedback. On phase 2 initial evaluation, the patient had a Sunnybrook Composite score of 27; on discharge, the score was 33, with most limitations in the Resting Symmetry category. Voluntary Movement scores improved from 36 to 52. It should be noted that the patient discharged herself early during this phase of intervention and did not fully return to values achieved at the end of phase 1 on the Sunnybrook scale because she was going on vacation and then having her next surgical revision.

Two weeks after discharge from phase 2 of physical therapy, the patient underwent another revision surgery to remove more scar tissue at the left perioral region and to again tighten the temporal sling to enhance smile symmetry. She returned to physical therapy (phase 3) five weeks after this most recent surgery, which was 10 months after the initial physical therapy visit. During this latest phase of physical therapy, the patient reported setbacks, including edema, dysarthria, cervical spine stiffness, and drooling after her most recent surgery. This phase of physical therapy consisted of 12 sessions during two months. The focus was on cervical spine myofascial mobilization, including suboccipital release, resumption of MLD massage, NMES three times daily at home, scar mobilization, and sEMG biofeedback. On completion of phase 3, the patient returned to the status that was achieved at the end of phase 1, but with minimal further gains in function.

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DISCUSSION

A major focus of physical therapy for this patient was to address the adaptive shortening of the left perioral tissues caused by the long duration of facial paralysis before facial reanimation surgery. This adaptive shortening prevented the patient's newly transplanted postsurgical muscles from generating sufficient force to perform facial excursions against the resistance of tightened soft tissues. Another challenge for this patient was that the temporalis muscle that had been transplanted could only create its newly intended motion by having the patient contract in the motion of its original purpose. The patient had to “clench her jaw” to create a smiling motion on the left side, while coordinating the original facial muscles on the right to create a symmetrical smile. The patient noted that this smile was never quite reflexive and required concentration and volitional effort using the learned technique when the social situation called for a bilateral smile. The precision of motor control was aided by the use of sEMG biofeedback, mirror exercises, and functional exercise to reinforce the muscular control of smiling performance.

The cervical branch of the facial nerve innervates the platysma muscle, and there was no evidence during initial evaluation to show that the platysma had retained innervation, which raised the question why the surgeon transplanted the muscle. An article authored by this surgeon clarified the rationale for platysma transfer: “In the [surgeon's] experience, however, even in cases of denervation of the cervical branch of the facial nerve, the “static” pull of the platysma/autogenous fascia lata extension will effectively evaginate the lower lip and improve lip symmetry and function in repose.”19 Because it was unclear at the time of initial evaluation whether the platysma was innervated, it was determined that the patient's progress would not be hindered by working on the motion of frowning, which the newly transplanted platysma would perform, if only partially innervated.

To some extent, the positive outcomes for this patient were likely related to her adherence to her home program. Achievement of adequate functional outcomes is impeded when a patient is not able to adhere to a home program that requires performance of complex tasks. Subjectively, the patient reported that she was pleased by the ability to elicit a bilateral smile and to achieve increased left-sided expressions, but she continued to pursue operations to improve with cosmesis. These further surgeries did not modify the functioning or esthetics of the face as much as had the initial facial reanimation surgery; each surgical procedure was also associated with some regression in outcomes, prompting the need for further physical therapy. However, with physical therapy, the gains were re-established and no long-term negative effects of the repeated surgical procedures were noted. After phase 3, the therapist discussed with the patient some of the potential adverse effects of multiple surgeries, including keloid scar formation, risk of infection, and regression of cosmesis.

Limitations of this case study include its single-subject retrospective design, which lacks the rigors of a prospective study with a large sample and statistical significance to support treatment effectiveness. Other limitations could include incomplete recording of the details of relevant examination and treatment information and the inability to plan for reporting all information that might later be determined to be important. Another limitation is the lack of digital photographic documentation of progression of facial symmetry. Digital photography was used initially for clinical documentation, but these records were destroyed by a flood at the treating clinic. The use of digital photography for quantifying symmetry and facial excursions is recommended for future studies to provide a graphic record of progress.

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CONCLUSIONS

Facial reanimation surgery, after acoustic neuroma excision and facial nerve transaction, carries with it a number of opportunities and challenges for a patient with facial hemiparalysis. The patient in this case study was able to achieve limited facial motion on the left side in the direction of smiling, puckering, and frowning, where there was no such motion for 11 years. The patient struggled with chronic edema of left cheek and mandible region, which was managed with frequent MLD massage. Although functional recovery was incomplete (according to measurement instruments used) and there remained a marked difference in motion between sides, this residual difference did not have an impact on the patient's speech, eating, or drinking; the patient did, however, report continued perceived limitations in public interactions. The two subsequent surgeries temporarily reversed her functional gains, but additional sessions of physical therapy, concentrating on cervical spine myofascial mobilization, MLD, and daily home NMES, allowed her to recover to the functional levels achieved after the first intervention period.

Implications of this case study include the need for further study of the detailed effects of physical therapy interventions on facial muscle paralysis in surgical and nonsurgical cases. In addition, outcomes of various surgical techniques and use of electrical stimulation for facial reanimation should be compared to determine which procedures are most effective and offer the shortest recovery time.

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ACKNOWLEDGMENTS

The authors thank Elliot Rose, MD, Lisa Galazka, PT, MPT, and Janet Seidell, PT, MPT, for clinical advice during physical therapy management of the patient. They also thank Jackie Drouin, PT, PhD, Ralph Garcia, PT, PhD, and Chris Stiller, PT, PhD, for their critical review of this manuscript.

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