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Interview with Dr. Daniel Knott: New Procedures for Facial Paralysis

Hear an interview with Dr. Daniel Knott, director of Facial, Plastic and Reconstructive Surgery in Otolaryngology — Head and Neck Surgery, who treats patients with facial paralysis caused by stroke and other conditions such as Bell's palsy.

Audio Interview

Interview Transcript

Introduction

Andrew Schorr:

Facial paralysis, when a person can't move some or all of the muscles on one side of the face, is often caused by stroke or a condition called Bell's palsy. Coming up, we'll hear from an expert who will explain new procedures available to treat facial paralysis. It's all next on Patient Power.

Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr.

Imagine if you couldn't move part of your face and you present your face to the world and it's stiff. You just can't control it. Well, certainly that can happen after a stroke. It also can be an effect of something called Bell's palsy. What do you do about it, how is it tested to see what to do about it, and who can help? What are some of the more advanced procedures?

We're going to learn about that from someone who really knows, and that's Dr. Daniel Knott. He's director of Facial, Plastic and Reconstructive Surgery in Otolaryngology — Head and Neck Surgery at UCSF Medical Center in San Francisco. Dr. Knott, thank you for joining us.

Dr. Daniel Knott:

My pleasure. Thank you so much, Andrew.

Causes of Facial Paralysis

Andrew Schorr:

All right, let's talk about facial paralysis. I think people are most familiar with any kind of paralysis, like on one side of the body, with stroke. That could be an effect, facial paralysis as an aftermath of stroke, right?

Dr. Daniel Knott:

It's quite a common result of stroke, unfortunately. And the facial nerve that moves all of the muscles on one half of the face is the nerve that can be affected, along with half of the body.

Andrew Schorr:

Now, people with stroke, they go through rehab and they gain back various function, trying to get back speech and walking, but they may have this one side of the body paralysis. How do you determine whether rehab is going to be enough or whether you might need a surgical intervention?

Dr. Daniel Knott:

Often if the paralysis is reversible and if the nerve dysfunction can improve all by itself, time alone will really give you the full answer, but you can do some tests to see if you're recovering still or if you've reached the end of the line in terms of improvement. That test is called an EMG, electromyography, where you place a little needle in the muscle of the facial movement, and then you can test to see what kind of function the nerve has.

Andrew Schorr:

Now, I mentioned Bell's palsy. What is that, and where does that come into play as far as paralysis? I have a friend who years ago told me she had Bell's palsy, and sure enough, she could not move part of her face.

Dr. Daniel Knott:

Well, Bell's palsy is a diagnosis of exclusion, which means that you can only call it Bell's palsy once you have excluded all the other possible causes of a facial paralysis. The testing you need to do usually has to be done either with a neurologist or an otolaryngologist, head and neck surgeon, and often involves some scans, such as a CAT scan or an MRI of the face and the brain, just to be sure there's no tumor, growth or mass that could be the cause of the facial dysfunction.

Andrew Schorr:

[There are] some other causes of facial paralysis, too. I had read somewhere, [for example] Lyme disease. What are other causes of facial paralysis?

Dr. Daniel Knott:

What you need to move the face is sufficient brain function and an intact nerve that can communicate the signals down to the muscles of facial expression. If the signal is interrupted anywhere along that course, the face will not work.

So you need to have intact muscles of the face that can be damaged, say, in an automobile accident or some kind of trauma. The nerve has to be intact, and that can be interrupted either by infection, such as with Bell's palsy, middle ear infections, some brain infections, or after surgery. The nerve can be disrupted — either squeezed, stretched or even cut — and then the signals will be interrupted and the face will be paralyzed.

Andrew Schorr:

And some kind of tumor in the brain, too.

Dr. Daniel Knott:

There is a relatively benign tumor in the brain that can commonly cause facial paralysis right where the nerve tends to exit the brain and it goes into the skull bone.

Surgical Approaches

Andrew Schorr:

You're a surgeon. Where do surgery and your expertise come into play, and when do you sort of proceed with that? Tell us about the decision-making, selection of whom you can help and then some of the approaches you do at UCSF to help.

Dr. Daniel Knott:

Well, the most important thing, No. 1, to assess patients with facial paralysis is of course the cause, if you can, and then determine the time frame in which the paralysis came on.

Then one of the very important things is to assess eye function, because interestingly the muscles that open the eyelid are under different nerve control than the muscles that close the eyelid. Facial paralysis patients lose the ability commonly to close the eye. If you can't close your eyelid and protect the eye, the eye can dry out and get infected. If not cared for appropriately, this can lead to blindness.

The key is to determine if patients' eyes are at risk. Often this requires a visit to the ophthalmologist or optometrist. If the white part of the eye ends up being very red, if the tears kind of pool under the eye and then drip down the cheek, and if you can't fully close your eyelid all the way shut, often you need a procedure to protect the eye.

Andrew Schorr:

Well, let's go on. Give us the dimensions of surgery. Can you transplant muscles, nerves? How does all that work?

Dr. Daniel Knott:

We divide the face commonly into thirds — the upper third involving the eyebrow and the eye, the middle third involving the nose and the mouth, and the lower third involving the jaw and the chin. For the upper third of the face, there are some relatively easy ways — procedures you can do with the patient awake with local anesthesia — to correct the paralysis.

The first one is simply to put a little weight in the upper eyelid under the skin, just like you have weights in your drapes that keep your drapes from blowing in the wind or to hang straight down. The same thing occurs with the eyelid. With a little incision, the same one that I do in ladies and gentlemen who I'm trying to make look prettier by taking some of the excess skin out of the upper eyelid, you can implant a little gold or platinum weight under the skin to simply draw down the eyelid when you relax. That can be done also under local anesthesia.

The other is the lower eyelid. With the paralysis, the cheek or mid-face tends to pull the eyelid down. Without nerve input, the lower eyelid can get stretched and doesn't have the ability to pull back, so it kind of pulls down and sags outward.

What I do for that is simply tighten up the lower eyelid. Just like cinching your belt tight around your waist to pull your pants up, the same thing occurs with the lower eyelid. It's often a procedure that one would do for aesthetic patients who want to have their eyes more youthful. By pulling the eyelid tight, you actually facilitate the distribution of the tears over the eyeball and protect the lower part of the eyeball itself.

Nerve Transfers for Cheek and Jaw

Andrew Schorr:

What about lower down in the face? Take us down into the cheek and the jaw.

Dr. Daniel Knott:

For the cheek and the jaw, this is the area that is often the most difficult to treat. For example, with one of these benign brain tumors, or for somebody who has gotten brain radiation or for even a stroke patient, if the nerve is intact, often the best treatment is to simply attach the nerve of facial movement, the facial nerve, to another motor nerve, so the face still works.

The most common one of these that you can do is actually suturing the facial nerve to the nerve that moves the tongue. This keeps the muscles of the face with good tone and bulk. If you can't move your face, your face gets very thin and atrophic, just like if you had your leg in a cast for six weeks. When the cast comes off, your leg would be as thin as a little stick because you haven't used your muscles. The same thing happens with the face with facial paralysis. Simply keeping some nerve input into the face will keep it looking like it's equal to the other side.

Other nerves that you can use to attach to would be the nerve of chewing. It's called the nerve to the masseter. Both of these nerves are on the same side of the face, not too far from the facial nerve, and are relatively easy to access, often with a face-lift type approach incision. That way the scars from the operation are hard to notice.

At best, these nerves will allow your face to move again. Then, it requires some rehabilitation, some physical therapy and training to learn to reuse those muscles of the face so that you can have normal expressions.

Muscle Transfers to Regain Movement

Andrew Schorr:

And you can move muscles around, too.

Dr. Danel Knott:

There are some muscles in the face that are less important where they are than what they could be used to reanimate the face. The most common one being the temporalis muscle or the muscle of chewing. If you bite down you can feel this muscle tense up in your temple above your ear. What we do is a very simple operation where you saw or cut the muscle from its attachment to the lower jawbone and then simply move it over. I sew it to the muscles around the lips and the nose, and the muscle acts to pull up the lip and the nose when you bite down.

Once again, it requires retraining and learning, but you can actually start moving your lips again and smile again even if you have facial paralysis. Most importantly, this operation gives you results immediately. As soon as you're in the recovery room after your operation, you can move your lip, while these nerve operations require sometimes one or two years to gain full recovery of function.

Andrew Schorr:

So I understand based on what the cause is, the approach is different, the recovery is different, the immediacy of the result is different, but it sounds like in your field and what you're able to do now is just incredible and so important to people where otherwise they're almost afraid to be seen in public because half of their face can't move.

Dr. Daniel Knott:

Your face really is your portal to the world, and your face is critical for — besides speaking, eating, breathing, blinking — it's your portal for expressing emotions.

If the face doesn't move, you're completely incapacitated in terms of your emotive ability to interact with your friends and family and the public in general. So there's a frighteningly high rate of depression, and people tend to be house bound simply because they do not want to go into public because people ignore them. There's this downward spiral of psychology associated with long-term facial paralysis, so this is a very handicapped or struggling population of patients who can really benefit from some of these newer procedures.

Andrew Schorr:

I bet along the way you have seen a tremendous turnaround in people you've been able to help.

Dr. Daniel Knott:

It is among the most gratifying of operations that I do.

Recently, I had a gentleman who had had paralysis of the face for over 15 years. He came in to see me and I, with an operation that took about two hours under general anesthesia, moved that temporalis muscle over from his jaw to his cheek, and it changed his entire life. People didn't even recognize him. They were so accustomed to his face without movement, and then moving again, he didn't know that he could experience these feelings again. So it's just tremendously gratifying.

Andrew Schorr:

Wow. To give someone back their smile, and their face to the world. So it would seem if somebody has this condition that's persisted, maybe they've been recovering from a stroke and other aspects, they're walking again and maybe they're talking again and other things have been improving, but paralysis has not been one of them. As we said with Bell's palsy or some of the other conditions, if this has been going on for a while . . . you mention this guy, 15 years, hopefully not that long . . . a consultation would be worthwhile.

Dr. Daniel Knott:

One of the key things is if the paralysis lasts for more than two years, the muscles are often irretrievably injured. No matter what you do with the nerve, it cannot wake up again.

In those situations, you need to do these muscle transfers from the face, or in some situations you can even take a muscle from another part of the body such as a thigh muscle or a back muscle, along with blood vessels and a nerve. You move it up to the face and reattach the blood vessels and the nerve to make that muscle work again. Those are also possibilities.

Even for long-term paralysis, there are options for patients that rarely require what are called static suspensions, where you simply hike the face up or hike the lips up and leave them there without motion. That is a procedure that was done relatively commonly even five years ago and now is almost never indicated. So patients with paralysis lasting more than several months, I would say would warrant an evaluation. Again, if their eye is a problem, they should be seen more or less immediately.

Other Procedures

Andrew Schorr:

It sounds like when I take all this together, there is a lot you can do to help.

Dr. Daniel Knott:

Oh, yes, absolutely. We talk about patients with symmetry at rest or symmetry and movement. There are many things you can do to help patients just have equal sides to the faces without an expression. That includes Botox to the face and some of these muscle transfers to the chin so that your lips are equal and your eyes are equal and your eyebrows are equal.

There are procedures to lift the eyebrows. One of the more common esthetic operations is called an endo brow, which is done to lift the eye brows to make them more youthful. You can do those as well for facial paralysis. Even unilateral brow lifts to bring the brows back into symmetry.

Andrew Schorr:

I know for people who have this condition, this is really great news. Dr. Daniel Knott, director of Facial, Plastic and Reconstructive Surgery in Otolaryngology — Head and Neck Surgery at UCSF Medical Center in San Francisco, thank you for explaining this. Thanks for what you do. I know for a lot of people, it gives them their life back.

Dr. Daniel Knott:

Andrew, thank you very much for the invitation to be here today

Andrew Schorr:

This is what we do on Patient Power — connect you with leading experts like Dr. Knott. We hope it's helpful. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.

Recorded February 2012

 

Reviewed by health care specialists at UCSF Medical Center.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

Related Information

UCSF Clinics & Centers

Otolaryngology

Facial Plastic and Reconstructive Surgery
2330 Post St., Fifth Floor
San Francisco, CA 94115
Phone: (415) 353-9500
Fax: (415) 885-7800