Journal of Plastic, Reconstructive & Aesthetic Surgery
Secondary surgery in paediatric facial paralysis reanimation
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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