Conclusion

Static suspension of the face with Gore-Tex strips for rehabilitation of the paralyzed face has provided our patients a reasonable alternative to more invasive procedures such as hypoglossal to facial nerve crossover or temporalis muscle transposition. When combined with upper lid loading, using gold weights, Gore-Tex suspension significantly improves many of the sequelae of facial paralysis in a simple, one-step procedure that is reversible and that is associated with no donor site morbidity. A major application of Gore-Tex suspension is in the management of patients with intact facial nerves but with paralysis after skull base surgery. While awaiting regeneration of the nerve, Gore-Tex suspension ameliorates many of the sequelae of facial paralysis and continues to add support after the nerve has begun to function. Other strong candidates for Gore-Tex suspension are patients with loss of the ipsilateral temporalis muscle or distal facial nerve, or both (as in lateral face or skull base malignancies) in whom there are no good alternatives. To date the vast majority of Gore-Tex implants we have used have been well tolerated with good maintenance of suspension and only one extrusion.

In our practice, Gore-Tex suspension has become the primary modality for management of facial paralysis against which other techniques must show significant superiority before being recommended to patients.

REFERENCES

Shumrick—CHAPTER 22

1. Ueda K, Harii K, Yamada A. Free vascularized double muscle transplantation for the treatment of facial paralysis. Plast Reconstr Surg 1995;95:1288-1296

2. Rubin LR. Discussion of free vascularized double muscle transplantation for the treatment of facial paralysis by Ueda et al. Plast Reconstr Surg 1995;95:1297-1298

3. McO'Brien B, Kumar PAV. Cross-face nerve grafting with free vascularized muscle grafts. In: Rubin LR, ed. The Paralyzed Face. 2nd ed. St. Louis: Mosby-Year Book; 1991:201-212

4. Harii K. Microneurovascular free muscle transplantation. In: Rubin LR, ed. The Paralyzed Face. 2nd ed. St. Louis: Mosby-Year Book; 1991:178-200

5. Sobol SM, May M. Hypoglossal-facial anastomosis: its role in contemporary facial reanimation. In: Rubin LR, ed. The Paralyzed Face. 1st ed. St. Louis: Mosby-Year Book; 1991:137-143

6. Conley J, Baker D. Hypoglossal-facial nerve anastomosis for reinnervation of the paralyzed face. Plast Reconstr Surg 1979; 63:63-72

7. Pitty LF, Tator CH. Hypoglossal-facial nerve anastomosis for facial nerve palsy following surgery for cerebellopontine angle tumors. J Neurosurg 1992;77:724-731

8. Kunihiro T, Kanzaki J, O-Uchi T. Hypoglossal-facial nerve anastomosis. Acta OOtolaryngol (Stockh) 1991;487:80-84

9. Pensak ML, Jackson CG, Glasscock ME, Gulya AJ. Facial reanimation with the VII-XII anastomosis: analysis of the functional and psychologic results. Otolaryngol Head Neck Surg 1986;94:305-310

10. May M, Sobol SM, Mester SJ. Hypoglossal-facial nerve inter-positional-jump graft for facial reanimation without tongue atrophy. Otolaryngol Head Neck Surg 1991;104:818-825

11. Konoir RJ. Facial paralysis reconstruction with Gore-Tex soft tissue patch. Arch Otolaryngol Head Neck Surg 1992;118:1188-1194

12. Petroff MA, Goode RL, Levet Y. Gore-Tex implants: applications in facial paralysis rehabilitation and soft-tissue augmentation. Laryngoscope 1992;102:1185-1189

Static versus Dynamic Management of the Paralyzed Face

Maisie L. Shindo

CHAPTER 23

Facal paralysis can lead to a variety of troubling symptoms for the patient, including ocular problems, speech difficulties, drooling, and nasal obstruction (Table 23-1). Facial paralysis can be devastating for patients because of the emotional impact from the facial disfigurement as well as difficulties with communication, eating, and drinking in a social setting. Numerous options are available for rehabilitation of prolonged facial paralysis (Table 23-2). The rehabilitation procedures can be divided into dynamic and nondynamic reanimation procedures; the latter include static slings, ocular protective procedures, and adjunctive cosmetic procedures. When assessing which procedure(s) to perform, one should not simply look at the problem as dynamic versus static reanimation of the entire face. Rather, it is best to approach the analysis by dividing the regions of the face to be reanimated into upper third, middle third, and lower lip and then to determine the functional deficits, cosmetic deformity in each region, and the patient's desires. Furthermore, one must determine the feasibility of performing the procedures for achieving the desired goals.

Three basic questions need to be answered in the decision tree:

1. What are the patient's functional and aesthetic needs?

2. What is the potential for spontaneous recovery?

TABLE 23-1

Problems Frequently Experienced by Patients with Facial Paralysis*

TABLE 23-1

Problems Frequently Experienced by Patients with Facial Paralysis*

Problems

Reasons

Eye irritation

Inadequate eye closure and corneal

protection

Epiphora

Inability to effectively "pump" tears

into the lacrimal drainage system

Visual-field defect

Ptosis of brow and soft tissues of the

forehead

Speech difficulties

Lip incompetence, resulting in diffi

culty pronouncing consonents such as

P and B

Drooling and difficulties

Lip incompetence and frequent biting

eating/drinking

on buccal mucosa, which protrudes

into the oral cavity

Nasal obstruction

Collapse of nasal alar rim from

flattened nasolabial fold

* In addition to lack of facial motion.

* In addition to lack of facial motion.

3. Is the patient medically fit to undergo a long operative procedure?

Figure 23-1 presents a suggested algorithm based on the answer to these questions. This logical and rational approach to facial analysis for rehabilitation of the paralyzed face takes into consideration the aesthetic units that need to be restored, specific functional deficits and patient's desires, duration of paralysis, patient's medical condition, and the status of the distal facial nerve fibers and motor end plates.

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