One of the most socially and functionally disruptive maladies is a facial paralysis.  Facial paralysis usually results from trauma, surgery, or a Bell’s palsy.  Problems that result from a facial paralysis include exposure of the eye which can lead to chronic irritation, a disfiguring appearance, and drooling.

The duration that the facial paralysis has been present will help Dr. Lopez determine which procedures the patient would benefit from.  Dr. Lopez comprehensively treats patients with facial paralysis by addressing the eye, cheek and area around the mouth.

Patients that have a facial paralysis are unable to completely close their eye and therefore leave the cornea exposed to the elements which can cause irritation, infection and even blindness.  Dr. Lopez performs procedures that include a gold weight to the upper eyelid and a lower eyelid elevation which narrows the fissure of the eye and protects the eye from exposure.

With time, a patient with a facial paralysis will experience sagging of the face. To correct this, Dr. Lopez performs a browlift and midfacelift which provides a more natural youthful appearance.

One of the most distressing results from a facial paralysis is the drooping of the corner of the mouth which can lead to drooling as well as a disfigured appearance.  Dr. Lopez performs a minimally invasive temporalis tendon transfer (T3) to correct the asymmetry of the mouth as well as give motor function to allow for smiling.

For patients that have had a facial paralysis for less than 18 months, a nerve procedure can restore tone and some muscle movement to the lower third of the face.  Dr. Lopez connects part of the nerve that innervates the tongue to the facial nerve that no longer works. This will give tone to the lower muscles of the face to prevent drooping and possibly restore some motor function.

When discussing reanimation procedures the best place to start is by looking at before and after photos to see just what can be accomplished. Often times many procedures are combined to achieve a complete facial reanimation.  The most common combination includes a gold weight for the upper eyelid blepharoplasty, a lower eyelid elevation, a browlift, a midfacelift, and a minimally invasive T3.

At your initial consultation, Dr. Lopez will evaluate the bony and soft tissue architecture of your face. An overall assessment of the face provides the basis for what one may expect from facial reanimation. Age, along with the degree of deformity and function are important factors influencing the outcome of an operation.

As with all facial plastic surgery, a thorough health assessment and realistic expectations are prerequisites. Your understanding of procedures and preoperative and postoperative routines is essential to a successful final result.

BEFORE FACIAL REANIMATION SURGERY

At your preoperative appointment Dr. Lopez will go over the instructions with you to follow before and after surgery.  Preoperative photographs will be taken and your questions will be answered.  A complete facial reanimation can take about 4-5 hours depending on the underlying structure. Recovery time from the anesthetic takes about an hour and most patients are admitted to the hospital for overnight observation.

PREOPERATIVE FACIAL REANIMATION INSTRUCTIONS

AFTER FACIAL REANIMATION SURGERY

When you wake up from surgery you will notice a  soft, bulky head wrap dressing.  You will be asked to come to Dr. Lopez's office the following day after surgery for dressing removal. You will be asked to return in five to seven days for suture/clip removal.

POSTOPERATIVE FACIAL REANIMATION INSTRUCTIONS

Wound care

Medications

Most patients complain of discomfort more than pain. Use pain medication as directed/as needed. Vicodin and Percocet contain Tylenol. Do not take additional Tylenol or acetaminophen while taking Vicodin or Percocet. Do not drive or drink alcohol while taking pain medication. Taking pain medication with food helps minimize nausea sometimes associated with pain medications.

Diet

Advance diet from liquids to soft food (oatmeal, French toast, yogurt, soup, pasta) to your regular diet as tolerated. You have no diet restrictions.  Often the anesthesia you received can make your stomach feel uneasy for the first 24 hours so avoid large meals.

Activity

Rest for entire day after surgery. Sleep with head of the bed elevated or use two to three pillows for one week after surgery. Absolutely no bending, lifting or straining. If you have little children, bend at the knees or sit on the floor and let them climb on to your lap. No driving for one week following surgery. Two weeks off work is recommended.

After 48 hours, you are allowed to shower and gently wash your hair.  Make sure that the hair is dried thoroughly, but do not use a hair dryer for the first two weeks.  Sensation to the scalp will be diminished temporarily so you want to avoid causing a burn because of a hair dryer.

Bruising can be camouflaged at one week postoperatively with make-up. Always protect your face from the sun. At this point, a hat and sunglasses are a good idea. It is ok to apply sunscreen, cosmetics or facial creams two weeks after surgery. Avoid unprotected prolonged sun exposure for three months following facial reanimation surgery to prevent pigmentation of incision lines.

Swelling, bruising and disrupted sleep are very normal postoperative symptoms and will decrease as the healing process occurs. Since vision is temporarily compromised, assistance with daily activities is recommended.

Final Result

Following a facial reanimation procedure, it takes time for the swelling to subside and for the skin to heal. Most patients return to work two weeks following surgery, however three weeks is ideal, depending on the degree of privacy one is trying to maintain. At three weeks postoperatively, swelling and bruising may be apparent to you but not to many of your coworkers and closest friends.

Final results following a facial reanimation are not apparent for one full year following surgery. Dr. Lopez will want to see you 3, 6 and 12 months after the surgery to ensure that you’re healing as anticipated.

FREQUENTLY ASKED QUESTIONS

1) When should I get treatment for my facial paralysis?
One should seek consultation immediately with an ear, nose and throat doctor following a facial paralysis.  Most commonly the early treatment of a facial paralysis is with medicine (steroids and antiviral medications) and protection of the eye.  If the nerve was cut during an operation or from a trauma, surgery may be indicated.  Dr. Lopez will advise patients with a facial paralysis to have a gold weight placed early as this will help protect the eye, and the weight can be taken out if complete nerve function returns.

2) What is the difference between a facial paresis and a payalysis?
A facial paresis implies that there is some facial nerve function.  The nerve is stimulating some of the facial muscles to contract.  The prognosis for a facial nerve paresis that is not caused by a tumor is generally very good.  A facial paralysis implies that the nerve is completely not functioning.  There is no movement of facial muscles.  The prognosis for a facial paralysis is generally not as good.

3) I have a facial paralysis and my face sags. Why?
When the facial nerve is paralyzed there is no nerve conduction to the facial muscles.  When muscles don’t contract they atrophy so that nothing counteracts the force of gravity.  The longer the duration that a facial paralysis is present; the more severe the sagging of the facial tissue.

4) How does a gold weight help close my eye?
When a patient has a facial paralysis, the eye is unable to close because the facial nerve is responsible for innervating the orbicularis oculi muscle that closes the eye.  When the eye is unable to close, the cornea is left exposed which can lead to irritation, infection and possibly blindness.  Dr. Lopez places a gold weight in the upper eyelid which help close the eye and protect the cornea.

5) What treatment does Dr. Lopez use for the lower eyelid?
Facial paralysis causes the lower eyelid to pull down because of the lack of muscular tone of the face.  Dr. Lopez performs a lower eyelid recession with placement of a graft that helps raise the lower eyelid and in combination with a gold weight in the upper eyelid help to protect the eye.

6) Why do I need a browlift and/or a midfacelift when I have facial paralysis?
Facial paralysis causes the facial muscles to atrophy (decrease in size and strength) such that the side of the face that is paralyzed over time will settle at a very noticeable lower position than the normal side, causing an obvious asymmetry.  Dr. Lopez performs a browlift and/or midfacelift to restore the symmetry that was there before the paralysis.

7) What is a temporalis tendon transfer?
One of the most disfiguring and functionally disturbing sequelae of a facial paralysis is the drooping of the corner of the mouth on the paralyzed side of the face.  Patients often complain of drooling that can be professionally and socially disruptive.  Dr. Lopez performs a temporalis tendon transfer to elevate the corner of the mouth and enable the patient to have some voluntary movement to the corner of the mouth, i.e. smile.  The temporalis tendon transfer was recently described by a colleague of Dr. Lopez at Johns Hopkins.  The operation involves transferring the tendon of the temporalis muscle (which is innervated by the trigeminal nerve and not the facial nerve) to the muscles around the mouth.  A small incision is used in a naturally occurring crease of the face.  By elevating the corner of the mouth and giving voluntary movement, the patient’s face is more symmetric, and there smile is more natural appearing.

8) Will I still look like "me" after surgery?
After facial reanimation surgery you will look more like the former you before the facial paralysis occurred.

9) How much pain will I have?
Most patients who have facial reanimation surgery say how surprised they are that the pain is less than they anticipated. Understandably, after any surgical procedure, some discomfort can be expected. All patients are provided with prescriptions for pain medication. Patients sometimes use the prescription medication two to three days after surgery and then switch to Extra Strength Tylenol. Patients undergoing a midfacelift will have some pain on chewing for about 48 hours. It is uncommon for patients to report unmanageable pain after surgery.

10) What if I have a history of bad scars?
If you have pierced ears, the way you healed there is a good indication of how you will heal from facial plastic surgery. Scars on the rest of the body typically are not an indication for how patients heal following facial plastic surgery. At the time of your consultation, it's important to show Dr. Lopez any previous scars that are of concern to you so he can give you a realistic assessment of your healing potential following facial plastic surgery.

11) Will I be awake during surgery?
Patients are asleep during the surgery either with general anesthesia or using IV sedation (medicine administered through an IV) and a local anesthetic (numbing medication administered in the operating room). Patients do not hear or feel anything and are comfortable during the operation. Patients wake up very soon after the surgery is completed. Intravenous sedation is a type of anesthesia; therefore all patients must have a responsible adult to stay with them through the night following surgery. Patients may not drive for seven days following their procedure and this time may be longer, depending on the procedure.

12) Do I go home after surgery?
Most facial reanimation procedures are done on an outpatient basis. Because you will go home after receiving sedation, you will need to make arrangements for a responsible adult to drive you home, to stay with you overnight and to drive you to our office for your first postoperative appointment. Patients having surgery must stay in the immediate San Antonio area overnight.

13) Will I bruise and swell afterwards and how long will it last?
Unfortunately it is impossible to do surgery without causing swelling.  Dr. Lopez does everything possible to minimize the amount of swelling that occurs.  Generally, postoperative swelling begins to resolve at the end of the first week.  Bruising is extremely variable.  Patients that have a tendency to bruise will generally bruise for about 10 days.  Patients that don’t tend to bruise may have minimal if any bruising.   Complete resolution of bruising and swelling may take two to three weeks. However, bruises may be camouflaged fairly easily at seven to ten days with a concealer stick.

14) How long should I stay in San Antonio following surgery?
Most patients stay in San Antonio about seven to ten days following surgery. After that it's ok to fly or travel long distances.

15) When can I return to work?
Most of Dr. Lopez’s patients take about two weeks off of work. After two weeks, most of the residual bruising and swelling can easily be camouflaged with make-up.

16) When can I exercise?
Dr. Lopez prefers that aerobic activities be avoided for two weeks after surgery.  In addition, heavy weightlifting or more strenuous workouts should be avoided for three weeks postoperatively. It' is extremely important to avoid bending, lifting or straining during the early postoperative period as these activities can increase swelling and delay healing. 

FACIAL REANIMATION PREOPERATIVE INSTRUCTIONS

17) Should I do anything before to prepare for surgery?
You will have a preoperative appointment with Dr. Lopez and his staff to go over the preoperative instructions.

18) Why do I need a preoperative appointment?
This is an essential appointment to prepare you for your upcoming surgery.  Dr. Lopez will take preoperative photographs at the visit as well as go over the procedure again to ensure that everyone is on the same page.  All questions that you have will be answered on that visit as well.  You will often times be given your prescriptions on the preoperative visit day. If you are having a T3, Dr. Lopez will teach you how to do exercises that you will do before the surgery as well as after to learn how to make a symmetric smile.

19) What else can I do to do to prepare for surgery?
Dr. Lopez likes to have patients that have well controlled blood sugar to drink three eight ounce glasses of pineapple juice for at least one week before surgery.  Pineapple juice can help minimize the postoperative swelling. Patients that use tobacco will be asked to stop for six weeks before and six weeks following surgery. Tobacco has properties that impede wounds from healing.  Dr. Lopez will encourage tobacco users to not resume smoking at all after surgery; in fact many of his patients have used the surgery as their motivation to quit smoking.

20) What about my daily medications before surgery?
In general you will be allowed to take most of your daily medications.  Medications that thin the blood such as ibuprofen, vitamin E, and herbal supplements need to be stopped two weeks before surgery.  You can continue to take a multivitamin.  Aspirin needs to be stopped three weeks before surgery.  Dr. Lopez will provide a "Medication List" that reviews all medications and supplements to avoid prior to surgery. 

21) Do I need any special prescriptions before surgery?
Dr. Lopez will generally give you a prescription for an antibiotic, a pain medicine, antibiotic ointment, as well as an anti-swelling medication. Dr. Lopez does prefer patients to start Arnica, a natural herbal substance, the day before surgery in order to minimize brusing. He also asks you to start taking Vitamin C before surgery. 

FACIAL REANIMATION POSTOPERATIVE INSTRUCTIONS

22) What does it feel like when I wake up from surgery?
Most patients report only mild to moderate discomfort, which may be associated with some numbness, itching, tightness or a pulling sensation. These postoperative symptoms subside with time. We will make sure you are not nauseated or queasy. Our nurses will be right there with you as you wake up from surgery to give you special attention.

Patients initially experience numbness for the first six to twelve months following surgery. About two months after surgery, it is common to have itching or "pins and needles" as the sensation returns. This itching is significantly less with an endoscopic browlift than a traditional browlift. This is actually an important point because patients who scratch or "itch" their hairline can thin the hair.

23) Tell me more about the incision.
The head wrap will be removed in the office the day following surgery. After the head wrap dressing is removed, you will notice little clips in your hair. Apply antibiotic ointment to the incision sites three times a day. You will be asked to return to the office about seven days from the surgery date for removal of clips. Because most patients tell us their forehead is temporarily numb the removal of clips is usually not too uncomfortable.

24) What do I look when I wake up from surgery?
Following the procedure, you will have a soft head wrap around your head and under your chin. This helps minimize swelling. The head wrap will be removed in the office the following day. A second dressing will be gently applied for 48 hours to minimize swelling. You may have some bruising, however, this typically is more pronounced 24-48 hours after the procedure.

25) Can I do anything to prevent brusing?
Most patents will have a little bruising. We can minimize bruising by using Arnica before and after the procedure. Arnica is a natural "herb" that helps prevent bruising.

26) Tell me more about the sutures.
If there are sutures near your ears they will require some simple care. We will ask you to use a Q-tip to cleanse them with peroxide once a day and apply an antibiotic ointment three times a day to keep the sutures soft. In six to eight days, when the time arrives for suture removal, sutures that have been lubricated glide out easily.

27) When can I shower?
You can shower once the second dressing is removed. Make sure that you pat dry the incisions well after the shower and apply the antibiotic ointment.

28) What medications do I take following surgery?
Dr. Lopez will ask you to take the following medications starting the day of surgery:
  1- An antibiotic - generally Keflex for one week.
  2- Pain medicine - Vicodin or Percocet to take as needed.
  3- Antibiotic ointment- to place on the incision sites at least three times a day.
  4- Antiswelling medication- for patients that are not diabetic a Medrol dosepak will be given.
  5- Vitamin C for 1 week following surgery to promote healing.
  6- Arnica- place under the tongue three tabs three times a day before meals for two weeks.

29) When do I begin taking the medications?
Patients take their pain medication as needed. Begin taking vitamin C one week before surgery. You can begin taking Arnica the day before surgery. The antibiotic and swelling medications begin when you arrive home following surgery. Unless you are notified otherwise, resume all daily medications when you arrive home from surgery.

30) Are there any food to avoid following surgery?
No. Dr. Lopez encourages you to eat a well-balanced diet.  You may notice that saltier foods can cause you to swell for a longer period of time.

31) When is my first postoperative appointment?
You will be asked to see Dr. Lopez on the first day following your facial reanimation procedure for removal of head wrap dressing. You will need someone to drive you to this appointment.

32) Are there any instructions about my regular daily activities?
Sleep with head of the bed elevated or use two to three pillows for one week. Facial fullness, headache and disrupted sleep are very normal postoperative symptoms and will decrease as the healing process occurs. Absolutely no bending, lifting or straining. If you have little children, bend at the knees or sit on the floor and let them climb on to your lap.

33) How long does the healing take?
As numbness wears off patients experience a "pins-and-needle" sensation. At about two months postoperatively patients experience an itchy scalp. It is important not to scratch as scratching can thin the hair. These sensations can take up to a year to dissipate completely. Medications are available to be used on an as needed basis to ease any significant sensations. Healing and evaluation of the final result takes one full year. However, after three months, most patients have about 90% of their final result.

34) How can I minimize the swelling and brusing?
Most of Dr. Lopez’s patients will have a little bruising. He minimizes bruising by having patients stop all blood thinners well ahead of surgery as well as using Arnica before and after the procedure. The cold packs around the eyes should be used every 20 minutes while awake after surgery to help prevent swelling and bruising. The cold packs should be used for the first 72 hours. You do not need to wake up to use the cold packs. A good night’s sleep is vital to healthy healing. Patients are also asked to sleep with their head at least at 45 degrees to minimize the swelling.

35) When will I look normal?
You will be presentable at two to three weeks. You will look great at six weeks and even better at six months as things settle and expressions become more natural. At three weeks you know you are well on the way to recovery and most patients resume routine activities around two to three weeks following surgery. Final results are evaluated at one year.

36) How often do I need to return for postoperative visits?
Dr. Lopez likes to see his patients 3, 6, and 12 months after the procedure to ensure that the healing is going as expected.