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Facialnerveinjuryandreanimation 151120170444 Lva1 App6892
Facialnerveinjuryandreanimation 151120170444 Lva1 App6892
• Carries preganglionic
parasympathetic fibers and special
afferent sensory fibers
(( Intra temporal part ))
Important branches of facial
nerve in this part :
• Temporal
• Zygomatic
• Buccal
• Marginal mandibular
• Cervical
Component of nerve
• Endoneurium :
• Surrounds each nerve fiber
• Provides endoneural tube for
regeneration
• Perineurium :
• Surrounds a group of nerve fibers
(fascicle).
• Provide tensile srtength
• Protect nerve from infection
• Epineurium :
• Surrounds the entire nerve
• Provides nutrition to the nerve
Sunderland Nerve Injury Classification
Class I (Neuropraxia)
• Axon remain intact
• Conduction block caused by cessation of axoplasmic flow
• Full recovery
Class II (Axonotmesis)
• Axons are disrupted
• Endoneural tube still intact
• Full recovery expected
Class III (Neurotmesis)
• Neural tube is disrupted
• Poor prognosis
• If regeneration occurs, high incidence of synkinesis (involuntary
movement of muscles associated with voluntary movement other
muscles )
Sunderland Nerve Injury Classification
Class IV
• Epineurium remains intact
• Perineurium, endoneurium, and axon disrupted
• Poor functional outcome with higher risk for synkinesis
Class V
• Complete disruption
• Little chance of regeneration
• Risk of neuroma formation
Causes of Facial nerve paralysis
supranuclear lesions :
• Congenital abnormalities, stroke ,
malignancies, trauma , vascular conditions
and other causes .
infranuclear lesions :
• Malignancy (parotid gland as well as
tumors of adjacent structures) , trauma,
infections, Bell’s palsy, osteopetrosis and
iatrogenic causes .
I Normal
IV Obvious weakness,
asymmetry of mouth
Incomplete eye closure
VI No movement at all
Preoperative evaluation
ELECTROMYOGRAPHY (EMG)
• Electromyography is often used as an adjunct to
ENOG
• EMG can be used to identify false positive ENOG
results
Goals
– Functional
• EYE PROTECTION
• Oral competence
– Cosmetic
• Symmetry at rest
• Volitional movement
– Facial expressions
MANAGEMENT of facial nerve paralysis
Prednisolone 60-80 mg/day in divided doses intial 4-5 days,then taper over next
7-10 days.
– Decreases the possibility of permanent paralysis .
– From swelling of facial nerve in facial canal .
– Decreases the severe pain .
Antiviral may be effective in some cases of paralysis (bells palsy).
• Acyclovir 400mg 5 times a day –10 days
• Valacyclovir 1000mg /day 5-7 days .
Surgical Reanimation Techniques
Broadly classified into:
I . Neural methods:
• Facial Nerve Decompression
• Micro-neurological surgery to re-suture the damaged nerve.
• Nerve graft (to overcome gaps)
• Cross-Facial Nerve Grafting
• Nerve Transfers
• Hypoglossal to facial
• Spinal accessory to facial
• Phrenic to facial
II . Musculofascial transpositions:
• Move new muscles and nerves into the face to take the place of the injured facial nerve.
III . Facial plastic procedures.
IV. Prosthetics.
OTHER CLASSIFICATION
• Static • Dynamic
– Slings – Nerve grafting
– Gold weight – Muscle transfer
– Tarsorrhaphy • Regional
• Free flap
– Lower lid shortening
Facial Nerve Decompression
• Performed in severe cases when the facial nerve is seriously
deteriorating.
• Patients are at risk of permanent paralysis and have a poor
prognosis without aggressive intervention.
• To be effective, the surgery must be performed within 2 weeks of
the onset of symptoms.
More recently, tissue engineering has provided nerve conduits, which function as
guides for axonal growth.
Depending on the materials used for their construction, they can be classified as
natural, when based on laminin, collagen or even vessels and decellularized
nerves, or artificial, usually made of polymers .
The major limitation for use of nerve conduits is the low rate of axonal growth,
which may not yield full repair within the available time and chronic inflammtion
which should be removed after period of time
Studies have shown that the conduits are effective in promoting repair of nerve
gaps measuring up to 3 cm, while nerve autografts are required for bridging of
larger distances
• disadvantages :
• Additional donor site in the leg.
• Violating the normal side of the face.
• Two or more suture lines for the axons to
cross.
• Long interval until return of function
Static Suspension Procedures
It is used for suspension of the forehead , eyelids, nares, oral commissure,
upper and lower lip.
used to achieve symmetry at rest .
They provide no dynamic return of function.
It can be used alone or in combination with muscle transfers.
• Autologous materials
• Tensor fasciae lata.
• Temporalis fascia.
• Synthetic materials
• Silastic rods.
• Gore-Tex.
• Dynamic transfers .
Local Muscle Transposition
Free functioning muscle transfer.
Static slings before and after the operation
Dynamic transfers
• The best protection for night/sleep hours is to place a clear eye guard
over the eye. This can be secured in place with tape.
• Any eye problems or irritation which does not quickly pass should
warrant consultation with ophthalmologist as soon as possible.
46
Miniature Micro Chip Technology and Artificial
Muscle Implant
47
The Nose
• The collapse of the nasal sidewall can be
corrected either from the outside or the
inside of the nose.
48
Adjunctive Procedures
• The bone marrow is a rich source of mesenchymal cells, which can be differentiated
in vitro into Schwann cells and subsequently engrafted into the damaged nerve.
• Nerve regeneration depends critically on Schwann cell structure which provide support
and growth factors that is essential for nerve growth . The problem is that Schwann
cells are scarce in an organism. So the ulternative is the use of stem cells to bridge this
gap
• The study was conducted in animals (rats) subjected to neurotmesis .The animals were split
into four groups. In the first, the two remaining parts of the selected nerve were connected
by a hollow silicon tube; in the second, the tube was filled with an acellular gel; in the third, it
was filled with undifferentiated stem cells; and finally, in the fourth, in was filled with
Schwann-like differentiated stem cells .
• The result was that all animals that received stem cells (undifferentiated or differentiated)
had a much more significant improvement than those that received an empty tube or a tube
filled with gel. Which confirme the rule of stem cells in nerve regeneration .
• the experiment brought one surprise: undifferentiated stem cells had a better performance
than differentiated (schwann cells) .
Effect of Platelet Rich Plasma on Facial Nerve Regeneration
Grabb___Smith_s_Plastic_Surgery__6th_Ed.2007
Facial_Plastic_Reconstructive_and_Trauma_Surgery