FACIAL NERVE AND FACIAL REANIMATION

1. FACIAL NERVE PALSY AND
FACIAL REANIMATION
Dr Gautam Kalra
Senior Resident
Dept of Plastic and Reconstructive Surgery

2. INTRODUCTION
 FACIAL NERVE
 CONSCIOUS AND SUBCONSCIOUS MOTOR CONTROL
 OCULAR PROTECTION
 NASAL AIR FLOW
 ORAL CONTINENCE
 BILABIAL SPEECH ARTICULATION
 INJURY MANIFESTS FUNCTIONAL, AESTHETIC AND PSYCHOSOCIAL INSULTS

3. ANATOMY
EMBRYOLOGICALLY DERIVED FROM 2nd BRACHIAL ARCH
AND INNERVATES ALL THE STRUCTURES ORIGINATION
FORM IT

4. ANATOMY OF THE FACIAL NERVE
Unique as it has:
Sensory fibres
Motor fibres
Autonomic fibres
Special Sensory fibres

5. ANATOMY OF THE FACIAL NERVE
 Facial Nucleus - lie in PONTINE REGION OF BRAIN STEM
 Intratemporal anatomy
 Extratemporal anatomy

6. NOTE THE CLOSE PROXIMITY OF CN VII AND CN VIII
THE CP ANGLE
The cell bodies giving rise to the frontal
branch of the facial nerve receive
bilateral cortical input explaining why
an upper motor neurone lesion results in
contralateral facial paralysis with sparing
of the frontalis muscle.

8. INTRA TEMPORAL ANATOMY

10. ANATOMICAL LANDMARKS/POINTERS
 1. JUST ABOVE THE POSTERIOR BELLY OF DIAGASTRIC.
 TYMPANOMASTOID SUTURE LINE
 TRAGAL POINTER
 STYLOID PROCESS

12. Extra-Cranial ANATOMY

13. CLASSIFICATION AND ETIOLOGY

14. CONGENITAL CAUSES
 Mobius syndrome
 GOLDENHAR`S SYNDROME

15. NEUROLOGICAL CAUSES
 GB Syndrome
 Stroke

16. INFECTIONS
 Ramsay Hunt Syndrome – VZV infection
 VII CN palsy + OTALGIA + RASH IN EXT. AUDITORY CANAL
 Bell’s palsy –accounts for 65-85% & commonest cause of acquired facial palsy
 Middle ear infections

17. RHEUMATOLOGICAL CONDITIONS
 Diabetes Mellitus
 Sarcoidosis

18. TRAUMA – 2nd MOST COMMON CAUSE
 Forceps delivery/OBSTETRIC INJURY
 Skull/ temporal fractures
 Penetrating trauma

19. IATROGENIC
 Cranial base surgery
 Ear Surgery
 Parotid Surgery

20. TUMORS
INTRACRANIAL TEMPORAL BONE EXTRATEMPORAL
VESTIBULAR SCHWANNOMA GLOMUS JUGULARE PAROTID TUMORS
FACIAL NERVE TUMORS SQUAMOUS CELL CARCINOMA
COCHLEAR NEUROMA BASAL CELL CARCINOMA
MENINGIOMA

21. PRESENTATION AND INITIAL EVALUATION

22. BROW
 Position at rest
 Superior visual field
 May be acceptable in young.
 Obtain visual field documentation.

23. UPPER EYELID COMPLEX
 Closure of eyelid effected.
 Cleansing the sclera and cornea.
 Corneal ulceration and opacification.

25. EYE EXAMINATION
 Height of palpebral aperture.
 Degree of logaphtholmos.
 Bells phenomenon
 Height of lateral canthus
 Palpebral fissure and orbital width

26. BELLS PHENOMENON

27. LOWER EYELID COMPLEX
 Ectropion
 Turgor of skin
 Conjunctival irritation

29. MARGINAL REFLEX DISTANCE

30. SNAP TEST

31. NASAL VALVE
 2 Mechanisms:
 Excessive soft tissue collapse.
 Intrinsic collapse of internal nasal valve.
 Forced inspiration.
 NOSE instrument.

32. MIDFACE
 Soft tissue collapse
 Pull lower eyelid down.
 Also effect lower facial complex.

33. MOUTH
 Philtral deviation
 Nasolabial fold.
 Commisure depression or elevation.
 Upper lip droop.
 Vermilion inversion.

34. SMILE TYPES
 Zygomatic
 Canine
 Full denture

36. LOWER FACE
 Drooping of lower lip.
 Sagging of cheek.
 Disability of articulation and deglutition.
 Constant drooling

38. SYNKINESIS
 Aberrant regeneration of nerve after injury.
 6 weeks after injury
 Most common:
 Eyelid closure with smiling.
 Brow wrinkling with mouth movements.
 Mouth grimacing when eyes are closed.

39. GLOBAL ISSUES
 Underlying disease process.
 Nutrition.
 Social isolation.
 Physical pain.
 Depression.

40. HOUSE BRACKMANN GRADING

41. MANAGEMENT OF FACIAL PALSY
 SHOULD be tailored to the individual.
 It is important to assess what the aim is-
 To restore function
 Regain resting symmetry
 Achieve dynamic spontaneous movement

42. NON SURGICAL MANAGEMENT

43. EYE PROTECTION- FIRST PRIORITY
 Lubrication with artificial tears
 Protective glasses
 Goggles and sunglasses
 Moisture chamber
 TAPING OF EYE LIDS

44. BOTULINUM TOXIN
 Use on normal side to improve symmetry.
 Paralyses selected muscles by disrupting acetyl choline release.
 Eg. If marginal mandibular branch is damaged then the DEPRESSOR ANGULI
ORIS denervation can result in asymmetrical lower lip. (esp on smiling)
 BOTULINUM WEAKENS THE NORMAL MUSCLE

45. PHYSIOTHERAPY
 Exercise
 Thermal treatments
 Massage
 Electrical stimulus
 MIME THERAPY

46. SPEECH/ SWALLOWING THERAPY

47. NASAL VALVE
 Nasal dilator devices.
 Injectables as spreader grafts

50. BROW MANAGEMENT

51. SURGICAL MANAGEMENT
AIM OF OPERATIVE TREATMENT IS TO –
1. Protect the eye
2. Restore facial symmetry
3. Facilitate a spontaneous dynamic
smile
4. Improve speech

52. NERVE REPAIR
 Depending on NATURE AND LOCATION of injury
 Nerve repair be attempted at the time or as soon as possible after the event
 Exploration within 72 hours - identification of distal nerve stump by using a
nerve stimulator.

53. NERVE REPAIR INDICATIONS AND
TECHNIQUES
 Most effective way of reanimation.
 End to end is distal end has been identified.
 Epineural repair
 Key principle is to have no tension at the coaptation site (breakage of 8-0 suture is
the rule)
 Minimally debride the ends to expose epineurium

54. CABLE GRAFTING
 Potential donor- Gr. Auricular N. , Sural N. , Branches of cervical plexus
 Done when there is tension at the repair site.
 >2cm distance or breakage of 8-0 suture
 Grafting may be done 3 weeks to 1 year after the injury

55. Nerve transfers
 Require nerve regeneration only over a single neurorrhaphy.
 Potential indications for nerve transfers include:
• The distal stump is present
• Proximal, ipsilateral facial nerve stump is unavailable for grafting
• Facial muscles are capable of useful function after reinnervation
 The distal facial nerve stump may be coapted to:
• Hypoglossal nerve (most common)
• Nerve to masseter
• Glossopharyngeal nerve
• Accessory nerve
• Phrenic nerve

56.  However, nerve transfer may produce
 mass facial movement and synkinesis
 palliated with botulinum toxin
 function of the donor nerve is also sacrificed.

57. XII –VII SUBSTITUTION
best suited to providing input to the facial
nerve
When successful, intentionally manipulating
the tongue causes facial movement
(permits intentional facial movement)
Unlike CFNG, changes in facial expression
are not spontaneous
Recovery generally occurs over 6-24 months
and may be observed for up to 5 years
provide excellent tone, a normal
appearance at rest in 90% of patients and
protection of the eye

58.  time interval between initial denervation and nerve transfer is the primary marker of success.
 reinnervation must occur <2 years after injury (otherwise atrophy and neuro-muscular fibrosis)
 Paralysis and atrophy of the ipsilateral tongue occurs due to its denervation. (In 25% of patients leading
to speech and swallowing impairment).

59. CONTRAINDICATION
 Hypoglossal nerve transfer is contraindicated in patients at risk of developing
other cranial neuropathies e.g. NF type II
 patients with concomitant, ipsilateral low cranial nerve dysfunction (CN IX, X,
XI) palsies.

60. Classic hypoglossal nerve
transfer technique
Split hypoglossal transfer Hypoglossal jump graft techniques

61. MASSETERIC FACIAL NERVE TRANSFER
The motor nerve to the masseter
muscle is a branch of the
mandibular division of the
trigeminal nerve
minimal donor morbidity
Its anatomical location is
consistent

62. CROSS FACIAL NERVE GRAFT
 Harnesses neuronal activity from the uninjured facial nerve activity to the
contralateral side to power a free muscle transfer.
 gold standard to accomplish symmetrical, spontaneous facial movement

63.  Indications for CFNG include:
• A distal stump is present
• Complete transection when the ipsilateral proximal facial nerve stump is
unavailable for grafting
• The facial muscles are capable of useful function following reinnervation (probably
<1year post-injury)
However, a CFNG alone is usually not powerful enough to produce an adequate
smile.

64.  useful in association with other reanimation techniques to address a single territory e.g. in isolated marginal
mandibular nerve paralysis.
 useful with a partial facial palsy to enhance residual function.
 Less success has been reported with reinnervation of the marginal mandibular or temporal branches, although it
may provide adequate tone (Fattah et al. 2012).
 Limited success -facial musculature usually reinnervates poorly with time.

65.  CFNG may be done as a one- or two stage procedure
 One-stage CFNG: Both ends are repaired at the same operation.
 TWO STAGE CFNG-

66.  2nd stage
 This is often performed 9-12 months following the 1st stage
 A positive Tinel’s sign can be elicited at the end of the nerve graft (indicates the presence axonal
regeneration)
 Resect the terminal neuroma on the sural nerve and Suture the graft to distal (paralysed) stump of facial
nerve

67. BABY SITTER PROCEDURE

68. MANAGEMENT OF PARALYZED BROW
BROW LIFT
ELEVATES PTOTIC EYEBROW due to
paralysis of frontalis
Improves aesthetic appearance
Removes upper visual field obstruction

69. APPROACHES AND TECHNIQUES

70. CORONAL BROWLIFT
 Patients with low seated hairline.
 Advantages
 Disadvantages.
 Technique

72. TEMPORAL BROWLIFT
 Lateral orbital hooding.
 Advantages.
 Disadvantages.
 Technique.

74. PRETRICHIAL BROWLIFT
 Advantages
 Disadvantages.
 Technique.

76. MID FOREHEAD BROW LIFT
 Patients with deep forehead rhytids and receding hairline.
 Advantages.
 Disadvantages.
 Technique.

78. DIRECT BROWLIFT
 Advantages
 Disadvantages
 Technique

80. ENDOSCOPIC BROWLIFT

81. MANAGEMENT OF UPPER EYELID COMPLEX

82. LID LOADING

85. PALPEBRAL SPRINGS

86. MANAGEMENT OF LOWER EYELID COMPLEX

87. STATIC SLING

88. LATERAL TARSAL STRIP

89. LATERAL TRANSORBITAL CANTHOPEXY

90. MEDIAL CANTHAL TENDON REPAIR

91. KUHNT-SZYANOWSKI PROCEDURE

92. MANAGEMENT OF MIDFACE AND PARALYED LIPS

93. Upper lip andcheek
Paralysis of the oral musculature, including drooling of saliva and
speech difficulties.
lead to difficulties with chewing food, cheek biting, and pocketing
of food in the buccal sulcus due to paralysis of the buccinators.
The main emphasis of surgery is usually centered on reconstruction
of a smile.

94. SmileAnalysis
Itisrecognized that the unopposed smile on the normal side in
unilateral facial paralysis will be an exaggerated expression of the
same movement after reconstruction of the paralyzed side.

95. SmileAnalysis
 The preoperative plan : The two arrows on
the left cheek illustrate the direction of
movement of the left commissure and
upper lip when smiling.
 The location of the cross-facial nerve
graft is outlined in the upper lip.
 On the right side of the face is the intended
location of the transferred muscle.

96. Upper lip andcheek
Ifthe concern is primarily for asymmetry at rest, then a static
procedure with slings can be quite beneficial.
For the patient who is willing to apply conscious effort and desires
static correction as well as the ability to achieve a smile, dynamic
correction isrequired .

97. Static reconstruction
Autologous :made of fascia such as tensor fascia lata or a tendon,
preferably the plantaris, Ifthis tendon isnot available, the extensor
tendon of the second or third toe can be used.
immune compatible .
incorporated into the surrounding tissues and closely maintains its
pre-surgical length.

98. Static reconstruction
Alloplastic materials :polytetrafluoroethylene , polypropylene mesh,
and silicone rods that tend to form granulomata,
Granulomata formation.
have a high rate of extrusion .
are easily stretchable.

99. Photo 1: Subdermal dissection to expose SMAS Photo 2: Skeletonization of zygomatic arch
Photo 3: Orientation of Fascia lata

100. Photo 4: Insertion of Fascia lata Photo 5: Suspension with Fascia lata
Photo 6: Pre and post operative photos

101. Static reconstruction
Slight overcorrection is more acceptable than an under correction
because the patient is more symmetric when smiling.

102. Dynamic Reconstruction
Dynamic
Reconstruction
Regional muscle
transfer
Free muscle transfer

103. REGIONAL MUSCLE TRANSFER
 Local muscle flaps e.g. masseter and temporalis flaps
 Used when there is
 absence of suitable mimetic muscles after long-standing atrophy
 No further potential for useful function after reinnervation.

104. MASSETER MUSCLE TRANSFER
 All or part of the masseter can be used as a local muscle flap for facial
reanimation
 INTRA-ORAL APPROACH - the muscle’s insertion can be detached from the
lower mandibular border, transposed anteriorly, divided into three slips and
inserted into the dermis above the lip, at the oral commissure and below the
lip

105. Masseter muscle transplantation
 Baker and Conley : Transplanting the entire muscle
 Rubin : separating the most anterior half of the muscle only
and transposing it to the upper and lower lip.
 Rubin : transplanting the temporalis and masseter muscles
together
 The temporalis provides motion to the upper lip and nasolabial
fold; the masseter provides support to the corner of the mouth
and
lower lip.

106. Temporalis muscletransfer
• Retrograde temporalis muscle transplantation:Gillis
• Itinvolves detaching the origin of the muscle from the temporal
fossa and turning it over the zygomatic arch to extend to the oral
commissure.

107. Temporalis muscletransfer
Advantage :
excellent static positioning as well as voluntary activity.
Itis capable of producing an oblique lift to the mouth
Diadvantage :significant hollowing in the temporal region .
The bulge of muscle present where it passes over the arch of the
zygoma.
No control of the direction of movement.

108. Temporalis muscletransfer
Hollowing in the temporal region that can be filled with an implant.
Baker and Conley :recommend leaving the anterior portion of the
temporalis behind to partially camouflage the temporal hollowing.

109. Temporalis muscletransfer
McLaughlin : Antegrade temporalistransplantation
The temporalis muscle is detached from the coronoid
process of the mandible and brought forward.
Fascial grafts are used to reach the angle of the
mouth

110. FACIAL REANIMATION WITH FREE TISSUE TRANSFER

111. Free muscletransplantation
Free muscle
transplantation
Single Staged Two Staged

112. Two Staged Free muscletransplantation
Cross-facial nerve graft followed by the muscle transplantation.
Suitable approach is to pare down a muscle to the desired size
before transplantation.
Muscle can be used are : Gracilis , P.Minor ,rectus abdominis,LD,
ECRB,SA,RF , Abductor haullicis.
Gracilis muscle is suitable for facialparalysis reconstruction
because:

113. Free muscle transplantation :TwoStaged
Gracilis muscle issuitable for facialparalysis reconstruction because:
• The neurovascular pedicle is reliable and relatively easy to prepare.
A segment of muscle can be cut to any desired size based on the
neurovascular pedicle. Thisallows the surgeon to customize the
muscle to the patient's facial requirements.
There is no functional loss in the leg.
Because the scar is in the medial aspect of the thigh, it is reasonably
well hidden.
The thigh is far enough removed from the face that a simultaneous
preparation of the muscle and the face is easily accomplished

114. Free muscle transplantation :TwoStaged
The muscle issplit longitudinally & the anterior portion of the muscle
is used.
The amount of muscle that is taken varies from 30%to 70%of the
cross section of the muscle, depending on the muscle size and
needs of theface.
After facial measurements are taken, a piece of muscle with a little
extra length isremoved.
Itis usually inserted into the fibers of the paralyzed orbicularis oris
above and below the commissure and along the upper lip .
Preoperative smile analysis determines the points of insertion.

115. Free muscle transplantation :TwoStaged
The gracilis is positioned so that its hilum is close to the mouth and
the motor nerve can be tunneled into the upper lip.
The upper buccal sulcus incision is reopened, and the free end of
the nerve graft isidentified and coapted to the gracilis muscle
motor nerve.
vascular Anastomosis : facial vessels, superficial temporal vessels,
transverse facial vein .

116. Free muscle transplantation :TwoStaged
Movement :6 months or more haveelapsed
Maximal movement :gained by18 months.
At this stage, an assessment is made of the resting tension in the
muscle andits excursion with smiling.
Third procedure to adjust the muscle :either tightening or loosening.
This can be combined with other touch-up procedures such as
debulking or an adjustment of the insertion of origin.

117. Free muscle transplantation :TwoStaged
With this procedure, patients usually gain around 50%as much
movement on the paralyzed side as on the non paralyzed side.

118. 1st Stage
A “short” cross-facial nerve graft is seen lying on the
cheek in the position that it will be in when inserted End of sural nerve

119. 2nd Stage
Gracilis muscle with nerveand
vascular pedicle
Inset into orbicularis oris Gracilis muscle sutured to deep temporal fascia

120. Single-stage muscletransfers
Innervation :contralateral facial nerve.
Technique requires :muscle with a long nerve segment, such as the
latissimus dorsi or rectus abdominis,gracilis.
The nerve is tunneled across the lip and coapted to the facial nerve
branches on the opposite side of the face.
Advantages :
1. only one operation
2. only one site of coaptation for regenerating axons to cross.
3. There does not appear to be any significant denervation atrophy
of the muscle while it awaits reinnervation.

121. Single-stage muscletransfers
Disadvantage :
The muscle may function with facial movement, it may not contract
when the patientsmiles.
This is because the facial nerve branches that are used are close to
the mouth and are usually found through a nasolabial incision on
the unaffected side. This approach does not allow thorough facial
nerve mapping to be performed; thus, the most appropriate nerve
branches may not be recruited.

122. MANAGEMENT OF LOWERLIP

123. Lower Lip
The lower lip deformity caused by marginal mandibular nerve palsy .
The marginal mandibular nerve consists of one to three branches :
supplies the depressor labii inferioris, depressor anguli oris, mentalis,
and portions of the lower lip orbicularis oris.
The muscle function that is missed most by the patient is that of the
depressor labii inferioris.
Paralysis of this muscle results in the inability to depress, lateralize,
and evert the lower lip.

124. Lower Lip
In the normal resting position :the deformity is not usually noticeable
as the lips are closed and the depressors are relaxed.
However, when the patient is talking, the paralyzed side stays in an
elevated position, whereas the nonparalyzed side isable to move
inferiorly and away from the teeth.
The deformity is most accentuated when the patient attempts a full
smile, showing his or herteeth

125. Muscle Transplantation
Edgerton : transplantation of the anterior belly of the digastric muscle.
The insertion of the digastric muscle to the mandible on the
paralyzed side is divided and attached to a fascia lata graft that is
then secured to the mucocutaneous border of the involved lip.
Conley : modified this technique by leaving the mandibular insertion
intact but divided the tendon between anterior and posterior bellies,
rotated the muscle, and reattached the tendon to the lateral aspect
of the lowerlip.
digastric transplantation tends to act more as a passive restraint on
the lower lip rather than as an active depressor

126. Muscle Transplantation
T
erzis: has further modified the digastric transplantation by
combining it with a cross-facial nerve graft coapted to a marginal
mandibular nerve branch on the unaffected side, thereby allowing
the possibility of spontaneous activation with smiling.

127. Selective Myectomy
Achieves symmetry both at rest and with expression.
Selective myectomy of the depressor labii inferioris of the
nonparalyzed side.
Depressor resection can be performed as an outpatient procedure
under local anesthetic.
Simple myotomy will not produce long-standing results, whereas
results from myectomy have been permanent.

128. Selective Myectomy
Injection of either long-acting local anesthetic or botulinum toxin
into the depressor labi inferioris.
Thisinjection allows the patient a chance to decide whether to
proceed with the muscle resection based on the loss of function of
the depressor.
As a result of this operation, the shape of the smile is altered on the
normal side, and the lower lip isnow symmetric with the opposite
side.

129. Selective Myectomy
Depressor labii inferioris :marked preoperatively by asking the
patient to show the teeth and palpating over the lower lip.
The muscle can be felt as a band passing from the lateral aspect of
the lower lip inferiorly and laterally to the chin.
Incision : intraoral buccal sulcus incision.

130. The muscle is identified; it is partly hidden by the
orbicularis oris, whose fibers must be elevated to
reveal the more vertically and obliquely oriented
fibers of the depressor labii inferioris, which measures
approximately 1 cm inwidth
Care must be taken to preserve the branches of the
mental nerve during thedissection
Once the muscle has been identified, the central
portion of the muscle belly is resected

131. THANK YOU