Facial Paralysis

/ The Facial Paralysis Institute By Dr. Karaaltın

Intro

In last 10 years “Dr.Karaaltın” has devoted his skills in reconstructive surgery to improve and implement the most advance surgical techniques for treating these special patients.

Indeed, our basic incentive is to approach the patient in a more centered way. Not only concentrating on the disease the patient suffers from but the impact of it on the patient’s life.

There are different modalities in treating facial paralysis depending on the severity of the condition. Hence, we expertly customize each patient’s procedures based on his or her individual circumstances

What Is The Impact of Facial Paralysis?

Facial paralysis is an important disability from both the aesthetic and functional points of view .The totally or partially paralyzed face is characterized by generalized laxity, asymmetrical animation, loos of nasolabial symmetry, drooping of the corner of the mouth, difficulty with chewing and inability to purse the lips. When the zygomatic branch of the facial nerve is involved there is a serious condition regarding the inability to close the eyelids medically called “Lagophthalmus”. Hence when such a condition happens, the patient suffers a wide variety of social drawback, regression and loss of self-esteem.

Etiology of Facial paralysis

According to the medical literature, facial paralysis can be either congenital or acquired. Yet, the most common Etiology of a unilateral facial paralysis is idiopathic, which also referred to be called as Bell’s palsy. On other hand, several other etiologies are also listed in below.

  • Congenital (e.g. Mobius Syndrome, Craniofacial microsomia)
  • Trauma (e.g. temporal bone fracture, laceration)
  • Tumor (e.g. cerebellopontine angle tumor, facial neuroma, malignant head and neck neoplasm)
  • Iatrogenic (e.g. acoustic neuroma resection, parotidectomy, temporal bone resection, neck dissection, rhytidectomy)
  • Infectious (e.g. Lyme Disease, Ramsay Hunt)
  • Melkerson-Rosenthal
  • Idiopathic (Bell’s palsy)

Treatment Options In Facial Paralysis

Various treatment options ranging form medical treatment to surgical interventions is recommended according to the etiology, degree of paralysis and the time of insult. Dr.Karaaltın uses a special algorithm based on his long years of expertise and utilities in correlation with the House-Brackman classification to assess the severity of the condition and designate the procedures most appropriate for the patient.

/ HOUSE-BRACKMANN CLASSIFICATION OF FACIAL FUNCTION

GRADE

CHARACTERISTICS

I. Normal

Normal facial function in all areas

II. Mild Dysfunction

Gross

  • Slight weakness noticeable on close inspection
  • May have slight synkinesis
  • At rest, normal symmetry and tone

Motion

  • Forehead – Moderate-to-good function
  • Eye – Complete closure with minimal effort
  • Mouth – Slight asymmetry

III. Moderate Dysfunction

Gross

  • Obvious but not disfiguring difference between the two sides
  • Noticeable but not severe synkinesis, contracture, or hemifacial spasm
  • At rest, normal symmetry and tone

Motion

  • Forehead – Slight-to-moderate movement
  • Eye – Complete closure with effort
  • Mouth – Slightly weak with maximum effort

IV. Moderately Severe 
Dysfunction

Gross

  • Obvious weakness and/or disfiguring asymmetry
  • At rest, normal symmetry and tone

Motion

  • Forehead – None
  • Eye – Incomplete closure
  • Mouth – Asymmetric with maximum effort

V. Severe Dysfunction

Gross

  • Only barely perceptible motion
  • At rest, asymmetry

Motion

  • Forehead – None
  • Eye – Incomplete closure
  • Mouth – Slight movement

VI. Total Paralysis

No movement

/ Unique Treatments Invented by Dr.Karaaltın

The Sling Temporal muscle Double Strip For Reanimating The Peri-orbital Region:

In this unique technique a regional muscle called The “Temporalis” (figure1) is utilized to provide a power sphincter for correcting the eye-lid deformity.

The surgical technique (figure2) conveys by splinting the muscle fibers in to two slings and passed through a tunnel created in the side burn region were both muscle strips are laid over the upper and lower eyelids respectively. The lower strip is passed over the Nose Bridge and slang on the opposite brow level. This maneuverer provides an important support mechanism for the lower eyelid, as this part tends to sag and drop down under the effect of gravity.

Figure 2. The red arrow denotes to the vector of elevation of the temporalis muscle witch enable the closure of the eye promptl.

An Innovation In The Treatment of Total Facial Paralysis: The Extensor Digitorum Brevis/Extensor Hallucis Brevis Muscle Transfer Using the Masseter Nerve as Donor Impulser

In patients with long-term paralysis (> 2 years) or either congenital, the native facial muscles are not functional. A transplanted muscle from is necessary if one desires to create a natural and spontaneous facial movement. Muscles to be transferred by micro neurovascular method to the palsy site need to have such characteristics as having the appropriate length and thickness for the face, the vessel diameter’s being suitable for microvascular anastomosis, having a sufficient neural pedicle length, and creating minimal morbidity on the donor site. Yet, all over this the transferred muscle should be similar to the physical characteristics of facial musculature in regarding muscle volume and pliability. The common disadvantage of the muscles frequently used in free muscle transfer for facial reanimation is that they can undergo atrophy during the rein-nervation period and thus can fail to fulfill their function and that they create a bulky tissue on the face and require debulking operations, which entail the risks of damage to the repaired nerve and increase in morbidity. Besides, some commonly used muscles such as gracilis pose problems in fixing due to the shortness of proximal and distal tendons. It has been shown in the literature that the latter condition has an unfavorable impact on muscle functions in the late period.

The Extensor Digitorum Brevis/Extensor Hallucis Brevis Muscle

A historical attempt for utilizing the extensor digitorum brevis muscle as a muscle graft for facial paralysis by Rao et.al was used. But those attempts ended with failure, since microsurgery was not popular as it is today. The muscle resides on the dorsum of the foot and is innervated by nerve called the Deep peroneal nerve. It possesses four tendons, which can provide a superior pulling string when adapted to the facial points at recipient area. The average dimension of the muscle is 5×1.2×1.8 cm^3 which is considered dramatically small in comparison to the alternative muscles. Its vascular supply is quite long which makes it versatile to be adapted to the recipient area when connecting both vessels and the nerve. Finally, as it is considered as the short extensor of the toes, no functional deficit is encountered when harvesting it as a free muscle flap.

The Innovations and Advantages of The New Technique

As we look at the medical literature, either local muscle or distant muscle transfers are described. Such options provide limited action and improvement, which might be limited to the corner of the mouth. Most of the distant muscles indicated for facial reanimation are rather from the large muscle groups, which are responsible of coarse single vector movements. Another handicap is the number of innervated motor units. A motor unit can be defined as a unit made up of a motor neuron and the skeletal muscle fibers innervated by that motor neuron’s axonal terminals.

All muscle fibers in a motor unit are of the same fiber type. When a motor unit is activated, all of its fibers contract. In vertebrates, the force of a muscle contraction is controlled by the number of activated motor units. The number of muscle fibers within each unit can vary within a particular muscle and even more from muscle to muscle; the muscles that act on the largest body masses have motor units that contain more muscle fibers, whereas smaller muscles contain fewer muscle fibers in each motor unit.

Figure 3.The figure presents the motor unit to nerve ending relationship

As for the new technique described by Dr.Karaaltın, The muscle is rather small with higher number of motor units. Hence, providing an ultra fine movement that is required to restore a facial mimicry.

The other superior additives are the four tendons that can be directed to different parts of the face for restoring the animation as much as possible. On other the hand, two of the four tendons are designed (as described by Dr.Karaaltın) to create a purse movement around the upper and lower eyelids of the affected side. Thus this innovation provides an all-in-one treatment for both the mouth and eyelid region, which is not possible in the previously described techniques.

Traditionally in facial reanimation with a muscle transfer, a nerve is borrowed from the opposite site to innervate the transferred muscle. This is the reason that such operations are preformed in two sessions. As in the first session a nerve graft harvested from the leg is used to bridge the recipient nerve that is going to be connected to the transferred muscle in the opposite site. This problem is overcome by using the masseter nerve (responsible for mastication) as it resides in the same side where the muscle is transferred. This fact eliminates the necessity for the nerve grafting session. On other hand, the masseter nerve contains more nerve fibers than the buccal branch of the opposite site. As for this, it provides more powerful impulse to contract the muscle.

The fact that masseter nerve is responsible for mastication does not means that the person will not be able to animate in synchrony with the healthy side. Since the brain has the capability of plasticity. With a short practise of five weeks, the patient is able to synchronize both smile and cheeks pulling. In addition, as the muscle is consistent of two muscles, the person can separately animate the smile and eyelid closure in return (Figure4,5,6).

Figure 4.

A preoperative view of patient suffering of a total facial paralysis after removing a tumor from the cerebellopontine angle.

Figure 5.

The postoperative view after transferring the muscle.The animation shows the ability of patient to close the right eye, as well as animating the right corner of the mouth and cheek.

Figure 6.

The arrows show the precise movement vectors provided by the Extensor Digitorum Brevis/Extensor Hallucis Brevis Muscle.

Finally, besides it’s surgical difficulties the technique indeed provides a precise solution with a number of advantages that could be considered as a brake through in “Facial Reanimation Surgery”.

The Mimic Muscle Transfer Reinforced with A Masseter Muscle Transfer

In certain circumstances, patients with a weak animation in the peri-oral area can benefit from local muscle transfers rather than a major muscle transfer surgery. Dr.Karaaltın modified a simple technique that provides a superior outcome to the traditional masseter muscle transfer that is classically performed.

The procedure is carried out from an intraoral approach were the masseter muscle (A muscle of mastication) is identified. A portion of the muscle is elevated and transferred to the corner of the mouth. At the upper lip region the lip elevator muscles are identified (mimic muscles) re-routed and shortened to be directed to the corner of the mouth, in order to enhance the leverage effect of these mimic muscles (Figure7).

To add another motion power to these muscles a portion of the transferred masseter muscle is attached to the bulk of the re-directed mimic muscle in the upper lift. This important maneuverer.

Figure 7.The green arrow shows the mimic muscles responsible for the upper lip elevation. The black curved arrow shows the re-routing direction.

Autologous Cell Enriched Fat Injections

In general patients suffering of facial paralysis depending on the severity of the deformity encounter a great deal of volume loss in bulk of facial expression muscles. This indeed contributes to overall facial asymmetry in return. The stem cell enriched autologous fat injection is regarded as a strong tool to overcome this problem and easily provides sustainable volumes that can correct the deformity.

The Extended High SMAS Face Lift

In order to repose the structural architect of the facial smooth tissue, a Face lift surgery can help in a perfect way to correct sever asymmetries witch facial paralysis patients can suffer from.

Dr.Karaaltın successfully performs his personal method known as the “Extended” high SMAS technique in aesthetic rejuvenation. In certain candidates with facial paralysis this method can provide a perfect solution and effective integrant tool to achieve a profound result in the cosmetic outcome.

Contact us

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Bayıldım cad. Vişnezade mah. No:14/16 Balıklı Apt. Kat:1 Daire:3 Beşiktaş, İstanbul

SOCIALICON
SOCIALICON