COCLIA 9798 Eyelid Reconstruction, Facial Reanimation

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Slide 1 :

COCLIA10/6/08 `Welcome to the beginning of the academic year.’ -Samir Undavia, MD

Slide 2 :

Eyelid Reconstruction

Slide 3 :

Layers of the Eyelid

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Layers of the eyelid Anterior lamella Skin Orbicularis muscle Posterior lamella Eyelid retractor Tarsus Conjunctiva

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Layers of the eyelid- other contents Upper lid Orbicularis oculi Levator palpebrae superioris Muller's muscle Sweat glands Meibomian glands Wolfring's glands Tarsal plate Lower lid Tarsal plate Lower lid retractors Orbicularis oculi Sweat glands Meibomian glands Wolfring's glands

Slide 6 :

Eyelid repair Full-thickness laceration: 3-layer closure Conjunctiva: plain gut (avoids conjunctival irritaion), 6-0 or 7-0 Tarsal plate: fine absorbable suture (i.e. Vicryl) Skin: fine monofilament suture (6-0 prolene or nylon). Remove after 3-4d

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Entropion

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Entropion- Types Congenital Extremely rare, usually lower lid Hypertrophy of pretarsal orbicularis Deficiency/absence of tarsal plate Involutional Loss of orbital volume; enopthalmos Upward migration of preseptal orbicularis Thinning of tarsal plate Cicatricial Scarring of palpebral conjunctiva Acute spastic Ocular irritation; infectious, inflammatory

Slide 9 :

Entropion repair Medical- (for acute spastic) ocular lubrication, ABX, steroids, botox of orbicularis oculi m. Surgical Snellen procedure- everting suture correction Horizontal tightening Weis procedure- full thickness horizontal lid incision Quickert procedure (combination of above) Inferior retractor plication Wedge excision of tarsal plate

Slide 10 :

Entropion repair

Slide 11 :

Inferior retractor plication

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Ectropion Abnormal eversion of the lid margin away from the globe; puts eye at risk for corneal exposure, tearing, keratinization of the palpebral conjunctiva, visual loss. Types Congenital Involutional Cicatricial (scarring of anterior lamella) Paralytic (Bell's palsy) Mechanical (neurofibroma)

Slide 13 :

Ectropion

Slide 14 :

Congenital bilateral ectropion

Slide 15 :

Repair of ectropion Initial therapy with lubrication, tape closure, squinting exersizes; digital massage and steroids in cicatricial ectropion Surgical therapy- depends upon etiology Horizontal lid laxity-lid shortening procedure Cicatricial ectropion- excision of scar and augmentation of anterior lamella with postauricular or upper lid skin graft Medial ectropion- excision of medial conjunctiva and retractors

Slide 16 :

Canalicular injuries

Slide 17 :

Nasolacrimal system

Slide 18 :

Canalicular injury repair Dilate punctum Identify medial cut end of canalicular system (loupes/microscope usually needed) Place silicone stent through punctum, through cut end, and retrieve in nasal cavity Reapproximate laceration with fine (7 or 8-0) vicryl suture

Slide 19 :

Dacryocystorhinostomy Used to bypass blockage of NLD via fistualization of lacrimal sac into inferior meatus of nasal cavity. Epiphora is most common indication Can be performed externally; usually done endoscopically now

Slide 20 :

Endoscopic DCR Steps: Probe (lighted if necessary) inserted into upper or lower punctum, then viewed endoscopically Anterior portion of middle turbinate used as landmark Elevate mucosal flap to expose lacrimal fossa Drill out frontal process of maxillary bone and lacrimal bone to expose lacrimal sac Probe placed in sac to tent out Sac incised in order to create neo-ostium so tears can drain directly from canaliculus into nose through middle turbinate Keep open with Crawford tube stent for 6 weeks to months

Slide 21 :

Endoscopic DCR

Slide 22 :

Blepharospasm Idiopathic, progressive, involuntary spasm of orbicularis oculi and upper face (corrugators and procerus mm.). Spasm may extend to lower face May render patient functionally blind May be central in origin; mechanism unclear Mangement- selective destruction of peripheral innervation (identify branches, confirm with n. stimulator, resect) Botox Periorbital myotomy

Slide 23 :

FT lac of eyelid margin Principles Reconstuct in layers for normal function; both lamellae must be reconstructed One lamella must be well-vascularized in order to support the other (i.e. One flap/one graft, or two flaps; can't do two grafts--> leads to necrosis)

Slide 24 :

Repair of lid margin defects Principles: Can repair up to 25% of lid margin in younger person with primary closure (40% in older person with increasing lid laxity) <30%: direct closure with lateral cantholysis <50%: lateral rotational flap (Tenzel) >50%: different pedicled flaps (Kollner; Cutler-Beard)

Slide 25 :

Primary repair Prepare tarsal edges by preparing vertically oriented ends for direct approximation Approximate lid margin first Then, close tarsus with fine absorbable suture Close skin and conjunctiva with silk (nylon?), plain gut

Slide 26 :

Tenzel flap

Slide 27 :

Cutler-Beard Flap

Slide 28 :

Lower eyelid defect reconstruction

Slide 29 :

Facial reanimation

Slide 30 :

Facial reanimation Unilateral facial paralysis can be devastating Nerve injury, even slight, from otologic/ parotid/plastic procedures may not attain full function Surgical patients MUST understand risks of injury; but difficult to convey Goals: Resoration of facial symmetry +/- Restoration of motion

Slide 31 :

Facial nerve anatomy

Slide 32 :

Microscopic nerve anatomy

Slide 33 :

Sunderland Classification

Slide 34 :

Reconstructive modalities Considerations: First, availability of viable proximal facial nerve? Tumor ablation with nerve sacrifice: immediate reconstruction with cable graft If questionable viability (i.e., after CPA surgery), wait 9-12 months Static procedure if no viable reinnervation available; may also be combined with dynamic procedure for immediate function

Slide 35 :

Order of preference Spontaneous generation (observation) Facial nerve neurorraphy Facial nerve cable graft Nerve transposition Muscle transposition Microneurovascular transfer Static procedure

Slide 36 :

Management of the eye Failure to recognize eyelid dysfunction early results in entirely preventable ocular complications exposure keratitis corneal ulceration blindness Initial management Moisturization (artificial tears, ointments) Exposure prevention (taping, occlusive dressing) Education

Slide 37 :

Surgical procedures Lower lid (ectropion) Tarsorraphy Simple Lid-adhesion Wedge Resection Canthoplasty Upper lid (lagophthalmos) Gold weight Palpebral springs Silastic slings

Slide 38 :

Bell's phenomenon Idiopathic facial paralysis 15-40/100,000 Most common form of facial palsy Generally a dx of exclusion, but a positive one if: unilateral paresis of all facial muscle groups sudden onset absence of ear/CNS disease Etiology unclear (ischemic vs. viral vs. entrapment neuropathy); likely inflammation within constrained bony canal leading to ischemia Treatment extremely controversial; steroids likely improve outcome Prognosis Incomplete paralysis: excellent recovery Complete paralysis: 71% complete recovery 13% mild residual palsy 16% fair-poor recovery

Slide 39 :

Facial nerve grafting Settings Radical parotidectomy with nerve sacrifice Temporal bone resection Traumatic avulsion CPA tumor resection Donor nerves Greater auricular (opposite neck) Sural Medial antebranchial cutaneous

Slide 40 :

Nerve grafting Technique Transection of graft and stumps with sterile razor Anastomosis with four 9-0 or 10-0 nylon through epineurium only Tension free is critical! Need 8-10 mm of extra length for each anastamosis (“lazy S” configuration) Healthiest possible bed of supporting tissue

Slide 41 :

Nerve transposition Used when proximal facial n. stump unavailable Hypoglossal Best option due to close proximity, less donor disability, similar brainstem control and reflex response Pure vs. jump graft Disadvantages: tongue atrophy, synkinesis, facial hypertonia Spinal accessory Ansa hypoglossi plus muscle block Phrenic (obsolete)

Slide 42 :

Muscle transfer Used when first two options unavailable, or when significant muscle atrophy has occurred (i.e., complete paralysis for two years or more) Masseteric transfer Used for sagging/paralyzed oral commissure Requires intact CN V Provides posterior pull on midface Cannot be used for orbital rehabilitation Temporalis transfer Muscle divided into four slips Superior pull preferred to masseteric vector

Slide 43 :

Static procedures Indications debilitated patients with poor prognosis Lack of nerve/muscle availability Adjunct to dynamic procedure Advantages immediate restoration of symmetry Improvement in oral competence, nasal obstruction Materials Fascia lata Alloderm PTFE

Slide 44 :

Harii et al. One-Stage Transfer of the Latissimus Dorsi Muscle for Reanimation of a Paralyzed Face: A New Alternative. One-stage microvascular free transfer of the latissimus dorsi muscle for long-standing unilateral facial n. paralysis Thoracodorsal nerve is crossed through the upper lip and sutured to the contralateral intact facial nerve branches. Reinnervation of the transferred muscle is established at a mean of 7 months postoperatively, which is faster than that of the two-stage method. 24 patients, 21 patients (more than 87 percent) believed that their results were excellent or satisfactory, which also compares well with the results of the two-stage method combining free-muscle transfer with cross-face nerve graft.

Slide 45 :

Cronin et al. The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation Objective The study goal was to present the effectiveness of neuromuscular facial retraining techniques used in combination with electromyography forimproving facial function even in cases of longstanding paralysis. Study design and setting We conducted a retrospective case review in a tertiary neurotology clinic. Patients Twenty-four patients with facial paralysis received neuromuscular facial retraining between April 1999 and April 2001. The patient sample included 6 males and 18 females, with an average age of 44 years. A control group consisted of 6 patients (4 females and 2 males). Results All patient groups made significant improvements in function with improved symmetry in dual-channel electromyographic readings and increased facial movement percentages. Some of the percentages of posttreatment facial function were as follows: acoustic neuromas, 93%; Bell’s palsy/Ramsay Hunt syndrome, 80%; and facial nerve anastomosis, 71%. Synkinesis was reduced by at least 2 levels in patients who initially demonstrated synkinesis. Conclusions Neuromuscular facial retraining exercises and electromyography are effective for improving facial movements.

3D automatic segment...

Facial nerve palsy

Facial nerve palsy d...

Facial tics

Facial trauma

Cranial Nerve Evalua...

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