READYTALK. Moderator: Melissa Baumbick June 6, :00 p.m. ET

Transcription

1 Page!1 READYTALK June 6, :00 p.m. ET Operator: This is Conference # Melissa Baumbick: Welcome to the first Webinar in ANA's 2016 Summer Series. We are honored to welcome Dr. Babak Azizzadeh of the Facial Paralysis Institute who will present "When is it Time to Consider Facial Reanimation after Acoustic Neuroma Surgery?" I am Melissa Baumbick, the communication specialist for the Acoustic Neuroma Association and your moderator today. Before we get started I want to let you know that all attendees are in listen-only mode and will remain that way throughout the Webinar. There is a chat feature in the control panel on your screen that could be used to type comments or question while Dr. Azizzadeh speaking. We will dedicate the last portion of the Webinar to answering as many questions as we can. There will be a recording of this Webinar that includes the audio and all PowerPoint slides available next week in the member section on the ANA Web site. There will also be a written transcript available. We will send an e- mail to all registrants to let you know when the Webinar is available and how it can be accessed.

2 Page!2 As you know, this Webinar is being hosted by the Acoustic Neuroma Association. ANA is a patient member organization providing information and support to those dealing with acoustic neuroma diagnosis since Among other things, we publish a quarterly newsletter, distribute patient information booklets, provide access to a network of local support groups, maintain a Web site and social media sites for patient information and discussion and present these informational Webinars. We would like to thank our platinum series sponsors, House Clinic Acoustic Neuroma Center at St. Vincent Medical Center and Vanderbilt University Medical Center. We'd also like to thank our gold seasonal sponsors, USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck Medicine of USC, USC Acoustic Neuroma Center and Weill Cornell Medicine. If you are interested in an annual sponsorship with ANA please contact our office today to learn more. Finally, I'd like to introduce our speaker. Dr. Azizzadeh is a world-renowned facial plastic and reconstructive surgeon and the director of the Facial Paralysis Institute in Beverly Hills where he provides patients with revolutionary procedures to restore smile and promote facial reanimation. Dr. Azizzadeh is double board certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology-Head and Neck Surgery. Because of his prestigious training at the Harvard Medical Harvard School of Medicine and extensive experience, Dr. Azizzadeh has a remarkable insight into both the facial nerve and the aesthetics of the face. His expertise and facial plastic surgery has made him one of the most sought after surgeons in the world. Dr. Azizzadeh co-edited the definitive textbook entitled "The Facial Nerve" and has published numerous articles in peer-reviewed journals. He is regularly asked to present both nationally and internationally on facial

3 Page!3 paralysis and once one of the keynote speakers at the 2013 Acoustic Neuroma Association Symposium. He was recently awarded the honor of being co-chairman of the 2007 International Facial Nerve Symposium by the Sir Charles Bell Society, the largest interdisciplinary symposium for facial nerve experts. In addition to his practice, Dr. Azizzadeh is extremely active in several different humanitarian causes including the Global Smile Foundation and the Facial Paralysis and Bell's Palsy Foundation, which he founded in It is now my pleasure to get started and turn the Webinar over to our presenter. Dr. Azizzadeh, please go ahead. Babak Azizzadeh: Thank you so much, Melissa. I want to thank the Acoustic Neuroma Association for giving me the opportunity to speak about this very important subject. The ANA has been just unbelievable, I think, with patient education. And hopefully, this Webinar will be worthy of it. So today, I'm going to talk about when is it time to consider facial reanimation surgery after acoustic neuroma surgery. I have no disclosures or conflicts for this speaking Webinar. And historically, basically, statics and procedures, temporalis muscle transfers and hypoglossal facial nerve transfers have been kind of the mainstay treatment for facial paralysis. In this Webinar, I will try to outline the anatomy of facial nerve and muscles so that the audience can better understand what causes facial paralysis and why we need to do. I'll talk about my current evolution in facial reanimation techniques and concepts in patients who develop facial paralysis following acoustic neuroma surgery or radiation therapy. Discuss the timing of the surgery which is very, very important. Discuss some newer combination treatments that I really believe can improve and achieve optimal outcome. Overview some surgical techniques to address partial paralysis and synkinesis and I'll explain those in further details.

4 Page!4 Please note that the majority of the patients that you'll see before and after have undergone eyelid and (canthal) reconstruction. I will not discuss those in detail, that's kind of a discussion all on to its own. And the majority of patients will required neuromuscular retraining, Botox, and those are important adjunct to treatment. And those one have already been discussed in this Webinar as they required their own complete Webinars at their own. So facial nerve anatomy, kind of, to simplify it, as the facial nerve kind of exits the brain, it travels with cranial nerve VIII which is the vestibulocochlear nerve. And that's where acoustic neuromas develop. And as you could see, right here, that's the facial nerve and this is the cranial nerve VIII, they really travel intimately close to each other. And this is where the vestibular nerve and vestibular schwannomas develop. The facial nerve kind of separates as it enters the bone right behind the ear, which we call the temporal bone, and kind of takes a various circuitous route, exits, and then divides into multiple branches. We have branches that then go to eye, branches that go the small muscles and branches that go to the frowning muscles. As this illustration demonstrates, the axons or fibers within the nerve, different axons are destined for different areas. Some are destined for the eyes, smile and the frowning. Now, as the nerve goes out into the face there's a lot of cross connection here. So, what does the facial nerve do? Obviously, it allows our facial expression and smile. It also provides taste fibers in front of the tongue and it also provides nerve fibers to the tear gland and salivary glands for secretions of those glands. Now, what are the primary smile muscles? The primary smile muscles, the first, the most important one is the zygomatic major which can be seen right here going from the corner of the mouth to the cheekbone. But we also have zygomatic minor and levator labii alaeque nasi. These muscles help elevate the corner of the mouth.

5 Page!5 We have frowning muscles, the two major ones are the platysma and the depressor anguli oris. These bring the corner of the mouth down and when we're grimacing or frowning these muscles are activated. We also have a very important muscle called the buccinators. And this basically, is the muscle that's deep underneath the facial muscles and this is also controlled by the facial nerve. And this holds the cheek to the teeth as this would join. So when there is dysfunction of the facial muscles outside the lining of the inner gum which are drooling, and if patients have hyperactivity of this muscle, they get a lot of tension and smile dysfunction. The most common cause of facial paralysis is not acoustic neuroma and it's actually Bell's palsy, which is a reactivation of the herpes simplex virus that causes Bell's palsy. Acoustic neuroma, as well as temporal bone fractures, are the next most common cause of facial paralysis. So acoustic neuromas are what we called cerebellopontine angle tumors or CPA tumors. And, as I was showing in an earlier slide, they develop right as the nerve exits the brain and goes into the temporal bone. There are tumors of the Schwann cell sheath, and the vestibular nerve is the most common area where it's developed. And it accounts for about 80 percent of all cerebellopontine angle tumors. The other 20 percent are mainly meningiomas. It's actually pretty common, 1 in 100,000 populations can develop it and individuals who have neurofibromatosis too can develop them bilaterally. Now, the growth of acoustic neuromas is slow so that facial nerve typically can accommodate the stretching without any clinical symptoms. And that's why most patients who present with acoustic neuromas actually don't present with facial paralysis. The majority who develop facial paralysis develop it after treatment because of its intimate relationship to the facial nerve. And the three main approaches for surgery of acoustic neuromas is the retrosigmoid which is, as you can see approaching the acoustic neuroma from

6 Page!6 behind this bone, the temporal bone, translabyrinthine which goes through the temporal bone, or the middle cranial fossa which is above the temporal bone. Each of them have advantages and disadvantages as far as facial nerve disorders all along. Now, we have to fully understand facial paralysis. We also understand the various types major different types. There's two focus on are patients who develop complete facial paralysis and those who develop partial facial paralysis and synkinesis. And I'll go through that in a minute to describe them. These are the ones that we see most commonly with patients who have developed facial paralysis following acoustic neuromas. So, this is a patient who has complete facial paralysis. This patient has a facial nerve injury that is irreversible, that has not returned and will likely not return if it last more than 12 months and the patient continues to have an appearance like this, which this individual has complete smile dysfunction, the corner of their mouth is heading down, inability to close eyes, brow drooping, lower eyelid drooping, complete facial asymmetry, atrophy of the muscles on the affected side. And typically speaking, if there is no nerve input into a muscle beyond 18 to 24 months that muscle will atrophy and cannot be reinnervated. In this type of patient, we see premature aging on the affected side, a lack of laugh line, collapse of the nasal valve. And these individuals, unfortunately, have significant articulation and speech difficulty, fluid escaping from the mouth, biting of the lips and gums as a result of nerve control paralysis. Now, some individuals develop facial paralysis and present right after surgery with a complete facial nerve paralysis. However, their nerve was maintained and was kept intact or the nerve graph was grafted. The nerve area was removed and grafted. So, any form of nerve repair or regrowth after an injury can lead to misdirection of those nerves leading to what we call aberrant regeneration or synkinesis.

7 Page!7 And this shows us really clearly, so this is a nerve and these are those fibers that we talked about. The green is going to the eye area. The red is going to the smile. The blue is going to the frowning. And if there's an injury at the time of surgery or the nerve was cut and resewn together, aberrant regeneration can occur which some fibers may not flow through, some fibers may sprout and go to multiple different locations, and some fibers may go into a different location. And this is how you can develop synkinesis. And essentially, what happens in synkinesis is the smiling, which is the blue, frowning, which is the red and the buccinator, which is going that way, muscles work simultaneously. So this leads to frozen or frowning smile. And this is what we see for someone who has synkinesis. As you could see, it's very different than someone who has complete paralysis. Their eyes are more narrow, the corner of the mouth is frozen and not coming down to get dimpling and hyperactivity of the platysma. And so they have a very different issue than someone who has a complete paralysis. You don't have as much eye issues but that tightness and tone, increased tone to their face, and in fact the affected side ages slower than the unaffected side. And the patients end up having a lot of tension as a result of synkinesis because the muscles are just over and over and over getting activated. So these individuals don't smile because the muscles don't have any coordination and the frowning muscles are really, really, really hyperactive, not allowing the smile muscles to work independently. So, now that we know, kind of, what the two main types of facial paralysis or paresis is, how do we fix it? First, before we go any further, I do need to let you know, unfortunately, facial nerve reconstruction is not perfect, and just cannot truly reproduce a perfect smile that one had prior to their injury. However, over the last decade, we've really improved outcomes and I believe that this is we're moving in a great direction.

8 Page!8 So, there are three concepts for facial paralysis treatment, for smile especially that we want to think about. We can kind of statically improve someone's face. For instance, if they have complete paralysis we could do a face lift or kind of do a tendon graft where we lift the corner of the mouth, but that patient won't have any improvement in smile. We really, really want to focus on developing dynamic treatment plan. And with dynamic treatment plan, we give the patient an opportunity to smile. Now, that dynamic treatment plan can develop either voluntary movement, which is, you can create a smile by biting down or trusting the tongue and I'll go through the different ways, or a spontaneous movement. Someone doesn't have to think about their smile and their conversation is emotive. And this is really the most that's my goal when I see a patient. I really want to try to give them the best dynamic and spontaneous movement, not just for their smile mechanism but on their day-to-day conversation. 93 percent of our time is spent talking to other people not smiling, and if your face is not moving or you have to think about moving it while you're talking, it's nearly impossible. So that's why an emotive, what we call an emotive conversations, this is important as a smile mechanism. So, what are my goals? So, we want to improve dynamic smile mechanism. We want to enhance the natural facial movement while communicating. We want to improve speech articulation, reduce drooling, reduce the biting of the gums, improve nasal obstruction. We want to definitely prevent any eye complication. We want to reduce tension and tightness if the patient has synkinesis. We want to create symmetry of the face, eyes and brows. And all of this is to really help improve one's self confidence, ability to socialize. I mean, at the end of the day, us, we're human beings that are built on socializing and communicating with other people and facial paralysis is a major impediment in that process. So, what we're looking and I'm looking at a patient who has a facial paralysis. I kind of think about, OK, is this something that's very recent or something

9 Page!9 that's been going on for a long time. So if it's a very recent process, if for instance, the patient have an acoustic neuroma, we know what the cause was. But sometimes patient present and we don't know what the cause is, so we have to definitely do a complete evaluation in those cases. History, neurologic, your evaluation and imaging, most important thing when we're doing immediate treatments is eye care. We want to make sure their eyes are have ointment, artificial tear, their eyes are able to close. If there is an issue with the cornea, because dryness of the eye can lead to major vision loss and corneal scaring, we need to get an ophthalmologist or an oculoplastic surgeon and that's why a multispecialty team is really important to achieving this. So, a patient for who's having acoustic neuroma, if the surgeon, the neurotologist sees that the nerve has been compromised at the time of surgery and they can nerve graph it to a little nerve graph, that is the most important thing that will give us the best possible outcome. If either the surgeon could not nerve graph it or they thought the nerve was intact or they knew that the nerve was not intact, postoperatively we need to know that. And that's why communication between your facial paralysis surgeon and your neurotologist is very important because we don't want to wait a long time. And this is I had this entire conference and Webinars about this, but this is where the key factor is. Do not wait over 18 months if your or your loved ones' face is completely paralyzed without any return of function after an acoustic neuroma treatment, whether it's surgery or radiation therapy, because the muscles will atrophy beyond 18 to 24 months. And certain treatments that we'll go through cannot be performed, which are really, really important in a long-term improvement of one's facial appearance and smile. So, if someone has had facial paralysis for a long time and they present with complete paralysis, first I want to make sure that there's no evidence of tumor reoccurrence, especially if it's an acoustic neuroma. So I'd almost always want to see a recent MRI.

10 Page!10 We technically initiate treatment after a year, but if the surgeon, neurotologist tells me that the nerve was sacrifice, I could not graft it, then we're going to consider earlier reconstruction. There's no reason to wait that long. An eye reconstruction, eyelid reconstruction can start immediately if we feel that this is going to be a long process. So what's my personal philosophy for facial reanimation? I will go through a lot of those, you may or may not have heard about but I'll explain them in the following slides. So, someone who presents to me with an irreversible, complete facial paralysis that has no movement, I see no tone, someone that looks like this individual. We want it immediately take care of their ophthalmic issues with ophthalmologist, oculoplastic surgeon depending on their severity of the condition. If we've determined that this condition is irreversible, within 18 to 24 months or sooner, again, we'll proceed with the two-stage operation that I'll discuss with you guys, to improve facial tone and provide spontaneous smile mechanism. I personally like to incorporate a nerve transfer called the masseteric facial nerve transfer and to give tone to the face. I will discuss that. And then we'll use the opposite side of the face which is a normal facial nerve. We'll borrow nerve from the other side, their activity, to help create a spontaneous movement. We'll also utilize neuromuscular retraining, Botox, fillers, face and neck lift to optimize outcome, because at the end of the day we want to give, not just movement, but we want to give aesthetically create movement, so that the patient looks great and moves great. I don't know if you've seen some patients who've had really big chunky muscles in their face, and their face smiles but they just doesn't look great. So we want to think aesthetics and function. Patients who've had complete irreversible facial process of longer than 24 months, then we'll just we can't do the masseteric facial nerve transfer. And

11 Page!11 I'll go through why that's important if we can do it. But if we can't, there's hope. We can still utilize the opposite side of the face to help move the paralyzed side. The other options that you'll hear about and talk about, I will kind of briefly go over orthodromic temporalis tendon transfer, which is fantastic, treatment but doesn't give spontaneity, hypoglossal facial nerve transfer. And sometimes we can also utilize the masseteric nerve to move the gracilis muscle but it doesn't give spontaneity. So let's go through all of these options. So, when the when we have a complete and irreversible facial paralysis, like you've seen here, what do we want? These muscles, if it's less than 24 months old, these muscles are still active. They are still potentially viable. The nerve, as it exits the ear is still present because an acoustic neuroma surgery, the nerve injury is in the cerebellopontine angle. So, if we can utilize another nerve, for instance, a nerve to the tongue, a nerve to the chewing muscles called the masseteric nerve then we can give nerve input into those muscles. Even though the smile may not be fantastic and, obviously, won't be spontaneous because the patient those nerves that, nerves to the tongue and the nerves to the chewing muscles don't spontaneously get activated when you're smiling, it does provide nerve input into the muscles and gives tone and prevents long-term issues. Like, for instance, complete premature aging process, significant drooping and so forth. And it's a very, very important thing. So we called these nerves substitution techniques. And essentially, these are opportunities. If the patient has had paralysis less than 24 months, preferably less than 18 months, we can utilize some of the other nerves, the hypoglossal nerve with the most commonly used, that goes to the tongue. And the results are very, very good. It gives good lasting tone but the individual has to use their tongue to move their face, and it's not a very natural movement. And the patients get significant synkinesis because tongue movement is completely different than any of the other smile movements.

12 Page!12 So we the main factor what we call hypoglossal facial nerve transfer is we cannot use this if someone has neurofibromatosis too because they may have other cranial nerves involved, because you can't reduce the activity of the tongue and have other cranial nerve issues because a patient may develop significant functional issues. We can't use this if someone has partial paralysis or other cranial nerve issues. So, I generally have moved away from using the hypoglossal facial nerve transfer in favor of the masseteric facial nerve transfer. Because you can use the masseteric nerve for any of these situations as long as the masseteric nerve is activated. Now, hypoglossal facial nerve transfer can really you could see it give tone to the face. You see the cheeks, the mid face, the laugh lines are recreated. The corner of mouth is elevated. The eyes are even better, the tone is better. But the corner of the mouth, you see, when he smiles is moving down and there's a lot of synkinesis. In a masseteric facial nerve transfer, we use the masseteric nerve which is a member or a aspect of the cranial nerve number V or the trigeminal nerve. And basically, I've devised a technique. There are couple of different techniques but this is my, kind of, preference and this is what I pioneered, is using the entire facial nerve and attaching it to the masseteric nerve and reducing the activity to the frowning muscles so the patient's smile can be more powerful. And this is an excellent option for patients who have multiple nerve disorders, neurofibromatosis, acoustic neuroma that have no return of function. And, again, this is on intraoperative. Now, unfortunately, we can't do videos in today's Webinar but the videos are pretty powerful. And the videos will be on my Web site if you guys want to see it, facialparalysisinstitute.com. But basically, as you could see, this is a four months result. This is before the patient had no movement. And you could see the corner is going up. We see

13 Page!13 a lot more teeth showed. These are signs of great improvement in one's smile. However it's just not spontaneous, the patient has to bite down to move. This is another example of a patient with an acoustic neuroma. Eyes are better, corner of the mouth, laugh line, really great, great overall improvement. This is another patient, again, elevation of the corner of the mouth naturally. This patient doesn't have a face lift or tendon lift or anything like that. This is purely from the masseteric facial nerve transfer. Now, what I like is to combine that, we do that, and at the same time setup the stage, giving the patient spontaneity. And the only way we can give spontaneity if the patient has had an irreversible complete facial paralysis, you see, utilize a facial nerve on the normal on the opposite side of the paralysis. Because that nerve is going to move every time you're smiling. And our smile is bilateral, it's on both sides. So the way that we introduce the spontaneity is we do a nerve graft to the opposite side. We have so many different nerves that we can utilize, so we get we utilize, get a nerve from the ankle, we'll show that, attach it to the opposite side, and then we'll bring in a new muscle. About 6 to 12 months later a gracilis muscle, and attached that gracilis muscle to the nerve graft that we'd set up at the same time as the masseteric nerve transfer. So this helps with both smiling during routine speech and communication in the patient's facial move. So, the nerve graft is pretty easily. I've pioneered a single incision operation where we're going to get what's called the sural nerve graft and we'll get it from the ankle. There's really very little deficit other than a little bit of decrease sensation on the outer part of the ankle. Then we'll go, and go to the normal side, identify a little branch that's going to the normal facial nerve and support it there.

14 Page!14 Now, the reason we can't do this all at the same is because nerves need to get activated. And they grow about one millimeter per day. And if the muscle is not does not have the nerve input, then the muscle will atrophy and won't be utilized. Now, this is a pretty straightforward five days after surgery incisions, patients do well, a little bit bruising. Then, the patient has had by now the masseteric nerve transfer and the cross face nerve graft that was done all at the same time. Then, we'll come back 6 to 12 months later, bring in that muscle. We'll sew the nerve graft actually under the gums. And then, postoperatively the patients will get neuromuscular retraining, we typically start seeing some movements six months after the second stage and it continues to improve for about 18 months. Now, this is a patient that did not have the masseteric facial nerve transfer. She had had paralysis much longer than 24 months. So we did only the cross face nerve graft and the gracilis muscle transfer. And as you could see there's improved movement. These are the incisions. They're pretty well hidden. This is another example of the same thing. This is another example, (all side) strabismus surgery, eyelid surgery. And you could see this is a significant life-changing operation. Another patient with a brain tumor that we did the same surgery. This is a 10- year follow-up. As you could see, it grows very nicely with the patient. Good smile, good symmetry. This is an adult patient who had, again, cross face nerve graft, gracilis, following an acoustic neuroma. And this is where it all comes to, combination of treatment, it's like matching the masseteric facial nerve transfer with the cross face nerve graft and gracilis, really just gives phenomenal outcomes. And for this patient who had 18-month duration, facial paralysis following an acoustic neuroma, you see they had done intratemporal fossa approach, so she had this hole on this here, atrophy, atrophy of the face, drooping and complete

15 Page!15 smile dysfunction. We did a masseteric facial nerve transfer and a cross face nerve graft in the first stage. Second stage, we did a gracilis muscle transfer. And this is the results. We also did some fillers for the temporal area, Botox, on both sides of the face, improve symmetry. And there's their soft smile, there's a bigger smile, you could see teeth and nice laugh line, good symmetry. There's another patient with a masseteric facial nerve transfer cross face nerve graft followed by gracilis. So the results are really outstanding symmetrical. Now, this is the patient I'd shown you that had a 12-7 but just was not happy with spontaneity. So we went back, did a cross face nerve graft then went back into the gracilis, and you can see the smile is more symmetrical and more elevated that her teeth show. There's a patient who had had a fill, statics cling and a gracilis flap. And as you could see, didn't get a lot of movement. So, for this patient, we've utilized or the patient has utilized a lot of techniques and has not really gone on a great result. So for this patient, we decided to utilize the temporalis tendon transfer which is a great operation. Basically, the temporalis muscle is a muscle of chewing, like the masseteric muscle, and its tendon, the muscle and its tendon can be the tendon can be rotated to the corner of the mouth. And it give a really nice elevation of that area. So, it gives a nice static improvement and the patient when they bite they can move it. So I use this for kind of salvage treatment if someone had not had success at another institution with some of the traditionals, surgeries or someone who is bolder, who's have a lot of radiation therapy, other types of cancers. And, as you could see, nice improvement, not spontaneous but it's only an improvement in the corner of the mouth. And these other examples of the orthodromic tendon transfer. And again, it's a little bit of a deep nasolabial fold but overall good improvement in the static

16 Page!16 and dynamic situation, and you could see how much elevation at least the patient was getting. These are some other examples of the temporalis tendon transfer. Now, we've talked about patients who have had an irreversible complete paralysis. Now, what about patients and individual who has had acoustic neuroma surgery, either had a nerve graft or had temporary paralysis that returned or had a 12-7 hypoglossal facial nerve transfer. And now they have partial paralysis with synkinesis. Now, this is a big population, and this is traditionally, these were patients that doctors go, "Oh, go live your life," and, "You look fine. Your face is not that bad," and patients are still really suffering from significant issues. And so, this is an area that I really think that we have undertreated and have not given patients really significant attention. And, I'll go through this patient population now and kind of give you my, kind of, philosophy on how I would approach that. So first, just like everybody else, we want to think about our form of care as needed depending on severity of, you know, the condition. If someone presents with synkinesis we want to start neuromuscular retraining as soon as movement returns. Botox treatment as soon as we see synkinesis because Botox can reduce some of the tightness and activity in the platysma and the dimples, and can be a really, really important adjunct therapy. Neuromuscular retraining, huge, very, very, very important, and, you know, I can't stress it enough for this population. And then I've pioneered this operation called the selective neurolysis and rerouting, and sometimes we combined it with a symmetric face lift. And this can really give patients spontaneous smile reanimation, a significant, just improvement in their appearance where they don't look like they have paralysis. They don't look like they have this frozen smile. And I'll show you some examples.

17 Page!17 And I can't stress enough how neuromuscular retraining, Botox, fillers, faceneck lift can really optimize outcome. And sometimes, these patients if we're still not satisfied, we can still do a cross face nerve grafting gracilis to compliment and improve their smile mechanism. So let's go through kind of so these are patients let's just have Botox. As you can see the dimpling, the neck tightness, the narrowing of the eyes, the symmetry of the area is just so much better and improved. Now, when Botox, neuromuscular retraining, and surgery can significantly improve the patient's outcome, so how do we treat it surgically? So there's an operation, we call it selective neurolysis and let's go through what we do. The main concept of this is we think that frowning muscles that we talked about, the platysma, the depressor anguli oris are preventing our smile mechanism. So we go in and map out the nerves and reduce the actively of these nerves. And also, kind of release the platysma, thereby allowing the nerves that go to our smiling muscles to work without interruption. And intraoperatively, we use a face lift incision and we do this simultaneously with at the same time. We'll map out all nerves. These are nerves, the zygomatic branches that go around the eyes and the small muscles. We don't touch those. The buccal branches go to the buccinators, platysma and depressor anguli oris. We reduced their activity. Marginal mandibular branch goes to a muscle called the depressor labii inferioris. We'll leave that alone. And then cervical branches go to platysma, will reduce that activity. So intraoperatively, we've mapped them out. We've done an EMG, electromyography. We'll go ahead and reduce the activities of that area and release platysma, and then reroute the nerve to give a little upgrading. So we'll upgrade and give additional input to zygomatic branches so their smile muscles are stronger and better. And if necessary causes a skin regraft if needed.

18 Page!18 Now, this is an example of a patient, you could see, had significant synkinesis, dimpling, tightness of the platysma, corner of the mouth going down. Now you could see a lot more even teeth. Now that's her jawline and this is a oneweek outcome believe it or not. This is another individual, corner of the mouth down, you see the teeth shows much less, eyes are much more narrowed, elevation, improved teeth. This looks less like she's had a facial palsy. Another patient who had had multiple surgeries at outside institutions and we did this selective neurolysis, a symmetrical face and neck lift. This is someone who had bilateral paralysis. And you could see this is her maximal smile, like a Moebius patient, cleft palate or paralysis and now she can smile on both sides. And this is someone that on the right side, you could see the corners turning down, teeth are asymmetric and now much more symmetric corner up. Doesn't look like she has paralysis here she looks like she has palsy. Another gentleman, down, asymmetric, more even corner of the mouth. And these are all spontaneous because the patient's utilizing their own nerve, their own facial nerve. It's not some other outside nerve coming. This is another patient with a Botox around the eye a selective neurolysis for the lower face. Another example. Another example. So, in conclusion, facial nerve paralysis is complex and it does require multispecialty approach. As you've seen, we've talked about ophthalmologist, oculoplastic surgeons, therapists, head and neck surgeons, facial plastic surgeons, facial nerve experts, neurologists, neurosurgeons, you know, radiologists, very, very important. Now we'd really, really this is an area that I can't stress enough and I really, you know, champion this with our own

19 Page!19 center. Facial reanimation is not perfect and cannot truly reproduce a perfect smile. However, we've taken significant strives over the past decade. Reinnervation with hypoglossal or masseteric nerve and appropriate candidates who have complete and irreversible facial paralysis within 18 to 24 months is crucial to restore muscular tone. Combining masseteric facial nerve transfer with cross face nerve graft and gracilis muscle transfer for me is the treatment of choice for acoustic neuroma patients who have irreversible and complete paralysis of less than 18 to 24-month duration. For patients who have more than 24-month duration, I we utilize a cross face nerve graft with gracilis muscle transfer, and these patients can do extremely well as you've seen. And neuromuscular retraining, Botox, and selective neurolysis can improve spontaneous, SPA mechanism and reduce tightness and tension. For acoustic neuroma patients who've had persistent synkinesis and partial paralysis, this treatment can be performed at anytime. And I usually wait after 12 months but patients who've had it for 20 years can have this. So, I'm finished with my Webinar and there were several questions that the ANA had received from before. And I want to, kind of, go through these. As soon as I go through these there's about and we'll try to maybe Melissa I can pick out some of the questions that we've gotten from the participants and discuss this. So someone had written in, that if a patient had a 3.2 centimeter acoustic neuroma removed from the right side, do a suboccipital approach in November 2015 and still suffers from facial palsy and inability to blink in the right eye. This patient was wondering what treatments are currently available and possibility of regaining function. So, as we talked about, November 2015 until now is roughly about 20 months. So from if the patient has complete paralysis, then I would recommend first

20 Page!20 stage cross face nerve graft and masseteric facial nerve transfer and second stage gracilis flap. For eyes, immediately see an oculoplastic surgeon to consider either gold, platinum weight and lower lid reconstruction, make sure an ophthalmologist is involved, corneas cover. And, you know, the eye health is probably just as important as anything else. So that's probably what I would recommend. The approach of the acoustic neuroma, whether suboccipital, middle cranial fossa, doesn't make that much difference. For the most part, if the facial nerve is accessible right as it enters the face, then we can do the masseteric facial nerve transfer. OK, second question is, 30 years post-trans op patient with facial paralysis, vision loss in the left eye due to corneal scarring, hearing loss. After having several facial grafts, significant facial droop remains. Three question, can facial issues be addressed and improved at this late date? If so, would this require face lift, or? To presume improvement, what kind of doctor would be required to consult, plastic surgeon or otolaryngologist? So, number one, this is an important lesson, that if the eyes are not managed from the get-go this can happen. You can develop vision loss. So the eye issues are very crucial from the get-go. So, those things need to be managed by an ophthalmologist and oculoplastic surgeon. Now, whether the patient has had nerve grafts and so forth, there are several options. What if that the patient has never had a cross face nerve graft and gracilis flap even though it's 30 years after the fact? That person can still have a cross face nerve graft and gracilis flap for facial reanimation. They can alternatively have a temporalis tendon transfer or a gracilis flap motorized by the masseteric nerve. So those are the options. And then supplement those for aesthetics, maybe with face lifts and so forth. But I still want to get facial movement,

21 Page!21 spontaneity, even if it's 40 years later, because it's really, really important in day-to-day livelihood to have that. As far as who to see, you know, generally speaking, make sure that your plastic surgeon, facial plastic surgeon, or head and neck surgeon has experience in reanimating and knows has experience in all of this things because this pair of one-trick-pony and all they do, for example, is 12-7 or all they do is about tendon transfer, or all they do is a cross face nerve graft, gracilis, then they're not going to be able to really figure out and customize what's necessary for you. So, I think plastic surgeons, facial plastic surgeons and head and neck surgeons, otolaryngologist, depending on their experience and expertise, can perform these operations. However, they just have to have a large volume of patients, know how to customize it, and be able to really analyze it from a variety of different angles. So, that's kind of the way that I would approach that. What might cause eyelid twitching and acoustic neuroma size for a patient that has undergone both surgery and radiation to treat acoustic neuroma? So typically speaking, twitching is usually a result of synkinesis. So neuromuscular retraining, Botox, are typically for the eye area, all I would recommend. Generally speaking, I'm not a big fan of aggressive eyelid nerve work for synkinesis. So, typically speaking, Botox and rehab can really help with those. What are reasonable expectations for the patients who have as far as how much improvement they can expect? I mean, my own personal expectations are high but as I said, it's not going to be if someone has complete paralysis from going following acoustic neuroma, I think getting a perfect smile is not possible. However, as you saw in my before and after patients, I think, if the patient is motivated and you have the right surgeon, I do think that we can a significant improvement.

22 Page!22 What's the recuperation rate pain level after surgery? Recuperation for most of these operations are actually pretty manageable. I would say it's nothing like having neurosurgical procedures. Typically speaking, the patients get back to their normal day-to-day life within 7 to 10 days socializing. Most of the swelling and healing process will subside within a few weeks. With the gracilis muscle transfer, the muscle swelling does take a few weeks longer to kind of settle down. So, I usually go over, you know, giving a timeframe of at least from a swelling standpoint on what they should expect. And so, recuperation, and I know this comes out to the next question. There's a lot of emotional factor because people have been through brain surgery and neurosurgical procedures. And having facial surgery, again, basically does not get you nearly to the level of what neurosurgical procedures are, and patients do quite well with it. The majority of these procedures that have outlined our outpatient, patients go home that evening or the next morning. So, we've really pushed that. And, for instance gracilis flaps, most institutions and, you know, when I trained 15, 16 years those patients would be staying in the hospital for week. Now, we do that as outpatient procedure. Patients have just do really well and have really, really, really improved outcomes with that. So, I think that ends my formal Webinar. And, I'd like to again thank the Acoustic Neuroma Association. And for professionals, I know there are few professionals, head and neck surgeons, otolaryngologist, and so forth that are on this Webinar, I do encourage you and to share. We will have International Facial Nerves Symposium, August 3rd through the 6th in Los Angeles. We are also working on joining the patient this is mostly for scientific presentations and for medical community. However, we are working on,

23 Page!23 perhaps, when you have this session for general population and interested patients. So, we look out for that. And if you have any questions this is my , feel free to me. And this is our number if you have any questions on about anything that I've discussed. And I really want to thank all of you for tuning in to this session. Melissa Baumbick: Dr. Azizzadeh that was a great presentation. We really, really appreciate it. And we have just a couple of minutes left that we can get you, maybe three or four questions. So, I want to go ahead and asked just a couple, one that has come up repeatedly several times throughout your Webinar was, are these procedures covered by insurance typically or is this something that tends to be in an out-of-pocket expense? Babak Azizzadeh: Yes. So insurance companies will always, always, always try to make this "cosmetic." So, it really depends on your insurance. And, like, in our practice, we generally try to get all the insurance information and contact the insurance company and do everything we can to have the insurance company participate. So, it really depends on your insurance and it depends on how involved you are in the process of allowing and getting in your insurance company to be involved in this. So Melissa Baumbick: OK. Babak Azizzadeh: that's kind of a short answer. It's very complex. Melissa Baumbick: Yes, and yes, I know it's much more complex than we can get into here. There was a question about, when facial paralysis occurs without nerve damage or cutting, what the indicators of that recovery, of the nerve recovery, will actually look like or be like? What will those show? How will the patient know? Babak Azizzadeh: So, the patient knows and it really goes back to I'm going to put a picture up in second, so it goes back to this. Let me see if I could get this. So, if a

24 Page!24 patient has recovery, if the patient has no recovery, this is what's going to be, flat, complete, no movement, no tone, nothing. Early signs of recovery, if you feel like there's a little bit more tone to the face, then you start seeing some subtle movements that transitions to looking like this, if there's partial recovery. And if it's complete recovery, then your face is going to move normally as it was before surgery. So, it's really tone, is the first time then you're going to start seeing some movement. And then you start seeing subtle movements, and then a lot of people they've had a dense paralysis that, you know, the nerves has been cut but it's a dense paralysis. A lot of patients will develop something like this patient with a synkinesis. And, you know, not a perfect smile, not a good smile, kind of a frozen smile. Melissa Baumbick: OK. And there are patients that has had both surgery and radiation treatment that are experiencing facial numbness and then wondering if that will progress or if it typically progresses to facial paralysis. Babak Azizzadeh: Yes. So facial numbness, technically, is a completely different nerve than facial paralysis. Facial numbness is a function of the trigeminal nerve, which does not really have anything to do with facial paralysis. So but, having said that some people, when they stop, kind of, having movement of their face, they get a sense of that they get a sense that their face is numb. But, for the most part, patients who have numbness, it's related to a different nerve. So it doesn't necessarily mean anything. Melissa Baumbick: OK. And the nerve several patients that have questions about numbness in their tongue, is there anything that can be done Babak Azizzadeh: Yes. Melissa Baumbick: that can reverse that?

25 Page!25 Babak Azizzadeh: Yes. I mean, again, the sense after a facial paralysis, again, numbness of the tongue is really related more towards the tip and the front portion. And if they have complete paralysis, they're going to have some of that aspect because that area taste fibers to that area are affected when that happens. Melissa Baumbick: OK. And does the and how does the nerve transfer that's being that you were discussing, how does that affect the tongue? Babak Azizzadeh: Yes, so if the and that's why I don't love the hypoglossal facial nerve transfer, it doesn't it just if it's done right and there noble we have newer techniques so we don't cut the whole nerve, we just use a partial aspect that a the patients have very limited tongue issue. But there is potential for atrophy of the tongue, of lack of movement, difficulty moving and atrophy of one side. So, that's why I really prefer the masseteric nerve because it doesn't affect any of our chewing, speech, tongue, drooping, drooling, all of that that we talked about. So, that's why I really moved away from I thought they were that is also actually pretty good as you saw, but I think there is a lot of other functional issues that I think come along with the hypoglossal nerve being addressed than the masseteric nerve being addressed. Melissa Baumbick: OK. And for a patient with partial paralysis after acoustic neuroma surgery and is experience some regaining of movement within six months, when do you decide at what point you decide that it's not going to improved anymore? Babak Azizzadeh: Yes, yes. So, at that time, at the six if it's a six month mark, if you start seeing synkinesis then I would start definitely doing neuromuscular retraining and Botox. That's a good time to start that. I will not go into surgery until about a year, a year and a half after the entire thing, you know, their acoustic neuroma surgery was done, because by that time you kind of know where they're at. You know, some people do change a

26 Page!26 little bit but for the most part you're just not going to see a tremendous amount of change after a year and a year and few years. That's a great question by the way. Melissa Baumbick: OK, good. OK, and I think we have time for one more. Babak Azizzadeh: Can we answer there's one, I think, (Joyce) wrote, had acoustic neuroma 33 years ago. I'm 80-years-old, am I too old Melissa Baumbick: Yes. Babak Azizzadeh: for any reconstruction? Melissa Baumbick: Yes. Babak Azizzadeh: And that's a question I get all the time. And the answer is, no. If you're in general good health and we now, you know, we're living so much longer and with great health, well into our 70's and 80's, I would say that no. Now, we'll have to discuss what options we have. Are we're going to do a two-stage operation? Are we're going to do a one-stage operation? Are we going to do a small operation, a big operation? There are so many different options. So those things have to be customized and individual, but no. I would say definitely not. And if someone on this Webinar, and they're definitely have certain level of motivation of wanting to do something, otherwise they wouldn't be on this Webinar. So I would say, definitely that's a great question. Melissa Baumbick: Wonderful. Well, we really appreciate your time. We're at the end of our time today. That will have to be our last question. I want to thank you, Dr. Azizzadeh for taking the time to speak to us and thank everyone that's attended our Webinar.