Julia K. Terzis, Elliot H. Rose, Ralph Manktelow, Robert L. Terzis: Facial nerve injury is something feared by every aesthetic surgeon who performs face lifts. Although most such injuries are transient, some are not.
I would aim for nerve restoration. Neuromuscular: Domain of conservative neurologic treatment. Otolaryngol Head Neck Surg. Manktelow: I have not done that, but if the nasalis is asymmetrical, then I would certainly consider Botox. Teaching sex techniques Can I interject? All the cases presented visible fracture on the HRCT scans, with other findings such as soft tissue density in epitympanum, middle ear, and mastoid bone in 12 cases
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As the injury may Adult quito services as far as 80 mm away from the muscle, we can afford to wait for 3 months. Open in a separate window. So, my plan is still to put in 2 cross-facials: one to the zygomatic and the other to the buccal. Terzis: So, you would place cross-facials to the zygomatic and buccal branches and then see how she would respond. You could address eye TTotal with either a temporary or a definitive procedure. The last patient is a Total facial nerve repair woman who neeve undergoing bilateral sagittal split osteotomy of the mandible when she sustained an iatrogenic lesion to the right facial nerve. Remember, she underwent 2 repairs. Walton in every respect except one. In the middle of the vertical portion, we have an idea that the upper bundles are destined to innervate the eye, and we also know that the lower bundles will go to the mandibular Total facial nerve repair cervical facial branches. I am rpair that conceptually, you could use the stump to do a fepair innervation. Development and pilot study of an oral health literacy tool for older adults. Rose, if this patient sought your help after 9 months, would you use electrical stimulation to salvage the target facial musculature?
Reconstructive surgery of the facial nerve is not daily routine for most head and neck surgeons.
- Julia K.
- Facial paralysis is a devastating condition with profound functional, aesthetic and psychosocial consequences.
Julia K. Terzis, Elliot H. Rose, Ralph Manktelow, Robert L. Terzis: Facial nerve injury is something feared by every aesthetic surgeon who performs face lifts. Although most such injuries are transient, some are not. The patients discussed in this panel present with facial nerve injury from a variety of causes, but in each case, the patient's goal is to achieve a more aesthetic appearance, beginning with the surgeon's assessment of the potential for nerve repair.
In a future panel, we will discuss adjunctive aesthetic procedures to maximize outcomes for such patients. The first patient is a year-old woman who underwent a face lift procedure elsewhere. Postoperatively she suffered a partial right-sided facial paralysis with complete paralysis of her right depressor complex Figure 1, A.
Walton, how would you manage this patient if she sought your help after 6 weeks? A, This year-old woman suffered a right-sided partial facial palsy after undergoing a full face lift with SMAS.
She would like restoration of a symmetrical smile and the ability to depress her right lip. B, Postoperative view 1 year after surgery demonstrates adequate right lower lip depression and a nearly normal smile.
Walton: If it was less than 6 weeks following surgery, I would think that she may experience some improvement in the tone of her lower lip and general facial animation if she waits a little longer.
After 8 weeks, however, if she has not exhibited any return of function, I would be inclined to explore the nerve. If results of an EMG indicate fibrillations in the depressor and platysma on the paralyzed side, this would also strengthen my resolve to explore, since fibrillations are a strong indicator of denervation injury.
I would also assess for a Tinel's sign to determine the possible site of nerve injury and to have a clinical landmark by which to follow nerve regeneration. If a Tinel's sign can be elicited, and there is no advancement of the Tinel's sign over time, this would be strong justification for surgical exploration. Walton: I would explain that if the nerve ends are ligated with suture, if they have been cauterized, or actually transected, I would remove the area of injury and attempt repair of the nerve directly or with a nerve graft.
The likelihood of recovery would be low, but there are adjunctive procedures that can be performed to improve the symmetry of her smile. Terzis: Are you saying that you would try to keep more drastic procedures, such as harvesting of sural nerve grafts, to a minimum in a cosmetic patient such as this one?
Walton: I would do what I felt was necessary to achieve an optimal aesthetic and functional result. In this case, I believe that the operative access could be limited to the face lift incision. If nerve grafts were required, I would prefer a branch of the great auricular nerve or an antebrachial cutaneous nerve of the forearm. Terzis: If you explored and discovered a lesion in continuity of the cervicofacial branch of the facial nerve that affects the mandibular and cervical areas, what would you do?
Walton: If I could define the area of injury, I would resect the area in continuity, obtain a frozen section of the proximal and distal nerve branches to assure that there was viable nerve devoid of neuroma, and repair the nerve microsurgically with an interposition nerve graft.
I would either take a small branch of the greater auricular nerve or resort to the antebrachial cutaneous nerve in the forearm. Terzis: Dr. Manktelow, assume that the patient is very distressed. She sought rejuvenation and now she is deformed. She is newly engaged with an imminent wedding and is deeply upset about her distorted smile.
How would you treat her? Manktelow: You can provide a lot of important therapy just by listening and being understanding. I would agree with Dr. Walton in every respect except one. I would be inclined to wait a little longer.
We would not lose anything in waiting for regeneration through the area of injury into the closest muscle probably the depressor anguli oris , and next the depressor labii inferioris, and mentalis. Terzis: If your electromyographer, with whom you have worked for 10 years, gives you EMG results indicating fibrillations at 6 weeks after an invasive procedure, would you still wait another 6 weeks?
Manktelow: Yes, because you can expect fibrillations in any muscle that is denervated. The nerve does not need to be divided to get fibrillation, just denervated. We are hoping that this denervation is not due to severing of the nerve but reflects an axonotmesis or Sunderland second- or third-degree injury.
If so, nerve regeneration will occur at roughly 1 mm per day. As the injury may be as far as 80 mm away from the muscle, we can afford to wait for 3 months. Walton: I do not disagree with waiting a while longer. By the time I have the patient on my surgery schedule, it would probably be 3 months later anyway. Terzis: If the injury was neurapraxic, it would have resolved by 3 weeks; neurapraxic injuries correspond to a local conduction block in the axon, and complete recovery takes place with segmental remyelination by the accompanying Schwann cells.
If the injury is axonotmesis, it makes sense to wait for 6 weeks, since it will take that long for functional recovery.
However, if there are fibrillations in the involved muscles, we know that this implies a neurotmetic lesion, which corresponds to complete nerve severance. Would you still wait another 6 weeks if there are fibrillations or explore now? Remember, this patient is angry and threatens litigation. Walton: With the information provided, I would be inclined to explore after 8 weeks of observation.
Terzis: This patient was explored very early, soon after presentation, and the injury was microsurgically repaired Figure 1, B. Since full function was restored within a year, she dropped all litigation procedures against the treating plastic surgeon. The next patient is a year-old man who was shot from a distance of 5 feet and was hit with 3 bullets over the left mastoid area Figure 2. Walton, if he presented for treatment at 3 months, how would you help him?
A, This year-old man was shot from a distance of 5 feet and hit with 3 bullets, including one over the left mastoid area, which exited at the lateral aspect of the left cervical area. He bled over the left facial area and immediately became paralyzed on the left side of the face.
Three months later, he requested restoration of his smile. B, Postoperative view after 6 months in which the patient demonstrates an excellent smile and adequate eye closure. There is residual paresis of the left depressor complex. Walton: First, I would like to know the exact trajectory of the bullet and the site of the injury to the facial nerve. Since he is 3 months out and not demonstrating any motion, surgical exploration and repair would be most appropriate.
I would do a CT scan to visualize the petrous portion of the temporal bone. If he had an injury within the canal, I would work together with an otolaryngologist to decompress the canal to access the proximal segment of the facial nerve. Rose: After confirming transection of the injured facial nerve intratemporally, I would use a combination of facial rebalancing procedures and attempt to reinnervate the left facial nerve with segmental nerve grafting.
I would aim for nerve restoration. Given the timing of the nerve regeneration, I might simultaneously perform a temporising facial rebalancing procedure with insertion of fascia lata slings to the lateral lip commissure and nostril base. Terzis: Given that the facial nerve has been injured but not transected, and the preoperative electromyogram EMG shows a complete paralysis at 3 months, would you want to explore the facial nerve or would you move to secondary rebalancing procedures?
Rose: I would determine if there is any bony compression of the nerve itself. If there is, I would consult with an otolaryngologist or neurosurgeon to attempt intratemporal facial nerve decompression and grafting procedures.
Terzis: If the nerve were injured outside of the mastoid, what would be your surgical strategy? Rose: I would resect the damaged portion of the nerve and place a series of specific nerve grafts to the individual damaged facial nerve branches. Terzis: After performing some microneurolysis and grafting of the branches, what would be your postoperative treatment? Rose: Postoperatively, I would treat the patient with low dose alternating current AC electrical stimulation to enhance nerve regeneration to the target muscles on the injured side.
Manktelow: First, I would elicit from the patient exactly what he is concerned about. Of course, this man would like to improve his smile, but what we do not know, from looking at his eye, is whether or not he has significant eye symptoms. You could address eye symptoms with either a temporary or a definitive procedure. In total facial nerve injury, either a CT scan or an MRI can establish whether or not this injury is within the facial nerve canal.
If it is, I would plan a reinnervation procedure. Walton: I generally do not. If there is viable nerve proximally and one repairs a segmental gap, the regenerating nerves grow back fairly rapidly. I really have not found any advantage to using percutaneous nerve stimulation and have found patient compliance with this adjunct to be problematic. Rose, if this patient sought your help after 9 months, would you use electrical stimulation to salvage the target facial musculature?
Rose: If there was a complete transection of the nerve, in the interval between the transection and the definitive repair, I would consider direct current DC stimulation. After nerve repair, I would consider low-dose subclinical AC stimulation until I began to see some degree of voluntary target muscle activity.
I would gradually increase the AC stimulation until I saw full voluntary muscle contraction, and then I would decrease the AC stimulation accordingly as voluntary motion improved. My physical therapy colleagues recommend DC stimulation for denervated muscle to protect the target from denervation atrophy.
They recommend AC stimulation following the regeneration period to increase the receptivity of the target muscle cells. Manktelow: I am not convinced that any type of stimulation has made much difference in the clinical setting.
However, I was impressed with Bruce Williams' work using the cardiac pacemaker for 24 hours each day. In terms of duration of application, longer application might be more effective compared with what is presently used.
Terzis: The wisdom of skeletal muscle stimulation for denervated or reinnervated muscle has often been challenged. Unfortunately, the time restrictions of this panel will not allow an in-depth discussion of this important topic. Having worked with Professor W. Theodore Liberson, a brilliant physiatrist, for 10 years, I can unequivocally state that I have strong proof that slow-pulse stimulation is beneficial to human denervated muscles. The patient in Figure 2 was treated with a single microsurgical procedure that involved exploration of the extratemporal portion of the facial nerve, resection of the segments that were injured by the bullets, microneurolysis, end-to-end repair, and interposition nerve grafts.
The third patient also suffered an iatrogenic lesion, but in her case, it was during a parotidectomy procedure for extirpation of a benign parotid tumor Figure 3, A. During exploration, the surgeon did not use magnification or bipolar coagulation, and when the patient bled profusely, he used regular cautery to control the bleeding. The patient woke up with a complete right facial paralysis.
Unfortunately, the time restrictions of this panel will not allow an in-depth discussion of this important topic. Facial nerve injury after trauma is usually common, especially when fracture of temporal bone is present 4. Terzis: Assuming she is 14 and unhappy that when she smiles her left lower lip comes into her mouth and she feels deformed, what would you do? Elliot H. I probably would opt for a cross-facial nerve graft. A hypothesis.
Total facial nerve repair. 1. Introduction
Comparison between early and delayed facial nerve decompression in traumatic facial nerve paralysis - A retrospective study. To study the intraoperative findings in case of early and delayed decompression of facial nerve paralysis and compare their results. Retrospective data analysis of 23 cases of longitudinal temporal bone fracture with House-Brackmann grade V and VI facial nerve paralysis.
All cases were thoroughly evaluated and underwent facial nerve decompression through the transmastoid approach. All cases were under regular follow-up till the date of manuscript submission. Clinical improvement of the facial nerve function was observed for early vs. Early decompression of facial nerve provides better results than delayed decompression because it enables early expansion of the nerve.
Facial nerve paralysis FNP is a debilitating and devastating condition causing disfigurement and functional consequences in the form of speech and masticatory difficulties 1 - 4. Temporal bone fractures are classified into longitudinal, transverse, or mixed in relation to the petrous pyramid axis 7. Management of FNP with facial nerve decompression FND remains a surgical challenge to otologists and neuro-otologists.
In recent times, imaging studies have provided excellent preoperative localization of injury and selection of surgical approach 4 , 9. Authors who believe in surgical management have different opinions regarding the timing of decompression 9 , 10 , and the most appropriate time of surgery remains a subject of controversy. The question to be answered is whether early decompression provides faster improvement of FNP as compared with delayed decompression.
The present study aimed to assess the intraoperative findings in case of early and delayed microsurgical decompression of FNP and compare their results.
Thirty-eight cases of facial nerve paralysis FNP were analyzed, and 23 cases of longitudinal temporal bone fractures were included in the study. Ten-year data were collected retrospectively, and the results were analyzed. All patients consented to participate in the study as per the aforementioned Institute protocol.
Fifteen cases of FNP caused by other etiological factors, such as iatrogenic and infections, were excluded from the study. Demography of all 23 cases of FNP is given in Table 1. Preoperative workup: After complete clinical history and examination, facial weakness was rated according to the House-Brackmann H-B grading system. Preoperatively, all patients presented grade V and VI paralysis. Pure tone audiometry was conducted by a trained audiologist to document the hearing status.
High-resolution computed tomography HRCT scans of 1-mm thick coronal and axial sections were obtained for operative planning Figure 1. All patients underwent electro-neuronography ENoG to quantify the regenerative status of the nerve. The decision to decompress the facial nerve was taken based on the following criteria:. The early decompression group EDG included patients who had undergone surgical decompression within six weeks of FNP onset, whereas the delayed decompression group DDG included patients who had been operated after six weeks of FNP onset.
The retro auricular-transmastoid approach canal wall up with posterior tympanotomy and superior extension technique was used to decompress the facial nerve. While performing the procedure, findings were documented for further analysis Table 2 ; Figure 2A and B.
Intraoperative vertical part of the facial nerve showing fracture line passing through the mastoid part of temporal bone white arrow , step deformity on the anterior meatal wall black arrow and central perforation blue arrow. B Intraoperative vertical part of the facial nerve showing neurinoma formation white arrow.
Follow-up varied considerably between individuals, but all the cases were monitored for up to two years. Patients were monitored weekly during the first month, then once a month for the next six months, and every six months subsequently.
All patients were subjected to physical rehabilitation in the form of facial tapping and light massage to restore the resting tone on the affected face side. Galvanic stimulation was performed to evoke the muscular contractions. The principle behind this is to reduce muscular atrophy to promote reinnervation of facial muscles.
A total of 23 patients had longitudinal temporal bone fractures causing facial nerve paralysis FNP. The male: female ratio was There were 14 The most common etiology was road traffic accident RTA - 17 cases On clinical examination of the 23 patients, 13 According to the H-B grading system, two patients had grade V 8.
Preoperative hearing documented by pure tone audiometry showed conductive hearing loss averaging 40 dB in 21 cases All patients underwent high-resolution computed tomography HRCT of the temporal bones with 1-mm coronal and axial sections with 3D reconstruction Figure 1. All the cases presented visible fracture on the HRCT scans, with other findings such as soft tissue density in epitympanum, middle ear, and mastoid bone in 12 cases The remaining cases showed suspected injury proximal to the geniculate ganglion, such as impingement of bony spicules.
Clinically apparent step deformity was confirmed by HRCT in 10 cases All 23 patients were operated and divided into two groups early and delayed decompression depending on the time elapsed between onset of FNP and surgery.
This delay ranged from eight to days. Findings on the extra- and intra-fallopian canals in both groups were recorded Table 3.
A The extra fallopian canal findings included tympanic membrane perforation in two cases Displaced bony segments and other findings such as soft tissue were identified in nine cases B The intra fallopian canal findings included edema in two cases Overall, the extra fallopian canal findings in both groups included tympanic membrane perforation in six cases In the DDG, the preoperative status was grade V in one case 7.
After surgery, it improved to grade II in one case 7. Overall, postoperatively in both groups, nine patients improved to grade II Pre- and postoperative H-B grading classification of patients is shown in Table 4. Facial nerve paralysis FNP can be caused by infections, iatrogenic, road traffic accidents RTA , and tumors involving the nerve 2 , 7. TBF are classified into longitudinal, transverse, and mixed depending on the site of fracture in relation to the petrous pyramid axis 4 , 7 , Recently, they have been classified as otic capsule sparing or otic capsule violating, labyrinthine and extra labyrinthine fractures, respectively 4 , 5.
According to Ulrich et al. In this site, the fracture line usually runs superior to the external auditory canal EAC into the middle ear and along the facial nerve, especially in the perigeniculate area 8 , 11 - The mechanism of FNP may be due to traction by displaced bony segments in the aforementioned area 4 , A thorough evaluation, which is conducted in all cases through clinical, audiological and radiological examinations and electro-diagnostic testing methods, is the key to determine the prognosis of palsy.
All these investigations can be used to assess the site of lesion, status of the tympanic membrane and middle ear, hearing level, and selection of surgical approach, offering better counseling to patients regarding prognosis 4 - 6 , 10 , The House-Brackmann grading system was adopted for preoperative grading of the facial nerve functions because of its reliability and ease of application 3. All patients presented grade V 8. High-resolution computed tomography HRCT of the temporal bone remains the only important investigation needed for patients affected by TBF, for preoperative surgical planning and better patient counseling.
It can detect not only the site of facial nerve involvement, but also other possible severe complications such as meningeal involvement and vascular injury 4 - 6 , 8 , 10 , 14 , All the patients presented fractured line radiologically, which was confirmed intraoperatively. In contrast, incudo-stapedial IS joint dislocation was suspected in 15 cases Electro-diagnostic tests are based on the principles of electric stimulation of nerve to evoke electromyography response and provide information regarding the degenerative status of the nerve and, possibility, benefits with early surgical interventions.
These tests ascertain the degenerative status of the nerve by comparing the side of lesion with the normal side. Facial nerve decompression is still a matter of universal debate with respect to the onset of palsy and time of surgery. Many studies have suggested that early decompression provides early expansion of the nerve, relieving edema; it can remove bony spicules impinging on the nerve and drain the blood collected from the fallopian canal.
If decompression is delayed, fibrotic bands are formed following pathological repair and impinged bone fragments affect nerve conduction. A long delay can compromise blood supply, causing degeneration and shrinkage of the nerve, formation of scar and neuroma, and atrophy of the peripheral structures. Endoneuronal hematoma and fibrosis are the main causes of nerve dysfunction 1 , 7 , 10 , 12 , 14 , This study compared early and delayed decompression with respect to onset of FNP and time of surgery, and the results are shown in Table 4.
These results encourage performance of early decompression when compared with delayed decompression. A wide variety of surgical approaches to decompress the nerve in FNP are available. In otic capsule violating fractures, which are associated with sensorineural hearing loss SNHL in a significant proportion of cases, the translabyrinthine approach is preferred for complete nerve decompression; however, in otic capsule sparing fractures, with preserved cochlear and 8 th nerve function, the transmastoid supralabyrinthine and middle cranial fossa approaches provide appropriate exposure without violating the labyrinth, depending on the site of lesion and mastoid pneumatization.
In well pneumatized mastoids with nerve involvement limited to the perigeniculate area, transmastoid supralabyrinthine access provides enough exposure, whereas a fracture involving the labyrinthine segment of the facial nerve can be better accessed via middle fossa approach.
The literature reports that the facial nerve should be decompressed from the labyrinthine segment to the stylomastoid foramen 1 , 5 - 8 , 10 , 16 , Removal of the incus is also helpful in reducing the risk of SNHL, which can occur due to contact of the rotating burr with the intact ossicular chain while working in narrow space 7 , 10 ; in addition, many patients already presented IS joint dislocation.
The incus can be repositioned as the last step of surgery. In the population of this study, the most common site of injury was at the geniculate ganglion, involved in 15 cases Bony spicules, blood collected inside the fallopian canal, nerve edema, and dislodged incus were the predominant findings in the group explored early on, whereas bony spicules impinging on the nerve and fibrotic bands compressing the facial nerve were the factors related with FNP in the cases explored in delayed fashion.
Rehabilitation enables reintegration of stomatognathic functions such as suction, chewing, and swallowing, as well as cosmetic appearance to improve quality of life. All patients were subjected to physical and speech-language pathology rehabilitation and galvanic stimulation postoperatively 19 , The results are presented in Table 4.
All patients were monitored for up to two years. The data show a trend towards a better outcome with early decompression; however, they need to be statistically validated using a larger sample size.
Despite the limited data available, this study demonstrates that early surgical decompression provides better results in terms of facial nerve function improvement, possibly because it enables early expansion of the nerve by removing impinged bony particles, avoiding compression from dislodged ossicles or bony step deformities, and by reducing the traction injury from displaced bony segments.
In delayed decompression cases, the presence of fibrotic bands may not allow nerve regeneration because of the existing irreversible changes; in this situation, facial nerve grafting should be considered. Facial paralysis in temporal bone trauma. Am J Otol. Clinical features and management of facial nerve paralysis in children: analysis of 24 cases. J Laryngol Otol.