Transcript cross-facial nerve graft

Facial Nerve Paralysis
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Examination of the mouth and surrounding structures
Philtral deviation
Nasolabial fold
Commissure depression and deviation
Upper lip droops
Presence of vermilion inversion.
With animation, the amount of bilateral commissure
movement is recorded;
• It is also noted how much of the upper incisors show
when the patient is smiling.
• Speech should be assessed
• An intraoral examination :to check dental hygiene and
to look for evidence of cheek biting.
• Nasal airway examination collapsed nostril
due to loss of muscle tone in the dilator naris
and drooping of the cheek.
• An intranasal examination should also be
done.
• Synkinesis
• The most common types of synkinesis :
• Eye closure with smiling,
• Brow wrinkling when the mouth is moved,
• Mouth grimacing when the eyes are closed.
• An assessment of the other cranial nerves,
particularly the fifth, is also performed.
Cranial nerve involvement may exacerbate the
morbidity of facial nerve paralysis. These
nerves should also be assessed as possible
donor motor nerves.
• Other cranial nerve involvment: 2,6,9,10
level of injury to the nerve
• In bony canal :
• Loss of ipsilateral taste appreciation
• Hyperacusis
• Facial weakness
• Because the chorda tympani and nerve to the
stapedius may be injured at this level
• Geniculate ganglion :
• Decreased secretory function of the nose, mouth, and
lacrimal gland.
Nonsurgical management
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Lid taping, particularly while sleeping
Soft contact lenses
Moisture chambers
Modification of spectacles
Eye patches
Forced blinking exercises in a patient with weak eye closure
Temporary tarsorrhaphy
• Corneal ulceration should be managed with prompt
referral for ophthalmologic assessment
• Incomplete facial nerve paralysis or
recovering muscle:
• Biofeedback,
• Electromyography
• Self-directed mirror exercises using slow,
small, and symmetric movements
• Patients can often relearn some facial
movements or strengthen movements that
are weak.
UP TO 72 hr AFTER NERVE TRANSECTION OR INJURY
• It is important to note that the distal nerve
segments can be identified intraoperatively by
electrical stimulation for, making early repair
critical.
• Most authors today recommend epineurial
repair of the facial nerve as suture placement
with fascicular or perineurial repair is difficult
and may injure the axon
Surgical management
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• It is important to listen to each patient carefully to
identify which aspects of the paralysis are most
troublesome and to treat each region of the face
separately
The Age of the patient,
Duration of the facial paralysis,
Condition of the facial musculature and soft tissues,
Status of the donor nerves and muscles
• M a tc h t h e n e e d s o f t h e p a t i e n t w i t h t h e
s k i l l o f t h e s u rg e o n
Cable grafting
• when a tension-free primary nerve repair is not possible.
• Popular choices for donor nerve grafts include: great
auricular nerve, sural nerve&the medial and lateral
antebrachial cutaneous nerves.
• The ansa cervicalis has been used as a donor nerve as
well as there may be some evidence that motor nerve
grafts are better than sensory nerve grafts.
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• With either primary nerve repair or cable grafting, it is
generally accepted that the best possible outcome is
House-Brackmann Grade III facial function.
Brow
• Direct excision of the tissue above the
brow (direct brow lift), best able to correct
such a large discrepancy >12mm
• Open brow lift
• Endoscopic brow lift
• Frontalis shorteninig
• Frontalis Weakening (transaction of the frontal nerve or
resection of strips of muscle of contralateral side )
Assessment of the amount of brow depression on the paralyzed side compared with
the normal eyebrow on the patient’s left. (B) Excision of skin and a strip
of frontalis muscle to correct brow ptosis. (C) Postoperative appearance
Upper eyelid(lagophthalmos)
• Temporalis muscle transfer (Gillies)
• Encircling the upper and lower eyelids
withsilicone or fascia lata (Freeman)
• Palpebral springs (Levine,May,Morel Fatio)
• Tarsorrhaphy (McLaughlin)
• Lid loading (Sheehan, others)
• Combinations
Upper eyelid(lagophthalmos)
• lid loading
• The appropriate weight is selected by taping trial
prostheses to the uppereyelid over the tarsal plate with the
patient awake.
• The lightest weight that will bring the upper eyelid within
2–4 mm of the lower lid and cover the cornea should be
used.
• As long as the patient has an adequate Bell phenomenon,
complete closure is not necessary.
• The prosthesis is fixed to the upper half of the tarsal plate
by permanent sutures, which pass through the tarsal plate.
• Care should be taken not to interfere with the insertion of
Müller muscle
Palpebral Spring
– Advantages
􀂃 Less visible
Gravity independent
– Disadvantages
􀂃 Technically difficult
􀂃 Higher risk of extrusion
Temporalis muscle transposition
For short-term use
• Implantable devices include :
• Magnetized rods inserted into the upper and
lowereyelids
• Silicon bands sutured to the lateral and
medial canthal ligaments.
Microneurovascular muscle
transplantation(new)
• Platysma transplantation procedures
• Revascularization with the superficial
temporal artery and vein
• Reinnervation with a cross-facial nerve graft
are tedious and complex
• Should be reserved for patients for whom
simpler techniques have been unsuccessful.
lateral tarsorrhaphy
• Anesthetic cornea,
• Severe corneal exposure,
• Failure of aesthetically more acceptable
techniques.
• Poor cosmesis
• Decreased peripheralvision
Lower eyelid
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Paralysis of the orbicularis
Lower eyelid to stretch and sag
Scleral show
The lid and inferior canalicular punctum roll away from the globe
Ectropion
2–3 mm of sceral show associated with symptoms of dryness and
aesthetic concerns.
• This situation requires support of the entire length of the eyelid
• It has become much more common to
recommend both a gold weight and a
lowereyelid sling at the same operative
sitting, which results in a 95% good
improvement in symptoms.
Surgical options:
• Lower lid sling
• Lateral canthoplasty
• Horizontal lid shortening(kuhnt-szymanowski
procedure& modification)
• Vertical lid shortening
• Cartilage grafts
Static sling
• 1.5–2 mm inferior to the gray line of the eyelid and fixed
both medially and laterally
• Tendon provides longer-lasting support with
less stretching than the fascia lata.
• A 1.5-mm-wide strip of tendon (palmaris or plantaris) is
sutured to the lateral orbital margin in the region above
the zygomaticofrontal suture and tunneled
subcutaneously along the lid anterior to the tarsal plate.
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Proper placement is crucial; too low a position will
exacerbate the ectropion
• A negative vector (proptotic eye)the lower
eyelid sling will correct ectropion, but it may
not decrease sclera show.
• In patients with a positive vector, the sling
will be effective.
lateral canthoplasty
• Milder eyelid problems (minimal scleral show &
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lower lid laxity)
Techniques of canthoplasty:
Tarsal strip
Dermal pennant
Inferior retinacular lateral canthoplasty
The canthal ligament must be reapproximated to the
position of whitnall tubercle, which is situated not only
above the horizontal midpupillary line but also 2–3 mm
posterior to the lateral orbital margin.
Cartilage grafts
• By augmenting the middle lamella and
suturing the cartilage to the inferior orbital
margin, there will be less of a tendency for the
lower eyelid to migrate inferiorly.
• Results may be poor because the cartilage
tends to rotate into a more horizontal position
rather than a vertical one, producing a visible
bulge and minimal eyelid support.
Horizontal lid shortening
distortion and expose the caruncle
 not lasting correction
vertical shortening of the inner aspect of
the lower lid
• Isolated medial ectropion (punctal eversion)
• By direct excision of a tarsoconjunctival ellipse.
• This causes a and helps reposition the punctum
against the globe.
• Medial canthoplasty will also support the punctum.
Nasal airway
• Paralysis of the nasalis and levator alaeque nasi drooping
and medial deviation of the paralyzed cheek support loss of
the nostril, collapse of the ala, reduction of airflow.
• Nasal septal deviation, which occurs in patients with
congenital facial paralysis, may further accentuate any
breathing difficulties.
• In the patient who complains of significant symptoms,
correction of airway collapse is best accomplished by
elevation and lateral support of the alar base with the
sling of tendon and by upper lip and cheek elevation
procedures.
• Septoplasty may be indicated to provide an improvement
in airway patency.
Upper lip and cheek:
smile reconstruction
 Two main goals:
 Correction of an asymmetric face at rest
 Reconstruction of a smile
 Paralysis of the oral musculature
 Drooling
 speech difficulties.
 chewing food
 cheek biting
 pocketing food in the buccal sulcus due to paralysis of the
buccinator.
• However, the main emphasis of surgery is
usually centered on reconstruction of a smile.
Dynamic reanimation
• Restore symmetry both at Rest and while smiling
 3 elements are required for the formation of a smile:
 Neural input
 Functional muscle innervated by the nerve,
 Proper muscle positioning
Answer these questions???
 Can you reconstruct on facial nerve or other cranial nerve?
Is the working muscle unit the original facial
musculature or a transferred muscle flap?
How long does it take from paralysis?
Primary nerve repair
1. Repair With or without graft
2. Contralateral facial nerve transfer
3. Cranial Nerve transfer
(ipsilateral proximal facial nerve stump is not
usable)
Resulting in good muscle tone and symmetry at
rest
• Unnatural action,
• An unsightly, unnatural mass movement with
activation.
Nerve transfer: Babysitter(proposed by Terzis)
• In cases of recent paralysis from contralateral facial
nerve branches .
• First stage: put 2 nerve grafts ( regenerate through the
sheath of the graft and innervate the muscle )over 4–8
months.
• Since muscle atrophy can develop while the facial
nerve regenerates, an ipsilateral motor nerve (either
masseter or hypoglossal) can be transposed to serve
as a temporary innervator .
• Second stage: after 6-9 months reopen paraliezed site
fasicular spilittilg and coaptation
• During 3-6 months animation start
Microneurovascular muscle transplantation
Smile analysis
One-stage procedures:
• Ipsilateral facial nerve trunk:
• Ideal source of reinnervation .
• Disadvantages:
• Difficult to determine branches to the lip elevators
• If incorrect innervation, muscle contraction may
take place only when the patient performs some
facial movement other than smiling, such as closing
the eyes or puckering the lips.
One-stage procedures
• Contralateral facial nerve
• Muscle with a long nerve segment
• (latissimus dorsi or rectus abdominis,the gracilis)
• The nerve is tunneled across the lip and coapted to the
facial nerve branches on the opposite side of the face.
• Advantages :
• One operation
• Only one site of coaptation
• No atrophy of the muscle
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Disadvantages of one stage:
No contraction with smiling
No facial nerve mapping
No best branche for coaptation
No assessment remaining intact branches
Bilateral facial paralysis
• Mِ obius syndrome or other causes
 Zuker et al. have shown
 In children this provides a symmetric smile with
excellent muscle excursion.
• These patients may never achieve involuntary
movement or a truly spontaneous smile.
• Many children and 50% of adults there appears
to be some cortical “rewiring” such that these
people are able to activate a smile without
performing a biting motion and without
conscious effort.
Two-stage :microneurovascular transplantation
First operation :cross-facial nerve graft:
 The facial nerve branches that produce a smile and
no other movement are selected
 The proximal ends of the donor facial nerve branches
are sutured to the distal end of the nerve graft such
that regenerating axons will travel in a distal to
proximal direction down the graft.
Short nerve graft
 Approximately 10 cm in length,
Bank the free end in the upper buccal sulcus
This should provide a well-innervated graft.
Waiting period from 12 months to around 6
months.
Achieve stronger muscle contraction than
was previously obtained with traditional long
crossfacial nerve grafts
• Movement >6 months
• Maximal movement by 18 months.
• Assessment by:
A. Resting tension in the muscle
B. Its excursion with smiling
• Third procedure :
A. adjust the muscle (i.e., either tightening or loosening)
B. other touch-up procedures (debulking or an adjustment
of the insertion of origin).
• Result:
 around 50%.
 Excellent resting position and a pleasing smile that is totally
spontaneous.
Muscle transplantation in the absence of
seventh-nerve input
 Bilateral facial paralysis and Moِ bius syndrome.
• The use of the 12th and 11th
 Preference is now given to the motor nerve to the
masseter.
• The nerve courses
 downward and anteriorly from the superoposterior border
of the masseter in an oblique fashion.
 The nerve is always on the undersurface of the masseter
muscle and enters this surface of the muscle belly
approximately 2 cm below the zygomatic arch.
 There is a remarkable similarity in size, and excellent
reinnervation can be achieved.
Bae et al. have shown
for patients with Moِ bius syndrome that the
oral commissure movement accomplished by
a gracilis transplant innervated by the
masseter motor nerve comes within 2 mm of
normal movement.
• We prefer to do each side separately spaced
at least 2 months apart.
Regional muscle transfer
• Patients who are not suitable candidates for
free muscle transplantation(older patient )
• (Temporalis or masseter)
• These muscles are innervated by the
Trigeminal nerve to activate a smile, patients
must initially clench the teeth
Gillies technique
• The retrograde or turnover temporalis muscle
transfer
• Fascial graft is required to achieve the necessary length to
reach the mouth
• Aesthetic disadvantage:
• Temporal hollowing(implant)
• Bulging in zygomatic arch
Baker and Conley
• Leaving the anterior portion of the temporalis behind
to partially camouflage the temporal hollowing.
McLaughlin
• An antegrade temporalis transfer.
• Through an intraoral, scalp, or nasolabial incision, the
temporalis muscle is detached from the coronoid
process of mandible and brought forward.
• Fascial grafts are used to reach the angle of the mouth.
Labbe and Huault
• Create a true myoplasty with a mobile insertion and
fixed origin and without the use of fascial grafts.
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 A further recent modification
Avoids undermining the anterior part of the
temporalis muscle
thus simplifying the procedure and ensuring an
enhanced blood supply.
The coronoid is now osteotomized through the
nasolabial incision, avoiding the transverse
incision parallel to the zygoma arch and the
osteotomy of the zygoma.
One of the key differences is that the temporalis
insertion is tunneled through the buccal fat pad,
thus aiding tendon gliding and consequently
commissure excursion
Baker and Conley
• The masseter muscle transplantation (entire
muscle or the anterior portion)
Rubin recommends
• Most anterior half of the muscle only and
transposing it to the upper and lower lip.
Rubin has advocated
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Transplanting the temporalis and masseter muscles together
• The temporalis provides motion to the upper lip and
nasolabial fold; the masseter provides support to the corner
of the mouth and lower lip.
Static slings
• Goals
 Symmetry at rest without providing animation
 Equal to or slightly overcorrected
 Alone or as an adjunct to dynamic procedures
 Made of fascia (tensor fascia latae), tendon, or prosthetic
material such as gore-tex
 Gore-Tex® produces an undesirable inflammatory reaction.
• The authors’ preference, however, is to use
tendon (palmaris longus, plantaris, or extensor
digitorumlongus)
It is possible to insert the static sling too tightly particularly in the upper lip,
which establishes a corridor through which air and liquid can escape.
Soft-tissue rebalancing
Adjuncts to both dynamic and static
management
Rhytidectomy with or without plication
 Suspension of the SMAS
 Midface subperiosteal lifts
Procedures on the nasolabial fold usually do not
help define this important structure.
Asymmetry of the upper lips may be corrected
by mucosal excisions
 These procedures, which may be minor, will often be of great
benefit to patients
Lower lip
• The marginal mandibular nerve consists of
one to three branches and supplies the
depressor labii inferioris, depressor anguli
oris, mentalis, and portions of the lower lip
orbicularis oris
Puckett et al. described
• Excising a wedge of skin and muscle but preserving
orbicularis oris on the unaffected side.
Glenn and Goode described
• A full-thickness wedge resection of the paralyzed side of the
lower lip.
 Edgerton described
 Transplantation of the anterior belly of the
digastric muscle.
 The insertion of the digastric muscle to the
mandible on the paralyzed side is divided and
attached to a fascia lata graft that is then secured to
the mucocutaneous border of the involved lip.
 Conley et al. modifiecation
 leaving the mandibular insertion intact but
divided the tendon to the lateral aspect of the
lower lip.
Terzis and Kalantarin modification
• The digastric transplantation by combining it with a
cross-facial nerve graft coapted to a marginal
mandibular nerve branch on the unaffected side,
thereby allowing the possibility ***************
 of spontaneous activation with smiling
Terzis recommends
 In patients with paralysis <24 months and there
is evidence of remaining depressor muscle after
needle EMG
 A mini hypoglossal nerve transplantation to the
cervicofacial branch of the facial nerve.
 This involves division of the cervicofacial branch
proximally and coaptation of the distal stump to a
partially transected (20–30%) hypoglossal nerve.
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 Terzis suggests
• In patients with long-standing paralysis with a
functional ipsilateral playsma muscle (i.e., an intact
cervical division of the facial nerve),
• Transplantation of the platysma muscle to
the lower lip.
Symmetry both at rest and with expression
• Do on nonparalyzed side:
1. Selective myectomy of the depressor labii
inferioris
2. Botulinum toxin into the depressor labii inferioris.
Patient showing a “full dental” smile before depressor resection (A) and
after depressor resection (B), with marked improvement in symmetry of
the lower lip.