management of bells palsy and facial reanimation surgeries-plastic surgery point of view

1. MANAGEMENT OF BELLS PALSY

2. Bell’s palsy
 Bell’s palsy is an acute, unilateral paresis or paralysis of the face in a
pattern consistent with peripheral nerve dysfunction, without
detectable causes.
 It is the most common cause of acute onset unilateral peripheral
facial weakness.
 It acounts for 60-70% of all cases of unilateral peripheral facial palsy.

3. Bell’s palsy
 Affects with equal frequency on the right and left sides of the face.
 Either sex is affected equally .
 May occur at any age, the median age is 40 years.(10 years -70 years)
 Patients who have had one episode of Bell's palsy have an 8 percent
risk of recurrence.
 Mean interval to first recurrence is reported at 9.8 years after the first
episode.

4. Bell’s palsy
 The cause is unclear.
 Viral infection, vascular ischemia, autoimmune inflammatory
disorders, and heredity have been proposed as the underlying
cause.
 A viral cause has gained popularity since the isolation of the herpes
simplex virus-1 genome from facial nerve endoneurial fluid in people
with Bell’s palsy.10

5. Bell’s palsy
 sudden onset and symptom typically peak within a few days.
 weakness or complete paralysis of muscles on one side of the face.
Additional symptoms:
1. Pain in or behind the ear.
2. Numbness or tingling in the affected side of the
face usually without any objective deficit on
neurological examination.
3. Hyperacusis.
4. Disturbed taste on the ipsilateral anterior part of
the tongue

6. Bell’s palsy
 Bell's phenomenon - on attempted closure, the eye rolls upward .
 Tear production decreases; however, the eye may appear to tear
excessively because of loss of lid control, which allows tears to spill
freely from the eye.
 Food and saliva can pool in the affected side of the mouth and
may spill out from the corner

7. Diagnosis
 Determine whether facial weakness is central or peripheral.
Bell's palsy is differentiated from other causes of facial palsy
such as diabetes mellitus, human
immunodeficiency virus (HIV) infection, Lyme disease,
Ramsay Hunt syndrome (peripheral facial palsy
with zoster oticus), sarcoidosis, Sjogren's syndrome,
parotidnerve tumors, leprosy, polyarteritis nodosa,
Amyloidosis.
Facial palsy secondary to other causes progresses over
days to months.

8. Diagnostic Workup
 Diagnosis of Bell's palsy in a patient with unilateral peripheral facial
weakness of unknown cause is purely clinical.
 However, electrodiagnostic testing done within 14 days of onset
may provide prognostic information

9. Trigeminal blink reflex
Measure intracranial pathway
Study various postparalysis sequelae such
as synkinesis and hemifacial spasms.
Prolongation of this response correlates with
greater loss of facial motor function
Nerve excitability test
Minimum electrical stimulus required to
produce visible muscle contraction.
Difference greater than 3.5 mA
between affected and unaffected
sides is considered to be significant in
terms of poorer outcome.
Gadolinium MRI:
reveals enhancement internal acoustic
meatal segment on the affected side;
however, this is a nonspecific finding.
should be the investigation to look for
other possible causes
POOR
PROGNOSIS
POOR
PROGNOSIS

10. Clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for
patients with Bell's palsy. Either acyclovir 400 mg can be given five times per day for seven days or valacyclovir
1 g can be given three times per day for seven days

11. Management
NONSURGICAL MANEUVERS TO PROTECT THE EYE
Lid taping, particularly while sleeping
Soft contact lenses
Modification of eyeglasses to provide a lateral shield
Eye patches
Temporary tarsorrhaphy
Physical Therapy
In Bell's palsy various physical therapies, such as exercise, biofeedback,
laser, electrotherapy, massage and thermotherapy are used to hasten
recovery.
However, the evidence for the efficacy any of these therapies, is lacking

12. Prognosis
 About 71% of patients with Bell's palsy have motor function recovery
completely within 6 months.
 Poor prognostic factors : old age, hypertension, diabetes mellitus,
impairment of taste and complete facial weakness.
 About one-third of patients may have incomplete recovery and
residual effect.

13. Residual effects
1. post-paralytic hemifacial spasm
2. co-contracting muscles
3. synkinesis
4. sweating while eating or during physical exertion
 2 most common abnormal regeneration patterns are:
1. ‘crocodile tears’ - lacrimation of the ipsilateral eye during chewing
2. ‘jaw-winking’ - closure of the ipsilateral eyelid when the jaw opens

14. SURGICAL MANAGEMENT OF ACUTE FACIAL
PARALYSIS (<3 WEEKS)
 Surgical decompression within three weeks of onset has been
recommended for patients who have persistent loss of function.
1. Transmastoid approach
2. Middle fossa approach
3. Translabyrinthine approach
The most common complication of surgery is postoperative hearing
loss, which affects 3 to 15 percent of patients.

15. SURGICAL MANAGEMENT OF ACUTE FACIAL
PARALYSIS (<3 WEEKS)
 National Guideline Clearinghouse & the American Academy of
Neurology does not currently recommend surgical decompression
for Bell's palsy.

16. AIMS OF RECONSTRUCTION
 to restore symmetry and coordinated dynamic animation with
normal appearance at repose.
 symmetry during voluntary and involuntary expression, competent
ocular and oral sphincters.
 preservation of existing facial function.
 minimal loss of function in other donor motor nerves should be the
goal.

17. SURGICAL TREATMENT OF INTERMEDIATE
DURATION FACIAL PARALYSIS
(3 WEEKS to 2 YEAR)

18. NERVE TRANSFER
Potential indications for nerve transfers include:
1. The distal stump is present .
2. Proximal, ipsilateral facial nerve stump is unavailable for grafting .
3. Facial muscles are capable of useful function after reinnervation .

19. NERVE TRANSFER
 1. Nerve transfer
a. Hypoglossal-facial
b. Spinal accessory-facial
c. Masseteric-facial
 2. Cross face nerve grafting using sural nerve

20. Hypoglossal-facial Nerve transfer
 The most commonly used procedure is the hypoglossal-facial
transfer.
 The classic XII-VII transfer:
transection of the entire hypoglossal nerve distal to the ansa
cervicalis and coaptation to the main trunk of the facial nerve.

21. Classic XII-VII transfer
 Divide the facial nerve close to the stylomastoid
foramen .
 The facial nerve can be further mobilised by
dissecting it freeing it from the parotid distal to its
bifurcation .
 Reflect the distal trunk of the facial nerve inferiorly.
 Sharply divide the hypoglossal nerve quite far
anteriorly along its course to secure an adequate
length of nerve to transfer.
 Reflect it superiorly up to the distal facial nerve stump.
 Coapt the hypoglossal and facial nerves.

22. Split XII-VII transfer
Approximately 30-40% of the hypoglossal nerve is
divided longitudinally for several centimeters.
As it provides fewer axons, it is best connected only
to the lower division of the facial nerve.

23. XII-VII jump graft
End-to-side neurorrhaphy between hypoglossal
nerve and a donor cable nerve graft (e.g. great
auricular nerve) which serves as a jump graft to the
main trunk of the facial nerve.

24. Mobilization of mastoid segment of facial nerve
 The facial nerve can be mobilized in its mastoid segment from the
2nd genu distally and rotated inferiorly to allow direct coaptation to
the hypoglossal nerve. This typically requires removal of the mastoid
tip.

25. Hypoglossal-facial Nerve transfer
 The major concerns with the XII-VII transfer is the potential of
hemitongue paralysis leading to dysphagia and dysarthria.
 Contraindications :
1. Multiple cranialneuropathies .
2. Developmental facial paralysis.
3. Prolonged facial palsy of greater that two year duration.
 Improved facial tone and symmetry - 90% of patients.
 often combined this procedure with static slings in order to obtain
immediate results until the reinnervation is completed.

26. Make a preauricular incision and elevate a skin flap over
the parotid .
Make a transverse incision in the parotid capsule
approximately 1cm below the zygomatic arch and 3cms
anterior to the tragus .
Bluntly dissect through the parotid tissue up to the surface of
the masseter muscle to avoid transecting branches of the
facial nerve .
Split the masseter to gain access to the deep surface of the
muscle .
Use a nerve stimulator to locate the nerve; the nerve is
generally located approximately 1.5cms deep to the
superficial muscular aponeurotic system (SMAS).
Follow the nerve anteriorly until it ramifies .
There is usually a branch-free segment measuring 1cm that
can be cleanly transected distally and reflected laterally
into the wound, ready for coaptation to the stump of the
facial nerve .
Masseteric-facial N Transfer

27. MASSETERIC – FACIAL NERVE TRANSFER
 It is increasingly being used for facial reanimation .
 Good option due to its minimal donor morbidity .

28. Cross-facial nerve grafting (CFNG)
 CFNG may also be useful with a partial facial palsy to enhance
residual function .
 The CFNG harnesses neuronal activity from the uninjured facial
nerve activity to the contralateral side to power a free muscle
transfer

29. Cross-facial nerve grafting (CFNG)
CFNG may be done as a one- or two-stage procedure –
1. One-stage CFNG : Both ends are repaired at the same operation.
2. Two-stage CFNG

30. Cross-facial nerve grafting (CFNG)
First stage
 on the unaffected side through a preauricular incision with a
submandibular extension .
 The zygomaticobuccal nerve branches medial to the parotid gland
are meticulously identified.
 Facial nerve mapping :identifies which nerve fibers stimulate the
orbicularis oris and oculi muscles , lip retractors.
 When stimulated, the facial nerve branches that produce a smile
and no other movement are selected.

31. CFNG
 All of the branches that create a smile are identified.
 Only branches that have smile function should be used.
 There should be no orbicularis oris function present in any of these
branches.
 then approximately one half of them are divided and coapted to
the nerve graft.
 Usually one or two branches are used.
 The nerve graft is passed across the face, and the end is banked in
the upper buccal sulcus just past the midline.

32. CFNG
 The sural nerve is the usual donor nerve.
 The proximal ends of the donor facial nerve branches are sutured to the distal
end of the nerve graft .
 Technical Modifications :
1. Splitting : split longitudinally and half is used splitting provides a better end-to-
end match
2. Nerve Graft Length : In the past 25-cm nerve was used for the nerve graft and
passed subcutaneously across the face to the opposite pretragal area..The
current practice is to use a short nerve graft, approximately 10 cm in length,
and to bank the free end in the upper buccal sulcus. This should provide an
innervated graft that is better.
3. the waiting period between the first and second stages is reduced with use of
a short cross-facial nerve graft from 12 months to around 6 months. Patients
who have had short nerve grafts achieve stronger muscle contraction than
was previously obtained with traditional long cross-facial nerve grafts

33. 1st stage of 2-stage CFNG

34. 2nd stage CFNG
 This is often performed 6-12 months following the 1st stage .
 The distal end of the sural nerve graft then coapted to
corresponding branches supplying specific muscle groups on the
paralysed side.

35. The Principle of Babystters
 Although the concept of CFNG is ingenious, it necessitates a
prolonged denervation period of the affected facial muscles while
regeneration and elongation of the contralateral axons take place.
 This could lead to irreversible muscle atrophy, unless the CFNG
procedure is undertaken soon after the facial nerve injury (within the
first 6 months).

36. The Principle of Babystters
 For later cases {over 6 months to 2years), Terzis in 1984 introduced
the "babysitter" procedure.
 This is a two-stage procedure : the first stage involves use of 40% of
the ipsilateral hypoglossal nerve, which provides powerful motor
fibers to the affected facial nerve, reaching target connectivity
quickly, and therefore preserving the facial muscle bulk.
 At the same time, several CFNGs are placed which are connected
to seleaed branches of the unaffected facial nerve.

37. The Principle of Babysitters
 The second stage, usually 9 to 12 months later, involves secondary
microcoaptations between the CFNGs and selected distal branches
of the affected facial nerve.
 Variations of the "babysitter procedure" have been reported,
including techniques such as end-to-side grafting and concomitant
CFNG and hypoglossal facial grafting using a single sural nerve
graft.

38. SURGICAL TREATMENT OF
CHRONIC FACIAL
PARALYSIS (>2 YR)

39. SURGICAL TREATMENT OF CHRONIC FACIAL
PARALYSIS (>2 YR)
 STATIC CORRECTION OF ASYMMETRY : Static procedures aim to
correct asymmetry at rest.
 DYNAMIC REANIMATION
1. Dynamic reanimation attempts to restore symmetry both at rest
and while smiling.
2. Three elements are required for the formation of a smile: neural
input, a functional muscle innervated by the nerve, and proper
muscle arrangement

40. Brow : Direct Brow lift
 Best able to correct large discrepancies.
 incision be placed just along the main line of hair follicles.
 An ellipse of skin and frontalis muscle is excised and the paralyzed
frontalis muscle repaired.
 Slight overcorrection is particularly beneficial if the person's normal
side of the forehead is quite active during facial expression.

41. Coronal brow lift with static suspension
 performed through a coronal incision
 leaves an inconspicuous scar.
 amount of lifting that can be achieved is much less.
 with or without a fascial graft to suspend the brow from the
temporalis fascia or medially on the frontal bone

42.  If there is marked wrinkling of the forehead on the normalside, a
normal-side frontal nerve resection with or without a frontalis muscle
resection will help to correct forehead asymmetry.
 Because a simple resection of the frontal branches often results in
reinnervation, the surgeon should consider resecting the entire
lateral margin of the frontalis to obtain a permanent paralysis.

43. MANAGEMENT OF UPPER EYE LID

44. LAGOPHTHALMOS
These are all directed at overcoming the unopposed
action of the levator palpebrae superioris.
Gold weight
Temporalis transplantation
Spring
Tarsorrhaphy

45. Gold weight
 lid loading with gold prostheses is the most popular technique
 technical ease and reversibility.
 patient's eyelid configuration is important .
 If the amount of exposed eyelid skin above the lashes is more than 5
mm when the eye is open.
 24-carat gold is used.
 Prostheses are available in weights ranging from 0.8 to 1.8 g.
Adequate improvement in eye closure can be obtained with a
weight of 0.8 to 1.2 g,

46. Gold weight
 The appropriate weight is selected by taping trial prostheses to the
upper eyelid over the tarsal plate with the patient awake.
 The lightest weight that will bring the upper eyelid within 2 to 4 mm
of the lower lid and cover the cornea should be used.

47. Complications include extrusion, excessive capsule
formation causing a visible lump, and irritation of the eye
by the weight

48. Gold weight
 There is a high extrusion rate (approxima-tely 10%) after 5 years.

49. Palpebral spring
 Described by Morel-Fatio
WIRE LOOP WITH 2 ARMS

50. palpebral spring
 The advantage of this procedure is that it is not dependent on
gravity.
 However, problems with malpositioning of the spring, spring
breakage or weakening, pseudoptosis due to excessive spring
force, and skin erosion have prevented the widespread use of this
procedure.
 It is certainly a more involved procedure than insertion of the gold
weight, and results may be dependent on the surgeon's skill level.

51. Temporalis Muscle transplantation
Gillies

52. Temporalis transplantation
ADVANTAGES :
 uses autogenous tissue
 addressing both upper eyelid lagophthalmos and lower eyelid
ectropion.
 an excellent static support.
 eye closure on command.
 good lubrication of the eye through distribution of the tear film.

53. Temporalis transplantation
DISADVANTAGES :
 disadvantages of this transfer are that with muscle contraction, the
lid aperture changes from an oval to a slit shape.
 there may be skin wrinkling over the lateral canthal region.
 an obvious muscle bulge over the lateral orbital margin.
 Movements of the eyelids during chewing may also be a disturbing
feature for the patient.

54. lateral tarsorrhaphy

55. lateral tarsorrhaphy
Main indication : lateral tarsorrhaphy is for the patient with
 an anesthetic cornea .
 severe corneal exposure .
 failure of aesthetically more acceptable techniques .

56. McLaughlin lateral tarsorrhaphy
 For mild degrees of orbicularis oculi palsy and lagophthalmos.
 A triangle of the anterior lamella (skin, muscle and eyelashes) is
removed from the lateral 1/4 of the lower lid (from the grey line
muco-cutaneous junction down).
 A similar triangle is removed from the posterior lamella (conjunctiva
and tarsus) of the upper lid (from the grey line up).
 The lower lid is thus drawn under the upper, effectively tightening
and elevating it.
 The lashes are preserved on the upper lid for camouflage of lateral
lid adhesion

57. McLaughlin lateral tarsorrhaphy
 The palpebral fissure’s horizontal length is reduced by this procedure
and the lateral visual field may be reduced.
 The elevation of the lateral canthus is minimal .

58. LOWER EYELID ECTROPION
 Ordinarily, the eyelid margin rests at the level of the limbus of the
eye.
 Ectropion with lid eversion and more than 2 to 3 mm of scleral show
is usually associated with symptoms of dryness and aesthetic
concerns.
 This situation requires support of the entire length of the eyelid.

59. LOWER EYELID ECTROPION
Options available are :
 Tendon sling
 Lateral canthoplasty
 Horizontal lid shortening
 Temporalis transplantation
 Cartilage graft

60. Tendon Sling
 Achieved with a static sling passed 1.5 to 2 mm inferior to the gray
line of the eyelid and fixed both medially and laterally.
 This procedure provides good support to the lower lid. It does not
deform the eyelid, it is not apparent to an observer.
 Tendon provides longer lasting support with less stretching than the
fascia lata.
 If the sling is placed too loosely, it may be tightened at the lateral
orbital margin.

61. Tendon Sling
 Proper placement is crucial; too low of a position will exacerbate
the ectropion.
 In the elderly patient with particularly lax tissues, too superficial or
high placement may result in an entropion.

62. Tendon Sling
 In patients with a relatively proptotic eye : patients with a negative
vector - the lower eyelid sling will correct ectropion, but it may not
decrease scleral show .
 In patients with a positive vector, in which the globe is posterior to
the lid margin and the lid margin is posterior to the cheek
prominence, the sling will be effective.

63. Lateral Canthoplasty
 Milder eyelid problems consisting of lower lid laxity and minimal
scleral show.
 The canthal ligament must be reapproximated to the position of
Whitnall tubercle, which is situated not only above the horizontal
midpupillary line but also 2 to 3 mm posterior to the lateral orbital
margin.
 Various techniques of canthoplasty, such as the tarsal strip, dermal
pennant, and inferior retinacular lateral Canthoplasty.

64. Lateral canthoplasty
 These methods are useful in the aesthetic or posttraumatic situation
but stretch over the long term in a patient with facial paralysis.

65. Horizontal lid shortening
 This procedure tends to distort and expose the caruncle and does
not provide a lasting correction.

66. Cartilage grafts
 prop up the tarsal plate.
 The cartilage, usually conchal, augmentation of the middle lamella
and suturing of the cartilage to the inferior orbital margin.
 The cartilage tends to rotate outward rather than sit in a vertical
position, thus producing a visible bulge and poor eyelid support

67. Upper lip and cheek
 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.

68. NASAL VALVE RECONSTRUCTION

69. Nasal Airway
 Paralysis of : nasalis and levator alaeque nasi combined with
drooping and medial deviation of the paralyzed cheek .
 This results in a visual asymmetry and significant breathing problems
particularly when sleeping, congenital facial paralysis, congenital
airway obstruction.

70. Nasal Airway reconstruction
 Sling of tendon from the lateral aspect of the alar base up to the
orbital margin.
 Use of spreader graft.
 Correction of the lower face and lips with either a static or dynamic
procedure will usually reposition the nasal base and correct the
nasal obstruction

71. MANAGEMENT OF UPPER LIP AND CHEEK

72. Smile Analysis
 It is recognized 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.

73. Smile Analysis
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.

74. Upper lip and cheek
 If the 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 is required .

75. Static reconstruction
Autologous : made of fascia such as tensor fascia lata or a tendon,
preferably the plantaris, If this tendon is not 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.

76. 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 .

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

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

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

80. Dynamic Reconstruction
Dynamic
Reconstruction
Regional muscle
transfer
Free muscle transfer

81. Temporalis muscle transfer
 Retrograde temporalis muscle transplantation : Gillis
 It involves detaching the origin of the muscle from the temporal
fossa and turning it over the zygomatic arch to extend to the oral
commissure.
 Fascial graft is required to achieve the necessary length to reach
the mouth.

82. Temporalis muscle transfer
 Advantage :
 excellent static positioning as well as voluntary activity.
 It is 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.

83. Temporalis muscle transfer
 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.

84. Temporalis muscle transfer
McLaughlin : Antegrade temporalis transplantation
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

85. 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.

86. Free muscle transplantation
Free muscle
transplantationSingle Staged Two Staged

87. Two Staged Free muscle transplantation
 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 facial paralysis reconstruction
because:

88. Free muscle transplantation : Two Staged
 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. This allows 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

89. Free muscle transplantation : Two Staged
 The muscle is split 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 the face.
 After facial measurements are taken, a piece of muscle with a little
extra length is removed.
 It is 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.

90. Free muscle transplantation : Two Staged
 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 is identified and coapted to the gracilis muscle
motor nerve.
 vascular Anastomosis : facial vessels, superficial temporal vessels,
transverse facial vein .

91. Free muscle transplantation : Two Staged
 Movement : 6 months or more have elapsed
 Maximal movement : gained by 18 months.
 At this stage, an assessment is made of the resting tension in the
muscle and its 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.

92. Free muscle transplantation : Two Staged
 With this procedure, patients usually gain around 50% as much
movement on the paralyzed side as on the non paralyzed side.

93. 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

94. 2nd Stage
Gracilis muscle with nerve and
vascular pedicle
Inset into orbicularis oris Gracilis muscle sutured to deep temporal fascia

95. Single-stage muscle transfers
 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.

96. Single-stage muscle transfers
Disadvantage :
 The muscle may function with facial movement, it may not contract
when the patient smiles.
 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.

97. MANAGEMENT OF LOWER LIP

98. 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.

99. 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 is able to move
inferiorly and away from the teeth.
 The deformity is most accentuated when the patient attempts a full
smile, showing his or her teeth

100. 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 lower lip.
 digastric transplantation tends to act more as a passive restraint on
the lower lip rather than as an active depressor

101.  Terzis : 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.

102. 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.

103. Selective myectomy
 Injection of either long-acting local anesthetic or botulinum toxin
into the depressor labi inferioris.
 This injection 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 is now symmetric with the opposite
side.

104. 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.

105. 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 in width
Care must be taken to preserve the branches of the
mental nerve during the dissection
Once the muscle has been identified, the central
portion of the muscle belly is resected

106. THANK YOU