Reconstructive Techniques for Flaccid Facial Paralysis

[Dr. Ashley Agan]
Focusing just on static procedures, how do you think about the different parts of the face and how are you counseling patients as you just walk through the different options you have that are specifically static procedures?

[Dr. Shiayin Yang]
You can go from the top down. We talked about this a little with synkinesis, but we can delve into a little bit further with our flaccid palsy, starting with the brow. They're going to have no movement of the brow. Elevating the brow, whether we elevate one side or both sides, there's multiple different ways you can approach the brow. If you think from a cosmetic type standpoint, a lot of people are doing endoscopic brow lifts.

Usually in these patients, I don't go down that path because it doesn't give the elevation I usually need with that asymmetry unilateral. Usually, what I do, it will depend on how much hair they have and their brow. With my patients who have flaccid facial palsy, if it's a male and he's bald, usually I'll do a direct brow lift. Just right above the eyelid, I'll do both sides if they have brow ptosis and take out a little bit more skin on the flaccid side. If it's a female, they have a significant asymmetry, a lot of times I'll do a pretrichial brow lift. That's an incision right in front of the hairline. You're able to elevate the brow. You can elevate it on both sides. You can do a unilateral one. You're excising skin and you can get pretty good control of their brow and where you're setting it. Really just addressing that brow, I would say is usually where I start first.

[Dr. Ashley Agan]
Like we talked about earlier, that can add the benefits of addressing the functional part of having brow ptosis. If their main issue is that they're having visual field defect or droop of that brow is causing some issues, then that affects that as well. You're addressing the visual symmetry part of it, but also the functional part of the eye.

[Dr. Shiayin Yang]
Correct.

[Dr. Ashley Agan]
Talking about the moving down to just the eye, procedures around the eye for static.

[Dr. Shiayin Yang] This is where it gets hard, truthfully, and this is an area of my practice that I actually really struggle in. When I was in training, I used to always think, "Oh, an eyelid wave, that's so easy." You put it in and that's easy. Now it's really looking at more than just the upper eyelid. You have to look at the lower eyelid. You also have to look at the brow.

There's different patients where I won't elevate the brow because the brow is actually helping them close their eye. There are some patients where the brow is so depressed that they need some type of elevation. You may be doing a little bit more conservative of a brow lift, but also putting an eyelid weight in so that they can close their eye because it's counterintuitive. Why would you raise their brow if they can't close their eye? There's definitely some patients where I do both.

It just depends on the scenario, the anatomy of the patient, because when the brow is depressed in some patients, if you have all that excess eyelid skin, they're not able to close their eyelid because it's actually interfering with the eyelid weight. This is something I talk to them a lot about. Essentially with the eye, I'm trying to balance two opposing factors. I'm trying to get them to close their eye, but not close their eye too much. How do you get a perfect result with that? I'm still learning.

With that, you have the upper eyelid that you're trying to close, but it's not just the upper eyelid. You also have the lower eyelid. When you have paralysis of your lower eyelid, the lid is going to droop down. You can get it to close pretty well, but if the lower eyelid is down, it's not going to be able to close completely. You have to address that lower eyelid. It's concerning all these aspects and figuring out what is best for that patient.

In terms of the upper eyelid, my honestly go-to is a platinum upper eyelid weight. I will size the patient. I do like doing these in clinic because you'll be able to see how well is it working. They're usually in a procedure chair, you can sit them up easily. They can give you feedback in terms of how well is it sitting, how well is it not. That's usually what I go to first. I guess I should back up first and talk about some other options before just jumping straight to an eyelid weight. If you're expecting the patient to have recovery back pretty quickly, you don't have to do an eyelid weight. If they're not closing their eye, you just want to make sure you are absolutely protecting it.

One way to do that easy at bedside, you could always do a tarsorrhaphy, where you're essentially closing the lateral aspect of the eye. Patients do not like this because it can be very deforming. It can also significantly limit how much they're able to see, but it's something that's easy and in the right patient can be appropriate. That's just the first step. Tarsorrhaphy can be an easy procedure, done at bedside, closing the lateral part of the eye can be easily undone.

Another option is if you expect them to recover quickly, a scleral contact can be a nice contact lens. It's a little bit harder to manipulate, but putting that into the eye can hydrate, protect the eye. Lots of eye drops, I have them, even if I'm doing an upper eyelid weight drops throughout the day, ointment at night, because I find that ointment is the most lubricating, but it can cause you to have blurry vision. Another option is moisture chamber. It looks like an eye patch, but it's usually clear so you can see through it. These are all just ways to hydrate, keep the eye intact, protect the eye. If you're ever unsure, just refer. Often I always have them see an ophthalmologist, look at the eye, make sure it's okay, because that is just very easy to-- You don't want to damage it, and you don't want patients to have inadvertent injury to the eye.

[Dr. Shiayin Yang]

Then we have weights that you can tape on to the eyelid, and that's how I measure to determine what weight they may need. If they don't want a weight, you could also do a temporary external eyelid weight where they just tape it onto their eyelid. It doesn't have to be a procedure. I've had plenty of ones that I have revised where I've either placed it, it's too heavy, it's too light, it's not in the correct position in terms of where it's at. I usually try to place my eyelid weight more medial; somewhere between the medial limbus and mid-pupillary line, and balancing how does this allow you to close your eye, but you're not closing your eye all the time?

Then when you're thinking about the lower eyelid, this is where it can get significantly more difficult because you're looking at not only the eye, you've lost movement, you've also lost tone. As we age, our mid-face ages, it's already pulling down on your lower eyelid, then you've lost that muscle tone. If you're older, it's really going to pull down. Then if you have excess eyelid skin, that's going to complicate that even more. That just makes it even more challenging to address.

The different steps you can think of. If they don't have that much laxity and they don't have that much lower eyelid ectropion, you can do a lateral tarsal strip where you're tightening that lower eyelid up and bringing it to a more appropriate position so that when they close with the upper eyelid weighed in, they're able to close. If that's not enough, another common procedure I do is the tarsoconjunctival flap where I'm taking conjunctiva and tarsus from the upper eyelid, bringing it down to the lower eyelid. It's like a suspender, so suspending it up. It's not as deforming as the tarsorrhaphy. You do see a little bit of the flap in that lateral aspect of the eyelid, but I've found it to be very helpful just in hitching up the lower eyelid.

In really severe cases, sometimes you have to restore that lower eyelid portion and put some type of spacer graft for your middle lamella, so a cartilage, auricular cartilage graft. These are for your patients that just have significant laxity, a lot of excess eyelid skin, their midface is already drooped because of their paralysis, but even before that, they probably had midfacial droop. Then there's those patients, if they have a lot of laxity immediately, those are usually the ones I'll refer to my oculoplastics colleagues to manage.

[Dr. Ashley Agan]
Any other surgeries that you want to mention for this patient group?

[Dr. Shiayin Yang]
Yes. I think there are a couple or two other surgeries that come to mind that I think we should touch on. Typically, these surgeries are dynamic surgeries that we usually treat flaccid facial palsy patients for, but there's been some research, some of my colleagues across the country have done them.

The first is looking in to see if any type of neural reanimation, so masseteric to facial nerve reanimation, could that help in conjunction with a selective neurectomy? There's been some studies on it, but I don't think the data has been great. I don't think this is an area that potentially will continue to gain momentum, but the thought behind it is, can you cut some of the facial nerve and interrupt that synkinesis and give it input from somewhere else?

Masseteric to facial nerve reanimation is when you connect the nerve to the masseter to a branch of the facial nerve. In patients with flaccid facial paralysis, it can give you really good oral commissure excursion because the masseteric has a significant amount of axons and is a very powerful nerve graft. The thought being, in these patients who have synkinesis, who are not getting oral commissure excursion, could we input the masseteric nerve into the facial nerve and get that excursion?

I know that there's been some research, a select handful of patients where this has been tried, but I think over the long term, the unfortunate result is that the synkinesis tends to overpower even the masseteric effect. I think, unfortunately, that hasn't bore out as a great option, but I think it is an interesting school of thought and interesting avenue that has been looked at.

The second surgery that I personally have not done yet for a patient, but I know other people around the country are doing a gracilis, so free muscle transfer to improve commissure excursion, improve patient smile who have severe synkinesis. You'll have some patients who are getting no oral commissure excursion, and essentially you're taking tissue from their thigh, putting it into the face to recreate a new movement and help improve their smile.

I think once we have a little bit more data on this and the improvement that patients could potentially get, I think this could, as well as the selective neurectomy, be an additional avenue that our synkinesis patients might have.

[Dr. Ashley Agan]
Interesting. Interesting. Those patients do not have flaccid facial paralysis on that side, but they're not able to have that smile. They're not able to elevate the oral commissure. You're specifically trying to fix that problem?

[Dr. Shiayin Yang]
Exactly.

[Dr. Ashley Agan]
Wow.

[Dr. Shiayin Yang]
You're going to have some patients who are so severe, it looks like they're just frozen. I have a patient, she has bilateral facial paralysis, and she just looks frozen. She can't move her mouth. She can't close her lips. I think the thought is in the right patient; you're essentially just creating a new muscle to give them a smile.

Granted, gracilis, traditionally we think of that being used in our flaccid facial paralysis patients who are out too long to do a neural reanimation. Those are typically the patients who are receiving these types of surgeries. Can we apply this to our synkinesis patients? Some people already are. I think seeing more data, more outcomes of these patients, and determining what are the best treatments, that's the frontier of this. The best treatment is improving regeneration of the nerve. Until then, these are the procedures we have to treat these patients.