REHABILITATION AND REANIMATION. Facial Plastic Surgery. University of Missouri Columbia, Missouri

Transcription

1 FACIAL NERVE PARALYSIS: REHABILITATION AND REANIMATION Matthew A. Kienstra, MD, FACS Facial Plastic Surgery Mercy Health Care Springfield, Missouri University of Missouri Columbia, Missouri

2 Incidence and Etiology Peripheral facial palsy most common CN pathology: cases/100,000 Mostly idiopathic palsy/bell s ll palsy Most recover Other facial nerve insult, examples: Iatrogenic Trauma Ear issue Tumors

3 Goals 1. Protect the eye 2. Attain facial symmetry at rest 3. Obtain voluntary facial motion 4. Restore involuntary, independent mimetic facial expression J. E. Aviv, M. Urken

4 Reality Complete, unrecoverable paralysis = Mediocrity is the best result

5 How good is this result?

6 Key Factors Cause of paralysis Extent of paralysis Duration of paralysis Likelihood of recovery Extent of functional defects M. May, S. M. Sobol

7 Key Factors Presence of other cranial il nerve defects Previous reanimation procedures Age and life expectancy Psychologic status and perceived needs and expectations M. May, S. M. Sobol

8 Cause of Paralysis Site of nerve injury Length of nerve injury Prognosis for recovery Prognosis for the patient Adjuvant therapy needed?

9 Extent Large nerve loss (main trunk) vs. Small nerve loss (branch) Partial vs. complete

10 Duration Immediate SEW IT!!!!!!!!!!! Greater than 1 year Greater than 2 years

11 Extent of Functional Defects Brow Ptosis/appearance Visual field obstruction Nose Obstruction Appearance Mouth/lip Appearance Drooling Dysarthria Chewing/eating/swallowing

12 Extent of Functional Defects Eye KEY!!!!!! Bell s phenomenon (Tear production and distribution) Corneal sensation Keratitis? Visual acuity Lagophthalmos Epiphora

13 BAD syndrome Coined by Guibor Bell s phenomenon loss Anesthesia (loss of sensation) Dry eye (loss of tear production)

14 BAD Syndrome

15 Young Person Acute

16 Young Person Congenital

17 Middle Age

18 Elderly

19

20 Presence of other cranial nerve deficits II, III, IV, VI cornea less relevant V sensation to the eye Muscles of mastication IX, X swallowing XII swallowing

21 Of Course Previous reanimation i (and other) procedures General health and life expectancy Psychologic considerations and patient expectations

22 Techniques for reanimation Physiologic i nerve repair or graft Synergistic nerve repair or crossover Dynamic reanimation Static supportive procedures Other LOWER DIVISION

23 Physiologic nerve repair or graft Must be done before 1 year Sooner the better Avoid tension Graft if nerve gap over 1 cm Just don t matter Type of repair Length or number of grafts Location of injury on the main trunk

24 Synergistic nerve repair or crossover LOWER FACE (mainly) XII VII (with/without nerve graft) V VII (masseteric nerve) VII VII with jump graft Sural Great auricular

25 Dynamic reanimation Eye Gold weight (Lid spring) Lower Face Temporalis or masseter muscle transfer Free flap (Gracilis, Pec. Minor)

26 Gold weight mis adventure

27

28 Static adjunctive procedures Browlift (direct versus other) Canthoplasty/Ectropion Repair Midface/face lift Goretex (fascia) sling nose, mouth Rhinoplasty

29 Other Blepharoplasty l Botox contra lateral side Lip excisions Muellerectomy Malar implant

30 Eye PROTECT IT ALWAYS DO THESE Lubricate Gold weight Canthoplasty/ectropion repair (last resort tarsorrhaphy) MAYBE DO THESE Midface lift Browlift

31 Lower face Goretex sling Temporalis transfer Synergistic nerve repair/crossover Free flap (Can be combined with a facelift) (Some can be combined together)

32

33

34

35

36

37

38

39 Keys PROTECT THE EYE Multiple options available Tailor to individual patient needs (careful exam) Include the patient in the decision making Be pragmatic

40 John Conley, MD It is untrue and an exaggeration to believe or state that any person with an acute or long standing facial paralysis secondary to lysis of the facial nerve will ever have normal facial movement again, regardless of the rehabilitative surgery used.