232b Coclia 97 98 Eyelid Reconstruction, Facial Reanimation


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  • 232b Coclia 97 98 Eyelid Reconstruction, Facial Reanimation

    1. 1. COCLIA 10/6/08 `Welcome to the beginning of the academic year.’ - Samir Undavia, MD  
    2. 2. Eyelid Reconstruction
    3. 3. Layers of the Eyelid
    4. 4. Layers of the eyelid <ul><li>Anterior lamella </li></ul><ul><ul><li>Skin </li></ul></ul><ul><ul><li>Orbicularis muscle </li></ul></ul><ul><li>Posterior lamella </li></ul><ul><ul><li>Eyelid retractor </li></ul></ul><ul><ul><li>Tarsus </li></ul></ul><ul><ul><li>Conjunctiva </li></ul></ul>
    5. 5. Layers of the eyelid- other contents <ul><li>Upper lid </li></ul><ul><ul><li>Orbicularis oculi </li></ul></ul><ul><ul><li>Levator palpebrae superioris </li></ul></ul><ul><ul><li>Muller's muscle </li></ul></ul><ul><ul><li>Sweat glands </li></ul></ul><ul><ul><li>Meibomian glands </li></ul></ul><ul><ul><li>Wolfring's glands </li></ul></ul><ul><ul><li>Tarsal plate </li></ul></ul><ul><li>Lower lid </li></ul><ul><ul><li>Tarsal plate </li></ul></ul><ul><ul><li>Lower lid retractors </li></ul></ul><ul><ul><li>Orbicularis oculi </li></ul></ul><ul><ul><li>Sweat glands </li></ul></ul><ul><ul><li>Meibomian glands </li></ul></ul><ul><ul><li>Wolfring's glands </li></ul></ul>
    6. 6. Eyelid repair <ul><li>Full-thickness laceration: 3-layer closure </li></ul><ul><ul><li>Conjunctiva: plain gut (avoids conjunctival irritaion), 6-0 or 7-0 </li></ul></ul><ul><ul><li>Tarsal plate: fine absorbable suture (i.e. Vicryl) </li></ul></ul><ul><ul><li>Skin: fine monofilament suture (6-0 prolene or nylon). Remove after 3-4d </li></ul></ul>
    7. 7. Entropion
    8. 8. Entropion- Types <ul><li>Congenital </li></ul><ul><ul><li>Extremely rare, usually lower lid </li></ul></ul><ul><ul><li>Hypertrophy of pretarsal orbicularis </li></ul></ul><ul><ul><li>Deficiency/absence of tarsal plate </li></ul></ul><ul><li>Involutional </li></ul><ul><ul><li>Loss of orbital volume; enopthalmos </li></ul></ul><ul><ul><li>Upward migration of preseptal orbicularis </li></ul></ul><ul><ul><li>Thinning of tarsal plate </li></ul></ul><ul><li>Cicatricial </li></ul><ul><ul><li>Scarring of palpebral conjunctiva </li></ul></ul><ul><li>Acute spastic </li></ul><ul><ul><li>Ocular irritation; infectious, inflammatory </li></ul></ul>
    9. 9. Entropion repair <ul><li>Medical- (for acute spastic) ocular lubrication, ABX, steroids, botox of orbicularis oculi m. </li></ul><ul><li>Surgical </li></ul><ul><ul><li>Snellen procedure- everting suture correction </li></ul></ul><ul><ul><li>Horizontal tightening </li></ul></ul><ul><ul><li>Weis procedure- full thickness horizontal lid incision </li></ul></ul><ul><ul><li>Quickert procedure (combination of above) </li></ul></ul><ul><ul><li>Inferior retractor plication </li></ul></ul><ul><ul><li>Wedge excision of tarsal plate </li></ul></ul>
    10. 10. Entropion repair
    11. 11. Inferior retractor plication
    12. 12. Ectropion <ul><li>Abnormal eversion of the lid margin away from the globe; puts eye at risk for corneal exposure, tearing, keratinization of the palpebral conjunctiva, visual loss. </li></ul><ul><li>Types </li></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>Involutional </li></ul></ul><ul><ul><li>Cicatricial (scarring of anterior lamella) </li></ul></ul><ul><ul><li>Paralytic (Bell's palsy) </li></ul></ul><ul><ul><li>Mechanical (neurofibroma) </li></ul></ul>
    13. 13. Ectropion
    14. 14. Congenital bilateral ectropion
    15. 15. Repair of ectropion <ul><li>Initial therapy with lubrication, tape closure, squinting exersizes; digital massage and steroids in cicatricial ectropion </li></ul><ul><li>Surgical therapy- depends upon etiology </li></ul><ul><ul><li>Horizontal lid laxity-lid shortening procedure </li></ul></ul><ul><ul><li>Cicatricial ectropion- excision of scar and augmentation of anterior lamella with postauricular or upper lid skin graft </li></ul></ul><ul><ul><li>Medial ectropion- excision of medial conjunctiva and retractors </li></ul></ul>
    16. 16. Canalicular injuries
    17. 17. Nasolacrimal system
    18. 18. Canalicular injury repair <ul><li>Dilate punctum </li></ul><ul><li>Identify medial cut end of canalicular system (loupes/microscope usually needed) </li></ul><ul><li>Place silicone stent through punctum, through cut end, and retrieve in nasal cavity </li></ul><ul><li>Reapproximate laceration with fine (7 or 8-0) vicryl suture </li></ul>
    19. 19. Dacryocystorhinostomy <ul><li>Used to bypass blockage of NLD via fistualization of lacrimal sac into inferior meatus of nasal cavity. </li></ul><ul><li>Epiphora is most common indication </li></ul><ul><li>Can be performed externally; usually done endoscopically now </li></ul>
    20. 20. Endoscopic DCR <ul><li>Steps: </li></ul><ul><ul><li>Probe (lighted if necessary) inserted into upper or lower punctum, then viewed endoscopically </li></ul></ul><ul><ul><li>Anterior portion of middle turbinate used as landmark </li></ul></ul><ul><ul><li>Elevate mucosal flap to expose lacrimal fossa </li></ul></ul><ul><ul><li>Drill out frontal process of maxillary bone and lacrimal bone to expose lacrimal sac </li></ul></ul><ul><ul><li>Probe placed in sac to tent out </li></ul></ul><ul><ul><li>Sac incised in order to create neo-ostium so tears can drain directly from canaliculus into nose through middle turbinate </li></ul></ul><ul><ul><li>Keep open with Crawford tube stent for 6 weeks to months </li></ul></ul>
    21. 21. Endoscopic DCR
    22. 22. Blepharospasm <ul><li>Idiopathic, progressive, involuntary spasm of orbicularis oculi and upper face (corrugators and procerus mm.). Spasm may extend to lower face </li></ul><ul><li>May render patient functionally blind </li></ul><ul><li>May be central in origin; mechanism unclear </li></ul><ul><li>Mangement- </li></ul><ul><ul><li>selective destruction of peripheral innervation (identify branches, confirm with n. stimulator, resect) </li></ul></ul><ul><ul><li>Botox </li></ul></ul><ul><ul><li>Periorbital myotomy </li></ul></ul>
    23. 23. FT lac of eyelid margin <ul><li>Principles </li></ul><ul><ul><li>Reconstuct in layers for normal function; both lamellae must be reconstructed </li></ul></ul><ul><ul><li>One lamella must be well-vascularized in order to support the other (i.e. One flap/one graft, or two flaps; can't do two grafts--> leads to necrosis) </li></ul></ul>
    24. 24. Repair of lid margin defects <ul><li>Principles: </li></ul><ul><ul><li>Can repair up to 25% of lid margin in younger person with primary closure (40% in older person with increasing lid laxity) </li></ul></ul><ul><ul><li><30%: direct closure with lateral cantholysis </li></ul></ul><ul><ul><li><50%: lateral rotational flap (Tenzel) </li></ul></ul><ul><ul><li>>50%: different pedicled flaps (Kollner; Cutler-Beard) </li></ul></ul>
    25. 25. Primary repair <ul><li>Prepare tarsal edges by preparing vertically oriented ends for direct approximation </li></ul><ul><li>Approximate lid margin first </li></ul><ul><li>Then, close tarsus with fine absorbable suture </li></ul><ul><li>Close skin and conjunctiva with silk (nylon?), plain gut </li></ul>
    26. 26. Tenzel flap
    27. 27. Cutler-Beard Flap
    28. 28. Lower eyelid defect reconstruction
    29. 29. Facial reanimation
    30. 30. Facial reanimation <ul><li>Unilateral facial paralysis can be devastating </li></ul><ul><ul><li>Nerve injury, even slight, from otologic/ parotid/plastic procedures may not attain full function </li></ul></ul><ul><ul><li>Surgical patients MUST understand risks of injury; but difficult to convey </li></ul></ul><ul><li>Goals: </li></ul><ul><ul><li>Resoration of facial symmetry </li></ul></ul><ul><ul><li>+/- Restoration of motion </li></ul></ul>
    31. 31. Facial nerve anatomy
    32. 32. Microscopic nerve anatomy
    33. 33. Sunderland Classification
    34. 34. Reconstructive modalities <ul><li>Considerations: </li></ul><ul><ul><li>First, availability of viable proximal facial nerve? </li></ul></ul><ul><ul><li>Tumor ablation with nerve sacrifice: immediate reconstruction with cable graft </li></ul></ul><ul><ul><li>If questionable viability (i.e., after CPA surgery), wait 9-12 months </li></ul></ul><ul><ul><li>Static procedure if no viable reinnervation available; may also be combined with dynamic procedure for immediate function </li></ul></ul>
    35. 35. Order of preference <ul><li>Spontaneous generation (observation) </li></ul><ul><li>Facial nerve neurorraphy </li></ul><ul><li>Facial nerve cable graft </li></ul><ul><li>Nerve transposition </li></ul><ul><li>Muscle transposition </li></ul><ul><li>Microneurovascular transfer </li></ul><ul><li>Static procedure </li></ul>
    36. 36. Management of the eye <ul><li>Failure to recognize eyelid dysfunction early results in entirely preventable ocular complications </li></ul><ul><ul><li>exposure keratitis </li></ul></ul><ul><ul><li>corneal ulceration </li></ul></ul><ul><ul><li>blindness </li></ul></ul><ul><li>Initial management </li></ul><ul><ul><li>Moisturization (artificial tears, ointments) </li></ul></ul><ul><ul><li>Exposure prevention (taping, occlusive dressing) </li></ul></ul><ul><ul><li>Education </li></ul></ul>
    37. 37. Surgical procedures <ul><li>Lower lid (ectropion) </li></ul><ul><ul><li>Tarsorraphy </li></ul></ul><ul><ul><ul><li>Simple </li></ul></ul></ul><ul><ul><ul><li>Lid-adhesion </li></ul></ul></ul><ul><ul><li>Wedge Resection </li></ul></ul><ul><ul><li>Canthoplasty </li></ul></ul><ul><li>Upper lid (lagophthalmos) </li></ul><ul><ul><li>Gold weight </li></ul></ul><ul><ul><li>Palpebral springs </li></ul></ul><ul><ul><li>Silastic slings </li></ul></ul>
    38. 38. Bell's phenomenon <ul><li>Idiopathic facial paralysis </li></ul><ul><li>15-40/100,000 </li></ul><ul><li>Most common form of facial palsy </li></ul><ul><li>Generally a dx of exclusion, but a positive one if: </li></ul><ul><ul><li>unilateral paresis of all facial muscle groups </li></ul></ul><ul><ul><li>sudden onset </li></ul></ul><ul><ul><li>absence of ear/CNS disease </li></ul></ul><ul><li>Etiology unclear (ischemic vs. viral vs. entrapment neuropathy); likely inflammation within constrained bony canal leading to ischemia </li></ul><ul><li>Treatment extremely controversial; steroids likely improve outcome </li></ul><ul><li>Prognosis </li></ul><ul><ul><li>Incomplete paralysis: excellent recovery </li></ul></ul><ul><ul><li>Complete paralysis: </li></ul></ul><ul><ul><ul><li>71% complete recovery </li></ul></ul></ul><ul><ul><ul><li>13% mild residual palsy </li></ul></ul></ul><ul><ul><ul><li>16% fair-poor recovery </li></ul></ul></ul>
    39. 39. Facial nerve grafting <ul><li>Settings </li></ul><ul><ul><li>Radical parotidectomy with nerve sacrifice </li></ul></ul><ul><ul><li>Temporal bone resection </li></ul></ul><ul><ul><li>Traumatic avulsion </li></ul></ul><ul><ul><li>CPA tumor resection </li></ul></ul><ul><li>Donor nerves </li></ul><ul><ul><li>Greater auricular (opposite neck) </li></ul></ul><ul><ul><li>Sural </li></ul></ul><ul><ul><li>Medial antebranchial cutaneous </li></ul></ul>
    40. 40. Nerve grafting <ul><li>Technique </li></ul><ul><ul><li>Transection of graft and stumps with sterile razor </li></ul></ul><ul><ul><li>Anastomosis with four 9-0 or 10-0 nylon through epineurium only </li></ul></ul><ul><ul><li>Tension free is critical! Need 8-10 mm of extra length for each anastamosis (“lazy S” configuration) </li></ul></ul><ul><ul><li>Healthiest possible bed of supporting tissue </li></ul></ul>
    41. 41. Nerve transposition <ul><li>Used when proximal facial n. stump unavailable </li></ul><ul><ul><li>Hypoglossal </li></ul></ul><ul><ul><ul><li>Best option due to close proximity, less donor disability, similar brainstem control and reflex response </li></ul></ul></ul><ul><ul><ul><li>Pure vs. jump graft </li></ul></ul></ul><ul><ul><ul><li>Disadvantages: tongue atrophy, synkinesis, facial hypertonia </li></ul></ul></ul><ul><ul><li>Spinal accessory </li></ul></ul><ul><ul><li>Ansa hypoglossi plus muscle block </li></ul></ul><ul><ul><li>Phrenic (obsolete) </li></ul></ul>
    42. 42. Muscle transfer <ul><li>Used when first two options unavailable, or when significant muscle atrophy has occurred (i.e., complete paralysis for two years or more) </li></ul><ul><li>Masseteric transfer </li></ul><ul><ul><li>Used for sagging/paralyzed oral commissure </li></ul></ul><ul><ul><li>Requires intact CN V </li></ul></ul><ul><ul><li>Provides posterior pull on midface </li></ul></ul><ul><ul><li>Cannot be used for orbital rehabilitation </li></ul></ul><ul><li>Temporalis transfer </li></ul><ul><ul><li>Muscle divided into four slips </li></ul></ul><ul><ul><li>Superior pull preferred to masseteric vector </li></ul></ul>
    43. 43. Static procedures <ul><li>Indications </li></ul><ul><ul><li>debilitated patients with poor prognosis </li></ul></ul><ul><ul><li>Lack of nerve/muscle availability </li></ul></ul><ul><ul><li>Adjunct to dynamic procedure </li></ul></ul><ul><li>Advantages </li></ul><ul><ul><li>immediate restoration of symmetry </li></ul></ul><ul><ul><li>Improvement in oral competence, nasal obstruction </li></ul></ul><ul><li>Materials </li></ul><ul><ul><li>Fascia lata </li></ul></ul><ul><ul><li>Alloderm </li></ul></ul><ul><ul><li>PTFE </li></ul></ul>
    44. 44. Harii et al. One-Stage Transfer of the Latissimus Dorsi Muscle for Reanimation of a Paralyzed Face: A New Alternative. <ul><li>One-stage microvascular free transfer of the latissimus dorsi muscle for long-standing unilateral facial n. paralysis </li></ul><ul><li>Thoracodorsal nerve is crossed through the upper lip and sutured to the contralateral intact facial nerve branches. </li></ul><ul><li>Reinnervation of the transferred muscle is established at a mean of 7 months postoperatively, which is faster than that of the two-stage method. </li></ul><ul><li>24 patients, 21 patients (more than 87 percent) believed that their results were excellent or satisfactory, which also compares well with the results of the two-stage method combining free-muscle transfer with cross-face nerve graft. </li></ul>
    45. 45. Cronin et al. The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation <ul><li>Objective </li></ul><ul><ul><li>The study goal was to present the effectiveness of neuromuscular facial retraining techniques used in combination with electromyography forimproving facial function even in cases of longstanding paralysis. </li></ul></ul><ul><li>Study design and setting </li></ul><ul><ul><li>We conducted a retrospective case review in a tertiary neurotology clinic. </li></ul></ul><ul><li>Patients </li></ul><ul><ul><li>Twenty-four patients with facial paralysis received neuromuscular facial retraining between April 1999 and April 2001. The patient sample included 6 males and 18 females, with an average age of 44 years. A control group consisted of 6 patients (4 females and 2 males). </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>All patient groups made significant improvements in function with improved symmetry in dual-channel electromyographic readings and increased facial movement percentages. Some of the percentages of posttreatment facial function were as follows: acoustic neuromas, 93%; Bell’s palsy/Ramsay Hunt syndrome, 80%; and facial nerve anastomosis, 71%. Synkinesis was reduced by at least 2 levels in patients who initially demonstrated synkinesis. </li></ul></ul><ul><li>Conclusions </li></ul><ul><ul><li>Neuromuscular facial retraining exercises and electromyography are effective for improving facial movements. </li></ul></ul>