SURGICAL TREATMENT OF SEVENTH NERVE PARALYSIS. By B. GRUNDT, M.D. Oslo, Norway

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1 SURGICAL TREATMENT OF SEVENTH NERVE PARALYSIS By B. GRUNDT, M.D. Oslo, Norway WE are all familiar with the patient who has paralysis of the facial nerve. The oblique mouth and the corresponding oblique smile are a source of embarrassment both to the patient and his relatives. It is not necessary to give a detailed description of the treatment of these patients, but it is sufficient to say that if the nerve has not recovered spontaneously within a reasonable time one should resort to operation. The surgical procedures for the alleviation of the symptoms are as follows :-- A. REINNERVATION OF THE FACIAL MUSCLES. There are four methods available :m I. End-to-end anastomosis. 2. Nerve grafting. 3- Facial anastomosis with a convenient motor nerve. 4. Decompression of the nerve. B. FASCIAL OR MUSCULAR SUPPORT. Blair (1926) was one of the first to use an autogenous fascia for elevation of the deformity caused by old seventh nerve paralysis, and Gillies (1917) and Lexer (1919) were first to use an anterior bundle of the masseter and the temporalis muscle. A combination of these methods was used by Gillies (1934). It is known, however, that the fascia tends to attach itself to the surrounding tissue, and that a muscle flap may degenerate, so that the result will be a "fixed smile." Author's Method.--A method which I have worked out myself for cases of established facial palsy is as follows :-- A suitable tendon is obtained, usually a portion of the palmaris longus ; as much of the paratenon as possible should be retained. The anterior fibres of the temporalis muscle are exposed through an incision just below the zygomatic arch. A strip of this muscle is easily detached from the coronoid process if the mandible is fully open. A further incision is made at the angle of the mouth. The incision should be in a natural fold and its position can be established by comparison with the normal side. One end of the tendon of the palmaris longus is then sutured to the orbicularis oris just medial to the angle of the mouth. The unattached end of the tendon is carried through a tunnel in the cheek to pass through a sling formed in the detached 5

2 SURGICAL TREATMENT OF SEVENTH NERVE PARALYSIS 51 portion of the temporalis muscle. The tendon is brought back through the tunnel and attached by means of another sling to the orbicularis oris muscle at the angle of the mouth. This sling allows adjustment for length (Figs. I to 3). i, IIf]~l!~l i femporal zygomatlc~s j' N I OrbiC. otis FIG. 2 FIG. i FIG. 3 FIG. 4 FIG. 5 Case I (Figs. 4 and 5).uThis is a patient aged 2I years. When 6 months of age a surgical incision was made from the zygomatic bone to the tip of the chin. He could give no further details. A complete paralysis of the facial nerve occurred after the operation (note that the sclera is unduly visible on the right side) and he had a long disfiguring scar.

3 52 BRITISH JOURNAL OF PLASTIC SURGERY Operation was carried out according to the method already described. The angle of the mouth is now level, he can smile, and a little of the cornea is covered. Figs. 6 and 7 show the maximum movement of the angle of the mouth. FIG. 6 FIG. 7 Case 2.--Figs. 8, 9, and IO are of a 28-year-old fisherman from Finmark. In 1943 he was wounded by a piece of shrapnel in the area of the right ear. He was sent to hospital, and whilst he was there a number of large sequestra were FIG. 8 FIG. 9 FIG. io discharged. His face soon became asymmetrical, he experienced difficulty in chewing, and an otitis media became chronic. He was transferred to my care from the Eye Department of Rikshospitalet (Oslo University Clinic). There was pronounced deviation of the jaw to the right, a complete paralysis of the right facial nerve, trismus, and a chronic otitis media.

4 SURGICAL TREATMENT OF SEVENTH NERVE PARALYSIS 53 The X-rays (Figs. II and I2) show a large defect of the posterior part of the right ramus of the mandible, including the condyle. As to treatment--first a new dental prosthesis was made for the upper jaw to FIG. II FIG. i2 FIG. 13 FIG. 14 fit the new position of the lower jaw. The most difficult task, however, was to replace the missing part of the ramus in such a way that the lower jaw would regain its normal position. As I could not completely rely on screws for fixation, I used a prosthesis in vitallium alloy with two spear-like processes which would give support even if the screws loosened (vitallium alloy: cobalt, 65 per cent. ;

5 54 BRITISH JOURNAL OF PLASTIC SURGERY chromium, 30 per cent. ; molybdenum, 5 per cent.). The use of vitallium was not detrimental to the patient as he had no metal fillings in his teeth. All the scar tissue was laboriously removed under local anmsthesia and the vitallium prosthesis placed in position, a procedure which took a very long time. Unfortunately the prosthesis was found to be too small, but in spite of this it was inserted until a new one could be made. Ten days later the new vitallium prosthesis was inserted, and at the same time a suitable piece of the iliac crest was chiselled off. Only the outer table with periosteum and cancellous bone was removed, whilst the inner layer was left in situ. Numerous holes were made in the cortex, which was placed on the medial side of the metal prosthesis, so that the whole defect was filled. Figs. 13 and 14 show the X-rays with the prosthesis in situ. FIG. I5 FIG. I6 At the time of the second operation the temporalis muscle was joined to the orbicularis oris muscle by means of the tendon of the palmaris longus, in accordance with the method previously described. Figs. 15 and 16 show the patient after his second operation. SUMMARY Surgical treatment of facial palsy depends upon the mtiology. With recent cases, end-to-end anastomosis, nerve grafting, facial nerve anastomosis with contiguous motor nerves or decompression of the nerve may be of value. With long-standing facial palsy a palliative operation is best with use of muscle, or fascial sling or combination of both. The author's method is to use a portion of the palmaris longus tendon with its paratenon and a flap of the temporalis muscle detached from the coronoid process. Through a tunnel in the cheek the tendon of the palmaris longus is then inserted and sutured on the orbicularis oris muscle and to the detached part of the temporalis muscle. This method has the advantage that the tendon moves freely because it does not attach itself to the surrounding tissue, and the angle of the mouth is drawn in the normal direction because the tendon is fastened to the temporalis muscle. The temporalis

6 SURGICAL TREATMENT OF SEVENTH NERVE PARALYSIS 55 muscle, including the separated part, contracts. One gets a mobile and not a fixed smile. Two cases with long-standing facial palsy are described where this method was applied. The second patient had also lost a large part of the posterior part of the mandible, including the condyle. The defect was repaired with a vitallium alloy prosthesis and a bone graft. I am indebted to Mr C. R. McLaughlin for his interest, and for reading the typescript and improving the set-out and phraseology. REFERENCES BLAIR, V. P. (I926). Sth. reed. ft., II, 352. GILLIES, H. D. (1917). St Bart.'s Hosp. Reports, May, p (1934). Proc. Roy. Soc. Med., 27, LEXER (1919). Neue Dtsch. Chirurg., 26, 548. McLAUGHLIN, C. R. (1949). Lancet, x, 255.

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