.png){kind=small}
.png){kind=small}
BackTable / ENT / Podcast / Transcript #188
Podcast Transcript: Surgical Management of Synkinesis & Static Procedures for Flaccid Facial Palsy
with Dr. Shiayin Yang
Facial nerve injury affects each patient in a unique way. Accordingly, surgical treatment of facial paralysis must be meticulously planned and personalized. In this episode, Dr. Shiayin Yang, Associate Professor of Otolaryngology at Vanderbilt University, addresses management of synkinesis and static procedures for flaccid facial palsy with host Dr. Ashley Agan. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Making Sense of Facial Paralysis: Flaccid versus Non-Flaccid
(2) Determining Treatment Goals of Synkinesis Patients
(3) Non-Surgical Treatment in Synkinesis
(4) Periocular & Brow Procedures for Synkinesis
(5) Myectomy and Selective Neurectomy for Synkinesis
(6) Static Reconstruction of the Upper Face in Flaccid Paralysis
(7) Static Reconstruction for Mid and Lower Face Flaccid Paralysis
(8) Introduction to Dynamic Procedures for Facial Paralysis
This podcast is supported by:
Listen While You Read
Follow:
Subscribe:
Sign Up:
[Dr. Ashley Agan]
Hey, everybody. Welcome to the Backtable ENT Podcast. My name is Ashley Agan. I will be your host today. Today on the show, we have Shi Yang, who is an associate professor in the Department of Otolaryngology–Head and Neck Surgery at Vanderbilt. You may recognize her from Episode 151 when we talked about synkinesis. She's back today for a deep dive into the surgical management of patients with facial paralysis. Welcome back to the show, Shi.
[Dr. Shiayin Yang]
Thanks, Ashley, for having me. It's good to be back.
[Dr. Ashley Agan]
Last time we talked about synkinesis specifically. For listeners who haven't heard that episode, I highly recommend going back and checking it out because it really sets the stage nicely. Today, we're going to elaborate on that and get into the nitty gritty about the surgical management of patients with facial paralysis, including those with synkinesis. Before we get into it, it's been a while since our last conversation, Shi. Any updates for our listeners? I noticed you've been promoted to associate professor. Congratulations. I think last time when we recorded, you were assistant. Correct me if I'm wrong.
[Dr. Shiayin Yang]
That's correct. Thank you very much.
[Dr. Ashley Agan]
What's new with you?
[Dr. Shiayin Yang]
Not much. The promotion was huge. Really excited about that. Just continuing to spread the news about synkinesis. Have been pretty busy in practice, especially with my facial paralysis patients. Got a lot of good feedback about the last episode. I think there's a ton of topics to cover, so I'm excited about this episode today.
[Dr. Ashley Agan]
Do you still have your synkinesis clinic there? I think the last time you had talked about it, you guys have a dedicated clinic for these patients where that's all you're focused on that day or that week.
[Dr. Shiayin Yang]
Yes. It's actually this week.
[Dr. Ashley Agan]
Okay, great.
[Dr. Shiayin Yang]
Perfect timing. We have it every three months. It falls May, August, November, and February.
(1) Making Sense of Facial Paralysis: Flaccid versus Non-Flaccid
[Dr. Ashley Agan]
All right. Let's get into it. Starting out, I think maybe for listeners who haven't heard our previous episode, just generally setting the stage, talking about facial paralysis and how you think about it, different types, how you categorize that in your mind.
[Dr. Shiayin Yang]
I think this is a really important point to touch on. Whenever I'm giving a talk or a lecture, it's usually the first thing I talk about or touch on, is just understanding exactly what is facial paralysis and in what category does your patient or whoever's presenting fall into. Anytime you have facial nerve injury, there's two different routes you can go down. One is where you have no recovery, meaning whatever side the facial nerve was injured, the face doesn't move. Complete paralysis or flaccid facial palsy. It's that classic picture, I think that many of us see in terms of one side of the face drooping, no movement, while the other side is able to move. That is, after facial nerve injury, you have no recovery of facial movement.
Then the next category is some type of facial nerve injury, where you get partial or even complete recovery. In the partial recovery and even the complete recovery, you can develop synkinesis. Then we categorize these patients into non-flaccid facial palsy. Flaccid facial palsy is when the face doesn't work. Then, non-flaccid facial palsy is when you've had some type of facial nerve injury. This could be Bell's palsy after surgery, traumatic injuries such as temporal bone fracture, or let's say, excision of the facial nerve after a parotid cancer that has then been reconstructed with a nerve graft.
After any type of that, if you get some type of partial or even complete recovery, you can still go on to develop abnormal facial movement, which we commonly characterize as synkinesis. Synkinesis is just a constellation of non-flaccid facial palsy. Non-flaccid facial palsy is a multitude of characteristics, one being synkinesis, where you have involuntary movement of the face with voluntary movement. You can also have areas that are weak and don't move. Then you can have areas that are very contracted, so this hypertonicity.
Important, I think, to understand because I think a lot of people misunderstand that synkinesis, it can only happen after maybe like Bell's palsy, but it can happen after any type of facial nerve injury. It can even happen after you've had a successful facial reanimation surgery.
[Dr. Ashley Agan]
I remember last time you talked about how it can happen, I think you said 6 to 18 months. The timeframe after injury can be a really long time. It can be a while before patients have synkinesis.
[Dr. Shiayin Yang]
Exactly. You can start just as the nerve is regenerating. Let's say someone had Bell's palsy, and they come in four months after that injury, and the face is completely working, they can still develop abnormal movements of the face depending on the severity of what their paralysis is, but they can start developing injury after that timeframe. I think that's why it's important for these patients to understand that not just because you've recovered function of your face.
A lot of people will say that, "Oh, I've seen my primary care doctor or neurologist," or whoever initially diagnosed them, and they're like, "My face regained function." Even though it's not normal, there's still things that can be done, and just understanding that it can still develop over a timeframe after when you originally had the injury.
[Dr. Ashley Agan]
Even if you have full recovery of your facial movement, if you're having synkinesis, unwanted movement of your face when you go to smile or blink or other things, that that's not a cosmetic issue, or seeking help for that is not vanity. That it's a problem that there are solutions for.
[Dr. Shiayin Yang]
Yes. I'm glad you brought up that point again, because that is really just something that I try to emphasize with patients, because so many of them say, "Oh, I just thought this was vanity and that there wasn't any reason I should get this fixed." There's so many functional aspects that can cause them trouble in the long term. I think understanding that, recognizing it, can really help people.
(2) Determining Treatment Goals of Synkinesis Patients
[Dr. Ashley Agan]
Thinking about first, managing synkinesis, that patient population has got some full or partial recovery. In our last episode, we talked about using Botox. We did talk a little bit about surgical management back in the last episode, but I think also before we get into that, just talking about a little bit of your process with Botox, specifically, last time you mentioned it's a long process. You counsel your patients that it's a journey finding the right amount and the right muscles to treat. Can you touch on that before we move to surgery?
[Dr. Shiayin Yang]
Once I see a patient and I see that they have this abnormal movement, some people are not bothered, and if you're not bothered, you don't have to have treatment. There's obviously different severities in terms of the synkinesis. Examples, for maybe listeners who are not as aware, what I mean by synkinesis is when a patient tries to, let's say, close their eye, the corner of their mouth may move, or when they talk, their eye closes, but it can also be more than that. A lot of people complain of just constant tightness and pain, and pressure.
At the end of the day, it can be really hard for them. They'll get headaches, or they just have constant soreness because those muscles are just hyper-contracted. Understanding that there's a severity of disease, I think, in anything we do. There's a severity of treatments. If they're not that bothered by it, then you don't have to have treatment. You don't need to seek treatment. This is really for those patients that have a debilitating disease that's affecting their quality of life. You're really seeing some of those patients.
Initially, when I see them, it's a consultation. If the diagnosis was Bell's palsy, it's really determining does the story fit with Bell's palsy because I have seen patients come in, say they were diagnosed with Bell's palsy, then I uncover all their causes. Bell's palsy, just as a reiteration, is a diagnosis of exclusion, meaning you've ruled out everything else, and because you don't have another cause, that's what it is. It really is a clinical diagnosis. Understanding the different symptoms they present with and symptoms that they lack will really lead you towards that diagnosis.
After once I clarify what I think is their diagnosis, it's a good physical exam, seeing what parts of the face look like they're working abnormally or normally. Then, also determining what areas are affecting them. What is it that bothers them? I may see certain things that they don't notice. It's really understanding what their motivation is for treatment, and this is a resounding theme in facial paralysis. Really understanding what is that patient's goal for therapy because sometimes, maybe it's the smile that really bothers them, but I notice that they're constantly closing their eye, and they just have a lot of tightness in the midface region. It's aligning our goals, seeing what we can obtain.
That's why that first visit is usually pretty long, is just confirming the diagnosis, doing a good exam, and then understanding what are their goals for treatment.
(3) Non-Surgical Treatment in Synkinesis
[Dr. Shiayin Yang]
After that, I usually recommend physical therapy, starting out, it helps with biofeedback, and there are some data to suggest that there's cortical remapping after facial nerve injury. I think working with a physical therapist is pretty low risk. Actually, there's also been research to show that patients really buy back into their treatment after starting that.
Then, after that, depending just what the physical therapist says, because sometimes they want to do physical therapy prior to initiation of Botox, we then go into Botox treatment. We treat with Botox, and like I said, it's a process, just figuring out those treatment algorithms and seeing how successful it is, what benefit they're getting, what they like about it.
[Dr. Ashley Agan]
I would think it would be hard for patients to articulate the sensations and things that they feel, unless they're really looking in a mirror and doing the movements. I'm sure they learn more about their disease process as they're doing physical therapy and looking in the mirror, and being able to see what's happening. Because if you're just coming in, with the smile, I think that's obvious. I've had patients who say, "Oh, yes, we took a family picture, and my smile is off." That's always a big one. With generalized tightness, or if those muscles are just moving and pulling, I imagine that would be hard for patients to articulate or describe.
[Dr. Shiayin Yang]
Yes, that's why I think it is very helpful. It can really just help them determine what part of the face is really bothering them. Like I said, a lot of people don't want to look in the mirror, they don't want to look at what their face is. I think it also helps them. That's why another thing is photo documentation is very important, because the onset of Botox is very gradual. It usually takes about 10 days to a full two weeks to have that full onset. Then it slowly wears off.
Having those photos documented, and then oftentimes, my new patients, I'll see back after a month to see what progress we've made, and they will feel things. Then, when we review the photos together, they'll really notice, "Oh, wow, that really helped open my eye, or that improved in the way that my smile is upturning."
[Dr. Ashley Agan] That's what I was going to ask you, is with your assessment, how you are documenting and following their synkinesis. With facial paralysis, you have different scoring systems, like House Brackmann, to say, "Okay, this is the severity of the paralysis." When you're doing your assessment, what kinds of things are you noting with photo documentation, what movements are you having them do, and how do you note that?
[Dr. Shiayin Yang]
That's a great question. They go through a couple of different poses so we can see essentially the different movements of the face. The first is brow elevation. You have them raise their eyebrows. The next I actually do in terms of evaluation, I have them gently blink their eyes, which, it's strange because you'll see in some patients with gentle eye closure, they're actually not able to fully close their eye. Then, when they forcefully close their eye, they're able to get it fully closed. You'll see different patterns as more and more of these patients.
The first photo is eyebrow-raising, the second one is eye closure, then I have them do a snarl to really try and see the differences in the mid-face. I have them do a pucker so you can see their orbicularis. I have them do a gentle smile without teeth, and then a big smile with teeth. Then I have them say “E”, so I can see their depressors and the movement there. I document those different photos. Also, take a video as well. It's a lot. The nice thing about being at an academic institution is it goes straight into the medical chart. You can put it in their visit note and document between visits, their improvement.
It is helpful also, if you're seeing patients back who've had paralysis, and you're watching their recovery, so you can see the parts that are recovering at different rates. Then you can also just show them the progress. Photo documentation is such a huge thing in facial plastics. It's really good not only for the patient, but for yourself and your learning and education. Especially for the facial paralysis patients, I think it's important to really have good photos. You can really learn off of your treatments from them, especially if you're doing Botox. Then, even with surgeries, what really worked, what didn't, and then just really improving the care for that patient as well as your own practice.
(4) Periocular & Brow Procedures for Synkinesis
[Dr. Ashley Agan]
Moving into the surgical management, first, thinking about surgical management of synkinesis specifically, so maybe patients who have had some success with Botox, but now they're looking to maybe not come in every three months or something like that, how do you think about those patients?
[Dr. Shiayin Yang]
That's a great question. There has been a lot of momentum in this field over the past five years, probably a little bit more than that. Because I think if you talk to a lot of people who are treating facial paralysis, the biggest portion of our practice is this non-flaccid facial paralysis. When you think of the exciting, cool surgeries with facial paralysis, it's more geared towards your flaccid facial paralysis patients, so the ones whose face is completely not working, but really, the bulk of your practice is non-flaccid facial paralysis, so synkinesis patients.
That's a lot. That can really take over your clinic very quickly if you're just doing Botox injections every three, four months. It's a lot for the patients. We have people driving three, four hours every three months to come see us. What can we do to make it better? Unfortunately, I hope this doesn't spoil the episode, but we don't have a perfect treatment or cure, for people listening. We're working, obviously, on ways that we can decrease how much Botox they're getting.
First, before jumping into those surgeries, other surgeries that you can also consider for these patients are general aesthetic, trying to get symmetry for these patients. A lot of facial plastic procedures that you do for your cosmetic patients, you can also do for these patients, so a brow lift. A lot of patients, when they've had some type of paralysis, their brow does not regain function. You can get this big asymmetry between the brows. Easy doing an indirect brow lift, a direct brow lift, depending on the type of patient, and just giving them more symmetry for their brows.
Another area is also the upper eyelid. When you get your brow dropped, you tend to have dermatochalasis or excess upper eyelid skin that can limit your vision. Depending on their age, many people need a blepharoplasty anyways. They can really benefit from having the upper eyelid skin removed. Depending how weak their eye is, there's a lot of procedures around the eye that can be done. You can place an upper eyelid weight if they're not getting great closure. It depends on the case and the patients.
I did have one patient who was taking a while to recover, especially the eye. I did place an eyelid weight. Eventually, they got recovery back, and so I removed it. It's a relatively easy procedure to do. I typically do them in the office, about an hour. It's something nice to help them protect the eye. The other thing you can do is treat the lower eyelid. Whether it be lower eyelid tightening, where you're suspending the lower eyelid so it's a little bit shorter. Again, in our older patients, who tend to have that lower lid laxity. This is something they probably could have even benefited with before the paralysis, and the paralysis just makes it more dramatic.
Another eyelid procedure we're doing a lot of is what's called a tarsoconjunctival flap, where you actually take a bit of the conjunctiva and the tarsus from the upper eyelid, swing it down to the lower eyelid to hitch it up a little bit better, give yourself some more support. Those are some of the things you can think of for these patients in terms of if they're having periocular issues and treating them.
[Dr. Ashley Agan]
For patients who, let's say, they've gotten some asymmetry with the brow or with the eye, how long does that take to develop after their Bell's palsy or whatever the injury was? Are you usually doing those procedures months down the road, years down the road?
[Dr. Shiayin Yang]
If it's the brow and the upper eyelid, that's usually when they're more stable. Probably like two years out from their original injury. A lot of these people I see significantly far out from their initial facial paralysis. It depends. I definitely have had patients who have had an acute-type injury, and I've done a cable graft to repair their facial nerve. Then it's going to take a while for that nerve to grow back. In the meantime, if it's an elderly patient, I've gone in and done a brow, done the eyelid weight at the same time, done the lower eyelid tightening. Because, like I said, even if they develop great function back, a lot of people are still very weak in their frontalis, and they don't get great movement back. They already need a brow lift.
If they're older, they already likely have brow ptosis and really elevating that brow. I will do both sides too. I try to do everything to make them symmetric. Maybe elevating the brow on the affected side a little bit more, but also elevating it on the non-affected side. It just depends on the etiology, and what I'm expecting of their recovery.
[Dr. Ashley Agan]
I was going to ask that if you do both sides, because a lot of people, yes, maybe at baseline already could have used something. Then you add that paralysis on top of it, and then things are really–
[Dr. Shiayin Yang]
It really magnifies it. Sometimes it is a little hard to get it through by insurance, just doing periocular work. They tend to be a little bit more resistant, but the photos are pretty obvious in terms of the issues they're having, and addressing both sides, it proves a lot for them. Really, the goal is symmetry and trying to just restore them back as much as we can.
[Dr. Ashley Agan]
I think that's a really good point. When you're arguing or trying to appeal insurance-type issues or denials, what kind of quality of life issues do your patients experience when it's periocular? Are they just having limited visual field or having to overexert the muscles around their eye to open their eye fully, and so then they fatigue there, or what's the argument you make?
[Dr. Shiayin Yang]
It's a couple of things. First, I just show them the photos and say, "Look how drastic this is.” They have one: definitely overexertion if they're constantly trying to lift their brow, but they can't lift it on that side if it is completely paralyzed. The second thing is visual defects. If they already have a brow ptosis, and then you add a paralysis on top of that, it significantly drops it, limits their lateral vision. Anytime they look down, it's hard for them to see.
The other thing for the lower eyelid is that these patients will complain of a lot of eye tearing because not only is their face not working, but their lacrimal system is not working appropriately either. They'll just be tearing a lot. That also limits their vision. Trying to help it not pull so much in the lower eyelid by improving suspension of that lower eyelid helps as well. Discussing all those three aspects in terms of just the asymmetry, visual field deficit, improvement in the tearing of the eye, and then also protection of the eye, because you want to make sure that they're getting good closure. They're protecting their eyes so they can protect the vision.
I've gotten the majority through. I'm trying to think of a case I haven't. Off the top of my head, I can't specifically. There may have been one or two potentially, but most of them, you have to send photos. Some people want a peer-to-peer, but it's discussing those aspects and how it's really affecting them.
[Dr. Ashley Agan]
It's way more than just a cosmetic thing. It's just restoring function to the eyes.
[Dr. Shiayin Yang]
Exactly. It's so much more than just the cosmetic aspect. That's what is so important for them to understand, and so important also for the patient to understand. Them understanding what they're going to achieve with surgery is so huge and I think it helps. You never want to put someone under a procedure that's not necessary. Really understanding the pros and cons about having surgery is important.
(5) Myectomy and Selective Neurectomy for Synkinesis
[Dr. Ashley Agan]
Other things that you're doing for non-flaccid palsy?
[Dr. Shiayin Yang]
I think for the static ones, that's usually the biggest, is a lot of the periocular work. Then the next type of procedures are really trying to work at improving the synkinesis or the abnormal movement. There's two different types of surgeries that can be done. One is a myectomy, where you're essentially targeting the abnormal end organ, which is the muscle. The other is neurectomy, where you're targeting the nerve that is inappropriately or rerouted the wrong way, getting innervation to the muscle and causing abnormal movement or unwanted abnormal movement.
These are the two areas. They've been around for a while, but there's been a lot more traction in terms of the neuroectomies recently and the procedures that are being done. This is the newer surgery that's gained a lot more popularity and is being done a lot more, and just still trying to figure out what is the best possible outcome. I guess starting with myectomies, what you're trying to do is you're trying to target muscles that may be in that more hyperkinesis or hypercontracted state, giving you unwanted movement.
The popular areas targeting is the depressor anguli or DAO, most commonly. That will give patients this downward-pulled smile. You'll see that a corner of the mouth is pulled down, and if you treat them with Botox targeting their DAO, or you could even do a test in the office with lidocaine numbing that area, seeing if it gives elevation of their oral commissure. That can be a good indicator that cutting that muscle would be beneficial and would help them give the upward movement of their smile. It's something that's easy. It can be done. You can do it through the mouth in the office, and you're literally just cutting out a large swath of that muscle.
[Dr. Ashley Agan]
When you say large, like a centimeter?
[Dr. Shiayin Yang]
Yes, like a centimeter, two centimeters, so that the muscle is completely disconnected.
[Dr. Ashley Agan]
Got you.
[Dr. Shiayin Yang]
That's probably the most popular one. The other one is or other areas that can be targeted is the platysma. Patients who have just a lot of platysmal banding, a lot of neck tightness, that's also an easy area where you can target that muscle. Sometimes the depressor, the DLI, can also be targeted, depending if they're getting a lot of downward pull. This one's I think a little harder to address than the DAO, but that can also be addressed just to help improve the appearance and their smile.
These can also be done in combination with neuroectomies. Doing a selective neuroectomy. With that, it's usually you're deciding on your patients in terms of your patients who have been doing really well with Botox, but maybe they have a pretty severe synkinesis. They either have a lot of tightness or a lot of unwanted movement. You've treated them with a lot of Botox. They've gotten good results from the Botox.
You can also do little lidocaine blocks to see in the general area. You can target their buccal branch if you do an injection mid-cheek or around where the marginal mandibular branch comes, so around the facial notch. That can give them evidence of what cutting those nerves in those areas might look like and help improve with their appearance. Essentially, a selective neurectomy, it's a facelift-type incision. You're exposing all the nerves within the face. Then you're actually stimulating the nerves in troughs, seeing which ones are giving you unwanted movement. It's a balance of finding ones that maybe cause this downward pull of the lip or significantly more the depressor type movement of the mouth and the smile, and clipping those nerves to essentially weaken that forceful effect that they have.
[Dr. Ashley Agan]
That sounds like a much harder surgery, tracing out all those little tiny nerves.
[Dr. Shiayin Yang]
It's a much more involved surgery, harder surgery. I think a little harder to predict as well what exactly their outcomes will be. A lot of these patients still need Botox or are still going to have Botox. It's not going to restore them back to what they were before. I think it's really having a good understanding with the patient, but even if you can decrease the amount of Botox, just having that constant relief of the pressure and neck pain or mid-facial pain, a lot of patients find it worth it.
[Dr. Ashley Agan]
You mentioned with the myectomy, the common targets are for patients who are having a lot of downward pull around the mouth or platysmal banding. With the selective neurectomy, are there common movements that that works best for?
[Dr. Shiayin Yang]
I think that is evolving in terms of what people are treating that for. The common ones for myself are tightness of the neck, downward pull of the mouth, very drastic, or my patients with more severe facial paralysis who have done really well with Botox. More and more people or I'd say some of my colleagues in the country, are now treating areas around the eye. The concern is, could you potentially risk these patients not being able to close their eye really well? There's still a lot that needs to be learned about how long is this effective, how long does it work? Tessa Hadlock, a while ago, actually published on patients who she did neuroectomies around the eye and found that over time these patients still needed increasing amounts of Botox. Questioning, how well does this actually work? The same argument can be done for the nerves around the face or the rest of the face. That's why I think it just needs a little bit more time to really understand how well these patients are doing after surgery and also understanding, what do you do with the clipped nerve ends.
I think that is an area that is further being explored. Not just cutting the nerve and clipping both ends, but also taking out a chunk of the nerve. About a centimeter of the nerve clipping both ends. Then some people are dunking the nerves into the masseter muscle, giving it something else to innervate. There's been some data within plastic surgery where they actually, in other peripheral nerves, wrap the nerves in muscle. You could take a little bit of the SCM and wrap it around the cut nerve end.
I think it's an exciting field and it still has a lot more that has to be understood and better developed before it becomes anywhere near the more regimented and predictable type surgery.
[Dr. Ashley Agan]
Interesting. For now, that selective neurectomy, it's not most of your patients, I would assume. That's kind of a select group of patients that maybe have a really severe synkinesis that they're just wanting that next step, but also it's not predictable, and there's no guarantees. I'm sure there's a lot of upfront counseling.
[Dr. Shiayin Yang]
Correct. It's, at least for my practice, it's for those patients who have very severe disease and extremely debilitating disease and trying to maybe lessen how much Botox they're getting and give them some type of permanent relief. It's really for my patients who have them and who are really motivated and saying they want to do something else. They realize that and may not be able to exactly predict how it is going to be after surgery, but they want to do something more than just Botox.
[Dr. Ashley Agan]
All right. For your outcomes for that, for the selective neurectomy, percent-wise, how many people have improvement, or how do you grade it? Some improvement, a lot of improvement, zero improvement? How do you assess your outcomes after that?
[Dr. Shiayin Yang]
Really it's just if we can decrease the amount of Botox and if they subjectively have improvement. Because a lot of this disease, outside from the way that I evaluate them, is also, like we said, the feeling of things and the improvement in the tightness that they're having or the feeling that it's more they're telling me that they have relief and they've noticed improvement in the way they eat or if they've noticed in their smile. That's the way currently, but there's definitely avenues in terms of how are we going to grade it? How do we determine if it's really been successful for them?
[Dr. Ashley Agan]
They should notice it immediately, right?
[Dr. Shiayin Yang]
Exactly.
[Dr. Ashley Agan]
Once the nerve is cut. They should know.
[Dr. Shiayin Yang]
Yes. Honestly, right in PACU, you should be able to tell the difference.
[Dr. Ashley Agan]
That's a lot more fun than Botox when you have to wait a little while. It's nice to have that instant, "Okay, did it work?" [laughs] Okay. Wrapping up surgical management of synkinesis, anything else before we move on to talk about static procedures for flaccid paralysis?
[Dr. Shiayin Yang]
I think that's it unless you have other questions about it.
(6) Static Reconstruction of the Upper Face in Flaccid Paralysis
[Dr. Ashley Agan]
Well, let's move on so we make sure we get everything covered in this category because this is a different group of patients. Now we're talking about the patient with flaccid facial palsy, like you said earlier, meaning no movement, and how you think through the static procedures that you can offer that patient group.
[Dr. Shiayin Yang]
Just to reiterate, the flaccid facial palsy patients are those with no movement. We think about the two different types of surgeries. The first category is static procedures. You're not trying to restore dynamic movement. Static procedures are to restore the symmetry and try to balance the face, but it's not going to give any type of movement back. Then the second category is dynamic, and dynamic is when we're trying to get movement on the face and have some type of movement back.
That's the two categories when you're looking at your flaccid facial palsy patient and discussing what can we do for the face? What are the different things in our toolbox to help improve this paralysis? It's also important because you need to understand what their motivations are and what you think will be the best treatment depending on what their prognosis is, the etiology of their facial paralysis, and also their underlying medical comorbidities.
In patients maybe who have a bad head and neck cancer and have to go through a lot of treatment, they may not be ready or able to undergo a big dynamic surgery and doing something smaller that will still-- Because static procedures can still give you improvement. They can help the way you eat, the way you speak, aside from just your appearance. I think looking at the patient as a whole, understanding what their motivations are, what they want to achieve with treatment will help guide you one pathway versus another. That being said, you can also combine static with dynamic.
[Dr. Ashley Agan]
It's a menu, and everybody's different. I'm sure there's a lot of shared decision-making. 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. Ashley Agan]
They're already dealing with their facial paralysis, so you don't want to add another issue on top of everything. When you are doing your assessment, can you support the brow? Just when you're clinically looking at them to be like, "Okay, if I pull it up this much, is that going to make them to where we're pulling their eyes open?" Does that help you at all, being able to just–
[Dr. Shiayin Yang]
No. That's exactly what I do.
[laughter]
[Dr. Shiayin Yang]
I do support the eyebrow at a position that I want it to be at, and then I will see how much is it closing, how much excess upper eyelid skin do they have that's interfering with their closure? Because some people don't need anything because their brow is so heavy, and they're able to close. If that's the case, and I expect them to regain recovery and they're doing okay, then we'll go down that path and just make sure they're doing drops and ointment.
That's usually never the case, but that is an option if they're protecting it. They can also tape at night. You put a little strip of tape at the bottom part of the eye, and then I usually have them do at the lateral aspect of the eye to try and tape it closed. You don't want to strip directly over the eye. I prefer to not do the taping because I worry that they won't necessarily do it right. I think it's easier just to wear a moisture chamber. Evaluating them, though, no, I do raise their brow.
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.
(7) Static Reconstruction for Mid and Lower Face Flaccid Paralysis
[Dr. Ashley Agan]
A lot of different options, a lot to think about when it comes to static procedures of the upper face and around the eye, with the main goals being around eye care and maximizing the patient's visual field while also giving them the ability to close their eyes and make sure they're protecting their eyes. Moving on to other procedures, maybe in the mid and lower face, what else is in your toolbox?
[Dr. Shiayin Yang]
The next one is static sling. This is where I'll take tensor fascia lata from the thigh. You do a facelift incision, elevate a facial flap in your subcutaneous plane, taking that tensor fascia lata, and then I'll cut a couple of different strips because what I'm really trying to target is, depending on their symptoms, but a lot of patients will have nasal valve collapse. I'll do a couple of different strips. I'll do a strip from the nose up to around the zygoma. Usually, I do a broader strip where I'll try and catch some of the upper lip, the oral commissure as well onto the lower lip, and then bring that, whether it be one strip or two strips or a large strip, bringing that up.
Depending on the patient, they can have significant laxity and pull to the unaffected side. Really trying to bring them more in a resting position, opening up that nasal airway and improving it so they're not constantly biting on their cheek, biting on their lower lip, and it also will help them speak better. That is something that I do in a lot of my patients who are older, who maybe have more medical comorbidities, do not want a bigger dynamic procedure. It's a good option. It can really give them significant improvement in breathing, speaking, and eating.
I've had patients where it's become loose and I've been able to re-suspend that in clinic and right away, they're able to know like, "Oh, I can breathe," or, "The mouth feels in a better position." It's the, I'd say, unsexy side of facial paralysis, but it's effective and it makes a big difference for these patients.
It also can be done at the same time you're doing a dynamic procedure. I've done this in patients where I'm cable grafting their facial nerve. If it's a cancer excision, it's an older patient, I do a cable graft and maybe a masseteric to facial nerve reanimation. If they have a lot of laxity and I know it's going to help, then I will also do a static sling at the same time because that will give them improved resting symmetry while I'm waiting for that nerve to grow back.
I would say, aside from the patient who doesn't want to have a dynamic surgery, the static sling is a good procedure for those patients, but it's also good in conjunction in the right patient for select dynamic procedures.
[Dr. Ashley Agan]
Because you're going to have that instant result. It gives you some symmetry while you're waiting for your cable graft to work.
[Dr. Shiayin Yang]
It can give you symmetry. It can give you improved function. There is talk about how far do you pull it, how much do you pull it. I tend to try to not drastically over-exaggerate the pull of the tensor fascia lata. There's concern of how much is it going to stretch or loosen. I've found it a little bit tighter than what I would want it to be, but not drastically overly tight. I've found to be a good in-between, but another procedure that I've found to be hard. Another modification is actually doing it in a similar way as to deep plane facelift, so going sub-SMAS, and you get a little bit more bulk from the tissue, a little bit more that you can anchor it to, and then giving them that increased support.
[Dr. Ashley Agan]
You have pretty good longevity with that?
[Dr. Shiayin Yang]
I do with the tensor fascia lata. I've definitely had patients where it has relaxed in figuring out what to do. Recently I had a patient where that happened. They weren't really excited about having to go under again for a surgery. I was able to open the incision in clinic. I opened the superior aspect of the incision, found it, it was still connected, and then attached. Then I just resuspended it, tightened it more, resuspended it. My thought is that the graft relaxed over time. Hopefully, they do well, and it doesn't happen again. It's one of those things that's a risk of that procedure.
[Dr. Ashley Agan]
All of our tissues are stretching and loosening over time, including the graft that you put there. Other procedures for helping create symmetry in the lower face?
[Dr. Shiayin Yang]
Yes. The only other one I would say, this one I don't really do as much, but I've had it in one or two patients where actually the lower lip has just been very stretched. In some patients, and I've done this in a lot of post-cancer reconstruction patients as well, actually taking a little bit of a wedge of the lower lip can help shorten it so that they have improved oral competence.
In those patients who have maybe an extremely stretched lower lip and they're just really pulled to one side, they're drooling a lot, they're having trouble with oral competence, I have done it in a handful of patients, both facial paralysis as well as post-cancer reconstruction. I've found it to be something that's relatively easy to do to improve overall oral competence, eating, and speaking.
[Dr. Ashley Agan]
Yes, which is huge for the patient to be eating and speaking. It's what we do all day long. It's a big quality of life factor.
[Dr. Shiayin Yang]
It is. It is. The other thing just around the mouth too is some things you can consider as well as fat grafting, because you have to think of these patients, not just that the face isn't working and facial paralysis, but you have to also think about just their general aging. Some people also benefit from fat grafting and just giving them more volume will help to improve oral competence, helping them close, helping them eat and speak.
Yes, it helps their appearance. I think the more harmony and the more symmetry you can give back to these patients, the better it helps with their overall mental health, which I don't think we talked about it much today, but last episode, that's just such a huge part of this and such a debilitating part of this disease. The more that you can restore them, the better it is, the better result you get.
I really think looking at these patients, not just what muscles are not working and how is the face not working, but also understanding from an overall harmony and symmetry standpoint, trying to restore that and restore both sides. Really, like I said, it's like with the periocular work, addressing both sides, addressing the eyes. That can have a huge impact for them.
(8) Introduction to Dynamic Procedures for Facial Paralysis
[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.
[Dr. Ashley Agan]
This has been a really awesome, thoughtful, and full discussion. Thank you so much for taking the time. Anything you want to leave our listeners with?
[Dr. Shiayin Yang]
Yes. I think just a couple of key takeaways is, one, for synkinesis, aside from Botox and physical therapy, in the right patient, there are options for surgery. First is trying to restore symmetry to their face. Whether it be periocular work, a brow lift, or blepharoplasty, these can have significant improvement just on the overall quality of life.
Then if you're trying to go more down the road of targeting that abnormal facial movement, some patients may be a great benefit for myectomy, which is something that could be done in clinic. Then for your patients who have had a lot of improvement with Botox, they're motivated to do something more, considering talking about selective neurectomy as a good option for these patients.
Then in terms of our flaccid facial palsy patients, you have the two different categories of static reanimation and dynamic reanimation. The latter part of this episode was talking about the static procedures, going zone by zone and figuring out, what you can achieve and accomplish. Paying a lot of respect to protection of the eye is very important. Just trying to restore function as well as form is important for them as well.
[Dr. Ashley Agan]
You're going to come back and you're going to be talking to Dr. Loyo Li about the dynamic procedures. We have a little teaser for you guys. Stay tuned. Coming soon, you guys are going to do a part 2 of this to be able to dive into the dynamic procedures, which I think will be amazing as well. Thank you. If people want to find you, you're at Vanderbilt. You're on socials. Remind me your Insta handle.
[Dr. Shiayin Yang]
It's ShiyangMD. S-H-I-Y-A-N-G-M-D on Instagram.
[Dr. Ashley Agan]
That's a wrap.
[Dr. Shiayin Yang]
Cool. Thank you.
Podcast Contributors
Dr. Shiayin Yang
Dr. Shiayin Yang is an assistant professor of facial plastic and reconstructive surgery with Vanderbilt University in Nashville, Tennessee.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, August 27). Ep. 188 – Surgical Management of Synkinesis & Static Procedures for Flaccid Facial Palsy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Up Next
Articles
Reconstructive Techniques for Flaccid Facial Paralysis
Facial Synkinesis Treatment: Surgical & Non-Surgical Approaches