facial palsy

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Page 1: Facial palsy

GOOD MORNING

Page 2: Facial palsy

FACIAL PALSY

COMPILED BY: Dr.Nuzhat Noor Ayesha PG student (OMFS) KCDS- B’lore

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• "The human face is the organic seat of beauty. It is the register of value in development, a record of Experience, whose legitimate office is to perfect the life, a legible language to those who will study it, of the majestic mistress, the soul."

• Farnham, Eliza

QUOTE

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CONTENTS

IntroductionNerve anatomy & injuriesFacial nerve anatomyFacial paralysisEtiologyBell’s PalsySurgical treatmentReferences

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INTRODUCTION• Facial function plays an integral part in our

everyday lives– Smile; nonverbal communication, etc.

• Facial paralysis is devastating on many levels– Functional– Cosmetic

• Fortunately, a plethora of techniques are available to treat the paralyzed face.

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NERVE FIBER COMPONENTS

• Endoneurium– Surrounds each axon– Adherent to Schwann cell

layer– Vital for regeneration

• Perineurium– Encases endoneural tubules– Tensile strength– Barrier to infection

• Epineurium (nerve sheath)– Outermost layer– Houses vasa nervosum for

nutrition

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NERVE INJURY

• Two acceptable classification schemes used to describe the histologic changes that occur following nerve injury.

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SEDDON CLASSIFICATION (1943)

• Neurapraxia-a conduction block from transient anoxia owing to acute epineurial/endoneurial vascular interruption resulting from mild nerve manipulation with rapid and complete recovery of sensation.

• Axonotmesis- This damage extends through and includes the endoneurium with no significant axonal disorganization. Recovery is slow and may take weeks to months, and it may not be complete.

• Neurotmesis- injuries result from complete or near complete transection of the nerve with epineurial discontinuity and likely neuroma formation. Spontaneous neurosensory recovery is unlikely.

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SUNDERLAND CLASSIFICATION (1951)

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NEURAL HEALING

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FACIAL NERVE

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7th Cranial nerveNerve of the 2nd branchial

archHas two roots. A large

motor and a smaller mixed sensory and parasympathetic (nervus intermedius)

FACIAL NERVE

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FUNCTIONAL COMPONENTS

• Brancial motor(special visceral efferent)-Supplies; Stapedius , Stylohyoid, posterior belly of digastric muscle and the muscles of facial expression.

• Visceral motor(general visceral efferent)

Parasympathetic innervations of the lacrimal, submandibular, and sublingual glands, as well as mucous membranes of nasopharynx, hard and soft palate.

•Special sensory(special afferent)-Taste sensation from the anterior 2/3 of tongue; hard and soft palates.

•General sensory(general somatic afferent)-General sensation from the skin of the concha of the auricle and from a small area behind the ear.

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FUNCTION

The facial nerve is responsible for:

I. Contraction of the muscles of the face

II. Production of tears from a gland (Lacrimal gland)

III. Conveying the sense of taste from the front part of the tongue (via the Chorda tympani nerve)

IV. The sense of touch at auricular conchae

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LEVEL OF NERVE INJURY AND SYMPTOMS

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FACIAL PARALYSIS

Commonly Unilateral

Nuclear- from destruction of the nucleus

Central or cerebral or Supranuclear

Peripheral- from a lesion of the nerve

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NUCLEAR LESIONS

Supranuclear lesions- usually a part of hemiplegia, only the lower part of the face is paralysed. The upper part (frontalis and part of orbicularis oculi)escapes due to bilateral representation in the cerebral cortex.

Infranuclear lesions- entire face is paralysed, as seen in bell’s palsy

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ETIOLOGIC CLASSIFICATON OF FACIAL PALSY

Various classification have been suggested in this respect.

Based on:Course of the nerve

Various etiologic causes

Degree of dysfunction observed

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Vascular abnormalitiesCNS degenerative diseasesTumours of the intracranial cavityTrauma to the brainCongenital abnormalities and agenesis

INTRACRANIAL (CENTRAL) CAUSES

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Bacterial and Viral infectionCholesteatomaTrauma- blunt temporal bone trauma,

longitudinal and horizontal fractures of the temporal bone and gunshot wounds.

Tumours invading the middle ear, mastoid and facial nerve

Iatrogenic causes

INTRATEMPORAL CAUSES

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Malignant tumours of the parotid glandTraumaIatrogenic causesPrimary tumours of the facial nerveMalignant tumours of the ascending ramus of the

mandible, pterygoid region and skin.

EXTRACRANIAL CAUSES

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RAINER SCHMELZEISEN CLASSIFICATION

CONGENITAL Moebius Syndrome Myotonic dystrophy Melkersson Rosenthal syndrome Congenital Cholesteatoma Birth injuries Osteopetrosis

NEUROLOGIC Myasthenia Gravis Multiple Sclerosis Guillain Barre syndrome

NEOPLASTIC Facial nerve tumours Glomus tumours Meningiomas, acoustic

neuroma Parotid tumours Temporal bone/external

auditory meatus tumours

INFECTIONS Otitis media, mastoiditis Bacterial causes Viral causes

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HOUSE-BRACKMAN(1985) CLASSIFICATION

• Grade I-normal function without weakness.• Grade II-mild dysfunction with sligth facial asymmetry with

a minor degree of synkinesis.• Grade III-moderate dysfunctions-obvious, but not

disfiguring, asymmetry with contracture and/or hemifacial spasm, but residual forehead motion and incomplete eye closure.

• Grade IV-moderately severe dysfunction- obvious, disfiguring asymmetry with lack of forehead motion and incomplete eye closure.

• Grade V-severe dysfunction-asymmetry at rest and only slight facial movement.

• Grade VI-total paralysis-complete absence of tone or motion.

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Facial Paralysis

CongenitalMÖbius syndromeMyotonic dystrophy

Infectious/IdiopathicMelkerson-Rosenthal syndromeRamsay-HuntOtitis media/mastoiditis/meningitisLyme DiseaseNecrotizing Otitis externaHIV, TB, EBV, syphillisTetanus

Toxins/TraumaHead traumaTemporal bone traumaBirth trauma

TumorParotidAcoustic neuromaGliomaMeningiomaFacial neuroma

EndocrineDMPregnancyHyperthyroidism

NeurologicGuillian-BarreMyasthena GravisStrokeMultiple sclerosis

SystemicSarcoidosisAmyloidosisHyperostosis

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BELL’S PALSY

• It is defined as an idiopathic paresis or paralysis of the facial nerve of sudden onset.

• The name was ascribed to SIR CHARLES BELL, who in 1821 demonstrated the separation of motor and sensory innervation of face.

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• INCIDENCE-15-40 cases per 1 lakh cases

• SEX PREDILECTION- women more affected than men.3.3 more times common in pregnancy and in the third trimester.

• AGE- can occur at any age, common in middle aged people.

• SIDE INVOLVMENT- can be equally seen, usually unilateral.

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CLINICAL FEATURES

• There is sudden onset, usually pt gives h/o occurrence after awakening early morning.

• Unilateral involvement of entire side of the face.

• Abrupt loss of muscular on one side of face.

• Inability to smile, close the eye or raise the eyebrow on affected side.

• Whistling is not possible.

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• In an attempt to close eyelid, the eyeball rolls upward.

• Inability to wrinkle forehead or elevate upper or lower lip.

• Obliteration of nasolabial fold.

Face appears distorted and mask like appearance to the facial features.

Speech becomes slurred.

Occasionally there is loss or alternative of taste.

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Course and prognosis

Partial paralysis always resolves completely within a few weeks.

Recovery from complete paralysis takes longer (months) and is complete in only about 60-70% of cases.

Approximately 15% of patients are left with troublesome

residual palsy and or synkinesis.

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COMPLICATIONS OF FACIAL PARALYSIS

Facial paralysis severely hinders:• Normal facial expressions• Mastication• Speech production• Eye protection.

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Psychological Trauma• The most significant complication is the social

isolation these patients often succumb to.

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COMPLICATIONS

The most serious complication is corneal damage. One of the greatest problems with Bell's palsy is the involvement of the eye if the lid fissure remains open. In this case, eye care focuses on protecting the cornea from dehydration, drying, or abrasions due to insufficient lid closure or tearing

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ASSESSMENT AND PLANNING

Cause of facial paralysisFunctional deficit/extent of paralysisTime course/duration of paralysis

Likelihood of recovery

Other cranial nerve deficitsPatient’s life expectancyPatient’s needs/expectations

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EVALUATIONS OF NERVE FUNCTION

• HISTORY is of vital importance to establish the onset characteristics,duration and degree of recovery.

• Previous trauma, surgery or infection may help in arriving at a diagnosis

• Examination of the face at rest and movement.• Radiolologic evaluations• Nerve excitability tests.

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• TEAR TEST: (Schirmer’s test)• Semiquantitative method for comparing lacrimal

secretion on normal & affected side.• 0.5×5cm strip of filter paper.• If moistened length in affected side <25% of

normal: significant hyposecretion is present.

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TASTECHORDA TYMPANI: • Subjective loss of sensation: unreliable symptom.• Swab sides of tongue by a cotton applicator dipped in lemon juice.• Threshold measured with electrogustometer (measured electric

current). N:30gk microamp• Patient percieves this as sour or metallic.

SALIVARY FLOW• Cannulate wharton duct on each side with no.50 polyethylene tube• Stimulate saliva with lemon juice• Output of saliva measured in each tube• 25% reduction is significant• Indicates interruption of chorda tympani or facial nerve to this branch.• LIMITATIONS- Unequal penetration of cannula, assymetry of glands.

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ELECTRICAL TESTING OF FACIAL NERVE

MAXIMUM STIMULATION TEST• Pulsed electric current is delivered through a cutaneous

electrode• Short pulse will stimulate an intact nerve & elicit a

muscular twitch.• In paralysed facial nerve, this indicates that lesion is

neuropraxia & distal neurons have not undergone degeneration

• Hence differentiates between neuropraxia & axonotmesis: prognostic value.

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NERVE EXCITABILITY TEST:• Current required for stimulation on normal side is compared with

paralysed side.• Disadv: even few intact fibres can elicit a response when rest in

undergoing degeneration.

Muscle twitch response is subjective

Uncomfortable procedure

Requires patient co-operation

ELECTRONEUROGRAPHY• Measures compound action potential in facial muscles in response to

facial nerve stimulation.• Similar to MST, except instead of visually ration the muscle

contraction, the muscle action potential is measured on EEG- more accurate.

• Best test to predict & follow facial nerve recovery.• Compare & represent it as percentage of normal side.

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Treatment

• Oral antivirals - Acyclovir • Corticosteroids• Eye protection • Follow progression with serial exams• Physiotherapy

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MEDICATION

• If the patient is seen within 2 to 3 weeks of onset of symptoms-tab. Prednisolone in doses of 1mg/kg/d for 10 to 14 days has been recommended with a gradual tapering.

• Vitamins B1, B6, B12 may be administered.• If pt is seen after 3-4 weeks, then steroid therapy

is of no use.

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SURGICAL TREATMENT MODALITIES

• Nerve decompression - Internally or externally

• Nerve anastomosis

• Nerve grafting

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A. Acute (< 3 wks)

1. Nerve exploration/decompression

2. Nerve repair

a. Primary anastomosis

b. Cable grafting

i. Great auricular nerve

ii. Sural nerve

B. Intermediate (3 wks- 2 yrs)

1. Nerve transfer

a. Hypoglossal-facial

b. Spinal accessory-facial

c. Masseteric-facial

2. Cross face nerve grafting using sural nerve

C. Chronic (>2 yrs) 1. Muscle transfers a. Temporalis b. Masseter c. Digastrics 2. Free muscle flaps/ microneurovascular transfer a. Gracilis b. Latissimus dorsi c. Serratus anterior d. Pectoralis minor

D. Static procedures/ancillary procedures (can be performed at any time period listed above) 1. Gold weight/spring implants 2. Slings 3. Lid procedures

Ryan Ridley. Facial Reanimation .Grand Rounds Presentation, UTMB, Dept. of Otolaryngology

SURGICAL TREATMENT MODALITIES

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Micro-neurological Surgery• Facial nerve repair is the most effective

procedure to restore facial function in patients who have suffered nerve damage from an accident or during surgery.

• It involves microscopic repair of a nerve that has been cut.

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PRIMARY NERVE REPAIR

End-to-end anastomosis preferredNo tension

Extratemporal repair performed < 72 hrs of injury

Most common methodsGroup fascicular repairEpineural repair Group fascicular repair

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Primary Nerve Repair Severed ends of nerve

exposedDevitalized tissue/debris

removed with fine scalpelSmall bites of epineurium

Epineural sheath approximated with 9-0 nonabsorbable sutureEpineural repair recommended

for injury proximal to pes anserinus and intratemporal

EPINEURAL REPAIR TECHNIQUE

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INTERPOSITION GRAFTING

Cable graftsUsed when defect > 17mm; nerve cannot be

reapproximated without tensionMost common

Greater Auricular Nerve Sensory nerves from superficial cervical plexus Sural nerve

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INTERPOSITION GRAFTING GREATER AURICULAR NERVE

Harvesting Located on lateral surface of

SCM at the midpoint of a line drawn between mastoid tip and mandibular angle

May extend postauricular incision or use separate neck incision

Advantages: Proximity to facial nerve Cross-sectional area Limited morbidity

Limitations: Reconstruction of long defects Ideal for defects < 6cm in length

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SURAL NERVE• Anatomy

– Formed by union of medial sural cutaneous nerve and lateral sural cutaneous branch of peroneal nerve.

Advantages : Length : >12cm Accessibility Low morbidity associated with

sacrifice

Disadv: Variable caliber

Often too large Difficult to make graft approximation

Unsightly scar

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NERVE TRANSPOSITION/ CROSSOVER

• Nerve transposition is also known as facial-hypoglossal transfer.

• Restores movement to the side of the face that has been paralyzed.

• With the stump of the 12th nerve hooked up to the end of the 7th nerve, the face will move when the tongue is moved.

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CROSSOVER TECHNIQUES

INDICATIONS: Irreversible facial nerve injury Intact facial musculature/distal facial nerve Intact proximal donor nerve Prior to distal muscle/facial nerve atrophy

Ideal if performed within a year of facial paralysis

Adv: Time interval until movement

4-6 months Avoid multiple sites of anastomosis Mimetic-like function achievable with practice

Disadv: Donor site morbidity Some degree of synkinesis

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Hypoglossal-Facial Technique1. Parotidectomy incision extended

into cervical crease ~ 2-3 cm below inferior border of mandible

2. Facial nerve identified and dissected distal to pes anserinus

3. Identify hypoglossal nerve

a. SCM retracted posteriorly

b. Dissect superiorly until posterior belly of digastic is identified

c. Retract digastric superiorly and CN XII is found inferiorly.

d. Hypoglossal is within

2-3 c m of main trunk of the facial nerve

4. Hypoglossal nerve is dissected anteriorly and medially into the tongue.

1. Transect distal to ansa hypoglossis

5. Facial nerve transected at the stylomastoid foramen

6. Anastomose nerves using 9-0 epineural suture.

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Hypoglossal Facial Nerve Transfer

Entire hypoglossal nerve transected

40% segment of nerve secured to

lower division.

54

Hypoglossal nerve reflected superiorly

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Hypoglossal Facial Nerve Transfer

Jump graft modificationReflection of the facial nerve out of the mastoid bone.

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CROSS-FACIAL NERVE GRAFTING

• Contralateral Facial nerve used to reinnervate paralyzed side using a nerve graft– Sural nerve often employed– ~25-30cm of graft needed

• Restitution of smile and eye blinking obtained.• Disadvantage

– 2nd surgical site– Violation of the normal facial nerve

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CROSS-FACIAL NERVE GRAFTING

FOUR techniques Sural nerve graft routed from buccal

branch of normal VII to stump of paralyzed VII

Zygomaticus and buccal branch of normal VII used to reinnervate zygomatic and marginal mandibular portions respectively

4 separate grafts from temporal, zygomatic, buccal and marginal mandibular divisions of normal CN VII to corresponding divisions on paralyzed side.

Entire lower division of normal side grafted to main trunk on paralyzed side.

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MUSCLE TRANSPOSITION (“DYNAMIC SLING”)

INDICATION:– Congenital facial paralysis – Facial nerve interruption of at least 3 years

• Loss of motor endplates

– Crossover techniques not possible due to donor nerve sacrifice

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TEMPORALIS

Often used for reanimation of the oral commisure.

Middle 1/3 of muscle is best for transfer (Sherris, 2004)

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Temporalis Transfer

1. Incision in preauricular crease extending to superior temporal line

2. Obtain wide exposure of temporalis muscle by dissecting above the SMAS

3. Incise down on periosteum to elevate muscle fibers

-Harvest middle 1/3

4. Large tunnel created over zygomatic arch

5. Orbicularis oris muscle exposed via vermilion border incision at oral commissure

6. Large tunnel over zygomatic arch used to connect oral commisure to zygomatic arch/superior incision.

7. Temporalis flap detached and elevated from its origin and tunneled to the oral commissure.

8. 3-0 prolene used to suture orbicularis to temporalis at oral commissure

9. Overcorrection of nasolabial fold and oral commissure

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MASSETER

• Used when temporalis muscle is not opted.• May be preferred due to avoidance of large facial

incision• Disadvantage:

– Less available muscle compared to temporalis– Vector of pull on oral commisure is more horizontal

than superior/oblique like temporalis

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Masseter Transfer

1. Expose muscle with gingival incision along mandibular sulcus

2. Dissection carried out in a plane between mucosa and muscle.

3. Muscle freed off of mandible medially and from the inferiolateral edge of mandible.

4. Vertical incision made in inferior portion of muscle

5. Anterior half of muscle is split into 2 divisions.

6. The 2 anterior slips of muscle are tunneled anteriorly to reach the oral commisure via external vermillion border incisions

7. Muscle slips are attached to lips and oral commisure in the deep dermal layer using suture

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MICRONEUROVASCULAR TRANSFERFREE MUSCLE FLAPS

• They have potential of achieving individual segmental contractions– Reduction of synkinesis

• Muscle flaps used are:– Gracilis– Latissimus dorsi– Inferior rectus abdominus

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MICRONEUROVASCULAR TRANSFERFREE MUSCLE FLAPS

Requires viable muscle and nerve innervation Traditionally done in 2 stages

1st: Cross-face nerve graft ~ 1 yr prior to muscle transfer 2nd: Muscle transfer performed after neural ingrowth of graft

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GRACILIS 1. “Workhorse” for free muscle

transfer

2. Long, thin muscle in medial thigh

-Good neurovasular pedicle

1. Adductor artery and vein

2. Anterior obturator nerve

3. 2 stages involved:

1. Sural nerve employed for cross-face graft

2. Gracilis muscle transferred after 6-12 months

4. Vascular anastomosis to the facial artery and vein or to superficial temporal vessels.

5. Obturator nerve of gracilis connected to distal end of sural nerve graft.

Anterior Obturator nerveAdductor a. & v.

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ADDRESSING PARALYTIC EYELIDS Complications of orbicularis oculi paresis

Delayed blinking Impairment of nasolacrimal systemDry eyeRisk of exposure keratitis, corneal ulceration and

blindness

Goal of treatment is to maintain cornea

Treatment OptionsTarsorrhaphyGold weight/spring implantsOpen / endoscopic brow lifts for significant brow ptosis

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GOLD WEIGHT IMPLANTATION

1. Small incision made several millimeters above the upper eyelid margin.

2. Tarsal plate exposed with sharp dissection

3. Gold weight secured to tarsus using 8-0 nylon.

4. Wound closed in 2 layers

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Horizontal mattress 5-0 nylonBegin 3mm medial to lateral canthus, 6mm from lid marginStitch travels through gray line to 5mm below lower lid marginBolster with 3mm, 4-french rubber catheter.Cosmetically unappealing, visual field affected.

TARSORRHAPHY

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Surgical management of LAGOPHTHALMOS

• F. Stagno d’Alcontres, G. Cuccia*, F. Lupo, G. Delia, M. RomeoThe orbicularis oculi muscle flap: Its use for treatment of lagophthalmos. Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 416e422

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STATIC PROCEDURES

Indications: Debilitated individuals; poor prognosis Nerve or muscle not available for dynamic procedures Adjuct procedure with dynamic techniques to provide

immediate benefit

Advantages: Immediate restoration of facial symmetry at rest No oral commisure ptosis

Drooling, disarticulation, mastication difficulties

Relief of nasal obstruction caused by alar collapse

• Static Facial Suspension is used to lift the corner of the mouth so that balance is restored to the face and drooling out of the mouth is helped.

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STATIC SLINGS

Variety of materials used• PTFE (Gor-Tex)• Alloderm• Fascia lata

Gor-Tex and alloderm have advantage of no donor site morbidity but higher risk of infection.

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STATIC FACIAL SLING TECHNIQUE

1. Preauricular, temporal or nasolabial fold incision may be used

2. Additional incisions made adjacent to oral commisure at vermillion border of upper and lower lip

3. Subcutaneous tunnel dissected to connect temporal to oral commisure incisions

4. Dissection may be carried out in midface adjacent to nasal ala, if needed (for alar collapse)

5. Implant strip is split distally to connect to the upper/lower lips

6. Implant secured to orbicularis oris/commisure using permanent suture

7. Implant is suspended and anchored superiorly to superficial layer of deep temporal fascia, or zygomatic arch periosteum, using permanent suture.

8. May also secure to malar eminence using small miniplate or bone anchoring screw

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REFERENCES

• Cranial nerves-Functional Anatomy – Stanley Monkhouse• Anatomy for Surgeons: Hollinshead• Maxillofacial surgery: Peter Ward Booth Vol 1 & 2• Peterson’s Principles of Oral & Maxillofacial Surgery, 2nd edition. • Oral pathology- Regezi.• Textbook of oral surgery – Neelima Malik • Gray’s anatomy.• Text of Anatomy by Roylce.

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