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
Rehabilitation of the Paralyzed Face Personally devastating Cosmetic deformity Psychological distress Functional deficits Lagopthalmos and ectropion Oral incompetence Nasal obstruction Mastication difficulties Articulation difficulties
Rehabilitation of the Paralyzed Face Goals Functional EYE PROTECTION Oral competence Cosmetic Symmetry at rest Volitional movement Facial expressions
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
Rehabilitation of the Facial Nerve Restore neural input Replace nonfunctional facial neuromuscular units Statically resuspend facial tissues Adjunctive procedures to address specific defects
Patient Evaluation History Etiology Prognosis Duration Past medical history Neurological disease Physical examination General appearance Complete head and neck exam Donor tissues
Rehabilitation of the Facial Nerve Restore neural input Replace nonfunctional facial neuromuscular units Statically resuspend facial tissues Adjunctive procedures to address specific defects
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
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
Rehabilitation of the Facial Nerve Statically resuspend facial tissues 3 rd choice Patient factors Temporizing measure Symmetry at rest Options Fascia or synthetic slings
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
Restoration of Neural Input Primary anastomosis Interposition graft Crossover graft Cross-facial graft
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
Restoration of Neural Input Interposition graft Great auricular nerve Sural nerve
Restoration of Neural Input Interposition graft Sural nerve
Restoration of Neural Input Interposition graft Sural nerve
Restoration of Neural Input Interposition graft Sural nerve
Restoration of Neural Input Crossover graft Proximal facial nerve disrupted Donor motor nerve Hypoglossal Accessory Ansa hypoglossus Trigeminal phrenic
Restoration of Neural Input Crossover graft - technique
Restoration of Neural Input Crossover graft - technique
Restoration of Neural Input - Crossover Advantages Reliable Good tone and symmetry Disadvantages Donor site morbidity Synkinesis and hypertonia Unpredictable result for voluntary movements
Restoration of Neural Input Crossover graft modifications Splitting hypoglossal nerve Jump interposition graft Branch of accessory to SCM
Restoration of Neural Input Crossover graft
Restoration of Neural Input Crossover graft
Restoration of Neural Input Crossover graft
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
Replacement of Nonfunctional Facial Muscles Regional muscle transfer Microneurovascular free muscle transfer Indications Long standing paralysis Abnormal neuromuscular junctions
Replacement of Nonfunctional Facial Muscles Regional muscle transfer Temporalis Masseter Preoperative evaluation Lower 1/3 of the face
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
Replacement of Nonfunctional Facial Muscles Temporalis muscle transfer
Replacement of Nonfunctional Facial Muscles Temporalis muscle transfer
Replacement of Nonfunctional Facial Muscles Masseter muscle transfer
Replacement of Nonfunctional Facial Muscles Regional muscle transfer
Replacement of Nonfunctional Facial Muscles Regional muscle transfer
Replacement of Nonfunctional Facial Muscles Regional muscle transfer
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
Replacement of Nonfunctional Facial Muscles Donor muscles Vascular pedicle Single Reliable Sufficient length Bulk Excursion Minimal morbidity
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition)
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition) Crossover (CN XII or XI)
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition) Crossover (CN XII or XI) Cross-facial
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer Vessels Nerves Facial (interposition) Crossover (CN XII or XI) Cross-facial
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
Replacement of Nonfunctional Facial Muscles Microneurovascular free muscle transfer
Static Resuspension of Facial Tissue Static elevation of the drooping paralyzed face Cosmetic Functional Indications Patient factors Temporary while awaiting return of nerve function
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
Static Resuspension of Facial Tissue
Static Resuspension of Facial Tissue
Static Resuspension of Facial Tissue
Static Resuspension of Facial Tissue
Static Resuspension of Facial Tissue
Static Resuspension of Facial Tissue
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
Adjunctive Procedures Gold weight implant Advantages Technically straightforward Consistent Disadvantages Visibility Extrusion
Adjunctive Procedures Gold weight implant Advantages Technically straightforward Consistent Disadvantages Visibility Extrusion
Adjunctive Procedures Gold weight implant Advantages Technically straightforward Consistent Disadvantages Visibility Extrusion
Adjunctive Procedures Palpebral Spring Advantages Less visible Useful in cases with mixed orbicularis and levator dysfunction Disadvantages Technically difficult Higher risk of extrusion
Adjunctive Procedures Lower lid shortening Wedge excision with lateral canthopexy
Adjunctive Procedures Lower lid shortening Wedge excision with lateral canthopexy Tarsal strip procedure
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
Adjunctive Procedures Lower lip wedge resection with transposition of orbicularis oris
Adjunctive Procedures Lower lip wedge resection with transposition of orbicularis oris
Adjunctive Procedures Lower lip wedge resection with transposition of orbicularis oris
Adjunctive Procedures Brow lift Direct Mid-forehead Pretrichial
Adjunctive Procedures Endoscopically assisted brow and midface lift
Adjunctive Procedures Endoscopically assisted brow and midface lift
Adjunctive Procedures Classic rhytidectomy Deep plane rhytidectomy
Botulinum Toxin Beneficial for synkinesis and hypertonia Targets specific overactive facial muscles Advantages: easy, temporary, selective Disadvantages: temporary, recurrence of original problem
Facial Paralysis < 3 yr >3 yr
Healthy pt. Good prognosis Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis
Healthy pt. Good prognosis Facial Paralysis < 3 yr >3 yr Unhealthy pt. Poor prognosis Facial nerve present and free of disease? Static resuspension
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
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
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
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