Rehabilitation of the Paralyzed Face

1
Rehabilitation of the Paralyzed Face

• Elizabeth J. Rosen, MD
• Karen H. Calhoun, MD
• 10/30/02

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
• 2nd 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
• 3rd 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
lt 3 yr
gt3 yr
72
Facial Paralysis
lt 3 yr
gt3 yr
Unhealthy pt. Poor prognosis
Healthy pt. Good prognosis
73
Facial Paralysis
lt 3 yr
gt3 yr
Unhealthy pt. Poor prognosis
Healthy pt. Good prognosis
Facial nerve present and free of disease?
Static resuspension
74
Facial Paralysis
lt 3 yr
gt3 yr
Unhealthy pt. Poor prognosis
Healthy pt. Good prognosis
Facial nerve present and free of disease?
Static resuspension
Regional or free muscle transfer
NO
YES
75
Facial Paralysis
lt 3 yr
gt3 yr
Unhealthy pt. Poor prognosis
Healthy pt. Good prognosis
Facial nerve present and free of disease?
Static resuspension
Regional or free muscle transfer
NO
YES
Proximal nerve available?
76
Facial Paralysis
lt 3 yr
gt3 yr
Unhealthy pt. Poor prognosis
Healthy pt. Good prognosis
Facial nerve present and free of disease?
Static resuspension
Regional or free muscle transfer
NO
YES
Proximal nerve available?
NO
YES
End-to-end anastomosis or interposition graft
Crossover or cross-facial graft
77
Facial Paralysis
lt 3 yr
gt3 yr
Unhealthy pt. Poor prognosis
Healthy pt. Good prognosis
Healthy pt. Good prognosis
Facial nerve present and free of disease?
Static resuspension
Regional or free muscle transfer
NO
YES
Proximal nerve available?
NO
YES
End-to-end anastomosis or interposition graft
Crossover or cross-facial graft
78
The End