Archive for February, 2010
Facial paralysis can be an emotionally and psychologically devastating problem. There are numerous causes, with the final common pathway being either partial or total loss of facial movement on the affected side of the face. Sometimes nerve repairs are performed with in the first weeks to months of injury or at the time of paralysis if there has been an obvious transection of the nerve from trauma or tumor resection with a primary end to end repair or cable graft, which involves placing another, different nerve between the two residual ends. This commonly results in some degree of synkinesis, or dysfunctional muscle movement with good muscle tone at rest and is the best option to attempt to restore natural facial movements. If the proximal end of the facial nerve is not available for repair then a cross facial nerve graft or hypoglossal jump graft or direct repair may be used. The cross facial nerve graft involves using a branch of the opposite healthy facial nerve and a nerve graft that is tunneled to the damaged side to provide input to the damaged facial nerve and paralyzed muscles. With a hypoglossal procedure, the nerve that provides movement to the tongue is used to innervate the damaged facial nerve. The hypoglossal procedures require significant physical therapy for good outcomes and can be a good option in experienced hands.
If there is no option for one of the direct repairs or nerve graft procedures then facial reanimation is best achieved by restoring eye function and facial tightening and lifting procedures. When the eye is unable to close there can be chronic irritation due to dryness despite the use of lubricants and taping of the eyelid at night. The irritation can progress to corneal ulcerations and permanent vision problems if not addressed in a timely manner and should be co-managed with an Ophthalmologist to help make the decision for the timing of a definitive repair. With the loss of neural input, the upper eyelid does not close completely and the lower eyelid will droop with resultant chronic tearing and irritation. The procedure to restore eye function often includes placing a gold or platinum weight in the upper eyelid to assist with closure and tightening the lower eyelid to reduce tearing and allow for complete eye closure. Less commonly, some physicians may use a spring to assist with eye closure. Once eyelid function is restored the other facial asymmetries should be addressed either at the same procedure or with a separate surgery.
The general rule of thumb with the timing of facial reanimation is to wait 12 months before intervention to allow for return of function following the paralysis. The corner of the mouth and smile are often affected significantly with facial paralysis patients and can be addressed in several ways. Restoring symmetry of the mouth at rest is of primary importance. This can be accomplished with both static and dynamic reanimation procedures. The two most common static procedures include gortex suspension slings and fascia lata grafts. The facia lata graft is taken from the leg and each are used to pull the corner of the mouth up, but there is no ability for movement following the procedure. Dynamic reanimation procedures are intended to restore symmetry and movement of the lip following the procedure and they include: a temporalis muscle sling, a gracilis free graft, and a temporalis tendon transfer. The temporalis muscle sling uses one of the muscles involved in chewing, with a portion brought down and connected to the corner of the mouth. Because it uses healthy muscle, movement of the corner of the mouth is possible with smiling. The downside to this procedure is fullness and bulkiness over the cheek due to the extra tissue brought over the cheek bone. The gracilis free graft uses a muscle from the leg that is hooked up to the opposite facial nerve to allow contraction and movement of the corner of the mouth. Most recently, the temporalis tendon transfer has been used to restore symmetry and movement and involves repositioning the temporalis muscle tendon from the jaw to the corner of the mouth alleviating the bulkiness of the temporalis muscle sling.
Unfortunately there is no procedure to restore movement to the brow and consequently making the brow heights symmetric is the primary goal. This involves a brow lift procedure on the affected side to correct the asymmetry. Additionally, Botox may be used on the opposite, normal side to reduce movement and the ability of others to recognize differences with facial expressions. A facelift and midface lift may also be used to elevate the cheek and correct the jowls on the affected side, further improving facial symmetry. If significant problems with drooling and difficulty controlling secretions and food exist, the lower lip may be tightened by removing a portion of the lip and tightening the lip muscle.
Facial paralysis is a complex problem with many different ways to address the issues and no single best procedure. Often the management requires the expertise of a neurotologist and a facial plastic surgeon for optimal results. The type of procedure selected for corrective facial paralysis surgery requires knowledge about the options available and the indications for their use. Consultation with a skilled facial plastic surgeon is important to achieve the best results and avoid disappointing outcomes.
Post provided by: Benjamin C. Stong MD
The topic of neck rejuvenation requires a discussion of skin rejuvenation, liposuction, facelift surgery, and direct skin excisions. Age related changes in the neck occur simultaneously with the age related changes in the face. These changes include sun damage to the skin, accumulation of excess fat and skin, and the formation of vertical bands. There is no absolute predictable pattern to how a neck will age and is intensely affected by an individual’s anatomy, genetics, diet and exercise patterns, and sun exposure. As such, there is no single way to address a patient’s concerns and a rejuvenation plan must be tailored to a patient’s specific issues.
As with any area of skin, the neck skin accumulates sun damage over years. The skin of the neck is thinner than the skin of the face and is more prone to complications with aggressive rejuvenation procedures such as phenol peels and traditional CO2 laser resurfacing. In general, the goal of laser skin rejuvenation is to be as aggressive as the tissue allows while balancing results with safety. Although most laser companies do not recommend the use of ablative lasers on the neck, clinicians routinely use laser rejuvenation therapies with excellent outcomes. A critical element to good outcomes is to use lower settings on the resurfacing laser or less aggressive chemical peel than in the face.
Many patients believe they are good candidates for liposuction as a sole rejuvenation procedure. In fact, the opposite is true, only a select few individuals are candidates for liposuction in isolation. As we age the skin loses elasticity and subsequently its ability to contract. The ideal candidate for neck liposuction is someone in their 20’s or 30’s with minimal sun damage or excess skin. These individuals usually have skin that will contract back down following liposuction with good results. Once sun damage has occurred and excess skin has accumulated, removal of skin becomes necessary. Excellent liposuction techniques are also critical for great results.
Most patients in their 40’s and 50’s have enough sun damage and excess skin to require removal. There are two primary ways to address this issue. The first is with a facelift or neck lift. An abbreviated mini facelift incision can be used. The neck skin is removed from the portion of the incision placed behind the ear. Some surgeons may offer patients an isolated neck lift procedure using only the portion of the facelift incision behind the ear to avoid more obvious incisions in the neck. Patients must understand that in no way will this address the excess skin and jowling of the face and is performed to avoid placing incision directly in the neck skin. During the facelift or neck lift procedure the vertical bands are addressed by tightening the platysma muscle which acts as a corset for deeper neck fat that protrudes as we age. The second way to address the excess skin of the neck is with a direct neck lift using a direct skin excision technique such as the Grecian Urn or another such procedures. It is offered as a primary procedure almost exclusively in men. Sometimes residual skin following a face or neck lift will be removed with smaller direct neck excision techniques, but in general it is a bad idea in women as a primary procedure because it will leave visible scars. In men, because of their bearded skin, a direct neck excision can be a good alternative to a facelift procedure. During a direct neck excision, the vertical bands should be addressed by tightening the underlying platysma muscle during the skin excision.
Total neck rejuvenation in older patients should include removal of the excess skin by a method the patient and the physician are comfortable with, along with tightening of the platysma muscle and liposuction as indicated. A staged skin rejuvenation procedure may be performed either before or after surgery to complete the rejuvenation. Consultation with a knowledgeable and skilled facial plastic surgeon will help avoid bad outcomes and disappointing results.
Post provided by: Benjamin C Stong MD