Facial Palsy 01-22 Flashcards
A 16-year-old girl presents to the clinic 3 years after onset of a right unilateral Bell palsy with a chief complaint of absence of commissure elevation and asymmetry of the nasolabial fold when she smiles. She has undergone no previous treatment. Which of the following procedures is most likely to result in spontaneous smile animation with emotion on the affected side?
A) Cross-facial nerve grafting from the unaffected left face to the distal facial nerve branches on the affected right face
B) In-line temporalis muscle transfer
C) Single-stage gracilis free flap with neurorrhaphy to the right-sided motor nerve to the masseter muscle
D) Two-stage reconstruction with cross-facial nerve grafting from the unaffected left face followed by functional gracilis muscle free flap to the right face
The correct response is Option D.
Dynamic reconstruction options that restore the smile function to the face following facial (VII) nerve injury can be categorized as those restoring innervation to the native mimetic musculature and procedures including a muscle transfer. The decision to reinnervate the native facial musculature or to perform a muscle transfer is dictated by the elapsed time since the start of facial paralysis. In cases where facial paralysis is present for less than 12 months, the native musculature may be reinnervated. After 24 months of paralysis, muscles become irreversibly atrophic and a muscle transfer is necessary. In the case described, the facial paralysis has been present for 3 years and the native mimetic muscles can no longer be successfully reinnervated. Therefore, cross-face nerve grafting from the contralateral face to the distal facial nerve on the affected side will not be successful and does not represent a viable treatment for this patient.
Strategies for smile restoration can also be classified as those powered by the facial (VII) nerve and those powered by other cranial nerves. In-line temporalis transfer represents a direct transfer of the temporalis muscle, which is innervated by the trigeminal (V) nerve. Additionally, the nerve to the masseter muscle is another branch of the trigeminal (V) nerve commonly used to reinnervate functional muscle transfers such as a gracilis free flap. To activate both of these reconstructions, patients must actively clench their jaw. With therapy and practice, some patients may achieve the ability to smile without clenching the jaw, but a spontaneous smile with emotion is achieved by few patients.
Innervation from the facial (VII) nerve, whether ipsilateral or contralateral, is more likely to generate a spontaneous emotional smile compared with reconstructions powered by other cranial nerves. In the case described, the ipsilateral facial nerve does not represent a viable source of innervation, but a staged procedure using input from the contralateral facial nerve to innervate a microvascular gracilis muscle transfer represents a viable procedure to restore spontaneous smile function for this patient.
A 48-year-old woman presents to the clinic after Mohs micrographic surgery for a mid-cheek basal cell carcinoma. The defect is 4 cm and abuts the left eyelid-cheek junction. Which of the following is the most appropriate method to close the defect?
A) Cheek neck rotation flap
B) Lateral thigh flap
C) Radial forearm free flap
D) Split-thickness skin grafting
E) Xenografting
The correct response is Option A.
Mohs micrographic surgery is more often performed by the dermatologist, who then refers the patient to the plastic surgeon for closure. It allows for closure of margin-free carcinomas, typically either basal or squamous cell cancers. Defects of the cheek below the orbit can be challenging because ectropion of the lower lid can be a complication of surgery. For that reason, split-thickness skin grafts that can contract are not the first line choice of a large cheek defect below the orbit. An incision that extends upward toward the lateral canthus and then into the preauricular skin and down into the neck allows wide mobilization of the soft tissue to close relatively large defects. Free flap reconstruction is used in head and neck reconstruction, but it may provide soft-tissue reconstruction that is too bulky and a color match that is less than optimal. For those reasons, radial forearm and lateral thigh free flaps are not the optimal choice. There are autologous options, but xenografts are not used because the issues of cicatricial ectropion and graft rejection are overwhelming.
A 3-year-old girl with a history of congenital right trigeminal neuropathy is referred for recurrent corneal ulceration of the right eye. Physical examination discloses that she is completely insensate along the right V1 nerve/dermatome distribution. The right cornea is insensate with several areas of mild ulceration. Which of the following procedures is most likely to preserve vision in this child’s right eye?
A) Corneal neurotization with sural nerve graft from left supratrochlear nerve
B) Corneal transplantation
C) Ipsilateral supratrochlear nerve transfer to ophthalmic nerve
D) Laser-assisted in situ keratomileusis (LASIK)
E) Tarsorrhaphy
The correct response is Option A.
Neurotrophic keratitis is a rare vision-threatening condition caused by decreased corneal sensation due to trigeminal neuropathy. Subsequent inflammation and ulceration can lead to corneal opacification and, in young children, amblyopia. Preventing ulceration of affected corneas is critical to maintaining vision. In young children, however, tarsorrhaphy (surgical adhesion of eyelids) can result in deprivational amblyopia and permanent vision loss. Corneal transplantation has been attempted as well. However, without adequate sensation, most transplanted corneas become ulcerated and opacify as well. In the last decade, corneal neurotization has emerged as a means of restoring sensation and preventing persistent ulceration. In this procedure, fibers from the contralateral supratrochlear nerve are redirected via a sural nerve graft (or other graft) to the affected cornea, where they serve to reinnervate the affected eye. In cases with mild corneal ulceration, neurotization can reverse these neurotrophic changes and help restore normal corneal architecture.
Ipsilateral supratrochlear nerve transfer will not work in someone without functional sensation in that nerve. The ophthalmic nerve is upstream of the supratrochlear nerve and is also affected.
Laser-assisted in situ keratomileusis (LASIK) procedure involves reshaping the cornea in order to correct refractive errors. It does not affect sensation.
A 25-year-old man sustains a clean cheek laceration that includes transection of the facial nerve. Which of the following is the maximum time after which primary repair is unlikely to result in restored facial nerve function?
A) 3 weeks
B) 6 weeks
C) 6 months
D) 12 months
E) 24 months
The correct response is Option D.
Extracranial facial nerve injuries generally follow the principles of peripheral nerve injury and repair. For a clean, gapless, tension-free, primary repair, optimal motor nerve function outcomes are optimal if the nerve repair occurs within 3 to 6 months from the time of injury.
In contrast to peripheral motor nerve repairs, facial nerve injuries in young patients can tolerate repair at a later date, even up to 12 months post injury. Twelve months is the maximum time of delay where functional recovery would be expected with a tension-free primary repair of a facial nerve transection.
Muscle degeneration (from denervation) usually occurs around 24 months, so primary nerve repair is not even considered at that point, and muscle transfer options need to be considered by then.
A 69-year-old man presents to the office with a large (5 x 7-cm) melanoma involving his right cheek. A photograph is shown. After resection with clear margins, which of the following methods of reconstruction will provide the best aesthetic result?
A) Cervicofacial flap
B) Immediate tissue expansion
C) Primary repair
D) Radial forearm free flap
E) Split-thickness skin graft
The correct response is Option A.
Large defects of the cheek are best repaired with local skin when possible. Cervicofacial flaps can be used for moderate to large defects of the cheek with tension free repair (as shown in the photographs), which is vitally important to avoid eyelid-related complications, such as ectropion. Primary repair is useful for smaller cheek defects but would not be possible in this situation. A split-thickness skin graft would not provide optimal soft tissue match, and would undergo significant secondary contracture, resulting in eyelid malposition. They may be used in a temporary situation until definitive reconstruction. Full-thickness skin grafts may be an option; however, they tend to appear shiny and patch-like. Tissue expanders are useful in the head and neck, particularly in the scalp; however, in this particular case it is not advisable to use a tissue expander adjacent to an open wound. There is a significant risk of infection or extrusion. A radial forearm free flap could be an option if local tissue is not available, but would result in an unnecessarily long procedure with secondary donor site.
A 42-year-old woman suffers a dog bite injury to her lower lip. Following adequate debridement, the patient is left with a full-thickness, total lower lip defect, up to the lateral commissure bilaterally. The surrounding tissue is uninjured. Which of the following is the most appropriate method of reconstruction?
A) Abbe (lip switch) flap
B) Bernard-Webster (lip-cheek advancement) flap
C) Cervicofacial rotation advancement flap
D) Estlander (lateral lip switch) flap
E) Karapandzic flap
The correct response is Option B.
Complete lower lip defects can result from cancer resection or trauma. Reconstruction of lip defects relies primarily on local flaps, although free tissue transfer may be necessary in total lip reconstructions or if the surrounding tissue is unsuitable for flap transfer. In lower lip defects with a defect size greater than two thirds of the lip, bilateral lip-cheek advancement flaps are required for reconstruction.
Lip switch flaps are useful for one- to two-thirds lip defects that are centrally located, whereas lateral lip-switch flaps can similarly be used to address lateral defects involving the commissure. Although these flaps can be combined with lip-cheek advancement flaps for reconstruction of the lower lip, they are not sufficient alone for total lip reconstruction. Karapandzic flaps can be used for reconstruction of central defects with up to two-thirds of the lip being absent, but cause significant microstomia in lip defects with greater than two-thirds of the lip absent. Cervicofacial rotation advancement flaps are usually used for cheek reconstruction.
A 26-year-old man sustained complete right-sided unilateral facial nerve transection and paralysis from a circular saw 3 years ago. He is now seeking surgery to improve resting symmetry and to recreate a dynamic smile. Which of the following is the most appropriate surgical procedure to achieve these results?
A) Cross-facial nerve graft and delayed free functional muscle transfer
B) Fascial suspension
C) Hypoglossal nerve to facial nerve transfer
D) Ipsilateral nerve graft
E) Nerve repair
The correct response is Option A.
Three years after complete facial nerve transection and paralysis, the facial muscles are nonviable and incapable of reinnervation. Cross-facial nerve grafting and delayed free functional muscle transfer using the gracilis muscle is the procedure of choice in this situation.
Nerve repair, ipsilateral nerve graft, and hypoglossal nerve to facial nerve transfer require viable facial muscles. Static reconstruction, such as a fascial suspension, would not be indicated in a young person when facial reanimation is possible. Static reconstruction is not indicated because facial reanimation with cross-facial nerve grafting and delayed free functional muscle transfer is possible and has not been attempted yet. Static reconstruction is the procedure of choice for elderly patients with multiple comorbidities and a poor prognosis or for patients who have failed facial reanimation surgery.
A 30-year-old woman presents to the office with new-onset left facial paralysis from Lyme disease. The most appropriate next step in management is administration of which of the following medications?
A) Acyclovir
B) Dapsone
C) Dexamethasone
D) Doxycycline
E) Fluconazole
The correct response is Option D.
Lyme disease is carried by ticks with Borrelia bacteria. While a “bull’s eye” rash is a common finding, a lack of this rash does not exclude Lyme disease. This patient has new onset facial paralysis brought on by her Lyme disease infection. Neurological manifestations (early disseminated infection) can present as early as a few days to a few weeks after the initial tick bite.
Treatment should be directed to the underlying disease, and doxycycline is the antibiotic of choice unless there are contraindications. There is no role for antivirals.
Surgical treatment is contraindicated at this time unless the patient’s facial palsy becomes permanent.
Early initiation of corticosteroids has been shown to improve outcomes in idiopathic Bell palsy, but it has shown no efficacy for facial palsy caused by Lyme disease (Lyme neuroborreliosis), and in fact, has been associated with worse outcomes.
Antivirals can be used in facial palsy caused by the herpes simplex virus, but they have not been proven to be beneficial alone (antivirals must be used in conjunction with corticosteroids). However, antivirals have not demonstrated efficacy in facial palsy caused by Lyme disease.
Cephalexin is used as a third-line treatment for Lyme disease. Dapsone has been used in post-treatment Lyme disease syndrome.
A newborn has unilateral facial paralysis. The remainder of the physical examination shows no abnormalities and there is no evidence of birth trauma. Which of the following studies will most likely reveal the cause of facial nerve paralysis in this patient?
A) CT scan of the head
B) Electromyography
C) Electroneurography
D) Stapedius (acoustic) reflex test
E) Ultrasonography
The correct response is Option A.
The most likely cause of unilateral facial nerve paralysis in a newborn with an otherwise normal physical examination is a temporal bone abnormality. A CT scan of the head and temporal bones is the study of choice to identify a temporal bone abnormality.
Electromyography is a neuroelectrophysiological test used to evaluate the function of the facial nerve. Small needles are inserted into certain facial muscles and patients are asked to contract those muscles. Action potentials are seen in muscles undergoing reinnervation. Fibrillation potentials are seen in muscles that are still alive but awaiting reinnervation, and electrical silence is seen with chronically denervated muscles that cannot be reinnervated.
Electroneurography is another neuroelectrophysiological test used to assess the function of the facial nerve. One electrode is placed over the stylomastoid foramen behind the ear and emits an electrical pulse, and one electrode is placed at the ipsilateral nasolabial fold that detects any signal transmitted by the facial nerve. Electromyography and electroneurography assess the integrity of the facial nerve, but would not reveal the cause of the facial nerve paralysis in a newborn baby.
Ultrasonography is the test of choice to look at soft tissues but will not image the skull base adequately for this purpose. The stapedius or acoustic reflex is an involuntary muscle contraction of the stapedius muscle of the middle ear in response to high intensity sound. The efferent limb of the reflex is the facial nerve, which innervates the stapedius muscle. The rate of return of the stapedius reflex can be used to predict the rate of return of facial nerve function after facial nerve paralysis, but would not identify the cause of facial nerve paralysis.
A patient with Möbius syndrome is referred for facial reanimation with free gracilis muscle flaps. Which of the following donor nerves has the lowest morbidity and is used most often for this type of reconstruction?
A) Contralateral facial
B) Glossopharyngeal
C) Hypoglossal
D) Masseteric
E) Spinal accessory
The correct response is Option D.
In cases of facial palsy where the facial nerve is unavailable for use as a donor nerve, nerve transfers are the best option. Of the local options, the masseteric nerve provides the most appropriate and most commonly used transfer because of its proximity and low morbidity when harvested.
While the hypoglossal nerve is sometimes used as a donor nerve for ipsilateral facial reanimation, the process of harvesting can be associated with considerable oropharyngeal morbidity because of ipsilateral tongue atrophy. In addition, the patient in this scenario requires a bilateral facial reanimation procedure, and harvesting of both hypoglossal nerves would paralyze the tongue.
A cross-facial nerve transfer is not an available option in this scenario because the patient has Mobius syndrome with bilateral facial nerve agenesis. Use of bilateral glossopharyngeal nerves as donors would create significant oropharyngeal function morbidity, and, even in cases of unilateral facial reanimation, is not commonly used. Use of both spinal accessory nerves as donor nerves in this case would create significant morbidity. Even in a case of unilateral facial reanimation, use of the masseteric nerve is a significantly better choice.
An 8-year-old boy with congenital right facial hemiparesis is seen in consultation for possible facial reanimation. MRI shows absence of a right facial nerve trunk. A two-stage cross-facial nerve grafting procedure is planned. A sural nerve graft coapted to a buccal branch of the facial nerve with 10-0 nylon is planned. Which of the following factors will have the greatest influence on the outcome of this procedure?
A) Advanced patient age
B) Donor nerve axon density
C) Duration of hemiparesis
D) Length of obturator nerve pedicle
E) Method of nerve coaptation
The correct response is Option B.
While reanimation techniques have been proposed to restore function in nearly every part of the face, the most well-studied and reliable are for restoration of the smile. There are two primary operations to restore a dynamic smile: the two-staged cross-facial nerve graft and the single-stage transfer using nerve to the masseteric branch of the trigeminal nerve. Both utilize free muscles transfer and the gracilis muscle has become the gold standard donor for most surgeons. This muscle is favored largely because it boasts excellent muscle contraction characteristics with limited bulkiness, but it also boasts an anatomically consistent vascular pedicle, a long donor nerve (obturator), and no functional impact from its harvest. The two-stage procedure is well described and utilizes a nerve graft(s), usually sural, coapted to branches of the buccal or zygomatic branches of the facial nerve at or just distal to the anterior edge of the parotid gland. Although various factors can influence the outcome of this procedure, several recent studies highlight the importance of donor nerve (i.e., buccal or zygomatic branches) axonal density. While the results of two-stage facial reanimation in older patients (i.e., adults, especially older adults) are typically inferior to pediatric patients, there is no evidence that age is a major factor in children under 10 years of age. Unlike a patient with acquired or traumatic facial nerve injury, the duration of paralysis has no bearing in this patient with a paralysis secondary to facial nerve agenesis since the muscles of facial animation on the right side would be absent or fibrotic as well. The length of the obturator nerve and method of nerve coaptation would have no effect on the outcome.
A 5-year-old girl is evaluated because of acute onset of unilateral facial paralysis including inability to close the left eyelid, lack of smiling, and inability to lift the ipsilateral brow. Which of the following is the most likely cause of this patient’s paralysis?
A) Acute otitis media
B) Bell palsy
C) Cerebrovascular accident
D) Neoplasm
E) Trauma
The correct response is Option B.
There are several described causes of facial nerve paralysis in children, including congenital (delivery traumas, genetic deformity) and acquired (infectious, inflammatory, neoplastic, traumatic or iatrogenic) conditions. In approximately 40-75% of cases, the etiology remains idiopathic. Idiopathic facial paralysis, either in adulthood or childhood, is commonly known by the eponym Bell palsy. The major cause of acute facial nerve paralysis in children is infection, with the majority being a complication of acute otitis media. Trauma is not an uncommon cause, and in the neonatal period is usually from a traumatic delivery. In older children, sports or motor vehicle collisions are common traumatic causes. Both populations overall have an excellent prognosis for recovery unless penetrating trauma has occurred, which necessitates surgical repair. Tumors rarely cause facial nerve weakness in children. Congenital facial nerve paralysis is present since birth and would not present acutely. Cerebrovascular accident is a rare cause in children.
A 15-year-old girl is brought to the office for follow-up evaluation 5 months after sustaining facial injuries from being bitten by a dog. She has an abnormal facial nerve examination and cannot generate a smile on the right side. Prior exploration during anesthesia showed missing segments of the facial nerve. Which of the following is the most appropriate management at this time?
A) Babysitter procedure
B) Cross-facial nerve grafting
C) Dynamic reanimation with gracilis free flap
D) Interpositional nerve grafting
E) Primary nerve repair
The correct response is Option D.
The critical components of facial nerve reconstruction are the cause of the injury, timing of the injury, and age of the patient. These generally dictate the management options.
In this case we have a young patient with a traumatic injury that occurred 5 months ago. The goal is reconstruction of the facial nerve with enough time for nerve regeneration prior to loss of the motor end plates of the muscle. This can usually be done if nerve regeneration is anticipated to occur within 18 months of the initial injury.
With a history of missing segments of facial nerve, it is unlikely that primary repair of the facial nerve branches will be feasible.
The proximal facial nerve is available for reconstruction, making cross-facial nerve grafting unnecessary. Without the addition of nerve grafts, a cross-facial nerve graft alone would not restore facial reanimation.
Since the timing of the injury is only 5 months, reconstruction with nerve grafts should be attempted prior to the use of facial reanimation with a gracilis free flap. It could be used in the event that nerve grafting fails.
The babysitter procedure is a procedure that is intended to send strong motor fibers quickly to denervated facial muscles while waiting for cross-facial nerve grafts or dynamic reanimation procedures to complete nerve regeneration and healing. The babysitter procedure preserves muscle bulk while waiting for the cross-facial nerve graft or other mode of reanimation to enable coordinated animation.
An 18-year-old man is brought to the emergency department because of a vertical stab wound to the mid cheek immediately posterior to the level of the lateral canthus. Primary repair is planned within 72 hours. Which of the following is the primary reason to perform the procedure within this time frame?
A) Anatomical location precludes surgical expiration and repair
B) Motor end plates will atrophy
C) Nerve endings will have retracted markedly
D) Neurotransmitter stores will become irreversibly depleted
E) Risk of soft-tissue infection of the face increases markedly
The correct response is Option D.
On the face, and posterior to the lateral canthus, the facial nerve should be repaired as early as possible such that identification of the transected nerve stumps is possible. After 72 hours, the neurotransmitter stores required for motor end plate depolarization are irreversibly depleted. As a result, the target muscles no longer respond to stimulation of the distal nerve stump.
Because of marked arborization and cross-innervation of the facial nerve, injuries anterior to an imaginary line drawn from the corner of the eye to the corner of the mouth commonly recover spontaneously. It takes 18 to 24 months for motor end plates to completely atrophy.
A 62-year-old woman is evaluated 1 hour after undergoing Mohs micrographic resection of a squamous cell carcinoma of the lower lip. After a clear-margin excision, the resulting defect is a full-thickness 25% central lip defect. Which of the following is the most appropriate repair method for this defect?
A) Coverage using the Karapandzic technique
B) Coverage with a V-Y advancement flap
C) Coverage with an Abbe flap
D) Full-thickness skin grafting
E) Primary closure
The correct response is Option E.
Defects of the lip can be categorized by the percentage of the total lip affected. Small full-thickness defects of the lip (25–33%) as described in this case are best repaired with primary closure using a vertical excision of remaining lip structures to enable a tension-free closure. Care should be taken to precisely realign the lip and repair the white roll to avoid step-offs that are easily noticeable. Larger defects (33–50%) are usually repaired using flaps. These flaps can be categorized as transoral flaps (e.g., Abbe or Estlander flaps) or circumoral advancement/rotation flaps (e.g., Gilles flap or Karapandzic technique). Subtotal lip defects may be repaired with bilateral circumoral advancement/rotation flaps, while total lip defects generally require reconstruction with free flaps. Skin grafts are rarely used for lip reconstruction (particularly if the white roll is involved) because these repairs result in a patch-like appearance that is highly noticeable.
A 35-year-old woman is evaluated for long-standing facial nerve palsy. The proximal stump of the facial nerve is not available for use in reconstruction. In addition to gracilis muscle transfer, the surgeon is considering cross-facial nerve graft or using the masseter nerve. Which of the following factors regarding masseter nerve use is often cited as a disadvantage to cross-facial nerve grafting?
A) Decreased excursion of the gracilis muscle
B) Decreased smile symmetry
C) Less spontaneity in smiling
D) Requirement of a craniofacial osteotomy for harvest
E) Significant, permanent weakness in chewing function
The correct response is Option C.
Use of the masseter nerve as the motor source for a gracilis free tissue transfer to restore smile is a single-stage procedure with many advantages over the more traditional use of cross-facial nerve grafting when the proximal stump of the facial nerve is not available for use. Its popularity has increased recently, particularly because it is a single-stage surgery and morbidity is minimal. Use of the masseter nerve, however, requires the patient to clench the jaw to smile, and is much less spontaneous than with cross-facial nerve grafting.
Less excursion of the gracilis muscle graft is incorrect. The masseter nerve is an excellent motor nerve and allows for powerful contraction of the transferred muscle.
Significant, permanent weakness in chewing function is incorrect because harvest of the masseter nerve is partial, and generally results in minimal donor site morbidity.
Craniofacial osteotomy is incorrect because while the masseter nerve is in proximity to the zygomatic arch, an osteotomy is not frequently needed to reach the nerve.
Decreased smile symmetry is incorrect because smile symmetry is comparable with both techniques.
A 34-year-old woman is scheduled to undergo resection of a left-sided cerebellopontine angle tumor with sacrifice of the facial nerve trunk. Staged cross-facial nerve grafting is planned. Which of the following treatment options is most likely to minimize the risk for permanent facial asymmetry at the time of tumor resection?
A) Free gracilis muscle transfer to the left facial nerve stump
B) Hypoglossal to facial nerve transfer and cross-facial nerve grafting
C) Insertion of a 1.2-g gold weight in the left upper eyelid
D) Percutaneous distal facial nerve branch stimulation
E) Placement of an extended temporalis fascia static sling
The correct response is Option B.
Cerebellopontine angle (CPA) tumor resection often requires intracranial facial nerve sacrifice. For best recovery of spontaneous ipsilateral facial nerve function, cross-facial nerve grafting (CFNG) should be performed from the contralateral facial nerve branches to the ipsilateral facial nerve branches. CFNG often results in delayed and weakened reinnervation of the ipsilateral facial musculature. For this reason, hypoglossal to facial nerve transfer and cross-facial nerve grafting (babysitter nerve transfers) are often employed to minimize muscle atrophy and enhance the strength of the ipsilateral facial musculature. Both hypoglossal nerve and nerve to masseter have been used. The other choices would not augment the ipsilateral facial musculature and would likely result in more pronounced facial asymmetry.
A 35-year-old man returns for postoperative evaluation 12 months after undergoing facial nerve reconstruction with free gracilis transfer. Physical examination shows significant hyperkinesis of the contralateral side. In addition to injections of botulinum toxin type A, which of the following measures has been shown to improve facial symmetry?
A) Cryotherapy of facial musculature
B) Mirror biofeedback therapy
C) Oral beta-adrenergic blocker therapy
D) Radiofrequency ablation
E) Selective contralateral facial neurotomy
The correct response is Option B.
Hyperkinesis is generally considered to be the hyperactivity of the contralateral, unaffected side. Mirror biofeedback therapy has been shown to significantly improve facial symmetry when used in conjunction with botulinum toxin injections in the treatment of facial hyperkinesis.
Beta-adrenergic blocker therapy is not indicated for facial hyperkinesis following facial nerve reconstruction.
While selective facial myotomy has been used for improvement in synkinesis, selective contralateral facial neurotomy is not generally indicated for correction of hyperkinesis.
Radiofrequency ablation and cryotherapy have only recently begun to be investigated as an option for improvement of synkinesis, but have not been generally accepted as treatments for hyperkinesis.
An otherwise healthy 20-year-old woman is evaluated 5 weeks after sustaining facial shear injury in a motor vehicle collision. She has a facial nerve palsy on the right and exposed mastoid, zygoma, and zygomatic arch. A photograph is shown. She has had previous debridement and titanium mesh cranioplasty for the traumatic cranial defect of the temporal bone. Multifocal extratemporal facial nerve injuries are suspected. Which of the following is the most appropriate management for the wound coverage and facial nerve palsy?
A) Free tissue transfer for wound coverage with delayed facial reanimation
B) Immediate cross-face nerve grafting with cervicofacial flap for soft tissue coverage
C) Immediate exploration and primary repair of the facial nerve followed by skin grafting for coverage
D) Split-thickness skin grafting for coverage with delayed facial reanimation
E) Temporalis muscle sling with skin grafting for wound coverage
The correct response is Option A.
The patient shown has a large soft tissue defect with exposed bone and hardware. There is friable granulation tissue, and the patient presents several weeks after injury. She has a complete facial palsy and her eye is closed at rest (good eye protection) without taping. The ultimate goals are to address both her wound and her facial palsy, with an aesthetic facial reconstruction.
In this setting, a simple nerve transection that would benefit from a simple neurorrhaphy is unlikely. The tissues are very friable, and tissue planes are not easily identified due to inflammation, extensive damage, and subacute time period. Dissection and exploration would be difficult and could lead to further damage.
Soft tissue coverage is a priority at this point in the patient’s reconstruction. She has a large defect with exposed bone and hardware. Free tissue transfer could provide stable coverage. A skin graft will not provide durable coverage over hardware and exposed bone. Delayed facial reanimation after stable soft tissue coverage will allow for improved healing.
Delaying addressing the facial nerve palsy a few weeks to months can still have good outcomes and there will be an improved healing environment.
A 30-year-old primigravid woman at 24 weeks’ gestation, who has a history of Bell palsy, has synkinesis and squinting of the left eye when smiling. She wants to know her treatment options, but is not interested in options that may put her pregnancy at risk or impact her goal of breast-feeding for 1 year after delivery. Which of the following treatment options is most appropriate for this patient?
A) Chemodenervation to the left orbicularis oculi
B) Chemodenervation to the left orbicularis oris
C) Facial neuromuscular retraining
D) Gold weight to the left upper eyelid
E) Selective neurolysis to the temporal branch of the facial nerve
The correct response is Option C.
Chemodenervation is a common treatment for ocular-oral synkinesis and perhaps the most effective. The chemodenervation medications have unknown effects for pregnant or nursing women. Botulinum toxin type A is a class C drug. Permanent surgical selective denervation is not recommended as it could impact eye protection. Surgery may also have risks for the fetus.
This patient would benefit from a physical therapy referral to work on facial neuromuscular re-education, including biofeedback using mirrors and electromyography. Additional strategies such as use of sunglasses and other strategies to avoid squinting can be helpful. These are likely the treatment modalities that this patient is most interested in.
Gold weight insertion would not be appropriate in a patient with symptoms of squinting.
A 45-year-old man with a 10-year history of unilateral facial palsy is evaluated for dynamic reanimation of the lower face. Single-stage free gracilis transfer to restore smiling function is planned. The proximal stump of the ipsilateral facial nerve is not available as a donor nerve. Which of the following options is most appropriate for this patient because it is associated with the lowest donor site morbidity/loss of function?
A) Cross-facial nerve transfer
B) Ipsilateral glossopharyngeal nerve
C) Ipsilateral hypoglossal nerve
D) Ipsilateral masseteric nerve
E) Ipsilateral spinal accessory nerve
The correct response is Option D.
In cases of unilateral facial palsy in which the ipsilateral facial nerve is unavailable for use as a donor nerve, nerve transfers are the best option. Of the local options, the ipsilateral masseteric nerve provides the best and most commonly used transfer due to its proximity and relatively low morbidity when harvested. In one study, spontaneous smiling was achieved routinely in 59% of patients and occasionally in 29% of patients by using this technique.
Although the hypoglossal nerve is sometimes used as a donor nerve for ipsilateral facial reanimation, its harvest can be associated with considerable oropharyngeal morbidity due to ipsilateral tongue atrophy.
A cross-facial nerve transfer does not provide for single-stage reconstruction. In many cases where there are sufficient contralateral branches of the facial nerve for cross-facial transfer, this option can provide optimal function, but its use requires a staged approach.
Use of the ipsilateral glossopharyngeal nerve as a donor in this situation would also create significant oropharyngeal function morbidity, and is therefore not commonly used.
Use of the ipsilateral spinal accessory nerve as a donor nerve is rarely used due to the fact that its use often requires uncoordinated movements for function. Ipsilateral masseteric nerve is a significantly better choice.
A 72-year-old man undergoes wide local excision of a squamous cell carcinoma of the lower lip. Margins are free of involvement. A photograph of the resulting defect is shown. Reconstruction using which of the following flaps is most appropriate in this patient?
A) Estlander
B) Facial artery myomucosal
C) Karapandzic
D) Melolabial
E) Submental artery island
The correct response is Option C.
Karapandzic flaps are appropriate for reconstruction of defects involving one to two thirds of the lower lip, such as the one in this patient. The Karapandzic technique involves performing circumoral incisions and mobilizing the orbicularis oris muscle, while preserving its innervations and vascular supply. The main advantage of this technique is that a continuous sphincter of functional orbicularis muscle is created, helping to restore oral competence.
The Estlander flap is a full-thickness, cross-lip transposition flap designed to reconstruct lateral defects of the lower lip (one to two thirds) requiring recreation of the oral commissure.
Melolabial flaps can be used to reconstruct large full-thickness lower lip defects. However, they require grafting of the deep surface of the flap, have a less reliable random blood supply, and do not provide a functional muscular oral sphincter.
The submental artery island flap is based on the submental branch of the facial artery. A paddle of skin, subcutaneous tissue, and fascia harvested from the submental area can be used for coverage of lower face and preauricular defects, as well as inferior and lateral neck wounds. Its use for reconstruction of partial lower lip full-thickness defects has not been established.
Facial artery myomucosal flaps consist of oral mucosa, submucosa, a small amount of buccinator muscle, and a more deeply lying facial artery and venous plexus. They are ideal for reconstructing the inner, most lip mucosa because they consist of similar tissue, with the same color, texture, and moisture. They can also be used for reconstruction of the dry vermilion, although some drying-out and scabbing of the mucosa will occur. They are not indicated for large, full-thickness lower lip defects.
A 78-year-old woman has a 6.5-cm defect of the right cheek (shown) just below the lower eyelid after wide local excision for a lentigo maligna melanoma. All final pathologic margins are negative. Which of the following is the most appropriate management?
A ) Cervicofacial flap closure
B ) Full-thickness skin grafting
C ) Healing by secondary intention
D ) Internal mammary artery perforator flap closure
E ) Primary closure
The correct response is Option A.
Optimal color and texture matches for cheek reconstruction are obtained from using local cheek tissues (see photograph below). The cervicofacial flap is classically an inferomedially based flap that allows for transfer of large amounts of cutaneous and subcutaneous soft tissues from the loose preauricular and neck regions to the medial cheek. The incision begins at the superior margin of the defect and extends along the outer canthus toward the zygoma and down the preauricular crease. The incision ends in the retroauricular hairline or curves anteriorly in the region of the neck, preferably within a cervical rhytid. The flap is advanced and rotated into the defect, and primary closure of the donor site can usually be achieved via wide subcutaneous undermining. Anchoring of the flap to the zygoma is recommended to reduce tension on the lower eyelid that could lead to ectropion.
Full-thickness skin grafts tend to appear shiny and patch-like with a poor contour match. Split-thickness or very thin full-thickness grafts are also associated with graft contracture. Split- or full-thickness skin grafts are sometimes used as a ? emporary. method of reconstruction during a period of tumor surveillance to rule out early recurrence prior to definitive reconstruction.
Closure by secondary intention would require a prolonged period of healing and result in a poor final appearance with significant scar contracture, resulting in lower lid ectropion and possibly an upper lip deformity.
The internal mammary artery perforator (IMAP) flap is based on perforating blood vessels from the internal mammary artery and vein. The IMAP flap is an island variant of the deltopectoral flap and can be transferred as a free flap with good color match to the cheek compared with more distant tissues, such as the thigh or forearm. Use of the IMAP flap may result in breast distortion in a female and would require a microvascular anastomosis while not necessarily resulting in a superior cosmetic outcome to the cervicofacial flap.
Primary closure is often the reconstructive method of choice for small defects with excellent cosmetic results when the scar can be oriented along lines of minimal tension or natural cheek borders. However, for such a large defect, primary closure cannot be achieved without significant wound tension and excessive distortion of surrounding structures.
The 12-year-old girl shown is brought to the emergency department after being bitten in the face by a neighbor €™s dog. Her mother has brought the avulsed piece of skin wrapped in gauze. Which of the following is the most appropriate method for coverage of the wound?
A ) Application of wet-to-dry dressings
B ) Placement of a vacuum-assisted closure device
C ) Replacement of the avulsed piece of skin
D ) Use of cross-lip Abbe flap
E ) Use of a nasolabial flap
The correct response is Option C.
Lip reconstruction requires skin cover that is thin, supple, and matching; oral lining that is thin, supple, and sensate; resemblance of a vermilion that is supple, sensate, and appropriately colored; a deep labial sulcus for competence; commissure definition that provides expressive function; adequate stomal diameter for speech, eating, oral hygiene, or denture insertion; and an oral sphincter that is competent to contain both food during eating and saliva at rest.
Upper lip reconstruction is guided by the need to provide a central philtrum and two lateral elements. In the scenario described, the patient has an intact philtrum and left lateral element. She is brought to the emergency department with a subtotal right upper lip vermilion, skin, oral mucosa, and partial muscle loss. All of these elements are in the avulsed segment; therefore, this would be the best possible replacement of the missing tissue since the principle of plastic surgical reconstruction calls for replacing tissue with like tissue. Postoperative photographs are shown.
Secondary closure by either vacuum-assisted closure or dressing change will lead to contracture and distortion. Because the lips have no bony, cartilaginous, or fibrous infrastructure, wound contraction can cause permanent retraction of the free margin of the lip. The Abbe flap is best used for defects of the philtral column. The nasolabial flap is bulky and lacks innervation.
A 50-year-old woman comes to the office for consultation regarding closing of the right eye one year after she had an episode of Bell’s palsy on the right side. She says her right eye closes when she chews. Photographs are shown. Which of the following is the most appropriate management of this patient’s symptoms?
(A) Injection of botulinum toxin into the orbicularis muscle
(B) Repair of levator aponeurosis
(C) Fascial suspension of the brow
(D) Unilateral temporal brow lift
(E) Upper blepharoplasty
The correct response is Option A.
As shown in the photographs, this patient has right-sided orbicularis oculi contracture with orbicularis oris contracture. Her symptoms and history of Bell’s palsy are consistent with recovered facial nerve animation with synkinesis. Her right eye closes when she eats. Injection of botulinum toxin to the orbicularis muscle would treat the synkinesis and allow the adverse effect of lower lid lagophthalmos. Repair of levator aponeurosis and fascial suspension of the brow treat forms of eyelid ptosis. A temporal brow lift would treat unilateral brow descent secondary to residual palsy of the temple branch of the facial (VII) nerve. Upper blepharoplasty would treat upper-eyelid excess skin only; however, this patient does not display eyelid or brow ptosis, and there is no significant excess of upper-eyelid skin.
