Face Rehabilitation Techniques For Facial Paralysis

1. (Facial Paralysis
RehabilitationTechniques)
Edited By Dr.Mosab Sharaf Al-Deen
Supervised By Dr.Wael Al-Zarif
Rationales
Techniques

2. ‫المحاضرة‬ ‫مخطط‬
•‫الوجهي‬ ‫الشلل‬ ‫حدوث‬ ‫كيفية‬.
•‫التأهيل‬ ‫إعادة‬ ‫تقنيات‬
‫العصبية‬
‫العضلية‬
•‫متممة‬ ‫عمليات‬

3. Face Paralysis reasons
• ParotidTumors
• Temporal Fractures
• IntracranialTumors
• Gunshots
• Congenital syndromes
• Infections

4. Basics to Know
• The patient as well as the surgeon must appreciate that once the facial nerve is damaged,
there is no chance to restore normal facial function.
• It has been interesting to note that young children rarely have complications of corneal
exposure, even when lid closure is incomplete. It is speculated that this may be because
children’s tears contain protective properties lacking in the tears of adults.

5. Basics to Know
Time is of the essence in achieving the best
possible results since an 8-fold decrease in
axon diameter occurs over 3 months.
The decrease is due to shrinkage and later
gradual thickening of the collagen of the
endoneurial sheath.

6. Basics to Know
• Axon sprouts are being pushed out from the central stump within 4 days and will seek the
distal motor unit end plate re-establishing connection between the pons and the facial muscles
at a rate of 1 to 3 mm/day.
• Some chemotherapeutic agents have a direct effect on the myelin tubes, which may in turn
affect the health of a nerve graft significantly, For this reason, muscle transposition
techniques might be more appropriately employed than nerve grafting to reanimate the face
of a patient in whom chemotherapy is planned.

8. Rehabilitation Techniques
(Cranial methods)
• Hypoglossal-Facial Anastomosis (XII-VII Crossover)
• Hypoglossal-Facial Nerve Jump Graft.
• Facial Nerve Cross-Face Anastomosis
“Get there first with the
most.”

9. Factors in Selecting Surgical
Technique
1. What was the cause of the paralysis?
2. Is the paralysis complete?
3. How long has the paralysis been present?
4. How old is the patient?
5. Is the patient in good health?
6. What is the patient’s psychological status; in particular, are the patient’s expectations for rehabilitation realistic?
7. What problem does the patient feel should be addressed; is a particular aspect of facial function troublesome?
8. What are the functional defects?
9. What is the patient’s life expectancy?
10.Are any other cranial nerves involved, such as the trigeminal, vagus, or hypoglossal?
11. What surgical reanimation procedures have already been performed? When, and what were the results?

10. The Most Important Factor is
Time
The time between nerve injury and repair was the most significant factor in determining which
procedures were appropriate and whether the surgery would be successful. The best results
were achieved when the central nerve stump was connected to the peripheral system of the
facial nerve performed within 30 days of injury. Tone, symmetry, and slight movement might be
achieved as late as 1 year.
Facial Paralysis- Rehabilitation Techniques – chapter1

11. The nasal ala flares on the
normal
side but not on the involved
side.
Fixing the corner of the mouth on the normal side so that the weak side
will not be pulled toward the normal side. This may uncover some minimal
movement on the weak side.
Bell’s Phenomena

12. Rehabilitation Techniques
Hypoglossal-Facial Anastomosis
(XII-VII Crossover) +
‫اإلصابة‬
30 ‫يوم‬ 6 ‫شهور‬ ‫سنتين‬
Hypoglossal-Facial Nerve Jump Graft.
Facial Nerve Cross-Face Anastomosis
MuscleTransposition
(Temporalis – Masseter-
Free Grafts)

13. Hypoglossal-Facial Anastomosis
(XII-VII Crossover)
Indications
• Complete and permanent facial paralysis.
• Intact: extracranial facial nerve mimetic facial muscles
donor hypoglossal nerve
• A patient who can physiologically and psychologically accept the neurologic deficit created by
sacrifice of the twelfth nerve.
• Facial nerve regeneration may take as long as 12 to 15 months before any significant sign of
recovery is noted.
Golden StandardRob Peter to Pay Paul

16. Improved facial tone and symmetry occurs in over 90% of patients, It is
predominantly seen in the midface and to a lesser degree in the lower face, while it is
seen least in the frontalis region.
Complication

17. Surgical Principles
• Connect the defect between the
proximal and distal ends of the nerve
without tension
• Match the endoneurial surface of each
end. Tension can be avoided by noting
whether the nerve ends meet and hold
together without the need for a suture.

18. Surgical Principles
• The working end of the
nerve is the endoneurial
surface and not the
diameter of the nerve
ends, so The greater the
endoneurial surface, the
greater the axon volume.
• The bridge created by
the graft should form an
“S” or “C” shape
ensuring that there is
extra length and
absolutely no tension.

19. Hypoglossal-Facial Nerve
Jump Graft
An 8-0 monofilament suture is placed through
the twelfth cranial nerve marking a point that
is approximately one-third of the diameter of
the nerve. to ensure that when one makes a
divet in the nerve that no more than one-third
of the nerve is divided ensuring
preservation of tongue function.

20. Hypoglossal-Facial Nerve
Jump Graft

22. Surgical Principles
• The length of the nerve graft
obtained must be of sufficient length
even after this trimming in order to
bridge the gap without any tension.
The length of the graft should be at
least 1 or 2 cm longer than the gap it
is to bridge.
• Because length and axon volume
are the most critical features of a
nerve graft, it is these features that
help the clinician choose the proper
graft for the proper situation.

24. Surgical Principles
• Usually one or two perineurial sutures (8-0/10-0 monofilament suture material) are all that is
required between the main trunk or peripheral branches of the nerve and the donor graft.
• The exposed nerves are stained with 1% methylene blue. the epineurial sheath stains dark blue,
while the endoneurial surface stains a lighter blue.
• Dealing with Infections developed in patients who had combination procedures involving the mouth
area:
 intravenous clindamycin 600 mg just prior to administering general anesthesia and repeated
every 8 hours for the first 24 hours following surgery.
the wound is irrigated with clindamycin solution, and suction drainage is applied to all wounds.

25. A number of suggestions have been
proposed to increase recovery of facial
function and discourage the development of
synkinesis:
(1)clipping nonessential branches of
the facial nerve
(2)rotating the donor nerve graft so
that the distal end is sutured to the
proximal end of the facial nerve.
(3)orienting the interposition grafts to
match the appropriate segment of
the facial nerve.
(4)suturing fascicles to fascicles.

26. Our recommendation to explore the facial nerve under
these circumstances is based on the following facts:
• Spontaneous recovery is unlikely without repair if the nerve has been completely transected.
• There is no sure way to determine the nerve’s status without exploration. (No response To
EEMG)
• The longer the interval between injury and repair, the worse the results.

27. Facial Nerve Cross-Face
Anastomosis
• The obvious disadvantage of the
procedure is that it sacrifices normal
facial function for the potential benefit
to the paralyzed side.
• The more distal the branches used on
the normal side, the less “fire power”
provided; the more proximal, the
greater the donor deficit.
• The length of the nerve grafts requires
more time for nerve regeneration,
and thus suggests that the procedure
must be carried out relatively soon
following injury before distal
neurofibrosis prevents successful
reneurotization.
Long run for a short slide.

29. Muscle Transposition Techniques:
Temporalis, Masseter, and Digastric
• The following are specific indications for muscle transposition surgery to reanimate the face:
• (1) developmental facial paralysis in a patient of consenting age, defined as one who
understands the risks, potential complications, and benefits
• (2) long-standing facial paralysis, defined as no improvement in facial function for a period
of time sufficient to be certain that spontaneous regeneration is unlikely—usually 2 years or
longer
• (3) following cerebellopontine angle surgery when the proximal stump of the facial nerve is
unidentifiable or is unsuitable for facial nerve grafting and when the patient refuses to have
the hypoglossal nerve sacrificed
• (4) massive soft tissue loss as a result of a shotgun wound to the face
• (5) poor prognosis for long term survival following total resection of the parotid, or partial or
total temporal bone resection for cancer

30. • (6) the presence of a tenth cranial nerve deficit where it is not advisable to consider a
hypoglossal-facial anastomosis for fear of crippling the swallowing mechanism
• (7) cases of von Recklinghausen’s disease when a likelihood of other cranial nerves being
involved exists
• (8) rare situations in which the cause of the facial paralysis is not found and spontaneous
recovery is still a possibility
• (9) to augment the results following a nerve graft or hypoglossal facial nerve anastomosis in
selected cases

31. Temporalis Muscle
• The strength of the temporalis muscle is
weak in the edentulous patient.
• In patients who have had skull base or
middle cranial fossa surgery, the temporalis
muscle may be partially or completely
denervated, injured, or removed as part of
the surgical procedure.

35. • The patient returns 3 weeks after surgery
so that the skin clips in the scalp incision
can be removed.
• A soft diet should be continued for a
minimum of 3 weeks.
• Jaw clenching exercises are begun 6
weeks after surgery. In most cases,
results achieved at 6 weeks have been
lasting, and patients have continued to
improve for the next year.

36. The results of using the temporalis muscle to
reanimate the mouth are recorded as
“excellent,” “good,” “fair,” or “poor,”
Over 90% of the patients are improved, and
close to 80% are classified as good to
excellent.

38. Masseter Muscle
Indication : Radical cancer surgery of the
parotid where nerve grafting is not
possible, and the temporalis is injured.
The disadvantage of using the masseter
muscle is
The introduction of additional bulk that
creates a bulge in the corner of the mouth
and leaves a depression along the
mandible at the site of its original
position.
Removal of buccal fat at the time of
masseter rotation is designed to alleviate
some of the distortion caused by rotating
the muscle into the perioral region.

39. Digastric Muscle
This procedure is ideal for
isolated marginal mandibular
nerve injuries and should not
be performed in patients with
total facial paralysis.

40. Other
Operations

42. ‫أخرى‬ ‫إجراءات‬
• Parotid ductTransposition
BennettTechnique

43. Parotid ductTransposition
May, Kay & Weinstein
•a

44. Home Messages
‫العصبية‬ ‫الطرق‬‫العضلية‬ ‫الطرق‬
‫قبل‬6‫شهور‬6‫شهور‬–‫سنتين‬
‫متأخر‬ ‫بشكل‬ ‫النتائج‬ ‫تظهر‬(6-8‫سنتين‬ ‫حتى‬ ‫شهور‬)‫الجراحة‬ ‫بعد‬ ‫فوري‬ ‫بشكل‬ ‫النتائج‬ ‫تظهر‬
‫األطفال‬ ‫عند‬ ‫مفضلة‬(10‫سنوات‬)‫األورام‬ ‫مرضى‬ ً‫وخصوصا‬ ‫بالسن‬ ‫الكبار‬ ‫عند‬ ‫مفضلة‬
‫الكيميائية‬ ‫بالمعالجة‬ ‫مستطبة‬ ‫غير‬‫الكيميائية‬ ‫بالمعالجة‬ ‫تتأثر‬ ‫ال‬
‫عصبية‬ ‫متالزمات‬ ‫وجود‬ ‫عند‬ ‫تستخدم‬ ‫ال‬(VRs...)‫تستخدم‬
Hypoglossal-Facial Anastomosis
(XII-VII Crossover)
Injury
30 Days 6 Months 2Years
Hypoglossal-Facial Nerve Jump Graft.
Facial Nerve Cross-Face Anastomosis
MuscleTransposition
(Temporalis – Masseter-
Free Grafts)