Secondary surgery in paediatric facial paralysis reanimation

doi:10.1016/j.bjps.2009.11.036

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 63, Issue 11, November 2010, Pages 1794-1806

https://doi.org/10.1016/j.bjps.2009.11.036 Get rights and content

Summary

Ninety-two children, the entire series of paediatric facial reanimation by a single surgeon over thirty years, are presented. The objective is to analyse the incidence and value of secondary revisions for functional and aesthetic refinements following the two main stages of reanimation. The reconstructive strategy varied according to the denervation time, the aetiology, and whether the paralysis was uni- or bilateral, complete or partial. Irrespective of these variables, 89% of the patients required secondary surgery. Post-operative videos were available in seventy-two cases. Four independent observers graded patients' videos using a scale from poor to excellent.

The effect of diverse secondary procedures was measured computing a mean-percent-gain score. Statistical differences between treatment groups means were tested by the t-test and one-way ANOVA. Two-thirds of the corrective and ancillary techniques utilized granted significantly higher mean-scores post-secondary surgery. A comparison of pre- and post-operative data found valuable improvements in all three facial zones after secondary surgery. In conclusion, inherent to dynamic procedures is the need for secondary revisions. Secondary surgery builds in the potential of reanimation surgery, effectively augmenting functional faculties and aesthesis.

Section snippets

Patients and methods

A retrospective search of all paediatric patients operated upon for facial paralysis since 1979 revealed 92 patients. All patients had their medical charts studied, and every reconstructive, revisional or ancillary procedure was analysed. The age range was 14 months to 16 years (8.2 ± 4.6, mean ± SD), with 37% of the patients being under five. Table 1 lists the diverse etiologies involved. Denervation time ranged from six to 204 months (79.6 ± 53.7, mean ± SD), with 95% of the cases (88/92) presenting

The upper-face

Complete paresis of the orbicularis oculi muscle (OOM) presents as lagophthalmos, ectropion and/or epiphora.²⁶ By the time of the first consult, most children had already received acute assistance and corrective eye surgery if needed. Nevertheless, all patients had corneal protection and sensitivity evaluated, and all developmental paralysis were referred for amblyopia screening. The senior author (JKT) has previously published the algorithms on which eye reanimation is based.18, 19, 21, 22

The mid-face

The main strategy for smile restoration (71/92, 77%) consisted of CFNG or nerve-grafting to an ipsilateral motor on the first-stage, followed by a free-muscle-transfer on the second-stage. Two cases of bilateral paralysis received a bilateral free-muscle-transfer to the masseter nerve. Two patients, who exhibited remarkable results following CFNG and Babysitter procedure respectively, were complemented with a mini-temporalis transposition to the oral commissure.²⁴ In a minority of cases (11

The upper-face

Of 72 patients in the study group, 58 received at least one intervention for eye management. These 58 patients were grouped according to the surgical intervention/s undertaken. For each mode of reconstruction, a mean-percentage-gain was calculated comparing pre- and post-secondary surgery scores. Table 9.

Ocular symptomatology improved in all patients to variable degrees. Orbicularis substitution efficiently restored eye closure and corneal protection irrespective of the muscle flap utilized

Discussion

It is widely held that a microneurovascular-muscle-transfer empowered by the contralateral facial nerve holds the greatest potential for an effective and coordinated smile. Yet, one cannot single out with the same certitude the revisional procedure/s best suited to compensate a misshapen result. There are few reports on revisional surgery, and at times confusing accounts are available. Scarce material and lack of consensus on eye and depressor reanimation complicates decision-making when

Acknowledgements

The authors thank Thomas S. Rieg, Ph.D, and Yueqin Zhao, MS, of the Naval Medical Centre and Eastern Virginia Medical School, Nofolk-VA, for their assistance in data analysis and statistical interpretations. Thanks to David Beck for providing patient's videotapes and images. Thanks to the IRB Committee of the Eastern Virginia Medical School, who reviewed the protocol of this retrospective study.

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The effect of various muscle transfer procedures on eye closure and blinking in longstanding facial palsy patients
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Facial palsy causes paralytic lagophthalmos, which remarkably deteriorates a patient’s quality of life. In cases where denervation time is over 18-24 months (longstanding facial palsy), a free or pedicled muscle transfer is needed to replace the denervated orbicularis oculi muscle.
The purpose of this systematic review is to investigate the effect of various eye sphincter substitution procedures (free or pedicled muscle transfers) in longstanding facial palsy patients on eye closure and blink.
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the Embase, Medline, Web of Science and Cochrane Library databases and Google Scholar. Our literature search yielded 4322 articles. Following a full-text review, 4 retrospective cohort studies and 21 case series were selected for this review. Meta-analyses using R package meta (version 6.5-0) were conducted.
All free and pedicled muscle transfers in this review showed an improvement in the scores and measurements on eye closure and blink. The pedicled temporalis muscle transfer was the procedure most commonly performed as eye reanimation surgery and showed consistent good results. Using the random effects model, the pooled effect of mean difference in lagophthalmos after gentle eye closure post-operatively versus pre-operatively (mm) in patients who received a pedicled (temporalis) muscle transfer was −6.19 (I² = 85%, 95% CI: −7.89; −4.49) whereas it was −4.11 (I² = 85%, 95% CI: −7.26; −0.95) for free (gracilis or platysma) muscle transfers. The pooled proportion of patients with complete eye closure after surgery was 0.69 (I² = 49%, 95% CI: 0.54; 0.82) in patients who received a pedicled (temporalis) muscle transfer and 0.40 (I² = 74%, 95% CI: 0.13; 0.74) in patients who received a free (platysma) muscle transfer.
Unlike smile reanimation, dynamic eye closure and blink restoration are rather neglected topics in facial reanimation. The pedicled temporalis muscle transfer is often recommended as the first treatment of choice for eye reanimation in longstanding facial palsy patients since it is a reliable, straightforward procedure, that does not require complex microsurgery. However, with the advancements in the field of microsurgery, free muscle transfers are promising therapies, which may regenerate voluntary and spontaneous blinking.
Reanimation of facial palsy following tumor extirpation in pediatric patients: Our experience with 16 patients
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Inadequate results with depressor complex reanimation are supplemented with static procedures. In such cases, the senior author favors myectomy of the normal side in order to restore symmetry in the lower lip.9 Contralateral selective neurectomy has the disadvantage of further weakening the lower lip.
The aim of this study was to present our experience with reanimation of facial palsy (FP) following tumor extirpation in pediatric patients and to analyze the functional outcomes based on different types of procedures performed considering demographic and electrophysiological data of the patients. Sixteen patients with FP post-tumor extirpation who underwent facial reanimation were reviewed. Three independent assessors evaluated the preoperative and postoperative videos using the Terzis' grading scale for eye closure, smile, depressor and overall esthetic and functional outcomes. Preoperative and postoperative electromyographic interpretations and the effect of demographic variables were also evaluated. There was significant improvement in all the patients regarding overall esthetic and functional outcomes (p < 0.0001). Good and excellent overall esthetic and functional outcomes were observed in 62.50% of the patients (n = 10). The difference between preoperative and postoperative EMG results was of statistical significance (p < 0.0001 for each target re-innervated). Better results were observed in younger patients (≤10 years) (p = 0.014) and in early cases (denervation time ≤2 years) (p = 0.033).
Functional results were significantly better if surgery was performed within 2 years and the patient was younger than 10 years. Augmentation of the paretic facial musculature in pediatric patients with post-tumor FP was feasible with the use of dynamic and/or static procedures. Advanced microsurgical techniques, such as the use of free muscle transfers, should be kept in mind in late cases (denervation time over 2 years).
Novel use of platysma for oral sphincter substitution or countering excessive pull of a free muscle
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
All the reconstructive operations were performed by the Senior Author (JKT) and each procedure was documented by video and detailed drawings. Surgical techniques of nerve grafting, free muscle transplantation and secondary procedures were performed as previously described.26–29 In all patients nerve conduction and electromyographic studies were performed preoperatively.
The present study demonstrates our experience with a novel use of the Platysma in facial reanimation, as a balancing procedure by counteracting an overactive free muscle transfer, and improving oral continence by re-establishing the oral sphincter mechanism.
Twelve patients, nine female (75%) and three male (25%), with a mean age of thirty-eight years (range: 2–66) are presented.
Of these, in seven patients (58%) who had excessive excursion of the free muscle, the contralateral pedicled platysma was transferred to counteract the excessive pull.
Four patients (33%) underwent bilateral platysma transfer for oral sphincter restoration, while one (8%) had ipsilateral platysma transfer.
Evaluation of aesthetic and functional results was performed by a panel of three independent observers, and the long term efficacy of the procedure was assessed through a patient questionnaire.
All patients demonstrated significant upgrading of their oral competence associated with eating, drinking and smiling, as it was confirmed by the behavioural analysis (p < 0.01).
Six of the ten patients that were available, responded to the Quality of Life Questionnaire.
Five out of six were satisfied with their mouth appearance when they smile and five patients have a regular diet and without drooling.
A novel use of Platysma transposition is described that can substitute for a paralysed orbicularis oris muscle in restoring oral sphincter function or to counter balance an excessively active free muscle that was previously transferred for smile restoration.
This novel Platysma transfer technique is intended to be used as an adjunct to other reanimation procedures.
Surgical management of facial nerve paralysis in the pediatric population
2011, Journal of Pediatric Surgery
Citation Excerpt :
Despite these advancements, there is still the need for improvements in the functional and aesthetic outcomes these children experience. As Terzis and Olivares [36] explain, until we develop a dynamic reconstructive procedure that simultaneously addresses the laxity at the level of the eye, smile, and depressors, we are sure to continue to experience less than satisfactory results. The surgical management of facial paralysis in children differs depending on the acute/chronic nature of the injury.
In the pediatric patient population, both the pathology and the surgical managements of seventh cranial nerve palsy are complicated by the small size of the patients. Adding to the technical difficulty is the relative infrequency of the diagnosis, thus making it harder to become proficient in the management of the condition. The magnitude of the functional and aesthetic deficits these children manifest is significantly troubling to both the patient and the parents, which makes immediate attention, treatment, and functional restoration essential.
A literature search using PubMed (http://www.pubmed.org) was undertaken to identify the current state of surgical management of pediatric facial paralysis.
Although a multitude of techniques have been used, the ideal reconstructive procedure that addresses all of the functional and cosmetic needs of these children has yet to be described. Certainly, future research and innovative thinking will yield progressively better techniques that may, one day, emulate the native facial musculature with remarkable precision.
The necessity for surgical intervention in children with facial nerve paralysis differs depending on many factors including the acute/chronic nature of the defect as well as the extent of functional and cosmetic damage. In this article, we review the surgical procedures that have been used to treat pediatric facial nerve paralysis and provide therapeutic facial reanimation.
Developmental facial paralysis: A review
2011, Journal of Plastic, Reconstructive and Aesthetic Surgery
The purpose of this study is to clarify the confusing nomenclature and pathogenesis of Developmental Facial Paralysis, and how it can be differentiated from other causes of facial paralysis present at birth.
Differentiating developmental from traumatic facial paralysis noted at birth is important for determining prognosis, but also for medicolegal reasons.
Given the dramatic presentation of this condition, accurate and reliable guidelines are necessary in order to facilitate early diagnosis and initiate appropriate therapy, while providing support and counselling to the family.
The 30 years experience of our center in the management of developmental facial paralysis is dependent upon a thorough understanding of facial nerve embryology, anatomy, nerve physiology, and an appreciation of well-recognized mishaps during fetal development.
It is hoped that a better understanding of this condition will in the future lead to early targeted screening, accurate diagnosis and prompt treatment in this population of facially disfigured patients, which will facilitate their emotional and social rehabilitation, and their reintegration among their peers.
An ACS-NSQIP Data Analysis of 30-Day Outcomes Following Surgery for Bell's Palsy
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Secondary surgery in paediatric facial paralysis reanimation

Summary

Section snippets

Patients and methods

The upper-face

The mid-face

The upper-face

Discussion

Acknowledgements

Clin Plast Surg

Clin Plast Surg

Clin Plast Surg

Microsurgical strategies in 74 patients for restoration of dynamic depressor muscle mechanism: a neglected target in facial reanimation

Plast Reconstr Surg

Expresion of emotion and quality of life after facial nerve paralysis

Otol Neurotol

Correcting facial paralysis

Plast Reconstr Surg

Cross-face nerve graft with free-muscle-transfer for reanimation of the paralyzed face: a comparative study of the single-stage and two-stage procedures

Plast Reconstr Surg

Revisional operations improve results of neurovascular free muscle transfer for treatment of facial paralysis

Plast Reconstr Surg

Analysis of 100 cases of free-muscle transplantation for facial paralysis

Plast Reconstr Surg

Results of management of facial palsy with microvascular free-muscle-transfer

Plast Reconstr Surg

Cross-facial and functional microvascular muscle transplantation for longstanding paralysis

Clin Plast Surg

Surgical correction of unilateral and bilateral facial palsy

Postgrad Med J

Multimodality approach to management of the paralyzed face

Laryngoscope

A histomorphometric analysis of the cross-facial nerve graft in the treatment of facial paralysis

J Reconstr Microsurg

Gains and losses of the XII-VII component of the ‘baby-sitter’ procedure: a morphometric analysis

J Reconstr Microsurg

Efficacy of the ‘baby-sitter’ procedure after prolonged denervation

J Reconstr Microsurg

Pectoralis minor: a unique muscle for correction of facial palsy

Plast Reconstr Surg