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Sending Out Messages to the World with Creativity, and Ingenious & Dexterous Operations Specific to Japan

From The University of Tokyo Hospital to the World
Department of Plastic, Reconstructive and Aesthetic Surgery

Mutsumi Okazaki, Professor and Chairman

Since ancient times, Japanese people have been strong at fostering creativity and developing ingenious and dexterous techniques, thereby fostering many traditional industries and contributing to the development of science. This is also the case with surgical operations. At Plastic, Reconstructive and Aesthetic Surgery in The University of Tokyo Hospital, we perform surgical operations that are highly satisfying for patients using our ideas and ingenious and dexterous techniques, and publish the achievements obtained for the benefit of the world. This article describes the state-of-the-art treatment of facial nerve paralysis, among other reconstructive operations of the head/neck and face.

1.Reconstructive operations around the eyes using eyeblink evaluation as an indicator
Figure 1

Patients with facial nerve paralysis suffers in two ways: eyelid opening difficulty occurs due to upper eyelid ptosis caused by frontalis muscle paralysis, and eyelid closure disorder also results from orbicularis oculi muscle paralysis. Regarding eyelid closure disorder, until now, the ability to intentionally close the eyelid has been used as an indicator. However, symptoms that trouble patients are related to eyeblink, such as corneal inflammation and dryness or pain in the eyes. Therefore, in 2016, our division was the first in the world to introduce an eyeblink evaluation using a high-speed camera. An eyeblink test is conducted on patients with facial nerve paralysis, with several tens of thousands of frames analyzed with each test. Based on the analysis results, a reconstructive procedure for the area around the eyes that best suits each patient is determined, as well as the appropriate amount of correction.

2. Reconstruction of laughing and eyelid closing functions using multi-split vascularized muscle

Patients with facial nerve paralysis tend to laugh as little as possible because facial asymmetry becomes conspicuous when laughing due to the mouth being pulled to the opposite side, caused by impaired muscle movement involved in the process. From the viewpoint of QOL, restoring the ability of patients to laugh by reconstructing movement affected by paralysis is a highly significant achievement. Nerve and muscle transplantation has been conducted using microscopic microvascular anastomosis. As the power source for muscle power movement, either 1) a facial nerve on the opposite side or 2) the masseteric nerve on the same side has been used. While 1) has the benefit of enabling unintentional spontaneous laughing, movement was occasionally weak. Similarly, while 2) enabled intentional and strong movement, unintentional spontaneous laughing is difficult, and therefore patients had to artificially make laughing motions through initiating biting movement. The technique required for 2) is easier, making this procedure widely performed in many countries, particularly Europe and the U.S. The procedure for 1), which is more technically challenging, is performed at five to ten facilities across Japan. Both 1) and 2) have their respective strengths and weaknesses, with the selection for one or the other largely depending on the skill level of the surgeon. Our division has devised and published a hybrid method that splits into two a single muscle supplied by an artery and vein pair, and sutures the nerve of the respective muscle to the facial nerve of the healthy side and to the masseter nerve of the affected side (Figure 2). This method combines the strengths of both procedures above and it enables the patient to laugh spontaneously as well as artificially, with a level of surgical intervention that is mostly equivalent to 1) or 2). We have also devised a procedure that further advances the technique above by splitting the muscle into three, and transplanting them while suturing the respective nerves to different nerves, thereby achieving intentional eyelid closing function in addition to the above (Figure 3).

Figure 2

Figure 3

3. More complex reconstruction of facial features and functional disorders

Major deformation of the face may result in patients with bone or soft tissue defects in addition to facial nerve paralysis, due to tumor resection or traumatic injury. For such patients, we perform surgery to transplant vascularized bones and adipose tissue at the same time as muscle. Simultaneous implementation of such a complex procedure reduces the required number of surgical operation sessions, thereby relieving burden to the patient, and also supporting faster rehabilitation.

4. Treatment of viral facial nerve palsy sequelae

Viruses make up a large share with regard to the causes of facial nerve palsy. Owing to multidisciplinary drug treatment in Otorhinolaryngology, severe sequelae have become rather rare in recent years. However, it is easy to imagine the extreme stress to patients resulting from sequelae to the face, as it is one of the most conspicuous parts of the body. Typical sequelae include: weak facial movement even though the face is pulled relatively strongly while the affected side is at rest (contracture type); synkinetic movement that is different from that intended (the corner of the mouth is pulled sideways, even though the patient wants to close his/her eyelid; the eye closes when the patient moves his/her mouth); and a drooping eyebrow resulting in a drooping eyelid that hinders the patient’s vision despite the patient being mostly recovered. We provide tailor-made treatment for each patient while listening to their complaints. At The University of Tokyo Hospital, a cooperative structure has been established with the Otorhinolaryngology Department. Once otorhinolaryngologic treatment has been completed, the patient is transferred to the Department of Reconstructive Surgery. We support enhanced QOL of patients by seamlessly taking over the treatment process, even if sequelae endure.

5. Other specialties of our division

Our division excels at all types of micro surgery-based treatments. Leveraging our ingenious procedures, we handle anastomoses of the lymphatic vessel with a diameter of only 1 mm or smaller to a vein; perform surgical treatment of lymphedema through lymph transplantation; perform breast reconstruction procedures that can be selected by patients; carry out replantation of amputated fingers; and perform treatments for various types of deformation and cramping. All members of the medical office examine the planned procedure before a surgical operation and review the results following surgery, thereby maintaining a structure that enables all patients to feel safe and secure in receiving treatment. We welcome patients who are seeking recovery from deformation or functional disorder.

For medical advice concerning facial deformation or movement disorder (facial nerve palsy), please check the info below:
1) See the details regarding symptoms and treatment by visiting Plastic, Reconstructive and Aesthetic Surgery > About > Specialties > Facial nerve palsy at
2) Requests for consultation and inquiries concerning hospital visits from patients with facial nerve palsy are accepted at the e-mail address below:

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