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Flashcards in Facial Palsy Deck (33):
1

A 45-year-old man with a 10-year history of unilateral facial palsy is evaluated for dynamic reanimation of the lower face. Single-stage free gracilis transfer to restore smiling function is planned. The proximal stump of the ipsilateral facial nerve is not available as a donor nerve. Which of the following options is most appropriate for this patient because it is associated with the lowest donor site morbidity/loss of function?

A) Cross-facial nerve transfer
B) Ipsilateral glossopharyngeal nerve
C) Ipsilateral hypoglossal nerve
D) Ipsilateral masseteric nerve
E) Ipsilateral spinal accessory nerve

The correct response is Option D.

In cases of unilateral facial palsy in which the ipsilateral facial nerve is unavailable for use as a donor nerve, nerve transfers are the best option. Of the local options, the ipsilateral masseteric nerve provides the best and most commonly used transfer due to its proximity and relatively low morbidity when harvested. In one study, spontaneous smiling was achieved routinely in 59% of patients and occasionally in 29% of patients by using this technique.

Although the hypoglossal nerve is sometimes used as a donor nerve for ipsilateral facial reanimation, its harvest can be associated with considerable oropharyngeal morbidity due to ipsilateral tongue atrophy.

A cross-facial nerve transfer does not provide for single-stage reconstruction. In many cases where there are sufficient contralateral branches of the facial nerve for cross-facial transfer, this option can provide optimal function, but its use requires a staged approach.

Use of the ipsilateral glossopharyngeal nerve as a donor in this situation would also create significant oropharyngeal function morbidity, and is therefore not commonly used.

Use of the ipsilateral spinal accessory nerve as a donor nerve is rarely used due to the fact that its use often requires uncoordinated movements for function. Ipsilateral masseteric nerve is a significantly better choice.

 

2

After schwannoma resection with facial nerve sacrifice, which of the following reconstructions provides the quickest restoration of natural reflexive dynamic blink?

A) Cross-facial nerve grafting
B) Functional muscle transfer
C) Gold weight insertion
D) Ipsilateral nerve grafting
E) Nerve transposition

The correct response is Option E.

All of the choices are suitable options for reanimation of the eyelid; however, transfer of a regional nerve, such as the motor nerve to the masseter, will result in the quickest reinnervation of the orbicularis oculi muscle. Nerve grafts may be used to overcome a wide neural gap; however, nerve regeneration proceeds slowly at only 1 mm per day. Cross-facial nerve grafts take an extended period of time to regenerate due to the long distance from the contralateral side. While gold weights are immediately effective, they are static procedures. Restoration of a reflexive blink requires neural input from the zygomatic branch of the facial nerve or direct neurotization of the orbicularis oculi muscle. Functional muscle transfers used for eyelid reanimation include the frontalis and temporalis; however, because they are innervated by nerves other than the facial, coordinated movements are not present.

 

3

A 60-year-old man is evaluated for a painful unilateral facial rash with blisters, intense ear pain, and complete ipsilateral facial nerve paralysis. Which of the following is the most likely diagnosis?

A) Cholesteatoma
B) Facial myokymia
C) Lyme disease
D) Möbius syndrome
E) Ramsay Hunt syndrome

The correct response is Option E.

This is a case of Ramsay Hunt syndrome, also known as herpes zoster oticus. It is a variant of typical herpes zoster, in that in its reactivation, it affects both afferent neurons as well as motor axons of the facial nerve. A combination of corticosteroids, narcotics, and acyclovir is the standard of care.

Facial myokymia is mainly associated with multiple sclerosis and causes a wormlike motion in the facial muscles.

Möbius syndrome is a congenital condition characterized by, among other nerve conditions, facial paralysis.

Cholesteatoma is a benign growth in the middle or external ear formed from desquamated keratin. It can act locally and be very aggressive, so much so, that if left untreated, it could cause destruction of the facial nerve.

This is not a typical presentation of Lyme disease.

 

4

A 20-year-old man is evaluated for reconstruction of the lip after sustaining a traumatic blast injury to the face with complete loss of the lower lip. The patient wishes to have a symmetric, dynamic, and competent lower lip. Which of the following treatment plans is most likely to achieve the patient’s desired outcome?

A) Innervated anterolateral thigh flap
B) Innervated gracilis muscle
C) Innervated regional advancement flaps (Karapandzic)
D) Prosthetic lower lip appliance
E) Radial forearm flap with tendon graft

The correct response is Option B.

Total lower lip reconstruction is very challenging. A prosthetic lower lip may have acceptable static appearance but does not afford competency or dynamic function. An anterolateral thigh flap would be bulky and adynamic. Innervated regional advancement flaps are not indicated for total lip loss and would lead to microstomia. A radial forearm flap with a tendon graft can achieve an acceptable appearance and competence. The radial forearm flap is unable to achieve spontaneous lower lip movement that is as symmetrical as that of the functional gracilis muscle flap. If a split-thickness skin graft from the scalp is used, the color match can be superior to radial forearm flap as well. The functional gracilis flap is most likely to achieve this patient’s goals.

 

5

A 25-year-old woman is evaluated for unilateral facial paralysis after she sustained an episode of Bell palsy that did not respond to oral administration of corticosteroids. Methods for functional reconstruction using a gracilis muscle transfer are discussed. Which of the following is an advantage of this muscle transfer for this patient?

A) Ability of the nerve to reach the contralateral side
B) Ability to incorporate overlying tendon
C) Multiple directions of pull
D) Reliable vascular pedicle
E) Two dominant nerves

The correct response is Option D.

The gracilis muscle has been widely used for facial reanimation because of its many advantages. The muscle is located in the inner thigh, which makes harvest easy in a supine position and keeps the donor site well hidden. It has a single constant vascular pedicle of adequate length for transfer. Although it is able to generate sufficient force for animation, it has only one direction of pull and is thus best suited for restoring only one component of smiling. There is no overlying tendon, and there is a single dominant nerve that is not able to reach the contralateral side of the face.

 

6

A 5-year-old girl with Möbius syndrome is brought to the office for evaluation of facial paralysis. Physical examination shows masklike facies, inability to animate the face bilaterally, and generalized hypoplasia of the tongue. Which of the following is the most appropriate donor nerve to restore facial function in this patient?

A) Hypoglossal
B) Ipsilateral facial
C) Masseteric
D) Spinal accessory
E) Phrenic

The correct response is Option C.

In the case of Möbius syndrome and most pediatric patients with facial paralysis in which the facial muscles are no longer available, a microneurovascular transfer with a muscle flap is the preferred treatment. The gracilis is the most advocated muscle used for this purpose. Pediatric patients are generally very motivated and do well with microneurovascular transfer with a muscle flap.

In Möbius syndrome, the sixth and seventh cranial nerves are commonly involved. Other cranial nerves may be involved as well. In addition to the facial muscles not being available for reconstruction, the cranial nerves are also not available in patients with Möbius syndrome. Hence, transfer to the ipsilateral or contralateral facial nerve is not a viable option for reconstruction in patients with Möbius syndrome, as the facial nerve does not function.

Use of the hypoglossal nerve in patients with Möbius syndrome is relatively contraindicated due to worsening of tongue function. The “babysitter” technique utilizes the hypoglossal nerve as a donor nerve.

The masseteric nerve is preferred over the spinal accessory and phrenic nerves as it provides better motor strength and lower morbidity in the muscle transfer.

7

A 65-year-old man is evaluated for right facial nerve paralysis. Upper eyelid reanimation is planned. The gold weight prosthesis is selected. Which of the following considerations is most appropriate for this patient?

A) Allowing coverage of the upper limbus at rest
B) Bringing the upper eyelid to within 2 to 4 mm of the lower eyelid
C) Enabling complete closure of the upper eyelid
D) Enabling the most rapid closure of the upper eyelid
E) Providing the best symmetry with the contralateral eye

The correct response is Option B.

Gold weight prostheses are commonly used for upper eyelid reanimation in patients with facial nerve dysfunction. The weight required can be estimated preoperatively by using two-sided tape to secure various test weights to identify the prosthesis that brings the upper eyelid to within 2 to 4 mm of the lower lid and completely covers the cornea. A common mistake is to use a weight that is too heavy in an effort to completely close the upper eyelid, resulting in upper eyelid ptosis and obstruction of field of view. Revision surgery is often needed in these cases. Contralateral symmetry is rarely achieved with gold weights and is not a criterion for assessment. Similarly, the speed with which the upper eyelid is closed is usually slower than the contralateral eyelid and is not a factor in weight selection.

8

A 30-year-old woman comes to the office for evaluation of an asymmetric smile. Two months ago, she underwent primary neurorrhaphy of a facial nerve laceration 2 cm lateral to the oral commissure. Physical examination shows no elevation of the upper lip with smiling on the side of the injury. Which of the following is the most appropriate management?

A) Cross-facial nerve grafting
B) Facial sling suspension
C) Free muscle transfer
D) Injection of botulinum toxin type A
E) Observation

The correct response is Option E.

The injury period is short enough that the potential for the initial neurorrhaphy to work is still likely. Clinical Tinel sign would be helpful to assess this further. Injection of botulinum toxin type A at this point would confuse the picture because it would prevent clinical monitoring of nerve recovery. If the patient does not recover nerve function within the next 6 months, then she is still a candidate for facial reanimation because the injury is not long-standing. A static procedure is not indicated unless the patient has a long-standing injury or is not a candidate for facial reanimation.

 

9

A 72-year-old man undergoes wide local excision of a squamous cell carcinoma of the lower lip. Margins are free of involvement. A photograph of the resulting defect is shown. Reconstruction using which of the following flaps is most appropriate in this patient?

A) Estlander
B) Facial artery myomucosal
C) Karapandzic
D) Melolabial
E) Submental artery island

Q image thumb

The correct response is Option C.

Karapandzic flaps are appropriate for reconstruction of defects involving one to two thirds of the lower lip, such as the one in this patient. The Karapandzic technique involves performing circumoral incisions and mobilizing the orbicularis oris muscle, while preserving its innervations and vascular supply. The main advantage of this technique is that a continuous sphincter of functional orbicularis muscle is created, helping to restore oral competence.

The Estlander flap is a full-thickness, cross-lip transposition flap designed to reconstruct lateral defects of the lower lip (one to two thirds) requiring recreation of the oral commissure.

Melolabial flaps can be used to reconstruct large full-thickness lower lip defects. However, they require grafting of the deep surface of the flap, have a less reliable random blood supply, and do not provide a functional muscular oral sphincter.

The submental artery island flap is based on the submental branch of the facial artery. A paddle of skin, subcutaneous tissue, and fascia harvested from the submental area can be used for coverage of lower face and preauricular defects, as well as inferior and lateral neck wounds. Its use for reconstruction of partial lower lip full-thickness defects has not been established.

Facial artery myomucosal flaps consist of oral mucosa, submucosa, a small amount of buccinator muscle, and a more deeply lying facial artery and venous plexus. They are ideal for reconstructing the inner, most lip mucosa because they consist of similar tissue, with the same color, texture, and moisture. They can also be used for reconstruction of the dry vermilion, although some drying-out and scabbing of the mucosa will occur. They are not indicated for large, full-thickness lower lip defects.

 

10

A 45-year-old woman is referred by her primary care physician because of left facial paralysis. She was hiking in the woods 2 weeks ago and pulled a tick off her leg at the end of the weekend trip. Three days ago, she had onset of a rash and fever. Since awakening this morning, she has been unable to move the left side of her face and has had painful spasms on the contralateral (right) side of her face when she tries to smile or talk. On physical examination, she is unable to move the left side of the face. Which of the following is the most appropriate management of this patient’s condition?

A) Acyclovir therapy
B) Botulinum toxin type A injection
C) Contralateral facial nerve grafting and free gracilis flap
D) Corticosteroid therapy
E) Doxycycline therapy

The correct response is Option E.

The patient described has new-onset facial paralysis brought on by Lyme disease infection. Neurologic manifestations (early disseminated infection) can show symptoms as early as a few days to a few weeks after initial bite.

Treatment should be directed to the underlying disease, and doxycycline is the antibiotic of choice unless there are contraindications. There is no role for antivirals.

Surgical treatment is contraindicated at this time unless the patient’s facial palsy becomes permanent.

Although botulinum toxin type A is efficacious in treating contralateral facial hyperkinesia, the patient is in the initial stages of Lyme disease, and treatment should be aimed at the primary disease at this time.

Corticosteroids are helpful in reducing inflammation and edema which are thought to contribute to the neurologic manifestations in Bell palsy but not for neurologic manifestations of Lyme disease (Lyme neuroborreliosis).

 

11

A 7-year-old girl with congenital palsy of the left facial nerve is scheduled to undergo facial reanimation using a free gracilis muscle neurotized by the motor branch to the masseter muscle. Compared with cross-facial nerve grafting from the contralateral facial nerve, use of this procedure is most likely to result in which of the following?

A) Decreased excursion of the reanimated oral commissure
B) Development of a crossbite
C) Increased risk of long-term muscle atrophy
D) Need for additional surgical procedures
E) Unpredictable smile symmetry

The correct response is Option E.

Facial reanimation procedures using free tissue transfer have largely supplanted static procedures for pediatric facial paralysis. Although cross-facial nerve grafting (CFNG) remains an excellent option, many surgeons now prefer using the motor branch to the masseter (trigeminal nerve), since it can be done in a single stage, yields excellent muscle reinnervation, and produces muscle contraction/commissure displacement that typically exceeds that of CFNG. Although this motor branch provides innervation to the masseter, there are no reports of crossbite after its use in facial reanimation. CFNG provides relatively consistent smile symmetry and spontaneity since the stimulus for muscle contracture on both sides of the face comes from the same facial nerve source. In contrast, smile spontaneity and symmetry are much more variable when the motor masseteric branch is used and requires some cortical adjustment and/or behavioral education to develop; younger patients respond much more reliably and naturally than older patients.

12

A 3-year-old girl is brought to the emergency department because of a 6-hour history of right-sided facial weakness. On physical examination, the patient has an asymmetric smile, and the right eyelid does not close completely. Which of the following is the most likely cause of this deformity?

A ) Congenital
B ) Idiopathic
C ) Infection
D ) Neoplastic
E ) Trauma

The correct response is Option B.

The most common etiology of new-onset facial nerve paralysis in a child is Bell palsy. While some studies with small cohorts have shown that many cases of Bell palsy may miss the underlying diagnosis, the large reviews still report Bell palsy as the most common etiology. Infection and trauma are the next most frequent causes, followed by neoplastic and congenital. Etiology is important because it guides treatment, and early treatment with antibiotics, antivirals, and in some cases, surgical decompression, results in a better long-term recovery of facial nerve function.

 

13

A 78-year-old woman has a 6.5-cm defect of the right cheek (shown) just below the lower eyelid after wide local excision for a lentigo maligna melanoma. All final pathologic margins are negative. Which of the following is the most appropriate management?

A ) Cervicofacial flap closure
B ) Full-thickness skin grafting
C ) Healing by secondary intention
D ) Internal mammary artery perforator flap closure
E ) Primary closure

Q image thumb

The correct response is Option A.

Optimal color and texture matches for cheek reconstruction are obtained from using local cheek tissues (see photograph below). The cervicofacial flap is classically an inferomedially based flap that allows for transfer of large amounts of cutaneous and subcutaneous soft tissues from the loose preauricular and neck regions to the medial cheek. The incision begins at the superior margin of the defect and extends along the outer canthus toward the zygoma and down the preauricular crease. The incision ends in the retroauricular hairline or curves anteriorly in the region of the neck, preferably within a cervical rhytid. The flap is advanced and rotated into the defect, and primary closure of the donor site can usually be achieved via wide subcutaneous undermining. Anchoring of the flap to the zygoma is recommended to reduce tension on the lower eyelid that could lead to ectropion.

Full-thickness skin grafts tend to appear shiny and patch-like with a poor contour match. Split-thickness or very thin full-thickness grafts are also associated with graft contracture. Split- or full-thickness skin grafts are sometimes used as a ? emporary. method of reconstruction during a period of tumor surveillance to rule out early recurrence prior to definitive reconstruction.

Closure by secondary intention would require a prolonged period of healing and result in a poor final appearance with significant scar contracture, resulting in lower lid ectropion and possibly an upper lip deformity.

The internal mammary artery perforator (IMAP) flap is based on perforating blood vessels from the internal mammary artery and vein. The IMAP flap is an island variant of the deltopectoral flap and can be transferred as a free flap with good color match to the cheek compared with more distant tissues, such as the thigh or forearm. Use of the IMAP flap may result in breast distortion in a female and would require a microvascular anastomosis while not necessarily resulting in a superior cosmetic outcome to the cervicofacial flap.

Primary closure is often the reconstructive method of choice for small defects with excellent cosmetic results when the scar can be oriented along lines of minimal tension or natural cheek borders. However, for such a large defect, primary closure cannot be achieved without significant wound tension and excessive distortion of surrounding structures.

14

A 45-year-old man comes to the office for consultation regarding improvement of facial movement and symmetry 1 year after a hypoglossal facial nerve transfer for treatment of a right facial nerve palsy. Today, examination shows gross hyperkinesis of the right side when he chews. Which of the following is the most appropriate treatment for the hyperkinetic side of this patient?

A ) Gabapentin
B ) Injection of botulinum toxin type A
C ) Myomectomy
D ) Neurectomy
E ) Reversal of the hypoglossal-facial anastomosis

The correct response is Option B.

Patients who undergo hypoglossal-facial nerve anastomosis for facial reanimation generally regain good facial tone. However, they will exhibit mass movement (synkinesis) of the treated side when they chew. In some cases, the movements are excessive (hyperkinesis) and disturbing. The treatment of choice is injection of botulinum toxin type A into the facial muscles that are most hyperkinetic, varying between 6 and 12 points of injection, until the desired effect is achieved, up to 24 units per treatment. The treated muscles will show attenuation rather than complete paralysis.

Gabapentin is a drug used for neurogenic pain and select seizure disorders. The use of gabapentin in hyperkinetic disorders has shown mixed results. It has no value in hyperkinesis associated with hypoglossal facial disorders. Some patients with untreated facial paralysis may experience hyperkinesis on the unparalyzed side as the central nervous system attempts to compensate by overfiring signals on both sides of the face. These patients will benefit equally from treatment with botulinum toxin type A on the unparalyzed side. Similarly, myomectomy and neurectomy are procedures reserved for the normal side to improve symmetry and facial balance.

Reversal of the nerve transfer is unnecessary, as the use of botulinum toxin type A is a much simpler procedure that can control the symptoms and preserve motion in the paralyzed side. In fact, experience has shown that patients prefer the embarrassing movements over disconnecting the anastomosis.

 

15

A 53-year-old woman undergoes resection of an adnexal tumor of the upper lip with negative margins. The resulting defect is a full-thickness excision of 75% of the upper lip. Which of the following is the most appropriate method of reconstruction?

A) Abbe flap only
B) Bilateral Estlander flaps with an Abbe flap
C) Bilateral Karapandzic flaps with an Abbe flap
D) Radial forearm flap only
E) Radial forearm flap with a palmaris longus sling

The correct response is Option C.

Lip defects are encountered commonly as a result of skin cancers such as squamous cell cancer and basal cell cancer. However, tumors of the minor salivary glands are also seen. The patient described is relatively young and has a large resection of the central upper lip. The best choice for reconstruction is closure with bilateral Karapandzic flaps and a central Abbe flap for philtral reconstruction. Karapandzic flaps enable transfer of the remaining upper lip while maintaining the innervations of the musculature (unlike the Gilles flap). Although bilateral Karapandzic flaps alone may be useful for defects up to 80% of the width of the upper lip, they are not an ideal choice in the patient described because the philtrum would be lost, thereby resulting in a significant cosmetic deformity. The Estlander flap is useful for reconstruction of commissure defects but not central defects. The Abbe flap alone is insufficient to close a 75% defect. The radial forearm flap, either with or without a palmaris longus sling, is not optimal because of differences in color match, innervation, and lack of vermilion reconstruction.

 

16

A 53-year-old woman comes to the office for consultation about lip reconstruction 1 week after resection of an upper lip adnexal tumor with negative margins. Examination shows a central full-thickness defect of 75% of the upper lip. Which of the following is the most appropriate method of functional reconstruction? 

A ) Abbe flap only 

B ) Bilateral Estlander flaps with an Abbe flap

C ) Bilateral Karapandzic flaps with an Abbe flap

D ) Radial forearm flap only 

E ) Radial forearm flap with a palmaris longus sling

The correct response is Option C. 

Lip defects are commonly encountered as a result of skin cancers, such as squamous cell cancer and basal cell cancers; however, tumors of the minor salivary glands are also seen. In the relatively young patient described, who has a large resection of the central upper lip, the most appropriate choice for reconstruction is bilateral Karapandzic flaps with a central Abbe flap for philtral reconstruction. Karapandzic flaps enable transfer of the remaining upper lip while maintaining the innervations of the musculature (unlike the Gilles flap). Although bilateral Karapandzic flaps may be useful for defects up to 80% of the width of the upper lip, in the patient described, this is not an ideal choice because the philtrum would be lost, thereby resulting in a significant cosmetic deformity. The Estlander flap is useful for reconstruction of commissure defects and not central defects. The Abbe flap alone would be insufficient to close a 75% defect. The radial forearm flap, either with or without a palmaris sling, would be suboptimal because of differences in color match, innervation, and lack of vermillion reconstruction.

17

The vector of commissure movement in a free gracilis muscle flap for facial reanimation should simulate the pull of which of the following facial muscles?

A ) Buccinator 

B ) Levator labii superioris 

C ) Risorius

D ) Temporalis 

E ) Zygomaticus major

The correct response is Option E. 

Free gracilis muscle transfer is a common method to produce a smile in patients who have complete facial nerve paralysis. It has several properties that make it ideal for this purpose: it is thin, has good contractility, leaves no functional deficit after muscle harvest, and has a relatively long motor nerve. The inset of the muscle, including appropriate tensioning and orientation, are critical for success. The muscle is attached proximally to the body of the zygoma or the temporalis fascia and distally to the orbicularis oris muscle near the modiolus just lateral to the oral commissure. Although there can be some variation in flap positioning, the desired vector of pull most closely simulates the normal pull of the zygomaticus major muscle. 

The temporalis and buccinator muscles are not involved in smiling. The levator labii superioris originates from the anterior zygoma and inserts near the orbicularis oris muscle in the upper lip. The vertical direction of this makes it a powerful vertical elevator of the upper lip. The risorius does not elevate the oral commissure but instead pulls the corner of the mouth in a nearly horizontal direction. 

 

18

A 45-year-old man is brought to the emergency department 2 hours after sustaining a laceration to the face from a circular saw. Physical examination shows a deep, vertically oriented wound that extends from the lateral aspect of the right lower eyelid to the neck. The patient is unable to elevate the right upper lip. Which of the following is the longest interval after the injury during which the distal nerve can be successfully stimulated?

A ) 3 Hours 

B ) 3 Days 

C ) 3 Weeks

D ) 3 Months 

The correct response is Option B. 

Injury to the facial nerve should be suspected in any deep laceration in the vicinity of the parotid gland and posterior cheek. Clinical confirmation can be readily observed by signs of complete or partial paralysis of facial musculature. Primary end-to-end repair yields the best results, but interposition nerve grafting may be necessary if there is a segmental defect. The distal end of the transected facial nerve may be stimulated for approximately 72 hours after nerve injury. Beyond this period, the neurotransmitter stores become depleted, and depolarization at the motor end plates of the facial musculature does not occur. 

 

19

The 12-year-old girl shown is brought to the emergency department after being bitten in the face by a neighbor €™s dog. Her mother has brought the avulsed piece of skin wrapped in gauze. Which of the following is the most appropriate method for coverage of the wound?

A ) Application of wet-to-dry dressings 
B ) Placement of a vacuum-assisted closure device 
C ) Replacement of the avulsed piece of skin 
D ) Use of cross-lip Abbe flap 
E ) Use of a nasolabial flap
 

Q image thumb

The correct response is Option C.

Lip reconstruction requires skin cover that is thin, supple, and matching; oral lining that is thin, supple, and sensate; resemblance of a vermilion that is supple, sensate, and appropriately colored; a deep labial sulcus for competence; commissure definition that provides expressive function; adequate stomal diameter for speech, eating, oral hygiene, or denture insertion; and an oral sphincter that is competent to contain both food during eating and saliva at rest.

Upper lip reconstruction is guided by the need to provide a central philtrum and two lateral elements. In the scenario described, the patient has an intact philtrum and left lateral element. She is brought to the emergency department with a subtotal right upper lip vermilion, skin, oral mucosa, and partial muscle loss. All of these elements are in the avulsed segment; therefore, this would be the best possible replacement of the missing tissue since the principle of plastic surgical reconstruction calls for replacing tissue with like tissue. Postoperative photographs are shown.

Secondary closure by either vacuum-assisted closure or dressing change will lead to contracture and distortion. Because the lips have no bony, cartilaginous, or fibrous infrastructure, wound contraction can cause permanent retraction of the free margin of the lip. The Abbe flap is best used for defects of the philtral column. The nasolabial flap is bulky and lacks innervation.

A image thumb
20

A 76-year-old man is evaluated for reconstruction of a defect of the left lateral lower lip and left commissure following resection with clear margins of a 2.5-cm lesion. Examination shows a full-thickness defect of the left lateral lower lip and left commissure. Which of the following flaps is the most appropriate method of reconstruction?

A ) Estlander

B ) Gillies

C ) Karapandzic

D ) Radial forearm, with palmaris longus sling

E ) Webster-Bernard

The correct response is Option A.

This scenario involves a significant resection of the lower lateral lip including the lateral commissure. Thus, reconstruction of both the lower lip and the commissure is required. The most appropriate flap for reconstruction of this defect is the Estlander flap. The Estlander flap is an upper lip-switch flap that is used to reconstruct defects involving the commissure. Rotation of the upper lip to the lower lip provides additional tissues for reconstruction of the lower lip defect and repairs the commissure. However, rotation of the upper lip in a defect that has no commissure results in a rounded commissure and often requires additional surgery.

The Karapandzic and Gillies flaps are advancement flaps of the remaining lower lip and are most useful for central defects of the lower lip. The main difference between these options is that the branches of the facial nerve are dissected and preserved in the Karapandzic flap thereby preserving facial nerve function. The Webster-Bernard flap advances the cheek skin by removing a Burrow triangle bilaterally. Similar to the Karapandzic and Gillies flap, this option is most useful for central lip defects and does not reconstruct defects of the commissure. Finally, the radial forearm flap with palmaris longus sling is most useful for total lower lip defects.

 

21

A 24-year-old man is brought to the emergency department 30 minutes after sustaining a laceration to the left cheek with a sharp piece of glass. Physical examination shows a 5-cm laceration extending from the left ear to the mid cheek. The patient has motor weakness of his upper lip. The wound is debrided and closed in layers. The patient has increasing swelling over the left cheek over the next five days. Which of the following steps in initial management was overlooked?

(A) Arteriogram

(B) Cannulation of Stensen duct

(C) CT

(D) Duplex ultrasound

(E) Nerve conduction studies

The correct response is Option B.

The buccal branch of the facial nerve travels with the parotid duct in the cheek. In a deep laceration of the cheek in which either of these structures is injured, it is likely that the other also will be injured. The facial artery and facial vein are lateral to the midfacial region at the mandibular angle. It is recommended that cut nerve branches be repaired immediately. The parotid duct must be explored. If it is injured, it must be repaired immediately. To diagnose an injury, the Stensen duct may be cannulated intraorally. An injection of saline or methylene blue will determine if the duct is intact. If there is no leakage, the duct is intact. If there is leakage, the proximal and distal cut ends of the duct must be repaired over a stent, often a Silastic tube or small feeding tube (see the photographs below). The tube must remain in place for approximately two weeks until the duct heals. If parotid duct injury is left undiagnosed, a sialocele will develop. Neither the temporalis nor masseter muscle will be injured and result in malocclusion.

Arteriogram, imaging studies (CT and ultrasound), and nerve conduction studies would not be effective in diagnosing an injury to the parotid duct.

22

A 72-year-old woman comes to the office for consultation because she has had inability to close the left eye, raise the ipsilateral eyebrow and lip, flare the nostril, or show the teeth since she experienced flu-like symptoms three months ago. She has had no previous surgeries and takes no medications. Physical examination shows ptosis of the left forehead, palsy of the ipsilateral mentalis and nasalis, and weakness of the zygomaticus major and depressor anguli oculi muscles. MRI shows intact facial (VII) and acoustic (VIII) nerve branches and no lesions. Which of the following interventions is most appropriate to achieve brow symmetry in this patient?

(A) Endoscopic brow lift procedure with no muscle transection

(B) Injection of botulinum toxin (Botox) into the left frontalis muscle

(C) Injection of Botox into the left orbicularis oculi muscle

(D) Injection of Botox into the right frontalis muscle

(E) Injection of Botox into the right orbicularis oculi muscle

The correct response is Option D.

The patient described has Bell palsy. Typical signs include ptosis of the brow and forehead, upper eyelid retraction, lower lid ectropion, decreased blink, and decreased ability to close the eye.

Injection of Botox is a temporary procedure that can be useful to achieve animated symmetry. The frontalis, zygomaticus, and depressor anguli oculi of the unaffected side are often targets for paralysis, so that the two sides can remain symmetric during animation. If the motor function returns, the affected side may require some mild Botox treatment; however, usually this is for blepharospasm.

An endoscopic forehead lift (Endobrow) or other static procedure may be useful once recovery seems unlikely and muscle denervation is probable (one to two years). A gold weight can help close the eye, a canthoplasty can tighten the tarsoorbicularis sling, and a brow lift can treat the ptosis. Studies have shown that in the older population, a skin resection procedure may be more effective than an Endobrow procedure.

 

23

A 45-year-old woman comes to the office for consultation regarding reconstruction three years after undergoing resection of a left acoustic neuroma (vestibular schwannoma) that resulted in permanent paralysis of the left side of the face. Which of the following best describes the advantage of using microneurovascular muscle transfer over using a temporalis muscle sling to reconstruct this defect?

(A) Cheek augmentation

(B) Decreased operative time

(C) Earlier symmetry at rest

(D) Improved facial rejuvenation

(E) Increased ability for spontaneous expression

The correct response is Option E.

Free-muscle transplantation is the treatment of choice for long-standing facial paralysis. It enables the reconstructive surgeon to restore facial movement and some emotional animation. Permanent facial paralysis is one of the most important functional and aesthetic handicaps among the sequelae observed in plastic and maxillofacial surgery. The affected patient is deprived of one of the essential means of mental and affective expressions: the mimic.

In 1934, Gillies had the idea of lengthening the middle third of the temporalis muscle, flipped over the zygomatic arch, by using a strip of the fascia lata. The major disadvantage of Gillies €™ (temporalis transfer) technique, in addition to the intermediate graft, was to place the muscle under the skin, creating the zygomatic bulge and a cheek augmentation. Temporalis muscle transfer requires the patient to activate the trigeminal nerve for motor function, but this function is generally static rather than dynamic.

 

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A 10-year-old girl is brought to the office by her parents for consultation regarding congenital unilateral facial paralysis. She has had no previous treatment of this condition. Physical examination shows no muscle activity on the affected side. Which of the following is the most appropriate first step in management to restore voluntary animation to the paralyzed side of the face?

(A) Cross-facial nerve grafting

(B) Gracilis neurovascular free tissue transfer

(C) Masseter muscle transfer

(D) Temporalis muscle transposition

(E) Tensor fascia lata suspension

The correct response is Option A.

The best treatment for this child with unilateral facial paralysis involving the eye is a two-stage surgical correction resulting in dynamic reanimation. In the first stage, cross €‘facial nerve grafting is constructed from the unparalyzed side of the face to the paralyzed side. The sural nerve is commonly used as a graft. The second stage consists of free tissue transfer of muscle, such as the gracilis or pectoralis minor, to the paralyzed side of the face. Microneurovascular anastomoses are completed, with the goal of functional reanimation of the paralyzed face.

Eyelid closure is a priority issue in treatment of facial paralysis. Lack of corneal protection can result in keratitis, conjunctivitis, corneal ulceration, and visual impairment. Although use of artificial tears and ointments is necessary, such treatment is neither permanently effective nor corrective in any type of functional repair.

Transposition of the temporalis muscle is another option for dynamic reconstruction of the eye in patients with facial paralysis. It has the advantage of immediate functional correction, compared with the lag period required for muscle reinnervation by cross €‘facial nerve grafting. However, one long-term study has shown overall better functional results, measured by eyelid closure and movement, in patients undergoing correction with two-stage cross €‘facial nerve grafting and muscle transfer compared with transposition of temporalis muscle. In addition, microneurovascular tissue transfer is a better choice in children with facial paralysis, who may be the best candidates to achieve functional adaptation after such a procedure. Furthermore, the use of a muscle of mastication in children may have potential deleterious effects on skeletal maturation.

Static correction of eyelid closure by means such as fascial or tendon sling creation, tarsorrhaphy, and placement of a gold weight does not produce dynamic movement and, therefore, does not fully correct the obvious functional deficit apparent on the paralyzed side with animation of the face. These options are more suitable for older patients with facial paralysis, in whom static correction may be more desirable and who may not be optimal candidates for more complex procedures such as free tissue transfer.

 

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A 45-year-old woman with Bell €™s palsy comes to the office because she has had inability to close the right eye, sagging of the right side of the mouth, and difficulty breathing through the right side of the nose for the past six months. Dysfunction of which of the following muscles of the external nose is the primary cause of this patient €™s symptoms?
(A) Corrugator supercilii
(B) Depressor septi nasi
(C) Nasalis 
(D) Procerus
(E) Zygomaticus major

The correct response is Option C.

The alar fibers of the nasalis muscle and the levator labii superioris are responsible for dilating the nasal apertures. The transverse fibers of the nasalis serve as nostril constrictors. The depressor septi nasi muscle functions to depress the nasal tip. These muscles comprise the inferior group of nasal musculature and are innervated by the buccal branch of the facial nerve.

The corrugator and procerus muscles are responsible for vertical frown lines and glabellar furrowing, respectively. They comprise the superior group of external nasal muscles and are innervated by the temporal branch of the facial nerve. The zygomaticus major elevates the oral commissure and is not considered part of the muscles of the external nose.

Facial paralysis can contribute to nasal airway obstruction.
 

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 A 50-year-old woman comes to the office for consultation regarding closing of the right eye one year after she had an episode of Bell’s palsy on the right side. She says her right eye closes when she chews. Photographs are shown. Which of the following is the most appropriate management of this patient’s symptoms?
(A) Injection of botulinum toxin into the orbicularis muscle
(B) Repair of levator aponeurosis
(C) Fascial suspension of the brow
(D) Unilateral temporal brow lift
(E) Upper blepharoplasty

Q image thumb

The correct response is Option A.

As shown in the photographs, this patient has right-sided orbicularis oculi contracture with orbicularis oris contracture. Her symptoms and history of Bell’s palsy are consistent with recovered facial nerve animation with synkinesis. Her right eye closes when she eats. Injection of botulinum toxin to the orbicularis muscle would treat the synkinesis and allow the adverse effect of lower lid lagophthalmos. Repair of levator aponeurosis and fascial suspension of the brow treat forms of eyelid ptosis. A temporal brow lift would treat unilateral brow descent secondary to residual palsy of the temple branch of the facial (VII) nerve. Upper blepharoplasty would treat upper-eyelid excess skin only; however, this patient does not display eyelid or brow ptosis, and there is no significant excess of upper-eyelid skin.

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Which of the following best describes eyelid function in patients with unilateral idiopathic facial nerve paralysis (Bell’s palsy)? 

(A) Ectropion resulting from dysfunction of the orbicularis muscle
(B) Ectropion resulting from dysfunction of the trigeminal (V) nerve
(C) Entropion resulting from dysfunction of the facial (VII) nerve
(D) Ptosis resulting from dysfunction of the oculomotor (III) nerve
(E) Ptosis resulting from dysfunction of the levator muscle

 

The correct response is Option A.


Bell’s palsy, or unilateral idiopathic facial nerve paralysis, is the most common cause of facial paralysis, occurring in approximately 80% of symptomatic patients. Diagnosing this condition involves excluding other causes, such as trauma, stroke, and tumor; as a result, thorough evaluation should be undertaken.

Patients with Bell’s palsy have dysfunction of the orbicularis oculi muscle, which is innervated by the zygomatic branches of the facial (VII) nerve. Ectropion, rather than entropion, is characteristic, and the patient is often unable to close the eye on the affected side.

The trigeminal (V) nerve is a sensory nerve that does not affect the muscle function of the eyelid.

Ptosis of the eyelids does not occur, because the levator muscle is innervated by the oculomotor (III) nerve and is thus uninvolved.

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For each patient, select the nerve most likely to cause the findings (A-E).

(A) Acoustic nerve
(B) Auriculotemporal nerve
(C) Chorda tympani
(D) Great auricular nerve
(E) Tympanic nerve

Q1) A 62-year-old man has gustatory sweating three months after undergoing rhytidectomy.

Q2) A 56-year-old woman has persistent numbness in the right ear one year after undergoing deep-plane rhytidectomy.

The correct response for Question 1 is Option B and for Question 2 is Option D.

The 62-year-old man with gustatory sweating has Frey’s syndrome, which may occur following rhytidectomy or parotidectomy. This condition is caused by dysfunction of the auriculotemporal nerve, which is a branch of the mandibular division of the trigeminal nerve (V3). During surgery, the pathways of the auriculotemporal nerve become disrupted and then regenerate incorrectly, resulting in parasympathetic innervation of sympathetic nerve receptors. As a result, affected patients have facial flushing and sweating that occur with gustatory stimulation. Appropriate management includes injection of botulinum toxin (Botox) and operative placement of acellular dermal homograft (Alloderm) or a dermis-fascia-fat graft over the affected area to curb the symptoms.

The 56-year-old woman has persistent numbness of the right ear caused by injury to the great auricular nerve, which is derived from branches of cervical nerve roots C2-3 within the cervical plexus. The great auricular nerve crosses the sternocleidomastoid muscle 6.5 cm inferior to the tragus and provides sensation to the ear and postauricular region. If it is not identified prior to dissection, it can be injured easily because of its superficial location. It is the most commonly injured nerve during rhytidectomy, resulting in numbness of the ear.

The acoustic (VIII) nerve, also known as the vestibulocochlear nerve, divides into vestibular and cochlear branches near the lateral end of the internal acoustic meatus. The function of these branches is related to balance and hearing. This nerve is not encountered during dissection for rhytidectomy.

The chorda tympani is a branch of the facial (VII) nerve and is not injured in rhytidectomy. This nerve branch provides taste sensation to the anterior two-thirds of the tongue and parasympathetic secretory fibers to the submaxillary and sublingual glands.

The glossopharyngeal (IX) nerve provides taste sensation to the posterior third of the tongue and sensation to the mucous membranes of the pharynx and palatine tonsil. The tympanic branch of the glossopharyngeal nerve, also known as the nerve of Jacobson, provides sensation to the tympanic cavity and can cause referred pain to the ear in patients with carcinoma of the head and neck.

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A 32-year-old woman has near complete paralysis of the lower portion of the left side of the face three years after onset of Bell's palsy. There has been no return of nerve function for the past year. Examination shows adequate function of the orbicularis oculi muscle and a good Bell's reflex.

Which of the following is the most appropriate management?

(A) Continued observation
(B) Hypoglossal nerve transfer
(C) Placement of a gold weight in the eyelid and static browlifting
(D) Neurotized free muscle transfer using innervation from cross-face grafts
(E) Temporalis muscle transfer to the upper and lower eyelids

The correct response is Option D.

Significant muscle atrophy is likely in a patient who has had facial paralysis for longer than 18 months. Because cross-face nerve grafting is a staged procedure that may not be completed for an additional year, it is not suggested in this patient who would almost certainly have atrophy of the native muscles. Neurotized free muscle transfer is the most appropriate option for restoring dynamic function of the lower left side of the face. This technique can be accomplished by using a cross-face nerve graft or the hypoglossal nerve as a donor.

Observation is inappropriate because the paralysis will not resolve spontaneously. Transfer of the hypoglossal nerve would merely innervate the atrophied muscle. Although placement of a gold weight in the eyelid is a recommended treatment for facial paralysis, it is not the procedure of choice in this patient who has function of the orbicularis oculi muscle and a good Bell's reflex, indicating that the cornea is adequately protected. Similarly, temporalis muscle transfer would also address the eye but not the paralyzed lower portion of the face.

 

30

A 42-year-old woman who has excess skin and subcutaneous tissue of the lower buttocks is scheduled to undergo excisional lipectomy with the incisions parallel to the gluteal fold. Which of the following is the most likely adverse effect?

(A) Dimpling of the buttocks
(B) Fat necrosis
(C) Flattening of the gluteal fold
(D) Painful scarring
(E) Widening of the gluteal cleft

 

The correct response is Option C.


Adverse effects reported with transverse excision lipectomy include flattening and asymmetry of the buttocks and hypertrophic scarring. Dimpling of the buttocks is more commonly associated with suction lipectomy in the region overlying the gluteal muscles because of the large amount of fibrous septa between the fascia and skin. Widening of the gluteal cleft is uncommon because the incision is made parallel to the gluteal fold.

Fat necrosis does not generally occur in the buttocks because of the good vascularity in this region. Long-term painful scarring is also rare.

 

31

A 30-year-old man has the sudden onset of weakness of the right eyebrow and cheek and the right side of the mouth. There is no history of trauma or disease; physical examination is otherwise unremarkable. Which of the following is the most appropriate initial step in management?

(A) Observation
(B) EMG
(C) MRI
(D) Facial nerve decompression
(E) Right eyelid tarsorrhaphy

 

The correct response is Option A.

This patient most likely has Bell's palsy, an idiopathic form of facial paralysis that is the most common diagnosis in persons with facial paralysis (approximately 80%). Diagnosing this condition involves excluding other causes, such as trauma, stroke, and tumor, and thus should be preceded by a thorough evaluation of the patient. Bell's palsy is often associated with diabetes mellitus and pregnancy.

Eighty-five percent of patients who have Bell's palsy will begin to have spontaneous recovery of neurologic function within three weeks. In 15% of affected patients, however, it may take three to six months before some recovery of function is experienced. But because Bell's palsy is rarely permanent, at least some recovery is expected.


Observation for three weeks is indicated prior to performing extensive diagnostic studies. Many of the tests used in the diagnosis of Bell's palsy are expensive and give limited information. Positive findings on electromyography will not be seen until 14 to 21 days after the onset of paralysis. CT scan or MRI may be appropriate after a three-week observation period, if the condition persists. Surgical decompression is not frequently recommended because it increases the risk for injury to the inner ear as well as to the nerve itself; moreover, it has not been clearly shown to be helpful in all cases. Ocular symptoms can generally be managed with artificial tears, use of ointments, and taping until function returns, so eyelid tarsorrhaphy is not necessary.

Although electroneurography (ENOG) will show nerve conduction defects immediately and objectively and is the most accurate and reproducible test currently available to determine the return of facial nerve function, it is generally considered to be prohibitively expensive and time-consuming.

 

32

A 36-year-old man has facial palsy on the right after sustaining a crush injury of the right mastoid. Reinnervation with cross-face nerve grafts is planned. Which of the following factors will best determine the success of this procedure?

(A) Density of contralateral facial nerve fibers
(B) Length of elapsed time between paralysis and surgery
(C) Number of cable grafts used
(D) Postoperative stimulus program with muscle re-education
(E) Use of motor donor grafts instead of sensory donor fibers

 

The correct response is Option B.

Cross-face nerve grafting offers the best chance of restoration of function in this patient in whom the ipsilateral proximal facial nerve stump cannot be used. The facial muscles remain viable for approximately two years; after this 
timulation has not been shown to increase the likelihood of reinnervation.

There will always be a sufficient density of contralateral fibers to use as donors. As few as one to as many as four cross-face cables can be used during surgery; the number used generally depends on the condition and location of the distal stump. Postoperative muscle re-education programs offer increased control only if reinnervation actually occurs. Finally, there is no evidence that using motor rather than sensory donor grafts makes a difference in outcome.

 

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