Facial Palsy - Cheek and Lip reconstruction Flashcards
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 24-year-old man is brought to the emergency department 30 minutes after sustaining a laceration to the left cheek with a sharp piece of glass. Physical examination shows a 5-cm laceration extending from the left ear to the mid cheek. The patient has motor weakness of his upper lip. The wound is debrided and closed in layers. The patient has increasing swelling over the left cheek over the next five days. Which of the following steps in initial management was overlooked?
(A) Arteriogram
(B) Cannulation of Stensen duct
(C) CT
(D) Duplex ultrasound
(E) Nerve conduction studies
The correct response is Option B.
The buccal branch of the facial nerve travels with the parotid duct in the cheek. In a deep laceration of the cheek in which either of these structures is injured, it is likely that the other also will be injured. The facial artery and facial vein are lateral to the midfacial region at the mandibular angle. It is recommended that cut nerve branches be repaired immediately. The parotid duct must be explored. If it is injured, it must be repaired immediately. To diagnose an injury, the Stensen duct may be cannulated intraorally. An injection of saline or methylene blue will determine if the duct is intact. If there is no leakage, the duct is intact. If there is leakage, the proximal and distal cut ends of the duct must be repaired over a stent, often a Silastic tube or small feeding tube (see the photographs below). The tube must remain in place for approximately two weeks until the duct heals. If parotid duct injury is left undiagnosed, a sialocele will develop. Neither the temporalis nor masseter muscle will be injured and result in malocclusion.
Arteriogram, imaging studies (CT and ultrasound), and nerve conduction studies would not be effective in diagnosing an injury to the parotid duct.
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 60-year-old man is evaluated for a painful unilateral facial rash with blisters, intense ear pain, and complete ipsilateral facial nerve paralysis. Which of the following is the most likely diagnosis?
A) Cholesteatoma
B) Facial myokymia
C) Lyme disease
D) Möbius syndrome
E) Ramsay Hunt syndrome
The correct response is Option E.
This is a case of Ramsay Hunt syndrome, also known as herpes zoster oticus. It is a variant of typical herpes zoster, in that in its reactivation, it affects both afferent neurons as well as motor axons of the facial nerve. A combination of corticosteroids, narcotics, and acyclovir is the standard of care.
Facial myokymia is mainly associated with multiple sclerosis and causes a wormlike motion in the facial muscles.
Möbius syndrome is a congenital condition characterized by, among other nerve conditions, facial paralysis.
Cholesteatoma is a benign growth in the middle or external ear formed from desquamated keratin. It can act locally and be very aggressive, so much so, that if left untreated, it could cause destruction of the facial nerve.
This is not a typical presentation of Lyme disease.
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
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 not spontaneous to when compared 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 72-year-old woman comes to the office for consultation because she has had inability to close the left eye, raise the ipsilateral eyebrow and lip, flare the nostril, or show the teeth since she experienced flu-like symptoms three months ago. She has had no previous surgeries and takes no medications. Physical examination shows ptosis of the left forehead, palsy of the ipsilateral mentalis and nasalis, and weakness of the zygomaticus major and depressor anguli oculi muscles. MRI shows intact facial (VII) and acoustic (VIII) nerve branches and no lesions. Which of the following interventions is most appropriate to achieve brow symmetry in this patient?
(A) Endoscopic brow lift procedure with no muscle transection
(B) Injection of botulinum toxin (Botox) into the left frontalis muscle
(C) Injection of Botox into the left orbicularis oculi muscle
(D) Injection of Botox into the right frontalis muscle
(E) Injection of Botox into the right orbicularis oculi muscle
The correct response is Option D.
The patient described has Bell palsy. Typical signs include ptosis of the brow and forehead, upper eyelid retraction, lower lid ectropion, decreased blink, and decreased ability to close the eye.
Injection of Botox is a temporary procedure that can be useful to achieve animated symmetry. The frontalis, zygomaticus, and depressor anguli oculi of the unaffected side are often targets for paralysis, so that the two sides can remain symmetric during animation. If the motor function returns, the affected side may require some mild Botox treatment; however, usually this is for blepharospasm.
An endoscopic forehead lift (Endobrow) or other static procedure may be useful once recovery seems unlikely and muscle denervation is probable (one to two years). A gold weight can help close the eye, a canthoplasty can tighten the tarsoorbicularis sling, and a brow lift can treat the ptosis. Studies have shown that in the older population, a skin resection procedure may be more effective than an Endobrow procedure.
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 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.
After schwannoma resection with facial nerve sacrifice, which of the following reconstructions provides the quickest restoration of natural reflexive dynamic blink?
A) Cross-facial nerve grafting
B) Functional muscle transfer
C) Gold weight insertion
D) Ipsilateral nerve grafting
E) Nerve transposition
The correct response is Option E.
All of the choices are suitable options for reanimation of the eyelid; however, transfer of a regional nerve, such as the motor nerve to the masseter, will result in the quickest reinnervation of the orbicularis oculi muscle. Nerve grafts may be used to overcome a wide neural gap; however, nerve regeneration proceeds slowly at only 1 mm per day. Cross-facial nerve grafts take an extended period of time to regenerate due to the long distance from the contralateral side. While gold weights are immediately effective, they are static procedures. Restoration of a reflexive blink requires neural input from the zygomatic branch of the facial nerve or direct neurotization of the orbicularis oculi muscle. Functional muscle transfers used for eyelid reanimation include the frontalis and temporalis; however, because they are innervated by nerves other than the facial, coordinated movements are not present.
A 7-year-old girl with congenital palsy of the left facial nerve is scheduled to undergo facial reanimation using a free gracilis muscle neurotized by the motor branch to the masseter muscle. Compared with cross-facial nerve grafting from the contralateral facial nerve, use of this procedure is most likely to result in which of the following?
A) Decreased excursion of the reanimated oral commissure
B) Development of a crossbite
C) Increased risk of long-term muscle atrophy
D) Need for additional surgical procedures
E) Unpredictable smile symmetry
Facial reanimation procedures using free tissue transfer have largely supplanted static procedures for pediatric facial paralysis. Although cross-facial nerve grafting (CFNG) remains an excellent option, many surgeons now prefer using the motor branch to the masseter (trigeminal nerve), since it can be done in a single stage, yields excellent muscle reinnervation, and produces muscle contraction/commissure displacement that typically exceeds that of CFNG. Although this motor branch provides innervation to the masseter, there are no reports of crossbite after its use in facial reanimation. CFNG provides relatively consistent smile symmetry and spontaneity since the stimulus for muscle contracture on both sides of the face comes from the same facial nerve source. In contrast, smile spontaneity and symmetry are much more variable when the motor masseteric branch is used and requires some cortical adjustment and/or behavioral education to develop; younger patients respond much more reliably and naturally than older patients
A 20-year-old man is evaluated for reconstruction of the lip after sustaining a traumatic blast injury to the face with complete loss of the lower lip. The patient wishes to have a symmetric, dynamic, and competent lower lip. Which of the following treatment plans is most likely to achieve the patient’s desired outcome?
A) Innervated anterolateral thigh flap
B) Innervated gracilis muscle
C) Innervated regional advancement flaps (Karapandzic)
D) Prosthetic lower lip appliance
E) Radial forearm flap with tendon graft
The correct response is Option B.
Total lower lip reconstruction is very challenging. A prosthetic lower lip may have acceptable static appearance but does not afford competency or dynamic function. An anterolateral thigh flap would be bulky and adynamic. Innervated regional advancement flaps are not indicated for total lip loss and would lead to microstomia. A radial forearm flap with a tendon graft can achieve an acceptable appearance and competence. The radial forearm flap is unable to achieve spontaneous lower lip movement that is as symmetrical as that of the functional gracilis muscle flap. If a split-thickness skin graft from the scalp is used, the color match can be superior to radial forearm flap as well. The functional gracilis flap is most likely to achieve this patient’s goals.
A 5-year-old girl with Möbius syndrome is brought to the office for evaluation of facial paralysis. Physical examination shows masklike facies, inability to animate the face bilaterally, and generalized hypoplasia of the tongue. Which of the following is the most appropriate donor nerve to restore facial function in this patient?
A) Hypoglossal
B) Ipsilateral facial
C) Masseteric
D) Spinal accessory
E) Phrenic
In the case of Möbius syndrome and most pediatric patients with facial paralysis in which the facial muscles are no longer available, a microneurovascular transfer with a muscle flap is the preferred treatment. The gracilis is the most advocated muscle used for this purpose. Pediatric patients are generally very motivated and do well with microneurovascular transfer with a muscle flap.
In Möbius syndrome, the sixth and seventh cranial nerves are commonly involved. Other cranial nerves may be involved as well. In addition to the facial muscles not being available for reconstruction, the cranial nerves are also not available in patients with Möbius syndrome. Hence, transfer to the ipsilateral or contralateral facial nerve is not a viable option for reconstruction in patients with Möbius syndrome, as the facial nerve does not function.
Use of the hypoglossal nerve in patients with Möbius syndrome is relatively contraindicated due to worsening of tongue function. The “babysitter” technique utilizes the hypoglossal nerve as a donor nerve.
The masseteric nerve is preferred over the spinal accessory and phrenic nerves as it provides better motor strength and lower morbidity in the muscle transfer
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.
An 8 year old boy presents with a dog bite to the upper lip. It appears that 2.5 cm of cutaneous lip and dry vermillion has been avulsed, lateral to the philtral column. The best technique for repair of this injury is which of the following?
A) Abbe flap
B) Full thickness skin graft
C) Primary closure
D) Rotation-advancement closure
E) Karapandzic flap
Correct answer is C.
Up to 25% to 30% of the lip can usually be closed primarily secondary to the structure’s inherent elasticity and redundancy. Primary closure, when possible, provides the best cosmetic outcome secondary to better color and texture match and avoidance of donor deformity. More complex techniques may be required with larger avulsions. Any type of repair can result in significant deformity if it is not performed with careful attention to alignment of the vermillion border.
A 30-year-old woman comes to the office for evaluation of an asymmetric smile. Two months ago, she underwent primary neurorrhaphy of a facial nerve laceration 2 cm lateral to the oral commissure. Physical examination shows no elevation of the upper lip with smiling on the side of the injury. Which of the following is the most appropriate management?
A) Cross-facial nerve grafting
B) Facial sling suspension
C) Free muscle transfer
D) Injection of botulinum toxin type A
E) Observation
Correct answer option E
The injury period is short enough that the potential for the initial neurorrhaphy to work is still likely. Clinical Tinel sign would be helpful to assess this further. Injection of botulinum toxin type A at this point would confuse the picture because it would prevent clinical monitoring of nerve recovery. If the patient does not recover nerve function within the next 6 months, then she is still a candidate for facial reanimation because the injury is not long-standing. A static procedure is not indicated unless the patient has a long-standing injury or is not a candidate for facial reanimation.
A 42-year-old woman who has excess skin and subcutaneous tissue of the lower buttocks is scheduled to undergo excisional lipectomy with the incisions parallel to the gluteal fold. Which of the following is the most likely adverse effect?
(A) Dimpling of the buttocks
(B) Fat necrosis
(C) Flattening of the gluteal fold
(D) Painful scarring
(E) Widening of the gluteal cleft
The correct response is Option C.
Adverse effects reported with transverse excision lipectomy include flattening and asymmetry of the buttocks and hypertrophic scarring. Dimpling of the buttocks is more commonly associated with suction lipectomy in the region overlying the gluteal muscles because of the large amount of fibrous septa between the fascia and skin. Widening of the gluteal cleft is uncommon because the incision is made parallel to the gluteal fold.
Fat necrosis does not generally occur in the buttocks because of the good vascularity in this region. Long-term painful scarring is also rare.
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 36-year-old man has facial palsy on the right after sustaining a crush injury of the right mastoid. Reinnervation with cross-face nerve grafts is planned. Which of the following factors will best determine the success of this procedure?
(A) Density of contralateral facial nerve fibers
(B) Length of elapsed time between paralysis and surgery
(C) Number of cable grafts used
(D) Postoperative stimulus program with muscle re-education
(E) Use of motor donor grafts instead of sensory donor fibers
The correct response is Option B.
Cross-face nerve grafting offers the best chance of restoration of function in this patient in whom the ipsilateral proximal facial nerve stump cannot be used. The facial muscles remain viable for approximately two years; after this
timulation has not been shown to increase the likelihood of reinnervation.
There will always be a sufficient density of contralateral fibers to use as donors. As few as one to as many as four cross-face cables can be used during surgery; the number used generally depends on the condition and location of the distal stump. Postoperative muscle re-education programs offer increased control only if reinnervation actually occurs. Finally, there is no evidence that using motor rather than sensory donor grafts makes a difference in outcome.
Drawbacks of scalp strip graft reconstruction of post-traumatic alopecia of the eyebrow include which of the following?
A) Excessive hair length
B) Multiple sessions required
C) Donor site deformity
D) General anesthesia required
Correct answer is a.
Many techniques exist for reconstruction of the eyebrow, including flaps, composite or strip grafts, punch and micrografts. The easiest technique is a strip graft, often harvested from the occipital region, is easily performed under local anesthesia. The donor site is well-hidden and reconstruction is usually accomplished in a single stage. However, scalp hair shaft caliber is often too thick to properly match native eyebrow hair, and scalp hair grafts require frequent trimming because of scalp hair growth.
A 30-year-old man has the sudden onset of weakness of the right eyebrow and cheek and the right side of the mouth. There is no history of trauma or disease; physical examination is otherwise unremarkable. Which of the following is the most appropriate initial step in management?
(A) Observation
(B) EMG
(C) MRI
(D) Facial nerve decompression
(E) Right eyelid tarsorrhaphy
The correct response is Option A.
This patient most likely has Bell’s palsy, an idiopathic form of facial paralysis that is the most common diagnosis in persons with facial paralysis (approximately 80%). Diagnosing this condition involves excluding other causes, such as trauma, stroke, and tumor, and thus should be preceded by a thorough evaluation of the patient. Bell’s palsy is often associated with diabetes mellitus and pregnancy.
Eighty-five percent of patients who have Bell’s palsy will begin to have spontaneous recovery of neurologic function within three weeks. In 15% of affected patients, however, it may take three to six months before some recovery of function is experienced. But because Bell’s palsy is rarely permanent, at least some recovery is expected.
Observation for three weeks is indicated prior to performing extensive diagnostic studies. Many of the tests used in the diagnosis of Bell’s palsy are expensive and give limited information. Positive findings on electromyography will not be seen until 14 to 21 days after the onset of paralysis. CT scan or MRI may be appropriate after a three-week observation period, if the condition persists. Surgical decompression is not frequently recommended because it increases the risk for injury to the inner ear as well as to the nerve itself; moreover, it has not been clearly shown to be helpful in all cases. Ocular symptoms can generally be managed with artificial tears, use of ointments, and taping until function returns, so eyelid tarsorrhaphy is not necessary.
Although electroneurography (ENOG) will show nerve conduction defects immediately and objectively and is the most accurate and reproducible test currently available to determine the return of facial nerve function, it is generally considered to be prohibitively expensive and time-consuming.
A 25-year-old woman is evaluated for unilateral facial paralysis after she sustained an episode of Bell palsy that did not respond to oral administration of corticosteroids. Methods for functional reconstruction using a gracilis muscle transfer are discussed. Which of the following is an advantage of this muscle transfer for this patient?
A) Ability of the nerve to reach the contralateral side
B) Ability to incorporate overlying tendon
C) Multiple directions of pull
D) Reliable vascular pedicle
E) Two dominant nerves
The correct response is Option D.
The gracilis muscle has been widely used for facial reanimation because of its many advantages. The muscle is located in the inner thigh, which makes harvest easy in a supine position and keeps the donor site well hidden. It has a single constant vascular pedicle of adequate length for transfer. Although it is able to generate sufficient force for animation, it has only one direction of pull and is thus best suited for restoring only one component of smiling. There is no overlying tendon, and there is a single dominant nerve that is not able to reach the contralateral side of the face.
A 10-year-old girl is brought to the office by her parents for consultation regarding congenital unilateral facial paralysis. She has had no previous treatment of this condition. Physical examination shows no muscle activity on the affected side. Which of the following is the most appropriate first step in management to restore voluntary animation to the paralyzed side of the face?
(A) Cross-facial nerve grafting
(B) Gracilis neurovascular free tissue transfer
(C) Masseter muscle transfer
(D) Temporalis muscle transposition
(E) Tensor fascia lata suspension
The correct response is Option A.
The best treatment for this child with unilateral facial paralysis involving the eye is a two-stage surgical correction resulting in dynamic reanimation. In the first stage, cross-facial nerve grafting is constructed from the unparalyzed side of the face to the paralyzed side. The sural nerve is commonly used as a graft. The second stage consists of free tissue transfer of muscle, such as the gracilis or pectoralis minor, to the paralyzed side of the face. Microneurovascular anastomoses are completed, with the goal of functional reanimation of the paralyzed face.
Eyelid closure is a priority issue in treatment of facial paralysis. Lack of corneal protection can result in keratitis, conjunctivitis, corneal ulceration, and visual impairment. Although use of artificial tears and ointments is necessary, such treatment is neither permanently effective nor corrective in any type of functional repair.
Transposition of the temporalis muscle is another option for dynamic reconstruction of the eye in patients with facial paralysis. It has the advantage of immediate functional correction, compared with the lag period required for muscle reinnervation by cross-facial nerve grafting. However, one long-term study has shown overall better functional results, measured by eyelid closure and movement, in patients undergoing correction with two-stage cross-facial nerve grafting and muscle transfer compared with transposition of temporalis muscle. In addition, microneurovascular tissue transfer is a better choice in children with facial paralysis, who may be the best candidates to achieve functional adaptation after such a procedure. Furthermore, the use of a muscle of mastication in children may have potential deleterious effects on skeletal maturation.
Static correction of eyelid closure by means such as fascial or tendon sling creation, tarsorrhaphy, and placement of a gold weight does not produce dynamic movement and, therefore, does not fully correct the obvious functional deficit apparent on the paralyzed side with animation of the face. These options are more suitable for older patients with facial paralysis, in whom static correction may be more desirable and who may not be optimal candidates for more complex procedures such as free tissue transfer.
A 3-year-old girl is brought to the emergency department because of a 6-hour history of right-sided facial weakness. On physical examination, the patient has an asymmetric smile, and the right eyelid does not close completely. Which of the following is the most likely cause of this deformity?
A ) Congenital
B ) Idiopathic
C ) Infection
D ) Neoplastic
E ) Trauma
The correct response is Option B.
The most common etiology of new-onset facial nerve paralysis in a child is Bell palsy. While some studies with small cohorts have shown that many cases of Bell palsy may miss the underlying diagnosis, the large reviews still report Bell palsy as the most common etiology. Infection and trauma are the next most frequent causes, followed by neoplastic and congenital. Etiology is important because it guides treatment, and early treatment with antibiotics, antivirals, and in some cases, surgical decompression, results in a better long-term recovery of facial nerve function.
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 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.
A 42-year-old man is brought to the emergency department after sustaining a dog bite to the tip of the nose. History includes hypertension. Physical examination shows a 3-cm soft-tissue deficit involving 80% of the nasal tip. In addition to resection of the remaining nasal tip, which of the following methods of reconstruction is most likely to provide the most satisfactory aesthetic outcome?
A) Split-thickness skin graft
B) Full-thickness skin graft
C) Dorsal nasal flap
D) Nasolabial flap
E) Forehead flap
The correct answer is option E.
Aesthetic principles, as outlined by Burget, et al, dictate that when greater than 50% of the tip or alar subunits are compromised, the best aesthetic outcome will result when the entire subunit is resected and reconstructed. While others such as Rohrich, et al, have argued that this is not an absolute rule and that each case must be analyzed individually, the best aesthetic outcome will result from avoiding scars directly on the tip of the nose in the scenario described. A skin graft will contract and show a different skin color and quality than the surrounding skin, making it less likely to be satisfactory to the patient described. A nasolabial flap, while an appropriate choice for smaller defects and alar defects, is unlikely to reach over the midline. A forehead flap is a classic reconstructive option for nasal tip defects. The dorsal nasal flap is also a possibility, but it is limited to defects up to 1.5 to 2 cm.
A 65-year-old man is evaluated for right facial nerve paralysis. Upper eyelid reanimation is planned. The gold weight prosthesis is selected. Which of the following considerations is most appropriate for this patient?
A) Allowing coverage of the upper limbus at rest
B) Bringing the upper eyelid to within 2 to 4 mm of the lower eyelid
C) Enabling complete closure of the upper eyelid
D) Enabling the most rapid closure of the upper eyelid
E) Providing the best symmetry with the contralateral eye
The correct response is Option B.
Gold weight prostheses are commonly used for upper eyelid reanimation in patients with facial nerve dysfunction. The weight required can be estimated preoperatively by using two-sided tape to secure various test weights to identify the prosthesis that brings the upper eyelid to within 2 to 4 mm of the lower lid and completely covers the cornea. A common mistake is to use a weight that is too heavy in an effort to completely close the upper eyelid, resulting in upper eyelid ptosis and obstruction of field of view. Revision surgery is often needed in these cases. Contralateral symmetry is rarely achieved with gold weights and is not a criterion for assessment. Similarly, the speed with which the upper eyelid is closed is usually slower than the contralateral eyelid and is not a factor in weight selection.
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.
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.
Injuries to the proximal parotid duct are best treated with which of the following techniques?
A) Repair over a stent
B) Proximal ligation
C) Parotidectomy
D) Distal ligation
The correct answer is option D.
Injuries of the proximal duct near the parotid gland are usually best treated by ligation of the duct as proximally as possible to decrease the risk of sialocele. Lacerations of the distal portion of the duct are often able to be repaired over a stent. In these cases the stent is trimmed at the level of the oral papilla and sewn to the oral mucosa or around the maxillary second molar with a chromic suture. Parotidectomy is rarely indicated in trauma as injury to the gland itself can often closed primarily with absorbable sutures.
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.
A 28-year-old man comes to the office because of fever and increasing pain 1 week after partial amputation of the right ear when he was bitten during a fight. The wound was irrigated and repaired in the emergency department. Temperature is 100.4°F (38.0°C). Examination shows erythema and swelling of the entire ear and a small area of dehiscence containing pus along the posterior suture line. Which of the following is the most important step in management?
A) Irrigation, debridement, and packing the wound open
B) Application of wet-to-dry dressings
C) Completion of the amputation with sparing of cartilage in a remote subdermal pocket
D) Intravenous antibiotic therapy
E) Oral antibiotic therapy
The correct answer is option a.
Auricular chondritis and perichondritis is a serious surgical infection requiring immediate surgical intervention as the primary course of treatment in traumatic cases. Culture swabs should also be obtained and will guide antibiotic therapy for associated cellulitis; however, broad spectrum coverage initially is appropriate. Chondritis complicating elective otoplasty is sometimes handled in a more stepwise approach, sometimes initiating intravenous antibiotics while removing a few sutures to allow drainage and/or insertion of a small irrigating catheter. Without a reasonable response in these cases, then standard open irrigation and debridement are done with removal of all sutures, and repeat otoplasty correction is deferred until several months after resolution of the infection.
Antibiotics alone, orally or intravenously, for localized suppurative chondritis are likely to be ineffective without surgical treatment. Likewise, topical dressings without formal opening of the suture line for wide exposure and drainage of the infected cartilage would also be ineffective.
Completing the amputation when the tissues still appear viable is overaggressive at this stage. If and when the majority of the tissue appears unable to sustain sufficient circulation to support its viability, then discarding precious tissue is justified. Salvaging the cartilage framework component in a remote subdermal pocket may be useful; however, the cartilage is infected in this scenario and would require caution, including thorough debridement and lavage with antibiotic solution and close monitoring of the bank.
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.
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.
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.
The vector of commissure movement in a free gracilis muscle flap for facial reanimation should simulate the pull of which of the following facial muscles?
A ) Buccinator
B ) Levator labii superioris
C ) Risorius
D ) Temporalis
E ) Zygomaticus major
The correct response is Option E.
Free gracilis muscle transfer is a common method to produce a smile in patients who have complete facial nerve paralysis. It has several properties that make it ideal for this purpose: it is thin, has good contractility, leaves no functional deficit after muscle harvest, and has a relatively long motor nerve. The inset of the muscle, including appropriate tensioning and orientation, are critical for success. The muscle is attached proximally to the body of the zygoma or the temporalis fascia and distally to the orbicularis oris muscle near the modiolus just lateral to the oral commissure. Although there can be some variation in flap positioning, the desired vector of pull most closely simulates the normal pull of the zygomaticus major muscle.
The temporalis and buccinator muscles are not involved in smiling. The levator labii superioris originates from the anterior zygoma and inserts near the orbicularis oris muscle in the upper lip. The vertical direction of this makes it a powerful vertical elevator of the upper lip. The risorius does not elevate the oral commissure but instead pulls the corner of the mouth in a nearly horizontal direction.
A 76-year-old man is evaluated for reconstruction of a defect of the left lateral lower lip and left commissure following resection with clear margins of a 2.5-cm lesion. Examination shows a full-thickness defect of the left lateral lower lip and left commissure. Which of the following flaps is the most appropriate method of reconstruction?
A ) Estlander
B ) Gillies
C ) Karapandzic
D ) Radial forearm, with palmaris longus sling
E ) Webster-Bernard
The correct response is Option A.
This scenario involves a significant resection of the lower lateral lip including the lateral commissure. Thus, reconstruction of both the lower lip and the commissure is required. The most appropriate flap for reconstruction of this defect is the Estlander flap. The Estlander flap is an upper lip-switch flap that is used to reconstruct defects involving the commissure. Rotation of the upper lip to the lower lip provides additional tissues for reconstruction of the lower lip defect and repairs the commissure. However, rotation of the upper lip in a defect that has no commissure results in a rounded commissure and often requires additional surgery.
The Karapandzic and Gillies flaps are advancement flaps of the remaining lower lip and are most useful for central defects of the lower lip. The main difference between these options is that the branches of the facial nerve are dissected and preserved in the Karapandzic flap thereby preserving facial nerve function. The Webster-Bernard flap advances the cheek skin by removing a Burrow triangle bilaterally. Similar to the Karapandzic and Gillies flap, this option is most useful for central lip defects and does not reconstruct defects of the commissure. Finally, the radial forearm flap with palmaris longus sling is most useful for total lower lip defects.
