April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Management of Flaccid Facial Paralysis

tone, whereas the masseteric nerve allows for a more natural smile with clenching, as well as reduced synkinesis ( Fig. 3 B). Finally, a partial hypoglossal nerve transfer may be used in conjunction with a CFNG coapted to a buccal nerve branch to provide a natural emotive smile, good resting tone, and reduced synkinesis ( Fig. 3 C). Beyond nerve transfer procedures, surgeons are also beginning to use dual innervation ap- proaches with free tissue transfer, although a discussion is beyond the scope of this article. 31,32 Nonetheless, dual innervation procedures have great potential for improving facial reanimation outcomes, although more research is required to define their exact role. Static Approaches and Adjunctive Procedures Static procedures for facial reanimation may be used in situations in which patients are not candidates for general anesthesia due to medical comorbidities or other factors, precluding more invasive dynamic procedures. Static procedures are more commonly used in longstanding facial paralysis but may be indicated in select cases of paralysis of shorter duration to augment dynamic procedures even when partial recovery of tone and dynamic motion is expected. For example, static suspension of the oral commissure may be used to more quickly rehabilitate patients as they await recovery of facial tone. Suture techniques or suspension with fascia lata or the palmaris longus tendon are all effective and minimally invasive. The periocular complex deserves special consideration. Patients who are expected to have expedient recovery of facial tone can often be managed with vigilant eye lubri- cation, moisture chamber use, and other conservative measures. In cases in which the periocular area is not expected to recover tone, eyelid loading with a platinum weight may be considered. Eyelid weights are useful when there is lagophthalmos exceeding 1 to 2 mm, poor Bell phenomenon, corneal anesthesia, or exposure keratopathy. One of the advantages of eyelid weights compared with other procedures is the reversibility and general tolerance for placing these with the patient under local anesthesia. In very severe cases, temporary lateral tarsorrhaphy may be performed. The authors pre- fer to defer permanent procedures until maximal recovery has been achieved, and the functional status of the periocular complex can be evaluated in that setting. Patients with lower eyelid paralytic ectropion may be candidates for canthopexy and/or the placement of a spacer graft, although this is generally deferred in patients who are ex- pected to regain midface or periocular tone. In all cases, it is imperative to involve an ophthalmologist who can monitor corneal health throughout the recovery process. Flaccid facial paralysis is a disfiguring condition that may profoundly affect the lives of patients. For patients with paralysis of less than 2 years’ duration, primary nerve repair and nerve substitution procedures serve as the primary modalities for dynamic reha- bilitation. Facial nerve surgeons should seek to restore facial symmetry through resto- ration of not only dynamic facial motion but also resting facial tone. The authors recommend an organized approach to treatment planning based on duration and cause of paralysis, status, and accessibility of the affected facial nerve, as well as medical comorbidities and patient-specific goals. SUMMARY

REFERENCES

1. Goines JB, Ishii LE, Dey JK, et al. Association of facial paralysis–related disability with patient- and observer-perceived quality of life. JAMA Facial Plast Surg 2016; 18(5):363–9 .

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