Term Paper on "Facial Reanimation in Facial Paralysis Direct Muscle Neurotization"

Term Paper 15 pages (5975 words) Sources: 30

[EXCERPT] . . . .

Facial Reanimation in Facial Paralysis, Direct Muscle Neurotization

Plastic Surgery- facial paralysis: Considerations

Paralysis of the face is uncommon and is estimated to occur one in four thousand persons. It is noted by various practitioners ranging from "neurologists and neurosurgeons, trauma surgeons, ENT surgeons, head and neck surgeons, plastic surgeons, internists, and psychiatrists." (1) the face being the most important part of the human existence, paralysis causes physical and psychological problems. For example the inability to animate one side of the face causes trauma and restricts normal communication. (1) People adopt various methods to disguise their paralysis and often avoid disclosure and sometimes express anger. The case of facial paralysis and the response by the patient vary with age. In children often tend to be withdrawn and have personality problems. In the case of children who have "a congenital Bell's phenomenon or closure of the eye with upward gaze, the paralysis is often incomplete, involving only the muscles to the upper lip or central face." (1)

The primary objective of face surgery is to restore spontaneous symmetrical animation. The use of the "spinal accessory, the hypoglossal, or the mandible nerve" can bring back animation to facial muscles. (1) the analysis of facial paralysis in animals throws some light on the actual causes of paralysis other than Bell's palsy. The paralysis could be as a result of 'brain stem inflammation' or through 'intracranial injury, with or without 'petrosal bone fracture'. Other causes noted could be due to compression of the 'neoplasia' or 'otitis'. It is also observed that in dealing with animal paralysis of similar nature, trauma in dogs and cats was successfully repaired by direct 'coaptation'; tabulation and grafting with the help of non-nerve elements. (38)

Direct neurotization technique in facial paralysis, during facial reanimation in facial paralysis

Facial paralysis creates "cosmetic as well as functional deficits." (Sataloff, ThayerSataloff (2) p. 525) the side of the face is paralyzed. There is a difference between facial paralysis where the muscles of the face stop working and facial 'paresis' where there is a weakness in the muscles and it is not totally unresponsive. Paralysis can be identified by the 'droop' on the side of a face, and non-closing of mouth which causes discharge of fluids beyond the control of the patient. Further the patient might not be in a position to close his eyes that is towards the paralyzed area, either fully or partially resulting in ocular problems. (2) the medical fraternity is prone to make a misdiagnosis of this paralysis. In 1821 the 'innervations' of the facial muscle system was studied by Sir Charles Bell who termed the motor nerve as the 'facial Nerve'. (2)

The condition of facial paralysis is therefore called 'Bell's Palsy'. (2) at that time the causes of the paralysis was not discovered. Today there are different methods of finding the cause and remedy of many types of paralysis. "Bell's Palsy" is now used to "refer to a condition where the cause cannot be ascertained." (Sataloff, ThayerSataloff (2) p. 525) Today most surgeons treat all paralysis as 'Bell's Palsy' which is erroneous. In determining the cause of and the nature of the condition, it is necessary to take in the results of the examination of ear, nose, throat, neck, and the 'parotid' glands. (2) Other special tests like hearing tests, electric stimuli test and blood tests will give indications of the nature of the problem. CT scans and MRI must be used in diagnosis. If by these tests, a true cause of the paralysis cannot be found, only then can it be classified as 'Bell's Palsy'. Patients suffering from the 'Bell's Palsy' show progress and usually recover in a bout a year's time. (2)

The face if paralyzed for more than a year indicates the diagnosis of Bells Palsy as wrong, and a new 'etiology' must be performed. (2) the severity of facial paralysis can be graded by using the 'House-Brackman' system and it is a simple classification that can be easily remembered. (2) if a person is normal it is GRADE 1, if the person shows least abnormality - GRADE 2 and so on to GRADE 4 where there is complete or near complete facial paralysis to GRADE 5 where the paralysis is total. In placing the type of paralysis difficulty is often noted in those cases which are likely to be Grade 3 and 4 types, where the paralysis is noticeable but patients can move the muscles of the forehead, or eyelids and close the eyes. The typical grade 4 and 5 patients have no control over the forehead muscles and also cannot close their eyes. (2)

The modality for treating individuals differs from patients to patients and from one surgeon to another. The accurate evaluation of the condition with the determination of the 'etiology, duration, and the scale of the paralysis' are important. (3) the surgeon must have a through assessment of the patient's health, and estimate the possibility of recovery and work out the most feasible reconstruction option. (3) the aim of performing a plastic surgery is to create a proper 'facial symmetry', and voluntary facial movement with normal smile, solving the problem of closing the eyes and preventing the 'synkinesis' and mass movement. (3)

The procedures adopted for restoration are both dynamic and static and the dynamic strategies bear instant fruit. The patient desiring reconstruction should be advised for dynamic methods unless a health risk or contraindication is present. (3) the common method for reconstruction entails facial nerve repair with or without nerve grafts, and muscle transfer. The muscle transfer can be "either regional muscle or free-muscle neurotized transfer." (3) the psychology and feeling of the patient is of paramount importance in plastic surgery, and methods must exist to show the patient the proposed surgical plan and the consequence in terms of pictures to which they can relate. Photographs are used to display existing problems that may also persist after surgery. The patient must be made to understand that congenital asymmetry cannot be corrected. Some patients may require "adjunctive orthognathic or cranio-facial procedures." (Romo, Millman (28) p. 107)

In all operation and care the emotional condition of the patient is a very important factor. Psychological evaluation of the patient is paramount in instances where there is expectation of cosmetic improvement. In elective surgery cases, emotional stress of the patient alters their perceptions and the anxiety results in a depression during the post operative period. The important factors for evaluation the mental condition of the patient varies in terms of the understanding of the patient of the intended outcome, patients realistic surgical expectations, patients emotional stability, and use of psychiatric medication by patient are determining factors to the overall psychology of the patient. Physical evaluation of the patient's condition is to be mapped with the psychological state. The need for photographs of the face from various angles, video imaging and surgical photography are today part of the plastic surgeon's arsenal. Surgical photography is essential with documentation especially where the surgery has cosmetic needs and recreates or alters the features of the patient. (4)

The "Intratemporal facial nerve" is the most important nerve that branches into the 'greater petrosal nerve', "which departs from the geniculate ganglion and is responsible for parasympathetic secretion of the nose, mouth, and lacrimal gland. The nerve to the stapedius is the next branch and arises from the proximal mastoid segment. The chorda tympani nerve emerges proximal to the stylomastoid foramen and carries parasympathetic secretory fibers to the submandibular and sublingual glands" as well "taste fibers" to the anterior two thirds of the tongue." (3) the second nerve that is to be considered is the "Extratemporal facial nerve." (3) According to Dingman and Grabb have detailed the series related to the 'marginal mandibular branch' and the temporal branch was identified by Pitanguy. (3) "The facial nerve has twenty three paired muscles and the 'orbicular oris,' but the body uses only eighteen of these muscles to produce facial animation." (3)

All etiologies of facial paralysis, congenital, post traumatic, secondary to tumor excision

In identifying the etiology of facial palsy secondary to retro cochlear pathology or mass lesions of the middle ear for example, the 'Audiometric testing', including 'acoustic reflexes' and 'tympanometry', may be useful, while the Radiography and CT and MRI scans are essential in the probe for 'traumatic facial nerve palsy' to evaluate patients with possible parotid, skull base, temporal bone, intracranial, or extra temporal tumors. (3) Electrodiagnostic tests of nerve function can include exitablity tests, "electroneuronography -- ENog, and electromyography -- EMG." (3) the test is done by 'percutaneous stimulation' of the 'facial nerve'. The 'Maximum Stimulation Test - MST' and the electroneurography -- ENog and the EMG are used to measure the volitional muscle response'. (3) the modern measure also includes photography and visual documentation. (3)

Etiology in some diseases like 'craniosynostosis' would be noted having undeveloped 'mesoderm' usually occurring in the embryo in the fourth week of pregnancy. The law of Virchow states that the premature closure… READ MORE

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