facial rehabilitation

							Cumming’s Otolaryngology-Chapter 35

REHABILITATION OF FACIAL PARALYSIS
ANATOMY
   1. The pes anserinus can be found
    1.5 cm deep to a point 1 cm anterior
    and 2 cm inferior to the tragal
    cartilage.

      2. The superior division courses
    from the pes anserinus to the lateral
    corner of the eyebrow,

    3. The buccal branch passing 1 cm
    inferior to the inferior border of the
    zygomatic arch

     4. The marginal mandibular
    branch passes from the pes
    anserinus directly over the angle of
    the mandible and then under the
    inferior border of the mandible . then
    crosses above the mandible at the
    level of the facial vessels.
PATIENT ASSESSMENT

   1.history

   2.physical examination

   3.EMG

   4.CT
PATIENT ASSESSMENT

  I.   History
  A.   Type of injury
  B.    Time since injury
  C.    Age, overall health, and life expectancy
  D.    Radiation therapy (past or planned)
  E.   Nutritional factors
  F.   Prior operative report
PATIENT ASSESSMENT
 II. Physical examination

 A. Prior incisions and scars

 B. Integrity of trigeminal, vagal, and hypoglossal nerves

 C. Facial motion (is entire face paralyzed?)

 D. Status of eye (lagophthalmos, ectropion?)

 E. Facial tone, structure (habitus, etc.)
PATIENT ASSESSMENT
    III. Electromyography and biopsy
(perform on all patients who have had paralysis for more than
   1 year)
   Occasionally, muscle biopsy provides additional information about the
    presence of viable muscle .

   If nerve fibrosis is suspected, nerve biopsy is occasionally indicated.
PATIENT ASSESSMENT

    IV. CT scan of temporal bone and magnetic resonance scan
    of parotid gland
if there is any question about the cause of paralysis)
THE HOUSE-BRACKMANN GRADING
SYSTEM
I. Normal facial function in all areas
THE HOUSE-BRACKMANN GRADING
SYSTEM
II.SlightAppearance:

    slight weakness noticeable on close inspection; may have very
    slight synkinesis
    At rest: normal symmetry and tone

   Forehead motion: moderate to good function

    Eyelid closure: complete with minimal effort

   Mouth motion: slight asymmetry
THE HOUSE-BRACKMANN GRADING
SYSTEM
III.ModerateAppearance:
   not disfiguring weakness between the two sides; noticeable but
    not severe synkinesis, contracture, and/or hemifacial spasm

   At rest: normal symmetry and tone

    Forehead motion: slight to moderate movement

   Eyelid closure: complete with effort

   Mouth motion: slightly weak with maximal effort
THE HOUSE-BRACKMANN
GRADING SYSTEM
IV.Moderately severe
   Appearance: obvious weakness and/or disfiguring

   At rest: normal symmetry and tone

   Forehead motion: none

    Eyelid closure: incomplete

   Mouth motion: asymmetric with maximal effort
THE HOUSE-BRACKMANN GRADING SYSTEM

V.SevereAppearance:
   only barely perceptible motion

   At rest: asymmetric

   Forehead motion: none

   Eyelid closure: incomplete

   Mouth motion: slight movement
   VI.Total No facial function
-Advantage scale : useful for evaluation of overall function

-Disadvantage:

   insufficient for assessment of defects one or more branches

   does not measurement of effectiveness of treatments isolated to
    one region

    does not assess deformity of the upper, middle, and lower thirds of
    the face independently.
CONSIDERATIONS IN FACIAL NERVE
REHABILITATION
order of preference :
   first. Spontaneous facial nerve regeneration
  (observation)
   2nd. Facial nerve neurorrhaphy
   3rd. Facial nerve cable graft
   4th. Nerve transposition
   5th. Muscle transposition
   6th. Microneurovascular transfer
   7th. Static procedures
    FACTORS INFLUENCING FACIAL
    REANIMATION PROCEDURES
   •    Etiology, location, and severity of injury
        • Time elapsed since injury
        • Presence of partial regeneration
        • Proximal and distal nerve integrity
        • Viability of facial muscles (no denervation atrophy)
        • Donor site morbidity
        • Status of donor nerves
        • Age of patient
        • Health status of patient
        • Radiation injury
        • Patient desires and goals
ETIOLOGY :
    Bell's palsy , observed
   penetrating traumatic lesions are explored and repaired
    acutely, ideally before 72 hours.
    blunt temporal bone trauma:
    complete facial paralysis , explore
                                   incomplete, observe
   Surgical trauma (e.g parotidectomy) , immediate nerve
    grafting.
    neurotologic procedures is observed if nerve integrity remains,
    require nerve transposition lack of intact proximal facial nerve.
TIME SINCE TRANSECTION

 EMG
 - most helpful method for assessing for muscle atrophy
-done more than 12 months' duration
-preoperative prerequisite for all reanimation candidates
- presence of nascent, polyphasic, or normal voluntary action
   potentials seen in a facial paralysis indicates reinnervation

-     in the first 12 months, these potentials may mean that
      reinnervation is occurring

    -more than 12 months ,situation can be stable then operativ
      procedure
TIME SINCE TRANSECTION

EMG findings is electrical silence:

means muscles have undergone denervation atrophy.

nerve grafting or transfer contraindicated.

muscle transfers are indicated.
PRESENCE OF PARTIAL
REGENERATION

   partial innervation sufficient to preserve the
    muscles for many years, even they may be totally
    paralyzed.
PROXIMAL AND DISTAL FACIAL
NERVE
   As a rule, the best neural source for rejuvenation is the
    ipsilateral facial nerve.
   least degree of voluntary and involuntary control of facial
    movement
   Exceptions to this rule:
   patient needs prompt relief from corneal exposure or drooling,
   tissue transfer/sling technique be preferred because its effects
    are immediate

For these reasons, the integrity of the proximal facial nerve is
  most important.

no reliable electrical tests exist to confirm the viability of the
  proximal nerve when it is discontinuous with its distal portion.
   facial nerve distal to the injury site serves as a conduit for
    neural regeneration to the facial muscles

identify anatomic integrity of the distal nerve:

    acute injuries (<72 hours old), the electrical stimulator identify
    the distal nerve

    After this "golden period," surgeon must rely on visual
    identification
MUSCULAR NEUROTIZATION:


:If no nerve branches are found, and EMG shows denervated
    facial muscles,
Then nerve graft may be sutured directly to the muscles
Muscles:
 zygomaticus major and minor,
 levator labii superioris
orbicularis oculi
VIABILITY OF FACIAL MUSCLES
   EMG is the single most important test in determining the type
    of operative procedure
Four types of information from EMG:
    Normal voluntary action potentials indicate that functioning
    motor axons have connections
    Polyphasic potentials ,during reinnervation and may precede
    visible evidence of reinnervation.
    Denervation or fibrillation potentials indicate normal
    denervated muscle exists.
   Electrical silence, indicates atrophy or congenital absence of
    muscle,
   Preexisting innervation prevents reinnervation by another
    neural source.

   axon fails to reach a "critical mass," not be sufficient to invoke
    movement.

   innervated motor endplates reject new innervation.

   this is not a problem ,the subclinical innervation will be
    transected in preparation for the suture anastomosis
STATUS OF DONOR NERVES

 hypoglossal nerve: most nerve source for transfer.
- Several reflex and physiologic similarities between the hypoglossal and facial
    nerves
-affect the integrity and function of this nerve :
 Irradiation of the brain stem, lesions of the skull base , surgical procedures
    of the upper neck.
   trigeminal nerve
  has been used for the masseter or temporalis muscle transfer
-Palpation of the muscle during jaw clenching confirm the muscle function
AGE

proximal neuron's ability to regenerate declines:

   time because of denervation

   advancing age of the patient
HEALTH STATUS :

   diabetes,

   Microangiopathy

   These factors would not preclude a nerve graft procedure in a
    diabetic patient,

Prior Radiotherapy :

   affects the neovascularization of the nerve graft by decreasing
    vascularity of the tissue .
EARLY CARE OF FACIAL NERVE INJURY
   Eye protection:
    Paralysis of the orbicularis oculi results in exposure and drying of the
    cornea
   Patients at increased risk for exposure keratitis may be identified "BAD,"
      (1 absense of Bells pheneomen

      , (2) corneal Anesthesia,

      (3) history of Dry eye


   ectropion, occurs because the atonic lower lid and lacrimal
    punctum fail to appose the globe .
PROCEDURES TO TREAT THE PARALYZED EYE
LID

Upper lid (lagophthalmos):
   Weights, Springs, and Slings
   Gold weight insertion is extremely effective ,minimal cosmetic deformity,
    ease of insertion

   some disadvantages:
   weights depend on gravity,do not effectively protect the cornea when the
    patient is supine,
    weight is placed too far superior, result in paradoxical opening of the eye in
    the supine
PROCEDURES TO TREAT THE PARALYZED EYE
LID

Lower lid(ectropion):

Tarsorrhaphy

   mild corneal exposure

   expeditious method

   longer-lasting protection, adhesion tarsorrhaphy is preferred.

Canthoplasty     and wedge   resection,   highly effective methods
FACIAL NERVE GRAFTING

 Cable or interposition nerve grafts are frequently desired
  approach
uses of interposition grafts :
 When tension-free apposition cannot be attained
 (1) radical parotidectomy with nerve sacrifice;
 (2) temporal bone resection;
 (3) traumatic avulsions;
 (4) cerebellopontine angle tumor resection;
 5) any other situation in which viable proximal nerve can be
  sutured
order of priority for reinnervation branches :

(1) buccal and zygomatic branches (equal),
(2) marginal mandibular,
(3) frontal,
(4) cervical (the latter may be disregarded or excluded). may steal
   reinnervation axons then advises clipping this branch
CHOOSING A DONOR NERVE

most common nerves:

   greater auricular nerve,

   sural nerve,

   medial antebrachial cutaneous nerve.
CHOOSING A DONOR NERVE

Greater auricular:
   In tumor resection,When harvesting, the ipsilateral nerve not be
    used.
   The surgical landmarks
    a line drawn from the mastoid tip to the angle of the mandible is
    then bisected by a perpendicular line
has several advantages:
 size
 fascicular pattern are similar to the facial nerve,
 has a favorable distal branching pattern.
The main limitation of this graft is the maximum of 10 cm available.
SURAL NERVE:
the longest donor nerve available, with up to 70 cm
caution :
 diabetics or patients with peripheral vascular disease ,ischemic
   pressure necrosis could result in the area of sensory deficit
The nerve lies immediately deep to and behind the lesser
   saphenous vein.
   a transverse incision made immediately behind the lateral
    malleolus.

   should be harvested immediately before grafting

   placed in lactated Ringer's solution
MEDIAL ANTEBRACHIAL CUTANEOUS NERVE

   supplies sensation to the medial aspect of the forearm.
   Nerve diameter and branching pattern are similar to the
    facial nerve,
    A linear incision is made in the bicipital furrow the medial
    aspect of the arm.
    is located in the subcutaneous tissue immediately adjacent to
    the basilic vein.
   More than 20 cm of nerve can be harvested
SURGICAL TECHNIQUE
   Both ends of the nerve graft should be prepared

   sutures of 9-0 or 10-0 monofilament nylon

   The needle should pass through epineurium only to avoid injury

   graft should lie in a "lazy S" configuration , to minimize tension

   Use of the mastoid portion of the facial nerve may require use
    of the longer sural or medial antebrachial cutaneous nerve as
    a cable graft
CROSS-FACE NERVE GRAFTING


 the only procedure that has the theoretic ability of specific
  divisional control of facial muscle groups
CROSS-FACE NERVE GRAFTING
Surgical Technique
 for the buccal branch, on the nonparalyzed side through a nasolabial
  fold incision.
 Cross-face grafts for the eye region are passed above the eyebrow.
 One to three sural nerve grafts are approximated to these normal
  contralateral branches.
 The nerve grafts are passed through subcutaneous tunnels, in the
  upper lip
 Tinel's sign may be elicited on the paralyzed side after several
  months
 At this time, the graft is explored and sutured to the appropriate
  branches on the paralyzed side.
 approached through a parotidectomy/rhytidectomy of the paralyzed
  side
   The cross-face technique suffers from a lack of sufficient axon
    population and neural excitatory vitality.

    Cross-face grafting currently is only used in conjunction with
    free muscle transfers
NERVE TRANSPOSITION


Hypoglossal Nerve Transfer
 hypoglossal nerve is prefered because:
 both arise from a similar collection of neurons in the
  brain stem,
 similar reflex responses following trigeminal nerve
  stimulation.
 in close anatomic proximity and is readily available
 criticism of hypoglossal nerve transfer is a lack of
  voluntary emotional control.
 end-to-side anastomosis of the facial nerve or a jump
  graft into the donor hypoglossal nerve
SURGICAL TECHNIQUE

 parotidectomy incision or modified facelift
 incision.
 the facial nerve is identified in its trunk-pes
 anserinus region
 hypoglossal nerve is dissected medial to the
 tendon of the digastric muscle
 the nerve ends are prepared , four to eight
 epineural sutures of 10-0 monofilament nylon
 hypoglossal-facial nerve jump graft is similar to
  pure hypoglossal-facial nerve transfer.
 A greater auricular nerve graft is harvested for
  use as a jump graft.
 hypoglossal nerve is incised to expose about
  30% of the nerve fibers.
RESULTS
   95% regained satisfactory tone in repose
   15% demonstrated hypertonia in the middle third of
    the face; decrease gradually over 10 to 20 years
    had success treating with selective injection of
    botulinum
   78%had moderate to severe tongue atrophy,
    whereas 22% showed minimal atrophy;
    Lingual Z-plasty minimize difficulties with tongue
    movement
    interpositional jump graft with partial hypoglossal
    nerve preservation preserved tongue function
THE SPINAL ACCESSORY NERVE :


 The phrenic nerve has been similarly used,
  but causes paralysis of the diaphragm
 undesirable involuntary inspiratory
  movements in the facial muscles.
 The neuromuscular pedicle ,transfers a
  branch of the ansa hypoglossi nerve and a
  small muscle block
 this procedure is only valuable for the perioral
  muscles
MUSCLE TRANSFERS

Masseter transfer
 be used only if ipsilateral cable nerve grafting is not
  possible.
Indication:
 when the proximal facial nerve and the hypoglossal
  nerve are unavailable,
 when facial muscles are surgically absent or
  atrophied,(last paralyze more 2 years)

   masseter transfer , for rehabilitation sagging paralyzed
    oral commissure and the buccal-smile complex
OPERATIVE APPROACH:


   externally through a rhytidectomy/parotidectomy
    incision,
    intraorally using a mucosal incision in the gingivobuccal
    sulcus lateral to the ascending ramus
   external approach is preferred,
    intraoral approach is associated with somewhat limited
    access,
    poorer muscle mobilization,
   and less vascular control.
   best results depend on the following:
     1. the intraoperative result should be a hyperelevation of the oral
    commissure.
      2. Preservation of masseteric nerve supply.
      3. Placement of many sutures in the transposed muscle: the
    oral commissure at the exaggerated overcorrected level during
    attachment of the muscle.
      4. After skin closure , and a tape dressing (which maintains
    overcorrection) should be left in place for 7 days
   Perioperative antibiotics
   NPO; nasogastric feedings for the first 5 days
   masseter's arc of rotation will not allow for rehabilitation around the
    orbit.,the temporalis transfer can be combined with
    TEMPORALIS TRANSFER
   Like the masseter transfer, requires an intact ipsilateral
    trigeminal nerve.
   he nerve supply to the temporalis lies along the deep surface
    of the muscle
   upper origin arises from the periosteum of the entire temporal
    fossa.
   insert the coronoid process
    muscle is best exposed through an incision that passes above
    the ear, slightly posteriorly, and then in an anteromedial arc.
   convenient aponeurotic dissection plane exists lateral to the
    temporalis fascia.
   muscle is dissected free from the periosteum

   turned down inferiorly to reach the oral commissure and eyelid
    area.

   A tunnel at least 1- to 1.5-inches wide must be made over the
    zygomatic arch to eliminate an unsightly bulge.

   attachment of the strip should be medial to the nasolabial fold

   A soft silicone block or temporoparietal fascia may be used to
    fill the depression in the donor defect.
   gold weight-canthoplasty technique is often preferred,
    temporalis muscle can be used for orbital rehabilitation

   Patients need to learn through videotape, biofeedback, the
    proper way to contract the muscles by chewing

   muscle transfer procedures will not allow any emotional or
    involuntary reanimation.

   In the best hands,provide symmetry and tone in rest with
    some learned and induced movements on attempted
    chewing.
MICRONEUROVASCULAR MUSCLE TRANSFER

   absence of facial musculature (Möbius syndrome), microneurovascular muscle
    transfer seems to have strong potential.
    most popular muscles :the gracilis, latissimus dorsi,inferior rectus abdominis
    Along with viable muscle, nerve supply must be brought
   Ideally, the proximal stump of the facial nerve ,but often not possible, the
    contralateral facial nerve is used.
   reinnervation has been accomplished in two stages, with a preliminary cross-
    face nerve graft performed about 1 year before muscle transfer.
   ingrowth within the grafted nerve is monitored by Tinel's sign
   When reinnervation has occurred, microvascular muscle transfer is performed.
    When facial nerve input is not available, alternative nerves , including the
    masseteric branch of V3, ansa hypoglossi, or the hypoglossal nerve.
STATIC PROCEDURES

 indicated :

     debilitated persons with poor prognosis

     whom nerve or muscle is not available

     provide immediate benefit in conjunction
    with dynamic techniques.
STATIC PROCEDURES


  benefits :
1.facial symmetry at rest can be achieved immediately.
2. complaints associated with ptosis of the oral commissure
   are improved.
Finally, nasal obstruction caused by alar soft tissue collapse
   improved by re-suspension and fixation of the nasal alar
   complex.
materials :
   most common have been fascia lata,,expanded
   polytetraflouroethylene (PTFE or Gore-Tex).
   acellular human dermis (AHD, or Alloderm)
ADJUNCTIVE PROCEDURES
   Upper Third of the Face

   Browlift techniques to manage paralytic ptosis ,

   in older patients, with bilateral browlifts improved result

   manipulations on the normal side of the face including
    selective myectomies and botulinum toxin injections

   conservative blepharoplasty , can decrease superior visual field
    defects
Middle Third of the Face :

   In older patients performing a facelift

   . The mid-face lift, also called the SOOF lift, (sub orbicularis
    oculi fat)

   The SOOF lift performed through a transconjunctival incision,
    with a lateral canthotomy and inferior cantholysis.
   Lower Third of the Face

   Reinnervation, free tissue transfer, dynamic slings,

   wedge resection of lower lip

   The most common dynamic technique for depressor
    dysfunction is the digastric transposition, (anterior belly of the
    digastric muscle. with or without supplemental cheiloplasty)
SYNKINESIS

 Patients with incomplete recovery from facial
  paralysis are typically troubled by both weakness
  and hyperkinesis (synkinesis).
 etiology in aberrant axonal regeneration,

management:
neurolysis
 botulinum A toxin injections

 selective myectomies.
BOTULINUM A TOXIN

   Botulinum toxin causes paralysis by blocking the presynaptic release
    of acetylcholine

   treated muscle for approximately 3 months.

   It is now a first-line treatment for facial synkinesis.

   can be used to denervate specific muscle groups.
   . Patients are asked to remain upright and avoid strenuous exercise
    for 4 to 6 hours after the injection

   Effected at 5 to 7 days.
BOTULINUM A TOXIN

   Adverse effects ,:
   ptosis after periocular injection,treatment with drop apraclonidine
   diplopia,
    further impairment of eyelid closure
   lower eyelid ectropion
   brow ptosis,
    drooling.

   In some patients, the effectiveness of botulinum toxin decreases
    over time
   not benefit from botulinum toxin treatments, candidates for
    selective myectomy.
SELECTIVE MYECTOMY

   Candidate: results of botulinum toxin injection are unsatisfactory

   brow incision ,The orbicularis oculi , the corrugator supercilii, and
    procerus muscles are excised.

   A more limited myectomy, A lid crease incision provides exposure to the
    orbicularis oculi,

   Chin dimpling ,by excision of the mentalis

   exaggerated nasolabial fold, by excision of the zygomaticus,

    inferior displacement of the lower lip by depressor anguli oris
    excision.