Simultaneous 'dual system' rehabilitation in the treatment of facial paralysis

M-Mode Echomyography of Facial Muscle Function Following Facial Reanimation with Temporalis Muscle Galea Pedicled Flap: Analysis of Ten Cases with Review of Literature

Introduction

Facial palsy is a condition where the patients lack voluntary movement on the affected side of the face and are not able to convey their emotions. Besides that, they also succumb themselves to social isolation. Various techniques have been devised to overcome this devastating problem. The aim of this article is to evaluate and compare facial muscle function before and after facial reanimation with temporalis muscle galea pedicled flap by motion mode echomyography in patients with long-standing facial paralysis.

Patients and Methods

Ten patients with long-standing facial paralysis were included in the study (six patients with LMN palsy and four patients with facial weakness involving specific peripheral branches), and they subsequently underwent facial reanimation surgery with temporalis galea pedicled flap. These patients were followed postoperatively for a period of 1-2 years and were subjectively graded as excellent, good, fair and poor and objectively evaluated by M-mode echomyography, and the results were evaluated and statistically analyzed.

Results

Subjectively, out of 6 patients with LMN palsy, results were graded as excellent in 2 cases, good in 3 cases, fair in 1 case, and out of 4 patients with weakness in specific facial nerve branches, the subjective results were excellent in 2 cases, good in 1 case and fair in 1 case. Objectively, the effect of transposed temporalis galea on orbicularis occuli, levator labii superioris and orbicularis oris was found to be statistically significant in patients with LMN palsy.

Conclusion

Our study proves the versatility of temporalis muscle galea pedicled flap in cases of long-standing facial paralysis by motion mode echomyography.

Motor Nerve Transfers

Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.

Physical therapy for Bell's palsy (idiopathic facial paralysis)

BACKGROUND

Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy.

OBJECTIVES

To evaluate physical therapies for Bell's palsy (idiopathic facial palsy).

SEARCH METHODS

We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011.

SELECTION CRITERIA

We selected randomised or quasi-randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which , took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability.

MAIN RESULTS

For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta-analysis because the interventions and outcomes were not comparable.For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment)(149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta-analysis from two studies, one of three months and the other of six months duration, (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74).Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months where significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD -2.10 weeks, 95% CI -3.15 to -1.05) but this was not a prespecified outcome in this meta analysis.Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome.

AUTHORS' CONCLUSIONS

There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials.

Functional and aesthetic reconstruction of extensive oral ablative defects using temporalis muscle flap: a case report and a sort review

PURPOSE

Temporalis muscle flap (TMF) provides a reliable solution in reconstruction of extensive intraoral ablative defects, providing a valuable alternative to more complex and extensive reconstructive procedures, combining excellent functional and aesthetic rehabilitation with minimal complications. In this article is described in detail the TMF surgical technique with attention to specific methods useful for preventing facial nerve injury and donor-site deformity.

MATERIALS AND METHODS

It is presented the case of a patient with malignant tumour in the region of the upper jaw, palate and inferior half of the nasal cavity, who underwent extensive surgical excision and the resultant defect was successfully reconstructed with TMF.

RESULTS

The reconstructive procedure resulted in excellent immediate and long-term functional (aspiration, feeding and speech) and aesthetic results. During the 5-year follow-up period no complications associated with the flap or the temporal implant, used for donor-site reconstruction were encountered and no local recurrence or tumour metastasis was observed.

CONCLUSION

The TMF is a reliable, technically easy and anatomically sound technique, which combines excellent aesthetic and functional results with minimal complications, if performed correctly.

Revisiting orthodromic temporalis transfer in treating long-standing facial paralysis

The treatment of long-standing facial paralysis through temporalis muscle transfer has stood the test of time. Herein, we present a modification in temporalis muscle transfer for lower facial reanimation. Instead of the traditional stripping of the temporalis muscle from its origin, its insertion is stripped from the coronoid process through an intraoral approach. The detached fibers were then sutured to a fascia lata graft, which was passed and secured to the orbicularis oris to reanimate the corner of the mouth. The procedure is less extensive and provides a direct "orthodromic" line of pull with good muscular excursion and power. This simple procedure has been applied to 12 consecutive cases with long-standing complete facial paralysis presenting to the Plastic and Reconstructive Surgery Clinic at the Ain-Shams University Hospital over the past 2 years. In addition to symmetry at rest, this easy procedure allowed for good movement of the corner of the mouth with restoration of a balanced smile.

Physical therapy for Bell s palsy (idiopathic facial paralysis)

BACKGROUND

Bell's palsy (idiopathic facial paralysis) is commonly treated by physical therapy services with various therapeutic strategies and devices. There are many questions about their efficacy and effectiveness.

OBJECTIVES

To evaluate the efficacy of physical therapies on the outcome of Bell's palsy.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (February 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2007), MEDLINE (January 1966 to February 2008), EMBASE (January 1980 to February 2008), LILACS (January 1982 to February 2008), PEDro (from 1929 to February 2008), and CINAHL (January 1982 to February 2008).

SELECTION CRITERIA

We selected randomised or quasi-randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified from the register were scrutinized. The assessment of methodological quality took into account secure method of randomisation, allocation concealment, observer blinding, patient blinding, differences at baseline of the experimental groups, and completeness of follow-up. Data were extracted using a specially constructed data extraction form. Separate subgroup analyses of participants with more and less severe disability were undertaken.

MAIN RESULTS

The search identified 45 potentially relevant articles. Six studies met the inclusion criteria. Three trials studied the efficacy of electrostimulation (294 participants) and three exercises (253 participants). Neither treatment produced significantly more improvement than the control treatment or no treatment. There was limited evidence that improvement began earlier in the exercise group.

AUTHORS' CONCLUSIONS

There is no evidence of significant benefit or harm from any physical therapy for idiopathic facial paralysis. The possibility that facial exercise reduces time to recover and sequelae needs confirming with good quality randomised controlled trials.

A modified temporalis transfer in facial reanimation

A modified surgical procedure for temporalis transfer in facial reanimation of five consecutive cases is presented. Instead of the traditional stripping of the temporalis from its origin, its attachment at the coronoid removed, and to its end, the harvested fascia lata graft was sutured to lengthen the muscle's action. These fibres were then passed to the Orbicularis Oculi and Oris to aid in reanimation and to improve their tone. The procedure is less extensive, provides a direct line of pull with good functional results, no muscle atropy since vascularity and innervation is maintained. No complaints of paresthesia, hyposthesia or scar on donor leg was noticed. None of the patients required a revision of surgery for unacceptable contour or asymmetry. This simple procedure has helped reconstruction of natural symmetrical smile with highly successful results.