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Trigeminal and Facial Reanimation: The State of the Art

Nate Jowett, MD

Facial palsy and trigeminal anesthesia can be devastating for patients—both in terms of pain and function as well as aesthetics. But cutting-edge surgical techniques are rapidly evolving and offering patients better opportunities for positive results.

Nate Jowett, MD, an assistant professor at Harvard Medical School and an associate surgeon and director of the Surgical Photonics and Engineering Laboratory at Massachusetts Eye and Ear, presented techniques he is implementing in his own practice during yesterday’s session, “Trigeminal and Facial Reanimation: The State of the Art.”

Dr. Jowett classified three specific management domains based on palsy type:

  • Facial palsy with viable facial musculature
  • Facial palsy with no viable musculature
  • Postparalytic facial palsy

Treatment options will vary based on the palsy domain. For a patient with facial palsy with viable facial musculature, for example, Dr. Jowett recommended direct or interposition of autograft repair (but said that the use of conduits or allografts is ill-advised). Patients with postparalytic facial palsy, on the other hand, may be candidates for physical therapy, chemodenervation, myectomy, selective neurectomy, and/or a nerve transfer.

Smile reanimation is a particular concern for many patients, but there’s no one-size-fits-all solution for this either.

“It depends which kind of management domain your patient is in,” said Dr. Jowett. He presented the accepted understanding of an individual’s smile, which is that it is a vector sum of forces and can be classified as either a Mona Lisa smile (showing the least amount of teeth), a canine smile (showing predominately top teeth), or a full denture smile (showing a patient’s full set of teeth as well as some gum).

Dr. Jowett cautioned attendees from focusing on one sole vector to correct a smile, though, noting that he himself used to underestimate the importance of the lower lip during smile reanimations.

“Multiple vectors are needed to restore smiles,” he said.

He discussed the difference in focusing on the depressor anguli oris (DAO) muscle, or the triangularis, which is a smile antagonist associated with frowning that is attached to the mandible, and the depressor labii inferioris (DLI), which is a four-sided smile agonist muscle that helps to draw the lower lip down to the chin.

Dr. Jowett also delved into trigeminal anesthesia, or a deficit in the sensory component in the trigeminal nerve, and re-neurotization. Trigeminal anesthesia can result in neural trophic support to the cornea as well as a loss of protective sensory feedback.

The transfer of nerves can help these patients as well, said Dr. Jowett.

“Just as motor nerves can be transferred to restore facial movement, sensory nerves may be transferred to restore corneal sensation.”

“If you can restore sensation,” he said, “You can go in about a year later and do a corneal transplant. This is vision restoring.”