Facial nerve injury Repair and Reanimation

Kourosh Parham May 21, 2004

Division of Otolaryngology University of Connecticut Health Center

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

 Facial nerve
10,000 fibers
7,000 myelinated
Facial muscles

3,000
Secretomotor Sensory (leave main trunk proximal to stylomastoid foramen)

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

A smile isnt just a smile!

Zygomaticus major pull lifts corner of the mouth

Levator labii superioris canine smile; some counteraction from depressors

All elevators and depressors contracting full-denture smile

 Facial nerve injury

Histologic and biologic changes
Cell body Axon
Proximal and distal to the site of injury May also lead to muscular aberrations and degeneration

Distance from the cell body to the site of injury

Determines the degree of injury to the entire neuron Axon interruption close to the motor end plate of much less consequence than intracranial and intratemporal injuries

 Facial nerve injury

Clean surgical transections
Produce less cell body disruption than do crushing injuries

Younger patients
Generally have a better chance of prompt and complete return of facial movement after peripheral nerve injury

Cross section of a peripheral nerve

 Seddon (1943) classification of nerve injury

Neurapraxia
Only the myelin sheath is affected The conduction of impulses is blocked but axoplasmic transport continues The nerve distal to the site of the lesion has abnormal voluntary motor function but retains normal electrical stimulability This usually occurs for several days after trauma and disappears spontaneously and completely

 Seddon (1943) classification of nerve injury

Axonotomesis
Axonal continuity is lost Wallerian degeneration distally (3-5 days) Although the neural element is separated and damaged, the myelin sheath remains intact Spontaneous but incomplete recovery may be expected If the endoneural tube is also disrupted, aberrant regeneration of axonal sprouts may randomly enter distal endoneural tubes
Synkinesis/mass movement (single fiber br to mult m.)

 Seddon (1943) classification of nerve injury

Neurotmesis
All components of the peripheral nerve are transected Wallerian degeneration distally (3-5 days) The epineural sheath is disrupted, allowing axon sprouts outside the nerve sheath to produce neuromas

Seddon (1943) classification of nerve injury

Axonotomesis & neurotmesis
Axons begin to regenerate about 3 weeks after injury Axon may regenerate at a rate of 1 mm/day Recovery begins within 2-4 months

Cross section of a peripheral nerve

 Sunderland Classification
Sunderland expanded Seddon's system by subdividing type 3 injuries and proposed the following classification types:
Sunderland I (Neuropraxia) - as in Seddon. Sunderland II (Axonotmesis) - as in Seddon. Sunderland III (Neurotmesis) - loss of continuity of endoneurial tubes, with intact perineurium, distal Wallerian degeneration occurs. Sunderland IV (Neurotmesis) - loss of continuity of perineurium, distal Wallerian degeneration occurs. Sunderland V (Neurotmesis) - loss of continuity of epineurium, distal Wallerian degeneration occurs.

 Sunderland Classification
most useful not only to describe the type of injury, but to select treatment and aid in prognosis. For instance, Sunderland I lesion usually results in complete recovery and does not typically require surgical intervention. On the other hand, a type V injury has a poor prognosis and requires surgical repair or grafting.

 Facial paralysis
Significant cosmetic and function deficit Emotionally and physically devastating

 Etiology Over 40 cuases; broadly classified into three major groups

Central or intracranial region
Vascular abnormalities Central nervous system degenerative diseases Tumors of the intracranial cavity Trauma to the brain Congenital abnormalities and agenesis
Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

 Etiology
Central or intracranial region
Congenital abnormalities and agenesis
Mobius syndrome (agenesis of motor nuclei) bilateral facial paralysis; syndactyly; other cranial nerve abnormalities (III, V, IV, IX, XII)

 Etiology
Idopathic
Bells palsy acute, unilateral onset; viral prodrome; pain or paresthesia of the face or neck; stapes reflex decreased or absent; forehead muscles intact; trigeminal/hypoglossal maybe involved: may improve! Melkerson-Rosenthal syndrome - a rare disease that consists of a triad of symptoms: recurrent orofacial edema, recurrent facial palsy, and lingua plicata (fissured tongue).

 Etiology
Temporal bone region
Bacterial (e.g., otitis media; malignant otitis externa) and viral (e.g., herpes zoster) infections Cholesteatoma Trauma
Longitudinal and horizontal fractures of the temporal bone Gunshot wounds

Tumors invading the middle ear, mastoid, and FN Iatrogenic causes (surgical injury) Congenitial osteopetrosis (hereditary)

 Etiology
Parotid gland region
Malignant tumors of the parotid gland Trauma (lacerations and gunshotwounds) Iatrogenic factors
Surgical injury Parotid main trunk, branches Facelift marginal TMJ frontal Tumor excision cystic hygroma; hemangioma At birth use of suction or forceps

Primary tumors of the facial nerve Malignant tumors of the ascending ramus of the mandible, the pterygoid region, and the skin

 Diagnostic Evaluation of Facial Palsy

History Physical examination

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

Diagnostic Evaluation of Facial Palsy

Topognostic tests
Hearing and balance tests Schirmer test Stapes reflex Submandibular flow test Taste test

As the quality of radiographic studies, primarily high resolution CT scan, has improved, the importance of topognostic testing has fallen off

 Diagnostic Evaluation of Facial Palsy

Electrical testing

 Electrical testing
Hilger nerve stimulator Minimal nerve excitability test
Compares paretic side to normal side A difference > 3.5 mA is significant

Maximal stimulation test

The highest current the patient can tolerate Compares paretic side to normal side Rank the difference as minimal, moderate, severe or no response

 In the first three days

electrical testing takes a back seat to clinical evaluation including the physical examination.

Between three days and three weeks

if the patient has visible facial motion, electrical testing is not needed and will be normal if obtained.

 If there is paralysis, early screening with a Hilger nerve stimulator is used

If the threshold on the involved side stays less than 3.5 mAmps above the normal side, no further testing is necessary. If the threshold difference goes above 3.5 mAmps, some recommend exploration. However, if ENoG is available it is recommended that serial examinations be performed every one or two days to follow the course of degeneration.

 Electroneuronography (ENog)
Transcutaneous stimulation of nerve trunk at stylomastoid foramen The response to maximal stimulation is compared between paretic and normal sides The percentage of the relative response is presumed to correspond to the percentage of degenerated fibers Disadvantage: Amplitudes are a 24-48 hour delayed representation of actual events occurring at site of lesion.

 Fisch guidelines
Degeneration to greater than 90% of nerve fibers as calculated by ENoG in the first three weeks
the prognosis is poor for spontaneous recovery patient should be explored

Anytime after three weeks

there is some controversy regarding the decision to explore, primarily because some nonpenetrating injuries can show spontaneous recovery.

 Electromyography
useful >14 days after insult when fibrillation potentials associated with denervated muscle develop Polyphasic potentials, whether spontaneous or voluntary suggest return of function (reinnervation)

 Trigeminal-facial reflex testing (Blink reflex)

Stimulate the supraorbital division of the ophthalmic branch of trigeminal nerve Record EMG from orbicularis oculi muscle Normal response consists of
Early action potential (oligosynaptic in pons, unilateral) Late action potential (polysynaptic in pons and lateral medulla, bilateral)

 Antidromic testing
Stimulate the nerve and record EMG Normal response consists of
Early action potential (orthodromic/direct stimulation) Late action potential (antidromic stimulation of motor neurons with subsequent orthodromic conduction)

 Diagnostic Evaluation of Facial Palsy

Radiographic studies
CT scans (brain stem, cerebellopontine angle, temporal bone, skull base)

Sialography of parotid Chest radiographic survey to detect sarcoidosis, lymphoma, carcinoma

 Diagnostic Evaluation of Facial Palsy

Special laboratory tests
Lumbar puncture (cerebrospinal fluid) to detect meningitis, encephalitis, Guiliain-Barre syndrome, multiple sclerosis, meningeal carcinomatosis

Complete white blood cell count and differential to detect infectious mononucleosis and leukemia Mono spot test to detect infectious mononucleosis Heterophil titer to detect infectious mononucleosis Fluorescent trepanemal antibody titer to detect syphilis Erythrocyte sedimentation rate to detect sarcoidosis, collagen vascular disorders

 Diagnostic Evaluation of Facial Palsy

Urinary and fecal examinations:
Acute porphyria: elevated porphyrins and urinary porphobilinogen Botulism: C. botulinum toxin in stool specimen Sarcoidosis: urinary calcium Diabetes mellitus: unrinary glucose

Glucose tolerance test to detect diabetes mellitus

 Diagnostic Evaluation of Facial Palsy

Serum
cryoglobulins and immune complexes to detect Lyme disease calcium to detect sarcoidosis angiotensin-converting enzyme level to detect sarcoidosis antinuclear antibody test (ANA) and rheumatoid factor (RF) to detect collagen vascular disorders (periarteritis nodosa)

Bone marrow examination to detect leukemia, lymphoma

 Facial paralysis
Treatment goals:
Functional eye closure, speech difficulties, oral compentency and nasal airway patency Cosmetic coordianted facial motion, balance and symmetry between both sides of face

 Nerve graft Static

Suspension by:
Fascia Dermis Silastic rubber

 Dynamic
Muscle transfer
Temporalis Masseter Digastric Sternocleidomastoid Muscle grafts (free)

 Inorganic motors
Metal spring (upper lid) Silastic bands-lip and lid Lid weights Lid magnets

 Sphincteric Reconstruction
Orbital (Canthoplasties) Oral (Buccal-oral reconstruction) Nares (Septal corrective surgery)

 Control of Antagonist
Muscles
Neurectomy
Temporary, chemical Permanent, surgical

Myomectomy

Face-lift Operations
Modified cheek plasty Blepharoplasty Nasolabial excision Supraorbital excision and brow lift Temporal lift Labial and mucosal excisions

 Surgical Formation of Folds and Wrinkles

Construction of nasolabial fold Forehead furrows

Terzia, JK & Mersa, B. Facial Reanimation. 2001. In The Unfavorable Result in Plastic Surgery, Avoidance and Treatment. Goldwyn R.M. & Cohen, M.N., Lippincott, Williams & Wilkins; pp. 597-610.

 Motor endplates functional vs nonfunctional

Status has impact on reanimation procedure chosen
Functional
Muscle fibrosis/atrophy minimal/reversible Nerve grafts

Non-functional
Nerve grafts not an option Muscle transplants (free neurovascular muscle vs. local transposition)

 Motor endplates functional vs nonfunctional

Assessed by EMG
Functional
Polyphasic potentials or voluntary action potentials Good recovery Fibrillation potentials If not addressed, poor recovery

Non-functional
Silence

 Static technique
Autogenous fascia (e.g., fascia lata)
Used to suspend paralyzed facial muscles May be used as an adjunct method in adults while waiting for functional results from nerve grafting, etc. May also be used in association with muscle transplants

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977

 Nerve Grafting
Indicated by trauma (penetrating, transecting wound; ablative surgery) Use longer graft than defect (shrinkage of up to 20%) to avoid tension at suture lines Most common: sural (anesthesia of lat aspect of dorsum of foot and lat malleolus, improves with time)

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

 Cross-facial nerve grafting

Identify branches on normal side Two-four sural nerve grafts At 9-12 mos (when positive Tinels sign present at distal end of the cross-facial grafts) second stage performed to coapt distal ends with selected branches of FN or facial muslces on paralyzed side

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

Baker, D.C. Reconstruction of the paralyzed face. In Grabb and Smiths Plastic Surgery, Aston, S.J. et al. (Eds). Lippincott-Raven, New York, 1997.

 Baby-sitter Procedure
Partial hypoglossal transfer to ipsilateral FN during first stage of cross-FN grafting to help maintain the bulk and tone of facial muscles If paralysis >6mos
Cross-facial nerve grafting must be supplemented by baby-sitter because the grafts are relatively weak motor donors.

 Baby-sitter Procedure
40% splitting of XII (preserves tongue muscles) Second stage operation
Needed for coaptation with contralateral facial nerve branches for direct neurontization of the facial muscles, or to supply the muscle transfers.

 Hypoglossal Nerve Crossover

The criteria for use of the hypoglossal nerve for facial paralysis
Intact extracranial part of the facial nerve Some ipsilateral facial musculature A direct VII-to- VII repair of the facial nerve injury or ipsilateral nerve grafting (VII-graft-VII) is not possible Facial paralysis is irreversible

 Hypoglossal Nerve Crossover

Patients with denervation of less than 18 months' duration are suitable for this procedure. When the denervation is more prolonged, fibrosis of the facial musculature prevents resuscitation, even if powerful ipsilateral motors are used.

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977

 Hypoglossal Nerve Crossover

Disadvantage if entire hypoglossal nerve transferred to the ipsilateral facial nerve
Various degrees of tongue atrophy and difficulty in speaking and swallowing

 Hypoglossal Nerve Crossover

Another chief complaints: Overactivity and mass movements.
Synkinesis and mass movements are seen in almost all patients, especially during talking and eating. Involuntary movements of one portion of the face typically occur while another part of the face moves voluntarily. Method to overcome problems: Reeducation; physical therapy is used to teach the patient to control facial muscles

 Hypoglossal Nerve Crossover

Another chief complaints: overactivity and mass movements.
Other methods attempted are injection of botulinum toxin, which prevents acetylcholine release at the neuromuscular end-plate, magnetic stimulation, and selective myectomy Rubin et al. (1984) advised a Z-plasty technique to restore tongue function.
The aim of this technique is to provide muscular neurotization from the normal side across the midline into the atrophic side.

 Spinal Accessory Nerve

Transfer of the spinal accessory nerve can provide good resting tonus However, shoulder disabilities are experienced by almost all patients if the entire accessory nerve is used. Loss of the ability to elevate the abducted arm, increased shoulder pain during activity, and frozen shoulder are the main forms of morbidity associated with this transfer.

 Spinal Accessory Nerve

Transposition of sternocleidomastoid branch of the accessory nerve avoids shoulder paralysis Example of a partial accessory transfer - 50% of the branch to the sternocleidomastoid and 40% of the branch to the trapezius. After these delicate splitting procedures, paralysis does not develop in the sternocleidomastoid or trapezius muscle.

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977

 Trigeminal Nerve
In cases of facial paralysis associated with Mobius' syndrome, the facial nerve is involved bilaterally. The masseter branch of the trigeminal nerve can be used as a motor source for local transposition or freemuscle transfers instead of a cross-facial nerve graft if it is not involved in the developmental mishap. As with other transfers of chewing muscles, the patient is retrained by biting for smile.

 Transposition of Local Muscles

Most common: masseter and temporalis muscles Their innervation remains the trigeminal nerve
Therefore, patient must be reeducated after transposition

Disadvantage of the use of chewing muscles: lack of synchronization with the healthy side of the face.
This is lessened by placing a cross-facial nerve graft and coapting the cross-facial nerve graft to the motor nerve of these muscles.

Baker, D.C. Reconstruction of the paralyzed face. In Grabb and Smiths Plastic Surgery, Aston, S.J. et al. (Eds). Lippincott-Raven, New York, 1997.

Baker, D.C. Reconstruction of the paralyzed face. In Grabb and Smiths Plastic Surgery, Aston, S.J. et al. (Eds). LippincottRaven, New York, 1997.

 Masseter Muscle
A powerful chewing muscle that can be used to reanimate the mouth Disadvantages
Lateral and posterior displacement of the muscle because of its deeper location. Involuntary facial movements during eating and talking Therefore, poor symmetry and coordination.

Baker, D.C. Reconstruction of the paralyzed face. In Grabb and Smiths Plastic Surgery, Aston, S.J. et al. (Eds). Lippincott-Raven, New York, 1997.

 Temporalis Muscle
The most commonly used muscle for transposition Used to reanimate both oral and eye sphincters simultaneously,
The results, especially for the eye sphincter, are not satisfactory. If the excursion and length of the muscle are not assessed correctly, lower eyelid ectropion develops.

 Temporalis Muscle
Transposition of this muscle empties the entire temporal fossa and causes a concave deformity.
Currently, alloplastic materials that can be reshaped have been used in an attempt to address this problem.

Another cosmetic sequela of temporalis transfer is swelling over the zygomatic arch.

Other complications: involuntary facial movements during biting, chewing, and talking and a lack of symmetrical and coordinated facial movement.

Baker, D.C. Reconstruction of the paralyzed face. In Grabb and Smiths Plastic Surgery, Aston, S.J. et al. (Eds). Lippincott-Raven, New York, 1997.

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977

 Platysma and Digastric Muscles

Depression of the paralyzed lower lip must be included in the overall treatment plan. Lack of depression of the lower lip leads to an unfavorable aesthetic and functional result. Pedicled platysma and digastric muscles are beneficial for providing depression to the lower lip.

 Platysma and Digastric Muscles

Platysma is the first choice for depressor reanimation of the lower lip
it is innervated by the facial nerve

When the platysma is absent or paralyzed

Use the digastric muscle A lower cross-facial nerve graft is usually coapted with the nerve to the anterior belly of the digastric muscle. Allows for coordinated and symmetrical depression

 Transfer of Free Muscles

Indication - when facial muscles are absent or their function is substantially diminished. Muscle atrophy should be proved with needle EMG If the ipsilateral facial nerve is available, the nerve of the muscle transplant is coapted directly to it. In the absence of an available ipsilateral facial nerve, cross.:facial nerve grafting from the healthy side is preferred.

 Transfer of Free Muscles

The results with cross-facial nerve grafting are always superior to those obtained with other motor sources
cross-facial nerve grafts offer the possibility of coordinated facial movement.

If the facial nerves are absent bilaterally

ipsilateral hypoglossal, trigeminal, accessory, or other motor nerves may be used as donors for the transplanted muscle.

 Transfer of Free Muscles

When the donor muscle is selected, the factors to be considered are
The strength, bulk, and excursion of the transplanted muscle should be appropriate for the muscle being substituted. The neurovascular pedicle must be reliable. Donor site morbidity must be minimal.

 Transfer of Free Muscles

Smile restoration procedure
Preoperative measurements and videotapes of the patient are needed to assess the excursion and force vectors.

Direction and degree of pull

Required at the level of the alar base, upper lip, commissure, and nasolabial fold should be considered carefully place free-muscle unit accordingly.

 Transfer of Free Muscles

Muscles used as free-tissue transfers include
Gracilis, pectoralis minor, rectus abdominis, latissimus dorsi, extensor digitorum brevis and serratus anterior

To reconstruct two functions, eye closure and upper lip elevation, with a single muscle flap usually produce unsatisfactory results
Except in the case of the pectoralis minor (because of its dual innervation).

 Gracilis
The first choice for free-muscle transplantation to reanimate the paralyzed face in adults Advantages: easy access, rare anatomical variations of the pedicle, easy shaping and debulking, and appropriate excursion to mimic the zygomaticus, major muscle during smiling Strong adductor muscle, but its absence results in no functional loss.

 Gracilis
Disadvantages:
A single direction of pull Excess bulk
easily prevented by meticulous shaping

Secondary revision is always needed; e.g., inadequate pulling force of the free muscle
a minitemporalis muscle flap

 Pectoralis Minor
Main indication - developmental facial paralysis in young children The length and width of the muscle at this age are ideal to fit the involved face Bulk at this age is optimal (no sculpting needed )

 Pectoralis Minor
Main advantage - can be transplanted as a whole
Integrity of each muscle fiber remains intact Minimal donor site morbidity Another important advantage: Dual innervation
Upper third is by a branch of the lateral pectoral nerve The lower two thirds by the medial pectoral nerve. Allows independent movement of the upper and lowerparts of the muscle: separate reanimation of the eye and mouth is possible

 Pectoralis Minor
Disadvantages
Deep position and the short and complex neurovascular pedicle - difficult to harvest. Brachial plexus injury in the infraclavicular region. The pedicle - much shorter than that of the gracilis and is variable.

If debulking necessary, do after muscle is harvested

Prolongs the ischemia time. If necessary, debulking is performed during the revision stage.

 Pectoralis Minor
Estimate percentage of bulk loss before the planned free-muscle flap is transferred Despite accurate preoperative planning, free muscles usually require revision. Muscle tension - an important factor in freemuscle transplantation
Mark tension in situ so that it can be reproduced following transfer.

 Muscle tension
Mark muscle every 1 cm along its longitudinal axis. Rule of thumb in adjusting the tension of the transferred muscle:
For facial reanimation, the tension of the muscle should be the same as the tension in situ, or slightly less. In contrast, for extremity reconstruction, the tension of the free muscle should be greater than the tension in situ.

 Pos-op care
External immobilization to maintain the position, e.g., of commissure
Inadvertent jaw movements do not affect the in setting of the free muscle.

Check patency of the vascular anastomosis every hour with a Doppler flowmeter. Diet: NPO->NGT vs liquid or soft for 2 to 3 weeks Speak without opening the mouth.

 Pos-op care
After the onset of muscle contraction
Perform facial exercises in front of a mirror, goal: coordinated animation of both sides of the face
Mirror/biofeedback

At 6 weeks
Ultrasound therapy and manual massage
To minimize scar formation on the operated side To help to avoid scar adhesions between the skin envelope and the free-muscle unit.

 Factors correlated with the onset of functional return after free-muscle transplantation for facial paralysis (Terzis and Noah 1997)
100 cases Key factors: age, sex, and ischemia time in free-flap transplantation
No correlation between ischemia time (0 to 3 hours) and the onset of muscle contraction. The onset of contraction was slightly earlier in women than in men, and the return of function was earlier in young than in older patients.

 Eye management
Denervation of the orbicularis oculi muscle insufficient eyelid closure Gravity pulls the upper and lower eyelids downward (i.e., lagophthalmos and ectropion, respectively) with loss of orbicularis oculi tonus The ectropion everts the margin of the lower lid and the punctum lacrimalis
Tear flow and the lacrimal drainage system are disturbed.

 Eye management
Constant exposure of cornea gives rise to loss of the tear film, dryness of cornea, conjunctivitis and keratitis If the condition progresses, corneal ulceration and blindness can develop. The age of the patient, presence of the blink reflex and corneal sensation, the degree of lagophthalmos, and the experience of the surgeon are critical factors in determining the method of treatment.

 Nonsurgical Methods
In the early period, the following nonsurgical methods protect the eye from the detrimental effects of chronic exposure:
Eye glasses or contact lenses Artificial tears and ophthalmic ointments Lid taping Occlusive moisture chambers Scleral shells

When lagophthalmos is permanent, seek surgical treatment

If the orbicularis oculi muscle is not yet atrophied, cross-facial nerve grafting or direct neurotization of the muscle can relieve the lagophthalmos.

 Tarsorrhaphy
Lateral overlapping tarsorrhaphy tightens and shortens the upper and lower eyelids
adequate functional results, but cosmetic results are unsatisfactory

The lateral tarsal strip procedure can be used as an alternative

No lid notching is required, baseline tear production is preserved, tarsal plate is not sacrificed; less morbidity than the classic technique

Neither provides equally sized eyes or coordinated movement; they limit vision, provide poor corneal protection.

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977

 Eye Spring
For patients w/o normal blink reflex or those with intact corenal reflex and trigeminal nerve. Inserted through two or three small incisions between the skin and tarsal plate Complications: spring breakage and extrusion through the skin, uncommon Reduction in tension is a more common complication, can be corrected under sedation. If lower eyelid drooping also present - specialized upper and lower eyelid springs

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977

Baker, D.C. Facial paralysis. In Plastic Surgery, McCarthy, J.G. (Ed). W.B. Saunders Company, Philadelphia, 1990.

 Lid Loading
Lagophthalmos - Gold weight Choose gold weights pre-op in upright position At insertion, pocket must be large enough to anchor to the tarsal plate Complications: displacement, implant infection, entropion, inflammatory reaction to gold, poor eyelid contour, corneal ulceration and scarring, asYmmetrical closure, residual lagophthalmos, and thickening of eyelid tissue over the prosthesis If complication encountered, remove implant, consider alternative reconstructive method.

 Minitendon Graft for Lower Eyelid

Treatment of choice for paralytic ectropion Helps decrease lagophthalmos
it raises the lower eyelid

A palmaris longus tendon graft (from the nondominant hand) Longitudinal split of the tendon is performed before it is transferred to the eye Punctum is canalized to prevent injury Retighten if the lower lid is still lax, symmetry with the normal eye is insufficient, and tearing cannot be controlled.

 Physiological methods of eye reanimation

Eye sphincter substitution in patients with unilateral, long-duration paralysis
Transplantation of free platysma muscle Transfer of pedicled contralateral frontalis m. Both muscles have thin flat bellies and have comparable density of innervation to that of orbicularis oculi.

 Physiological Methods of eye reanimation

Harvest the platysma muscle - through a submandibular incision Isolation of the frontalis is carried out through a bicoronal incision
Risk: webbing at the medial canthus level invariably requires Z-plasty revision

 A proximal motor axon injury induces a cascade of events, which could kill the neuron. Calcium has been claimed to play a major role in this cascade, and an intracellular overload through calcium channels is believed to be the ultimate cause of neuronal death. A new approach to maintaining motoneurons after injury is to give antagonists to L-type voltage-gated calcium channels, i.e. Nimodipine [7]. A 21-aminosteroid (lazaroid), which inhibits lipid peroxidation induced by oxygen radicals, has also been proved to enhance motoneuron survival significantly after axotomy [8].

 The motoneuron is dependent on interactions with its PNS environment for wellbeing and survival. Special attention has been paid to the relationship with the myelinating cell in the PNS, i.e. the Schwann cell, as well as the target muscle fibres in the skeletal muscles.

of the paralyzed face. In Grabb and Smiths Plastic Surgery, Aston, S.J. et al. (Eds). Lippin

 Mild weakness may develop during the immediate postoperative period, but this weakness resolves typically in 3 months Postoperative care is very important:
limit motions of the mouth and jaw to protect the coaptation sites. A fluffy cotton roll dressing and elastic bandages is placed around the patient's head to protect the repairs. During the first 24 hours, a plaster of Paris wrap is also utilized and subsequently removed. Antiemetics are given to prevent vomiting in the early postoperative period. Diet - fluids or a soft diet and speaks only through the teeth for 2 to 3 weeks.

 6 weeks post-op
Start massage and ultrasound treatments over the coaptation sites to prevent formation of scars around the nerves and adhesions with overlapping cheek skin flap. Start intensive slow-pulse stimulation of the denervated muscles to prevent further atrophy while the facial fibers are elongating across the face. Facial exercises, biofeedback, and physical therapy are important in restoring coordinated facial movements bilaterally.

 Neurontization procedures
Main donors for crossover procedures:
Hypoglossal, spinal accessory and trigeminal nerves

Advantages of nerve transfers

Ipsilat donors can be powerful motor nerves to rehabilate the facial musculature Because of the short distances involved, denervated mucles can be innervated rapidly

Converse J.M. (Ed). Reconstructive Plastic Surgery. W.B. Saunders Company, Philadelphia, 1977