Rehabilitation of the Paralyzed Face
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1 Rehabilitation of the Paralyzed Face Elizabeth J. Rosen, MD Faculty Advisor: Karen H. Calhoun, MD The University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation October 30, 2002
2 Rehabilitation of the Paralyzed Face Personally devastating Cosmetic deformity Psychological distress Functional deficits Lagopthalmos and ectropion Oral incompetence Nasal obstruction Mastication difficulties Articulation difficulties
3 Rehabilitation of the Paralyzed Face Goals Functional EYE PROTECTION Oral competence Cosmetic Symmetry at rest Volitional movement Facial expressions
4 Rehabilitation of the Paralyzed Face Static Slings Gold weight Tarsorrhaphy Lower lid shortening Brow lift Face lift Dynamic Nerve grafting Direct Interposition Crossover Muscle transfer Regional Free flap
5 Rehabilitation of the Facial Nerve Restore neural input Replace nonfunctional facial neuromuscular units Statically resuspend facial tissues Adjunctive procedures to address specific defects
6 Patient Evaluation History Etiology Prognosis Duration Past medical history Neurological disease Physical examination General appearance Complete head and neck exam Donor tissues
7 Rehabilitation of the Facial Nerve Restore neural input Replace nonfunctional facial neuromuscular units Statically resuspend facial tissues Adjunctive procedures to address specific defects
8 Rehabilitation of the Facial Nerve Restore neural input Procedure of Choice Distal facial nerve available Within 3 years of injury Best outcome Options End-to-end anastomosis Interposition graft crossover
9 Rehabilitation of the Facial Nerve Replace nonfunctional facial neuromuscular units 2 nd choice Long standing paralysis Lack of normal neuromuscular units Patient contraindications to nerve crossover Dynamic function Options Regional muscle transfer Free muscle transfer
10 Rehabilitation of the Facial Nerve Statically resuspend facial tissues 3 rd choice Patient factors Temporizing measure Symmetry at rest Options Fascia or synthetic slings
11 Rehabilitation of the Facial Nerve Adjunctive procedures to address specific defects Options Gold weight implants/lid springs Lid shortening procedures Lower lip wedge resection Brow/face lift botox
12 Restoration of Neural Input Primary anastomosis Interposition graft Crossover graft Cross-facial graft
13 Restoration of Neural Input Primary anastomosis Procedure of choice Performed immediately/asap Technique Magnification Epineural/perineural 8-0, 9-0, 10-0 nylon suture Must have no tension Rerouting if necessary
14 Restoration of Neural Input Interposition graft Great auricular nerve Sural nerve
15 Restoration of Neural Input Interposition graft Sural nerve
16 Restoration of Neural Input Interposition graft Sural nerve
17 Restoration of Neural Input Interposition graft Sural nerve
18 Restoration of Neural Input Crossover graft Proximal facial nerve disrupted Donor motor nerve Hypoglossal Accessory Ansa hypoglossus Trigeminal phrenic
19 Restoration of Neural Input Crossover graft - technique
20 Restoration of Neural Input Crossover graft - technique
21 Restoration of Neural Input - Crossover Advantages Reliable Good tone and symmetry Disadvantages Donor site morbidity Synkinesis and hypertonia Unpredictable result for voluntary movements
22 Restoration of Neural Input Crossover graft modifications Splitting hypoglossal nerve Jump interposition graft Branch of accessory to SCM
23 Restoration of Neural Input Crossover graft
24 Restoration of Neural Input Crossover graft
25 Restoration of Neural Input Crossover graft
26 Restoration of Neural Input Cross-facial graft Sural interposition graft From distal branch of normal facial nerve to distal nerve stump Good resting tone and symmetry Theoretically symmetric voluntary movements Disadvantage fewer regenerating axons = weaker muscle contraction
27 Replacement of Nonfunctional Facial Muscles Regional muscle transfer Microneurovascular free muscle transfer Indications Long standing paralysis Abnormal neuromuscular junctions
28 Replacement of Nonfunctional Facial Muscles Regional muscle transfer Temporalis Masseter Preoperative evaluation Lower 1/3 of the face
29 Replacement of Nonfunctional Facial Muscles Temporalis muscle transfer Advantages Technically straightforward Immediate midface symmetry Disadvantages Bulky over zygomatic arch Donor site deformity Chronic TMJ pain
30 Replacement of Nonfunctional Facial Muscles Temporalis muscle transfer
31 Replacement of Nonfunctional Facial Muscles Temporalis muscle transfer
32 Replacement of Nonfunctional Facial Muscles Masseter muscle transfer
33 Replacement of Nonfunctional Facial Muscles Regional muscle transfer
34 Replacement of Nonfunctional Facial Muscles Regional muscle transfer
35 Replacement of Nonfunctional Facial Muscles Regional muscle transfer
36 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Advantages Native facial nerve anastomosis Cross-facial anastomosis Disadvantages Technically difficult, longer OR time Staged procedure Unpredictable voluntary movements
37 Replacement of Nonfunctional Facial Muscles Donor muscles Vascular pedicle Single Reliable Sufficient length Bulk Excursion Minimal morbidity
38 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition)
39 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition) Crossover (CN XII or XI)
40 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition) Crossover (CN XII or XI) Cross-facial
41 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition) Crossover (CN XII or XI) Cross-facial
42 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
43 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
44 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
45 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
46 Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
47 Static Resuspension of Facial Tissue Static elevation of the drooping paralyzed face Cosmetic Functional Indications Patient factors Temporary while awaiting return of nerve function
48 Static Resuspension of Facial Tissue Fascia Fascia lata Donor site morbidity Increased OR time Tendency to stretch over time Decreased infection or extrusion Synthetic materials Gore-Tex Alloderm Technically easy No donor site Less stretch over time Increased risk of infection and extrusion
49 Static Resuspension of Facial Tissue
50 Static Resuspension of Facial Tissue
51 Static Resuspension of Facial Tissue
52 Static Resuspension of Facial Tissue
53 Static Resuspension of Facial Tissue
54 Static Resuspension of Facial Tissue
55 Adjunctive Procedures Upper third of the face Gold weight implant Palpebral spring Lower lid shortening Tarsorrhaphy Brow lift Lower third of the face Lower lip wedge resection Rhytidectomy
56 Adjunctive Procedures Gold weight implant Advantages Technically straightforward Consistent Disadvantages Visibility Extrusion
57 Adjunctive Procedures Gold weight implant Advantages Technically straightforward Consistent Disadvantages Visibility Extrusion
58 Adjunctive Procedures Gold weight implant Advantages Technically straightforward Consistent Disadvantages Visibility Extrusion
59 Adjunctive Procedures Palpebral Spring Advantages Less visible Useful in cases with mixed orbicularis and levator dysfunction Disadvantages Technically difficult Higher risk of extrusion
60 Adjunctive Procedures Lower lid shortening Wedge excision with lateral canthopexy
61 Adjunctive Procedures Lower lid shortening Wedge excision with lateral canthopexy Tarsal strip procedure
62 Adjunctive Procedures Tarsorrhaphy Advantages Addresses both upper and lower lid deformity with one procedure Technically easy and effective Disadvantages Visual field defect Lid margin deformity after release
63 Adjunctive Procedures Lower lip wedge resection with transposition of orbicularis oris
64 Adjunctive Procedures Lower lip wedge resection with transposition of orbicularis oris
65 Adjunctive Procedures Lower lip wedge resection with transposition of orbicularis oris
66 Adjunctive Procedures Brow lift Direct Mid-forehead Pretrichial
67 Adjunctive Procedures Endoscopically assisted brow and midface lift
68 Adjunctive Procedures Endoscopically assisted brow and midface lift
69 Adjunctive Procedures Classic rhytidectomy Deep plane rhytidectomy
70 Botulinum Toxin Beneficial for synkinesis and hypertonia Targets specific overactive facial muscles Advantages: easy, temporary, selective Disadvantages: temporary, recurrence of original problem
71 Facial Paralysis < 3 yr >3 yr
72 Healthy pt. Good prognosis Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis
73 Healthy pt. Good prognosis Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis Facial nerve present and free of disease? Static resuspension
74 Healthy pt. Good prognosis Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis Facial nerve present and free of disease? Static resuspension YES NO Regional or free muscle transfer
75 Healthy pt. Good prognosis Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis Facial nerve present and free of disease? Static resuspension YES Proximal nerve available? NO Regional or free muscle transfer
76 Healthy pt. Good prognosis Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis Facial nerve present and free of disease? Static resuspension YES YES Proximal nerve available? End-to-end anastomosis or interposition graft NO NO Crossover or cross-facial graft Regional or free muscle transfer
77 Healthy pt. Good prognosis Facial nerve present and free of disease? Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis Static resuspension Healthy pt. Good prognosis YES YES Proximal nerve available? End-to-end anastomosis or interposition graft NO NO Crossover or cross-facial graft Regional or free muscle transfer
78
Rehabilitation of the Paralyzed Face October 2002
TITLE: Rehabilitation of the Paralyzed Face SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology DATE: October 30, 2002 RESIDENT PHYSICIAN: Elizabeth J. Rosen, MD FACULTY PHYSICIAN: Karen H.
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