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Facial reanimation

The document discusses facial nerve palsy and facial reanimation. It begins with an introduction to the facial nerve and its functions. It then covers anatomy of the facial nerve, classifications and etiologies of facial nerve palsy, presentation and evaluation, non-surgical and surgical management options. For surgical management it discusses various nerve repair techniques including cable grafting and nerve transfers. It also covers approaches to managing specific areas like the eyebrow, eyelids, and lips which may be paralyzed. Both static and dynamic reconstruction techniques are outlined.

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FACIAL NERVE PALSY AND FACIAL REANIMATION Dr Gautam Kalra Senior Resident Dept of Plastic and Reconstructive Surgery
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
ANATOMY EMBRYOLOGICALLY DERIVED FROM 2nd BRACHIAL ARCH AND INNERVATES ALL THE STRUCTURES ORIGINATION FORM IT
ANATOMY OF THE FACIAL NERVE Unique as it has: Sensory fibres Motor fibres Autonomic fibres Special Sensory fibres
ANATOMY OF THE FACIAL NERVE  Facial Nucleus - lie in PONTINE REGION OF BRAIN STEM  Intratemporal anatomy  Extratemporal anatomy
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.
INTRA TEMPORAL ANATOMY
ANATOMICAL LANDMARKS/POINTERS  1. JUST ABOVE THE POSTERIOR BELLY OF DIAGASTRIC.  TYMPANOMASTOID SUTURE LINE  TRAGAL POINTER  STYLOID PROCESS
Extra-Cranial ANATOMY
CLASSIFICATION AND ETIOLOGY
CONGENITAL CAUSES  Mobius syndrome  GOLDENHAR`S SYNDROME
NEUROLOGICAL CAUSES  GB Syndrome  Stroke
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
RHEUMATOLOGICAL CONDITIONS  Diabetes Mellitus  Sarcoidosis
TRAUMA – 2nd MOST COMMON CAUSE  Forceps delivery/OBSTETRIC INJURY  Skull/ temporal fractures  Penetrating trauma
IATROGENIC  Cranial base surgery  Ear Surgery  Parotid Surgery
TUMORS INTRACRANIAL TEMPORAL BONE EXTRATEMPORAL VESTIBULAR SCHWANNOMA GLOMUS JUGULARE PAROTID TUMORS FACIAL NERVE TUMORS SQUAMOUS CELL CARCINOMA COCHLEAR NEUROMA BASAL CELL CARCINOMA MENINGIOMA
PRESENTATION AND INITIAL EVALUATION
BROW  Position at rest  Superior visual field  May be acceptable in young.  Obtain visual field documentation.
UPPER EYELID COMPLEX  Closure of eyelid effected.  Cleansing the sclera and cornea.  Corneal ulceration and opacification.
EYE EXAMINATION  Height of palpebral aperture.  Degree of logaphtholmos.  Bells phenomenon  Height of lateral canthus  Palpebral fissure and orbital width
BELLS PHENOMENON
LOWER EYELID COMPLEX  Ectropion  Turgor of skin  Conjunctival irritation
MARGINAL REFLEX DISTANCE
SNAP TEST
NASAL VALVE  2 Mechanisms:  Excessive soft tissue collapse.  Intrinsic collapse of internal nasal valve.  Forced inspiration.  NOSE instrument.
MIDFACE  Soft tissue collapse  Pull lower eyelid down.  Also effect lower facial complex.
MOUTH  Philtral deviation  Nasolabial fold.  Commisure depression or elevation.  Upper lip droop.  Vermilion inversion.
SMILE TYPES  Zygomatic  Canine  Full denture
LOWER FACE  Drooping of lower lip.  Sagging of cheek.  Disability of articulation and deglutition.  Constant drooling
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.
GLOBAL ISSUES  Underlying disease process.  Nutrition.  Social isolation.  Physical pain.  Depression.
HOUSE BRACKMANN GRADING
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
NON SURGICAL MANAGEMENT
EYE PROTECTION- FIRST PRIORITY  Lubrication with artificial tears  Protective glasses  Goggles and sunglasses  Moisture chamber  TAPING OF EYE LIDS
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
PHYSIOTHERAPY  Exercise  Thermal treatments  Massage  Electrical stimulus  MIME THERAPY
SPEECH/ SWALLOWING THERAPY
NASAL VALVE  Nasal dilator devices.  Injectables as spreader grafts
BROW MANAGEMENT
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
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.
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
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
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
 However, nerve transfer may produce  mass facial movement and synkinesis  palliated with botulinum toxin  function of the donor nerve is also sacrificed.
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
 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).
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.
Classic hypoglossal nerve transfer technique Split hypoglossal transfer Hypoglossal jump graft techniques
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
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
 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.
 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.
 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-
 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
BABY SITTER PROCEDURE
MANAGEMENT OF PARALYZED BROW BROW LIFT ELEVATES PTOTIC EYEBROW due to paralysis of frontalis Improves aesthetic appearance Removes upper visual field obstruction
APPROACHES AND TECHNIQUES
CORONAL BROWLIFT  Patients with low seated hairline.  Advantages  Disadvantages.  Technique
TEMPORAL BROWLIFT  Lateral orbital hooding.  Advantages.  Disadvantages.  Technique.
PRETRICHIAL BROWLIFT  Advantages  Disadvantages.  Technique.
MID FOREHEAD BROW LIFT  Patients with deep forehead rhytids and receding hairline.  Advantages.  Disadvantages.  Technique.
DIRECT BROWLIFT  Advantages  Disadvantages  Technique
ENDOSCOPIC BROWLIFT
MANAGEMENT OF UPPER EYELID COMPLEX
LID LOADING
PALPEBRAL SPRINGS
MANAGEMENT OF LOWER EYELID COMPLEX
STATIC SLING
LATERAL TARSAL STRIP
LATERAL TRANSORBITAL CANTHOPEXY
MEDIAL CANTHAL TENDON REPAIR
KUHNT-SZYANOWSKI PROCEDURE
MANAGEMENT OF MIDFACE AND PARALYED LIPS
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.
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.
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.
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 .
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.
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.
Photo 1: Subdermal dissection to expose SMAS Photo 2: Skeletonization of zygomatic arch Photo 3: Orientation of Fascia lata
Photo 4: Insertion of Fascia lata Photo 5: Suspension with Fascia lata Photo 6: Pre and post operative photos
Static reconstruction Slight overcorrection is more acceptable than an under correction because the patient is more symmetric when smiling.
Dynamic Reconstruction Dynamic Reconstruction Regional muscle transfer Free muscle transfer
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.
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
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.
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.
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.
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.
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
FACIAL REANIMATION WITH FREE TISSUE TRANSFER
Free muscletransplantation Free muscle transplantation Single Staged Two Staged
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:
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
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.
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 .
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.
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.
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
2nd Stage Gracilis muscle with nerveand vascular pedicle Inset into orbicularis oris Gracilis muscle sutured to deep temporal fascia
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.
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.
MANAGEMENT OF LOWERLIP
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.
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
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
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.
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.
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.
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.
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
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Facial reanimation

  • 1.
    FACIAL NERVE PALSYAND 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 FROM2nd BRACHIAL ARCH AND INNERVATES ALL THE STRUCTURES ORIGINATION FORM IT
  • 4.
    ANATOMY OF THEFACIAL NERVE Unique as it has: Sensory fibres Motor fibres Autonomic fibres Special Sensory fibres
  • 5.
    ANATOMY OF THEFACIAL NERVE  Facial Nucleus - lie in PONTINE REGION OF BRAIN STEM  Intratemporal anatomy  Extratemporal anatomy
  • 6.
    NOTE THE CLOSEPROXIMITY 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.
  • 10.
    ANATOMICAL LANDMARKS/POINTERS  1.JUST ABOVE THE POSTERIOR BELLY OF DIAGASTRIC.  TYMPANOMASTOID SUTURE LINE  TRAGAL POINTER  STYLOID PROCESS
  • 12.
  • 13.
  • 14.
    CONGENITAL CAUSES  Mobiussyndrome  GOLDENHAR`S SYNDROME
  • 15.
    NEUROLOGICAL CAUSES  GBSyndrome  Stroke
  • 16.
    INFECTIONS  Ramsay HuntSyndrome – 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.
  • 18.
    TRAUMA – 2ndMOST COMMON CAUSE  Forceps delivery/OBSTETRIC INJURY  Skull/ temporal fractures  Penetrating trauma
  • 19.
    IATROGENIC  Cranial basesurgery  Ear Surgery  Parotid Surgery
  • 20.
    TUMORS INTRACRANIAL TEMPORAL BONEEXTRATEMPORAL VESTIBULAR SCHWANNOMA GLOMUS JUGULARE PAROTID TUMORS FACIAL NERVE TUMORS SQUAMOUS CELL CARCINOMA COCHLEAR NEUROMA BASAL CELL CARCINOMA MENINGIOMA
  • 21.
  • 22.
    BROW  Position atrest  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  Heightof palpebral aperture.  Degree of logaphtholmos.  Bells phenomenon  Height of lateral canthus  Palpebral fissure and orbital width
  • 26.
  • 27.
    LOWER EYELID COMPLEX Ectropion  Turgor of skin  Conjunctival irritation
  • 29.
  • 30.
  • 31.
    NASAL VALVE  2Mechanisms:  Excessive soft tissue collapse.  Intrinsic collapse of internal nasal valve.  Forced inspiration.  NOSE instrument.
  • 32.
    MIDFACE  Soft tissuecollapse  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  Droopingof lower lip.  Sagging of cheek.  Disability of articulation and deglutition.  Constant drooling
  • 38.
    SYNKINESIS  Aberrant regenerationof 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  Underlyingdisease process.  Nutrition.  Social isolation.  Physical pain.  Depression.
  • 40.
  • 41.
    MANAGEMENT OF FACIALPALSY  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.
  • 43.
    EYE PROTECTION- FIRSTPRIORITY  Lubrication with artificial tears  Protective glasses  Goggles and sunglasses  Moisture chamber  TAPING OF EYE LIDS
  • 44.
    BOTULINUM TOXIN  Useon 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  Thermaltreatments  Massage  Electrical stimulus  MIME THERAPY
  • 46.
  • 47.
    NASAL VALVE  Nasaldilator devices.  Injectables as spreader grafts
  • 50.
  • 51.
    SURGICAL MANAGEMENT AIM OFOPERATIVE TREATMENT IS TO – 1. Protect the eye 2. Restore facial symmetry 3. Facilitate a spontaneous dynamic smile 4. Improve speech
  • 52.
    NERVE REPAIR  Dependingon 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 INDICATIONSAND 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  Potentialdonor- 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  Requirenerve 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, nervetransfer may produce  mass facial movement and synkinesis  palliated with botulinum toxin  function of the donor nerve is also sacrificed.
  • 57.
    XII –VII SUBSTITUTION bestsuited 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 intervalbetween 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 nervetransfer 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 transfertechnique Split hypoglossal transfer Hypoglossal jump graft techniques
  • 61.
    MASSETERIC FACIAL NERVETRANSFER 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 NERVEGRAFT  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 forCFNG 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 inassociation 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 maybe 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.
  • 68.
    MANAGEMENT OF PARALYZEDBROW BROW LIFT ELEVATES PTOTIC EYEBROW due to paralysis of frontalis Improves aesthetic appearance Removes upper visual field obstruction
  • 69.
  • 70.
    CORONAL BROWLIFT  Patientswith low seated hairline.  Advantages  Disadvantages.  Technique
  • 72.
    TEMPORAL BROWLIFT  Lateralorbital hooding.  Advantages.  Disadvantages.  Technique.
  • 74.
    PRETRICHIAL BROWLIFT  Advantages Disadvantages.  Technique.
  • 76.
    MID FOREHEAD BROWLIFT  Patients with deep forehead rhytids and receding hairline.  Advantages.  Disadvantages.  Technique.
  • 78.
    DIRECT BROWLIFT  Advantages Disadvantages  Technique
  • 80.
  • 81.
    MANAGEMENT OF UPPEREYELID COMPLEX
  • 82.
  • 85.
  • 86.
    MANAGEMENT OF LOWEREYELID COMPLEX
  • 87.
  • 88.
  • 89.
  • 90.
  • 91.
  • 92.
    MANAGEMENT OF MIDFACEAND PARALYED LIPS
  • 93.
    Upper lip andcheek Paralysisof 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 theunopposed 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 preoperativeplan : 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 Iftheconcern 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 :madeof 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: Subdermaldissection to expose SMAS Photo 2: Skeletonization of zygomatic arch Photo 3: Orientation of Fascia lata
  • 100.
    Photo 4: Insertionof Fascia lata Photo 5: Suspension with Fascia lata Photo 6: Pre and post operative photos
  • 101.
    Static reconstruction Slight overcorrectionis more acceptable than an under correction because the patient is more symmetric when smiling.
  • 102.
  • 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 • Retrogradetemporalis 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 : excellentstatic 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 inthe 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 WITHFREE TISSUE TRANSFER
  • 111.
  • 112.
    Two Staged Freemuscletransplantation 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 musclewith nerveand vascular pedicle Inset into orbicularis oris Gracilis muscle sutured to deep temporal fascia
  • 120.
    Single-stage muscletransfers Innervation :contralateralfacial 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 : Themuscle 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.
  • 123.
    Lower Lip The lowerlip 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 thenormal 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: hasfurther 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 symmetryboth 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 ofeither 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 labiiinferioris :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 isidentified; 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.

Editor's Notes

  • #8 MASTOID SEGMENT-1. TYMPANIC NERVE-small sensory branch to the external auditory canal Injury may cause hypoaesthesia of the part of EAC- HITSELBERGER`s SIGN 2. NERVE TO STAPEDIUS- STAPEDIUS MUSCLE DAMPENS LOUD NOICE hence hyperacusis occurs in facial nerve injury Interestingly, cell bodies of the motor nerve are not located in the facial nucleus hence stapedius muscle is unaffected in mobius syndrome 3. CHORDA TYMPANI – joins lingual nerve to provide special sense of taste Parasympathetic supply to submandibular and sublingual salivary glands
  • #9 Posterior auricular nerve is the first nerve branch after the exit from stylomastoid foramen
  • #13 The facial nerve then enters the parotid gland and arborises between the deep and superficial lobes of the parotid gland. The nerve first divides into temporozygomatic and cervicofacial divisions These divisions divide, rejoin and divide again to form the pes anserinus (Goose’s foot) to ultimately give the terminal bran-ches, namely, temporal (frontal), zygo-matic (malar and infraorbital), buccal, man-dibular and cervical nerves  Temporal (frontal) branch: This is the terminal branch of the superior division and travels along Pitanguy’s line which extends from 0.5cm below the tragus to 1.5cm above and lateral to the eyebrow. The nerve becomes increasingly super-ficial as it travels cephalad and lies just deep to the temporoparietal (superficial temporal) facia at the temple. At the level of zygomatic arch, it arborises into two to four branches to innervate the frontalis muscle from its inferior aspect. Temporal branch injury causes ipsila-teral frontalis muscle paralysis.  Zygomatic branch. This is arguably the most important branch of the facial nerve as it supplies orbicularis oculi, which enables eye protection. Conse-quently, injury to the zygomatic branch may cause lagophthalmos (inability to completely close the eye) with risks of exposure keratitis, corneal ulceration and scarring.  Buccal branch: This divides into multiple branches travelling at the level of the parotid duct. The surgical landmark to locate these branches is 1cm or one fingerbreadth below the zygomatic arch. The buccal branch innervates the buccinator and upper lip musculature. It is also important for lower eyelid function, as the medial canthal fibres of buccal branch innervate the inferior and medial orbicularis oculi. Injury to the buccal branch causes difficulty emptying food from the cheek and an impaired ability to smile. However, due to the high degree of arborisation (buccal branch always receives input from both the superior and inferior divisions of the facial nerve) damage to this branch is less likely to result in a functional deficit. The zygomatic/ buccal motor branch, that innervates the zygomaticus major can consistently be found at the midpoint (Zuker’s point) of a line drawn between the helical root and the lateral oral commissure  MARGINAL MANDIBULAR This is a terminal branch of inferior division and runs just below the border of mandible, deep to platysma and super-ficial to the facial vein and artery. It supplies the muscles of the lower lip (depressor anguli oris). Injury results in ipsilateral lack of depression of the lower lip and asymmetry of open mouth smiling or crying  Cervical branch: This is a terminal branch of the inferior division of the facial nerve. It runs down into the neck to supply platysma (from its deep surface)  Interconnections exist between buccal and zygomatic facial nerve branches in 70-90% of patients; hence injury to these branches may be clinically compensated for by these interconnections. This is not true for the frontal and marginal mandibular branches which are terminal branches without signi-ficant crossover. Hence injuries to the fron-tal and marginal mandibular branches are less likely to clinically recover.   
  • #15 MOBIUS SYNDROME- Unknown origin - Present with facial and ocular symptoms- incomplete eye closure, mask like facies, drooling of saliva & difficulty in sucking FACIAL NERVE always involved ABDUCENS AND HYPOGLOSSAL NERVE MAY ALSO BE INVOLVED. OTHER CN MAY ALSO BE INVOLVED (III, V, IX, XI) CAN BE U/L OR B/L ASSOCIATED ABNORMALITIES-CVS, LIMB ABNORMALITIES (CLUB FEET, SYNDACTYLY), POLANDS SYNDROME GOLDENHAR`s SYNDROME- HEMIFACIAL MICROSOMIA, EPIBULBAR DERMOID CYST AND VERTEBRAL ANOMALIES MELKERSON ROSENTHAL SYNDROME- TRIAD OF NON INFLAMMATORY FACIAL EDEMA CONGENITAL TONGUE FISSURES (LINGUA PLICATA) FACIAL PALSY.
  • #17 Ramsay Hunt Syndrome - paralysis of the facial nerve (facial palsy) and rash affecting the ear or mouth. Ear abnormalities such as ringing in the ears (tinnitus) and hearing loss may also be present. BELLS PALSY- AETIOLOGY UNKNOWN, LATENT HERPES VIRUS MAY BE THE CAUSE. IMMUNE REACTION CAUSING SWELLING OF THE NERVE WITHIN THE FACIAL CANAL resulting in microcirculation disruption and demyelination. INCIDENCE 1 in 5000. MORE COMMON IN DIABETICS SUDDEN ONSET FACIAL PALSY OR PARESIS PRODROMAL TASTE DISTURBANCES DUE TO CONDUCTION ANOMALY IN THE CHORDA TYMPANI BRANCH, HYPERACUSIS AND EXCESSIVE LACRIMATION. INITIAL MANAGEMENT CORTICOSTEROIDS AND ANTIVIRALS RECOVERY BEGIN BY 6th Month
  • #19 COMMONEST AMONG THE FACIAL PALSY IN NEW BORNS-RECOVER WITHIN MONTH
  • #26 Palpebral fissure 12 mm Orbital width 29 mm
  • #30 Marginal reflex distance-2 (M~) is the distance measured between the light reflex and central portion of the lower lid when a patient's eye is in the neutral position.
  • #55 Greater auricular nerve: a. well-matched to the facial nerve diameter, b. is in the same surgical field c. leaves patients only with sensory loss of the inferior 2/3 of the auricle and over the angle of the mandible. d. It is found just deep to platysma, and runs superiorly over the sternomastoid muscle from Erb’s point (one-third of the distance from either the mastoid process or the external auditory canal to the clavicular origin of the sternomastoid muscle) parallel and 1-2cm posterior to the external jugular vein  Sural nerve: a. Being distant to the face b. it facilitates a two-team approach c. well-matched to the facial nerve diameter d. leaves minimal donor site morbidity (scars are often inconspicuous and the patients are usually left with sensory loss on the lateral border of the foot d. is of greater length that the greater auricular nerve making it better suited to bridging longer defects and for grafting to more peripheral branches 
  • #60 A combined CN X-XII deficit may cause profound swallowing dysfunction. 
  • #61 This is identical to hypoglossal nerve transfer, except that it involves partial sectioning of the hypoglossal nerve, and performing an end-to-side neurorrhaphy between the hypoglossal nerve and a donor nerve graft which is then connected to the distal facial nerve, thereby preserving ipsilateral hypo-glossal function. It can be used when there is ipsilateral lower cranial nerve dysfunction or if the patient is unwilling to accept tongue dysfunction. 
  • #68 A cranial nerve is transferred to achieve quicker reinnervation and to preserve musculature and potentially the denervated stump while axons migrate across the CFNG