Facial Palsy / Lip & Cheek Reconstruction Flashcards
A 62-year-old woman is evaluated 1 hour after undergoing Mohs micrographic resection of a squamous cell carcinoma of the lower lip. After a clear-margin excision, the resulting defect is a full-thickness 25% central lip defect. Which of the following is the most appropriate repair method for this defect?
A) Coverage using the Karapandzic technique
B) Coverage with a V-Y advancement flap
C) Coverage with an Abbe flap
D) Full-thickness skin grafting
E) Primary closure
The correct response is Option E.
Defects of the lip can be categorized by the percentage of the total lip affected. Small full-thickness defects of the lip (25–33%) as described in this case are best repaired with primary closure using a vertical excision of remaining lip structures to enable a tension-free closure. Care should be taken to precisely realign the lip and repair the white roll to avoid step-offs that are easily noticeable. Larger defects (33–50%) are usually repaired using flaps. These flaps can be categorized as transoral flaps (e.g., Abbe or Estlander flaps) or circumoral advancement/rotation flaps (e.g., Gilles flap or Karapandzic technique). Subtotal lip defects may be repaired with bilateral circumoral advancement/rotation flaps, while total lip defects generally require reconstruction with free flaps. Skin grafts are rarely used for lip reconstruction (particularly if the white roll is involved) because these repairs result in a patch-like appearance that is highly noticeable.
2018
An 18-year-old man is brought to the emergency department because of a vertical stab wound to the mid cheek immediately posterior to the level of the lateral canthus. Primary repair is planned within 72 hours. Which of the following is the primary reason to perform the procedure within this time frame?
A) Anatomical location precludes surgical expiration and repair
B) Motor end plates will atrophy
C) Nerve endings will have retracted markedly
D) Neurotransmitter stores will become irreversibly depleted
E) Risk of soft-tissue infection of the face increases markedly
The correct response is Option D.
On the face, and posterior to the lateral canthus, the facial nerve should be repaired as early as possible such that identification of the transected nerve stumps is possible. After 72 hours, the neurotransmitter stores required for motor end plate depolarization are irreversibly depleted. As a result, the target muscles no longer respond to stimulation of the distal nerve stump.
Because of marked arborization and cross-innervation of the facial nerve, injuries anterior to an imaginary line drawn from the corner of the eye to the corner of the mouth commonly recover spontaneously. It takes 18 to 24 months for motor end plates to completely atrophy.
2018
A 35-year-old woman is evaluated for long-standing facial nerve palsy. The proximal stump of the facial nerve is not available for use in reconstruction. In addition to gracilis muscle transfer, the surgeon is considering cross-facial nerve graft or using the masseter nerve. Which of the following factors regarding masseter nerve use is often cited as a disadvantage to cross-facial nerve grafting?
A) Decreased excursion of the gracilis muscle
B) Decreased smile symmetry
C) Less spontaneity in smiling
D) Requirement of a craniofacial osteotomy for harvest
E) Significant, permanent weakness in chewing function
The correct response is Option C.
Use of the masseter nerve as the motor source for a gracilis free tissue transfer to restore smile is a single-stage procedure with many advantages over the more traditional use of cross-facial nerve grafting when the proximal stump of the facial nerve is not available for use. Its popularity has increased recently, particularly because it is a single-stage surgery and morbidity is minimal. Use of the masseter nerve, however, requires the patient to clench the jaw to smile, and is much less spontaneous than with cross-facial nerve grafting.
Less excursion of the gracilis muscle graft is incorrect. The masseter nerve is an excellent motor nerve and allows for powerful contraction of the transferred muscle.
Significant, permanent weakness in chewing function is incorrect because harvest of the masseter nerve is partial, and generally results in minimal donor site morbidity.
Craniofacial osteotomy is incorrect because while the masseter nerve is in proximity to the zygomatic arch, an osteotomy is not frequently needed to reach the nerve.
Decreased smile symmetry is incorrect because smile symmetry is comparable with both techniques.
2017
A 35-year-old man returns for postoperative evaluation 12 months after undergoing facial nerve reconstruction with free gracilis transfer. Physical examination shows significant hyperkinesis of the contralateral side. In addition to injections of botulinum toxin type A, which of the following measures has been shown to improve facial symmetry?
A) Cryotherapy of facial musculature
B) Mirror biofeedback therapy
C) Oral beta-adrenergic blocker therapy
D) Radiofrequency ablation
E) Selective contralateral facial neurotomy
The correct response is Option B.
Hyperkinesis is generally considered to be the hyperactivity of the contralateral, unaffected side. Mirror biofeedback therapy has been shown to significantly improve facial symmetry when used in conjunction with botulinum toxin injections in the treatment of facial hyperkinesis.
Beta-adrenergic blocker therapy is not indicated for facial hyperkinesis following facial nerve reconstruction.
While selective facial myotomy has been used for improvement in synkinesis, selective contralateral facial neurotomy is not generally indicated for correction of hyperkinesis.
Radiofrequency ablation and cryotherapy have only recently begun to be investigated as an option for improvement of synkinesis, but have not been generally accepted as treatments for hyperkinesis.
2017
A 30-year-old primigravid woman at 24 weeks’ gestation, who has a history of Bell palsy, has synkinesis and squinting of the left eye when smiling. She wants to know her treatment options, but is not interested in options that may put her pregnancy at risk or impact her goal of breast-feeding for 1 year after delivery. Which of the following treatment options is most appropriate for this patient?
A) Chemodenervation to the left orbicularis oculi
B) Chemodenervation to the left orbicularis oris
C) Facial neuromuscular retraining
D) Gold weight to the left upper eyelid
E) Selective neurolysis to the temporal branch of the facial nerve
The correct response is Option C.
Chemodenervation is a common treatment for ocular-oral synkinesis and perhaps the most effective. The chemodenervation medications have unknown effects for pregnant or nursing women. Botulinum toxin type A is a class C drug. Permanent surgical selective denervation is not recommended as it could impact eye protection. Surgery may also have risks for the fetus.
This patient would benefit from a physical therapy referral to work on facial neuromuscular re-education, including biofeedback using mirrors and electromyography. Additional strategies such as use of sunglasses and other strategies to avoid squinting can be helpful. These are likely the treatment modalities that this patient is most interested in.
Gold weight insertion would not be appropriate in a patient with symptoms of squinting.
2017
An otherwise healthy 20-year-old woman is evaluated 5 weeks after sustaining facial shear injury in a motor vehicle collision. She has a facial nerve palsy on the right and exposed mastoid, zygoma, and zygomatic arch. A photograph is shown. She has had previous debridement and titanium mesh cranioplasty for the traumatic cranial defect of the temporal bone. Multifocal extratemporal facial nerve injuries are suspected. Which of the following is the most appropriate management for the wound coverage and facial nerve palsy?
A) Free tissue transfer for wound coverage with delayed facial reanimation
B) Immediate cross-face nerve grafting with cervicofacial flap for soft tissue coverage
C) Immediate exploration and primary repair of the facial nerve followed by skin grafting for coverage
D) Split-thickness skin grafting for coverage with delayed facial reanimation
E) Temporalis muscle sling with skin grafting for wound coverage
The correct response is Option A.
The patient shown has a large soft tissue defect with exposed bone and hardware. There is friable granulation tissue, and the patient presents several weeks after injury. She has a complete facial palsy and her eye is closed at rest (good eye protection) without taping. The ultimate goals are to address both her wound and her facial palsy, with an aesthetic facial reconstruction.
In this setting, a simple nerve transection that would benefit from a simple neurorrhaphy is unlikely. The tissues are very friable, and tissue planes are not easily identified due to inflammation, extensive damage, and subacute time period. Dissection and exploration would be difficult and could lead to further damage.
Soft tissue coverage is a priority at this point in the patient’s reconstruction. She has a large defect with exposed bone and hardware. Free tissue transfer could provide stable coverage. A skin graft will not provide durable coverage over hardware and exposed bone. Delayed facial reanimation after stable soft tissue coverage will allow for improved healing.
Delaying addressing the facial nerve palsy a few weeks to months can still have good outcomes and there will be an improved healing environment.
2017
A 34-year-old woman is scheduled to undergo resection of a left-sided cerebellopontine angle tumor with sacrifice of the facial nerve trunk. Staged cross-facial nerve grafting is planned. Which of the following treatment options is most likely to minimize the risk for permanent facial asymmetry at the time of tumor resection?
A) Free gracilis muscle transfer to the left facial nerve stump
B) Hypoglossal to facial nerve transfer and cross-facial nerve grafting
C) Insertion of a 1.2-g gold weight in the left upper eyelid
D) Percutaneous distal facial nerve branch stimulation
E) Placement of an extended temporalis fascia static sling
The correct response is Option B.
Cerebellopontine angle (CPA) tumor resection often requires intracranial facial nerve sacrifice. For best recovery of spontaneous ipsilateral facial nerve function, cross-facial nerve grafting (CFNG) should be performed from the contralateral facial nerve branches to the ipsilateral facial nerve branches. CFNG often results in delayed and weakened reinnervation of the ipsilateral facial musculature. For this reason, hypoglossal to facial nerve transfer and cross-facial nerve grafting (babysitter nerve transfers) are often employed to minimize muscle atrophy and enhance the strength of the ipsilateral facial musculature. Both hypoglossal nerve and nerve to masseter have been used. The other choices would not augment the ipsilateral facial musculature and would likely result in more pronounced facial asymmetry.
2017
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.
2016
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.
2016
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.
2016
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.
2015
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.
2015
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.
2015
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.
2015
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.
2014
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
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.
A 69-year-old man presents to the office with a large (5 x 7-cm) melanoma involving his right cheek. A photograph is shown. After resection with clear margins, which of the following methods of reconstruction will provide the best aesthetic result?
A) Cervicofacial flap
B) Immediate tissue expansion
C) Primary repair
D) Radial forearm free flap
E) Split-thickness skin graft
The correct response is Option A.
Large defects of the cheek are best repaired with local skin when possible. Cervicofacial flaps can be used for moderate to large defects of the cheek with tension free repair (as shown in the photographs), which is vitally important to avoid eyelid-related complications, such as ectropion. Primary repair is useful for smaller cheek defects but would not be possible in this situation. A split-thickness skin graft would not provide optimal soft tissue match, and would undergo significant secondary contracture, resulting in eyelid malposition. They may be used in a temporary situation until definitive reconstruction. Full-thickness skin grafts may be an option; however, they tend to appear shiny and patch-like. Tissue expanders are useful in the head and neck, particularly in the scalp; however, in this particular case it is not advisable to use a tissue expander adjacent to an open wound. There is a significant risk of infection or extrusion. A radial forearm free flap could be an option if local tissue is not available, but would result in an unnecessarily long procedure with secondary donor site.
2021
