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Surgery Provides Options for Facial Paralysis, Sinus Fractures

A variety of facial reconstruction issues, ranging from managing the fracture of sinus bones to treating facial paralysis, were examined September 24 in a Maintenance of Certification Review Course, “Facial Plastic Surgery.”

Presentations touched on treatment options, signs of complications, and newer procedures for repairing facial fractures, assessing nerve injuries in facial paralysis, eye care, and tendon transfer.

Andrea Jarchow, MD, presented case studies to review best processes when treating trauma patients.

Andrea Jarchow, MD, presented case studies to review best processes when treating trauma patients.

Andrea Jarchow, MD, assistant professor in the Division of Facial Plastic and Reconstructive Surgery at the University of North Carolina-Chapel Hill, presented case studies to review best processes when treating trauma patients.

The first case was a 28-year-old male with a deep forehead laceration on the left side who lost consciousness after being struck by a car. On examination, he had decreased sensation unilaterally over his forehead. An early step, she said, is to consult with an ophthalmologist for an evaluation and order a CT scan with thin cuts to look for injury to the nasolacrimal duct. It also is important to consider the fracture description.

“So why do we care about each site individually? It is really because each site has its own short-term and long-term complications,” Dr. Jarchow said, adding that treatment options are dictated by the severity of the fracture.

The patient is found to have a frontal sinus fracture, the treatment options are observation, elevation of depressed segments without fixation, open reduction internal fixation (ORIF), obliteration, and cranialization, she said.

The “gold standard” for surgically approaches to frontal sinus fractures is coronal, but it has risk, such as leaving a large scar, paresthesias, alopecia, and facial nerve injury. Patients should be counseled about possible short-term complications, including meningitis and sinusitis, and long-term complications such as mucocele, contour irregularities, and osteomyelitis.

The second case Dr. Jarchow reviewed involved a 53-year-old female who fell down her porch steps and began having pain and difficulty chewing. She also has a history of narcolepsy and seizures. On examination, she demonstrated a deviation to the right when she opened her jaw and trismus.

The diagnosis is a subcondylar fracture. Closed treatment for four weeks to six weeks is often used to avoid surgery and a chance of injury to the facial nerve or a scar. However, a factor in treatment is the patient’s history of seizures, Dr. Jarchow said.

A second option is ORIF, and a third option is endoscopic-assisted reduction with internal fixation (ERIF). ERIF has a faster recovery time than ORIF, but is not suitable for all fracture types and is a difficult procedure to perform, she said.

“So, what fractures would we treat with ORIF versus ERIF continues to be up for debate,” Dr. Jarchow said. “Other fractures amenable to ERIF include minimal medial displacement, any minimally displaced fracture, or somebody unable to tolerate MMF.”

1008-Facial Surgery

John Chi, MD, discussed facial paralysis and issues related to it, such as assessing nerve injuries, eye care, and tendon transfer.

John Chi, MD, assistant professor of facial, plastic, and reconstructive surgery at Washington University School of Medicine, St. Louis, MO, discussed facial paralysis and issues related to it, such as assessing nerve injuries, eye care, and tendon transfer.

A starting point in assessing patients with facial paralysis, Dr. Chi said, is to engage them in conversation and try to get them to laugh to judge nerve damage. Showing a video of a young mother, “We tried to talk to her about her kids,” he said. “She laughed and reanimated her paralyzed side. We often forget how distressing this is for the patient.”

The four types of facial nerve injuries, are idiopathic, iatrogenic, traumatic, and developmental. With worsening injury, nerve edema worsens, axoplasmic flow decreases, nutrient flow to axons decreases, and axonal death ensues, he said.

Key tools in assessing nerve damage are neurological imaging, neurodiagnostic testing, ophthalmologic evaluation, photography, and video.

Neurological imaging should be performed on all new facial paralysis patients because it is important to follow the course of the facial nerve from the brain through the parotid, he said. For trauma injuries, facial paralysis is best evaluated with a CT scan of the temporal bone.

Four types of neurodiagnostic testing are electromyography (EMG), electroneuronography (ENOG), maximal stimulation test (MST), and nerve excitability test (NET). The most used test is EMG, which measures a muscle/motor unit’s electrical activity in response to EMG needle insertion, muscle at rest, or voluntary muscle contraction.

Ophthalmologic evaluation should include Bell’s Phenomenon, visual acuity, corneal examination, and marginal reflex distance.

Treatment for both acute and chronic facial paralysis should include counseling, ophthalmologic care, and physical therapy. Patients with chronic paralysis also should have facial re-animation.

Timing also is key, with facial reinnervation taking place before 12 months after onset, although it is possible to occur after 24 months. “If muscle is viable, you want to wait to see if anything comes back. In this situation you assume muscle may recover some function,” Dr. Chi said.

Eye care also is important and can include ophthalmologic examination, corneal protection, upper-eyelid loading, and lower-eyelid tightening. Steps to protect the cornea can include ocular lubricants and the use of eye tape at night, he said.

Static re-animation actions can include a brow lift, a facelift, and static midfacial suspension. Neuromodulator injections can be use at the frontalis, orbicularis oculi, zygomaticus minor and major, mentalis, depressor anguli oris, and platysma, Dr. Chi said.

Dynamic re-animation can include facial reinnervation with nerve repair, cable grafts, hypoglossal nerve, masseter nerve, and cross-facial innervation. It also can use extrinsic facial re-animation using muscle transportation and free muscle transfer from other parts of the body, he said. Other actions that can be used are temporalis tendon transfer and a gracilis free flap.