Outcomes of periocular reconstruction for facial nerve paralysis in cancer patients

Overview of Unilateral and Bilateral Pediatric Facial Paralysis: Workup, Treatment, and Frontiers

Pediatric facial nerve paralysis can present significant challenges based on its various etiologies, unique approach to treatment options, and overall outcomes. It can impact both the child and parent when regarding function, appearance, and psychosocial implications. The etiology of facial nerve palsy can include congenital, traumatic, iatrogenic, and idiopathic causes. In some, the paralysis is transient while others have permanent loss of function. A thorough evaluation and differential diagnosis are essential to guide treatment planning. The purpose of this paper is to review facial paralysis in children with a focus on surgical management.

Periocular management in recent facial palsy patients treated with triple innervation technique: A retrospective case series

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis. Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0-2 mm lagophthalmos in 66.6% and 3-4 mm lagophthalmos in 33.3%. The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0-2 mm lagophthalmos in 70.5%, 3-4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported. Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye.

Residual Epiphora After Successful Periocular Surgery for Facial Paralysis: Pathophysiology and Management

The prevalence of residual epiphora following successful periocular surgery for facial nerve paralysis can be as high as 30% or more. The pathophysiology of residual epiphora is complex, but identification of the etiology is paramount because the therapeutic approach varies accordingly. Treatments range from medical management of systemic disease to botulinum toxin injections for conditions that arise from aberrant reinnervation to surgical procedures that bypass the lacrimal drainage system completely. We describe a case report and review the pathophysiology and management of residual epiphora to provide a treatment algorithm for clinical use by facial plastic and oculoplastic surgeons. Laryngoscope, 131:E420-E422, 2021.

Rehabilitation of Eyelid Malpositions Secondary to Facial Palsy

Objectives:

To evaluate patient satisfaction and outcomes of surgical treatment of eyelid malpositions secondary to facial palsy.

Materials and Methods:

Consecutive patients with facial palsy who underwent surgical treatment by the same surgeon at İzmir Katip Çelebi University Atatürk Training and Research Hospital between Jan 2007 and Dec 2012 were included in the study. Ophthalmic examination findings, surgical approaches, and their outcomes were evaluated. A successful result for upper eyelid position was defined as more than 50% reduction in lagophthalmos and induction of less than 2 mm of ptosis. A successful outcome for lower eyelid position was defined as the lower eyelid residing at or within 1 mm above or below the limbus. Linear visual analog scale 1 (VAS-1) (subjective complaints) and VAS-2 (cosmetic outcome), both ranging from 0 to 10, were used to compare preoperative findings with findings at last postoperative visit.

Results:

The mean age of the 14 female and 21 male patients was 54.5±19.9 years. Gold weight implantation (n=31), lateral tarsal strip (n=22), tarsorrhaphy (n=15), suborbicularis oculi fat elevation (n=16), hard palate graft (n=14), and eyebrow ptosis repair (n=6) were performed. Average follow-up time was 17.9±16.9 months (range, 2-60). Surgical success rates were 90% for upper lids and 75% for lower lids. Mean lagophthalmos decreased from 7.1±2.7 mm to 1.6±1.6 mm postoperatively (p=0.000). The use of lubricating drops and gels was reduced from average preoperative daily values of 5.3±2.5 drops and 1.3±0.6 gel applications to 4.4±1.4 and 0.6±0.6, respectively (p=0.003, p=0.001).

Conclusion:

An individualized surgical approach tailored according to each patient’s severity of facial palsy and associated malpositions resulted in both functional and aesthetic improvements in our patients.

Facial Paralysis Reconstruction

Facial nerve paralysis is a devastating condition arising from several causes with severe functional and psychological consequences. Given the complexity of the disease process, management involves a multispecialty, team-oriented approach. This article provides a systematic approach in addressing each specific sequela of this complex problem.

Changes in functional visual acuity and ocular wavefront aberration after administration of eye ointment

PURPOSE

To investigate the influence of an eye ointment on functional visual acuity (FVA) and ocular wavefront aberration.

METHODS

In 11 healthy volunteers (6 men and 5 women), visual function parameters, such as FVA, visual maintenance ratios (VMR), and minimal visual acuity (minVA), were assessed by the FVA measurement system before and 2, 5, 10, 20, 30, 40, 50, 60, 90, 120, 180, and 240 min after administration of ofloxacin eye ointment. Ocular aberration was also measured, and the root mean square (RMS) of second-, third-, fourth-, and total higher-order aberrations was determined. The time course of changes in each parameter was statistically analyzed by using repeated-measures analysis of variance and the Dunnett post hoc test, and relationships between visual function and ocular aberration parameters were also analyzed by the Pearson correlation test.

RESULTS

FVA, VMR, and minVA showed significant deteriorations at 2-, 5-, 10-, and 20 min after administration of eye ointment compared with the baseline values (P<0.05). All components of ocular wavefront aberration such as second-, third-, fourth-, and total higher-order RMS significantly increased at 2- and 5 min after the administration of eye ointment compared with the baseline values (P<0.05). In addition, deteriorations of these visual function parameters were significantly correlated with reduced blink numbers (Pearson's correlation coefficient; r=- 0.76, P=0.017 for FVA, r=0.79, P=0.013 for VMR, and r=-0.62, P=0.040 for minVA), and VMR was significantly related with changes in second-order RMS (r=-0.60, P=0.049).

CONCLUSIONS

Eye ointment significantly reduced visual function for at least 20 min. Especially, minVA was worse than 0.155 logMAR, which is legally required for driving, for 3 h after the administration. In addition, increases in lower-order aberration and low blink rates were associated with the degradation of visual function.

Comprehensive management of temporal bone defects after oncologic resection

OBJECTIVES/HYPOTHESIS

To evaluate reconstructive outcomes following oncologic temporal bone resection.

STUDY DESIGN

Retrospective review.

METHODS

Subjects consisted of 117 patients undergoing temporal bone resection and reconstruction between 2000 and 2010. Reconstructive outcomes, including results following facial nerve repair, were analyzed.

RESULTS

Reconstruction was performed with a regional flap in 27 patients and a microvascular free flap in 90 patients. Operative time was shorter for cases involving reconstruction with regional flaps compared to free flaps (6.9 vs. 11.2 hours, P < .0001), as were intensive care unit and hospital stays (0.4 vs. 3.4 days, P < .0001 and 4.1 vs. 8.6 days, P < .0001, respectively). Overall complication rates were similar for regional and free flap cases (22.2% vs. 23.3%, P = 1.00), although donor site complications were more common with free flaps (0% vs. 13.3%, P = .07). Facial nerve repairs were performed in 19 patients. Of 14 patients with more than 12 months of follow-up, 71.4% demonstrated signs of reinnervation and 42.9% achieved a House-Brackmann score of 3 or better. The mean time to reinnervation was 7.9 months. Recovery was not significantly affected by preoperative nerve function, postoperative radiation, or advanced age (P = 1.00 in each case).

CONCLUSIONS

We recommend regional flaps for small defects based on minimal donor site morbidity, and shorter operative times, intensive care unit, and hospital stays. For extensive defects and in cases involving prior surgery or radiation, free flaps are preferred. Facial nerve repair should be attempted whenever feasible, even in the setting of preoperative weakness, planned postoperative radiation, and advanced age.

Gold weight implantation and lateral tarsorrhaphy for upper eyelid paralysis

BACKGROUND

Upper eyelid paralysis leads to lagophthalmos with the risk of exposure keratitis, corneal ulceration and blindness.

METHODS

Consecutive patients undergoing gold weight implantation and/or lateral tarsorrhaphy were identified from our prospective database and reviewed.

RESULTS

Sixty-three patients were identified, 36 of whom underwent immediate reanimation procedure either during cancer excision (n = 35) or repair of facial laceration (n = 1). Twenty-seven patients had a delayed procedure either following tumour excision (n = 21) or unresolved Bell's palsy (n = 3), or facial palsy due to complex craniofacial fracture (n = 3). Nine patients required revision to achieve optimal weight. Fifty-two patients had full eye closure. The remaining 11 patients had almost complete eye closure.

CONCLUSIONS

Facial paralysis is devastating for the patient and immediate facial reanimation should be performed. We have demonstrated that gold weight implantation and lateral tarsorrhaphy are simple and effective in achieving eye closure.

Modern concepts in facial nerve reconstruction

Background

Reconstructive surgery of the facial nerve is not daily routine for most head and neck surgeons. The published experience on strategies to ensure optimal functional results for the patients are based on small case series with a large variety of surgical techniques. On this background it is worthwhile to develop a standardized approach for diagnosis and treatment of patients asking for facial rehabilitation.

Conclusion

A standardized approach is feasible: Patients with chronic facial palsy first need an exact classification of the palsy's aetiology. A step-by-step clinical examination, if necessary MRI imaging and electromyographic examination allow a classification of the palsy's aetiology as well as the determination of the severity of the palsy and the functional deficits. Considering the patient's desire, age and life expectancy, an individual surgical concept is applicable using three main approaches: a) early extratemporal reconstruction, b) early reconstruction of proximal lesions if extratemporal reconstruction is not possible, c) late reconstruction or in cases of congenital palsy. Twelve to 24 months after the last step of surgical reconstruction a standardized evaluation of the therapeutic results is recommended to evaluate the necessity for adjuvant surgical procedures or other adjuvant procedures, e.g. botulinum toxin application. Up to now controlled trials on the value of physiotherapy and other adjuvant measures are missing to give recommendation for optimal application of adjuvant therapies.

The anterolateral thigh free flap for skull base reconstruction

Objective: To assess outcomes of patients undergoing reconstruction after resection of skull base tumors with the anterolateral thigh (ALT) free flap.

Study Design: Case series with chart review.

Subjects and Methods: Thirty-four consecutive patients with cancers involving the skull base that underwent reconstruction with the ALT free flap between 2005 and 2008 were reviewed.

Results: The ALT free flap was successfully used to reconstruct two, five, and 17 anterior, lateral, and posterior skull base defects, respectively. In addition, six and four combined anterior-lateral and lateral-posterior defects, respectively, were reconstructed. The overall complication rate was 29 percent. There were no flap losses. Nerve grafts (n = 6) and fascial slings (n = 14) for facial reanimation were performed using the lateral femoral cutaneous nerve and fascia lata from the same donor site as the ALT free flap. By harvesting the flap and graft(s) simultaneously with the resection, an average of 3.0 hours per case was saved.

Conclusions: The ALT free flap is a versatile, reliable flap that should be considered a first-line option for skull base reconstruction. Operative time is minimized by performing a simultaneous two-team approach to resection and reconstruction, and by harvesting nerve, vein, and fascial grafts from the same donor site as the flap.

Ocular outcomes after gold weight placement and facial nerve resection

OBJECTIVE: To assess the effectiveness of acute gold weight placement after facial nerve resection and to determine the role of concomitant lower eyelid procedures.

STUDY DESIGN: Retrospective review.

SUBJECTS AND METHODS: Twenty-two patients who received an upper eyelid gold weight at the time of parotidectomy and facial nerve resection were reviewed to assess ocular outcomes.

RESULTS: After gold weight placement, twelve patients (12 of 22, 54.5%) subsequently presented with symptomatic ectropion (n = 9) and/or lagophthalmos (n = 5). Nine patients received a lower eyelid procedure (7 tarsal strips only, 1 tarsal strip combined with a lateral tarsorrhaphy, and 1 lateral tarsorrhaphy only). Six patients, in addition to a gold weight, also underwent a static sling to the midface at the time of facial nerve resection. None of these 6 received a subsequent lower eyelid procedure. Two patients required gold weight upsizing. Two patients required weight removal.

CONCLUSIONS: Insertion of 1.2 gm upper eyelid weight with placement of midface sling is recommended at the time of facial nerve resection. Due to the need to tighten the lower eyelid in many of these patients, we now also consider performing a tarsal strip procedure at the time of facial nerve resection in any patient with pre-existing lower lid laxity.