 Okay, we can go ahead and get started as folks continue to roll in again. Thank you for being here today We're discussing innovative treatments for facial paralysis facial nerve disorders with Dr. Kalpash Vakarya He's an associate professor of head and neck surgery at the University of Maryland School of Medicine Chief of facial plastic and reconstructive surgery and also the director Of the University of Maryland Facial Nerve Center. We invite you to ask your questions for Dr. Vakarya You can submit them and the questions or chat function And at the end of the presentation He will be available to answer those questions So if you have anything in mind now, you can go ahead and send it in you can also email it to us at FPI underscore communication at FPI dot you Maryland edu Otherwise we'll go ahead and get started. Go ahead. Dr. Vakarya Well, thanks Meredith and thanks everyone for joining us To allow me to talk to you today about some innovative treatments to rebuild your face Talking about patients that have facial paralysis some of the new things that we can do So in terms of disclosures, I have no relevant financial disclosures I may discuss some non FDA treatment options and some products here I did use photos from the literature You know, I'll give you my references at the end to help demonstrate some of the principles we're going to talk about and then some patient photos have been Used with that patient approval and I encourage people in that take some pictures or share some of the patient photos, please And once again, I thank you for joining us So let's dive right in so kind of our objectives today. We're going to talk about facial nerve and muscle anatomy to really understand The anatomy behind what we see in patients in terms of the paralysis I'm going to touch it just briefly on patient assessment I'll focus the majority of the talk on Innovative treatment options that are now available to patients and really the way to summarize that is in the treatment triangle Which I'll which I'll be discussing So before talking about the abnormal in terms when patients have trouble moving their face We want to have an understanding of just the normal anatomy. So in general the facial nerve is comes out of the Within the brain stem It then enters the temporal bone, which is the bone that encompasses your ear and your sensory organs for hearing and balance It snakes through this bone at which point after leaving that bone It will enter the one of the saliva glands called the parotid gland At that point it will divide to an upper division and a lower division and then divide further as it makes his way And courses his way to the center of your face Now as we age or as you can imagine our facial nerves tend to age with us. So Dr. Rosen in 2017 described a very interesting study where he evaluated facial nerve axons in and people of different ages and he interestingly found that People that are younger tend to have more axons in their facial nerve than people that are older And so this this makes sense and it's not such a surprising finding except for the fact that it may explain why some of the nerve based Reanimation or rebuilding techniques that we have work better sometimes in younger individuals compared to older individuals However, depending on the technique you choose we can actually get pretty good results in older patients Especially if we start combining techniques and I'm going to talk about some of these combination of techniques Throughout the talk today So we've talked a little bit about the facial nerve how it Comes out of the brain goes through the ear and comes into the face as it makes its way The ultimate end target is the facial muscles. So now they're about four Muscles of facial expression and the facial nerve as it divides into its multiple divisions ultimately supplies electrical input into these facial muscles in general, there's a lot of muscles, but you can kind of think about them as What their goals are so there you can kind of divide the muscles as either intended to elevate some structure of the face or depress or Drop down a structure of the face. So for example around the mouth You're gonna have muscles that are located above the corner of the mouth or above the upper lips and muscles that are located Below the corner of mouth and below the lower lips. So as those muscles contract the goal is so the upper muscles will be Be intended to lift the corner of mouth or lift the upper lip So when you smile you're gonna have a lip uplift of these structures And the muscles below the goal is to either depress the corner of their mouth and so they help you with more so frown similarly in the upper face around the eye, you have your forehead muscles and So the goal of this muscle is to help raise your eyebrow just like the muscles below Are intended to drop your eyebrow So patients with facial paralysis tend to miss their smile the most of all of the facial Expression deficits that exist now. There's multiple different ways out there to classify Smiles in general you can kind of divide smiles as being open mouth smile versus closed mouth smile I myself when I pose for a picture, I tend to give a closed mouth smile However, my wife tends to give an open mouth smile. So it's very particular depending on the different person Now Ruben back in 1974 evaluated a hundred people and characterized their smiles in three basic forms And really kind of focused on the kind of more open mouth smiles and he characterized him as 60 in his hundred people He looked at he found that 67 percent back in the 1970s had what he called an open a Mona Lisa smile Where the corners of the mouth get pulled up and the upper left gets pulled up Just like a shown in Jennifer Aniston here where you have more upper dental show and 31% of people he evaluated had a canine smile. This would carry Washington is Demonstrating where you have some more action of your upper lip elevators where you'll get more show of your your canine teeth specifically And while about only two percent had what's called a full denture smile And this is where your upper teeth muscle upper lip muscles really Activate in your lower lip muscles activate so that you can see Your upper lip upper teeth as well as your lower teeth And this tends to happen in only about two percent of people as demonstrated here by Julia Roberts so now the understanding of the nerve anatomy and the facial anatomy really Gives us the ability to now put that together and really recognize that specific nerves as they Intervates specific muscles work together to create the various facial expressions as you can see in this chart on the left And so the different facial expressions that you see whether it's smile. It's a grimace. It's a frown It's a surprise look activate different segments of the nerve thereby activating different combination of muscles to demonstrate Any particular facial expression. So why is this important? So for patients that have facial paralysis the many of them will undergo physical therapy and so a lot of physical therapy is Gear tour having the patients understand the different nerves and segments and different muscle segments that are acting together So that they can take what's unconscious and make it conscious. So then now you have the ability to Manipulate one's facial muscles in a way to compensate for when muscles aren't working or only partially working This information is also really important in the operating room. So as surgeons We use this information when selecting nerve branches when we're doing nerve-based Reanimation techniques to help patients regain some facial function So we talked a lot about the anatomy and the anatomy of smile and how it works let's switch gears a little bit and talk about the assessment and so when you come to the facial nerve center as Physicians here work armed with two tasks and those two tasks are first determine the underlying etiology of why a facial paralysis may have happened and then the second task is addressing the facial deficit and treating the patient in the context of their goals and expectations and then hopefully in doing so We're trying to minimize the negative psychological impact that facial paralysis has on people So the symptoms vary according to the etiology and so I put this chart up here to kind of just hopefully really impress upon the audience that there's a lot of different sources of facial paralysis and So really step one is really figuring out what is causing the weakness or the paralysis the majority of the time Depending on where you practice that's usually Bell's palsy, but here at University of Maryland where we have a very intense Facial trauma center as shock trauma. I do see a lot of patients that have Paralysis related to various traumatic injury also as part of a big head and neck cancer program here We also see a lot of patients that have paralysis related to either benign or malignant tumors So when encountering patients with facial paralysis In addition to figuring out the etiology we spend a lot of time figuring out How to make the face look and function better? So patients with facial paralysis have been found on numerous studies to have decreased quality of life report higher rates of depression and Experienced a lot of social isolation and stress related to their facial deficit And so really we we are armed with the task in improving their facial function their appearance their function in the hopes to improve the quality of life the way we do this is by really understanding each patient's goals and In terms of what they're trying to improve upon Whether it's rest symmetry whether it's voluntary motion cemetery or emotional expression and whether it's you know Trying to regain some of the control of their facial function that they've lost facial function in terms of around their mouth Patients can have speech and swallow difficulties around their nose people can have nasal obstruction and then specifically around their eye in terms of tearing and eye lubrication What makes facial paralysis so exciting in terms of treatment is now compared to You know even as much as five to ten years ago, we have a lot of options That are available. It's no longer. Oh, I have a paralysis There's nothing you can be done about it And we have a lot of options and really we have the ability to tailor the therapies that we have available For any particular patient so we can maximize their function and hopefully improve their quality of life So when seeing a patient with paralysis Timing is really everything and so we classify patients further in terms of Acute versus chronic so cute is the patient that just had the paralysis They woke up yesterday or last week and now all of a sudden their face is not moving versus the chronic patient is the patient That's having facial dysfunction for a month or even years So when I'm seeing patients I'm asking my question some important questions to myself as I'm getting to know the patient in terms of what's causing the disorder Also What is the nerve status? Is the nerve still viable? How long has it been since the nerve has not been Being used and what is the status of the facial muscles that we've just learned about? Is the muscle viable and now if I all of a sudden start driving nerve input in the muscles is the face going to start moving and so these are important questions to ask ourselves because Depending on the amount of time that's passed from the paralysis Determines what treatment we have available So in general the thinking is after 18 to 24 months if the face has not been moving Because of fibrosis and because of scarring even if you start to drive Electrical input through the nerve into the muscles You're not going to get that much movement and so really time is muscle and so our goal is to try to Get as much movement back into the face as early as possible so the other way we classify patients with facial paralysis is we We think about the paralysis and we classify as in kind of three different forms the Flaccid paralysis the non-flaccid paralysis and some mixed type So the flaccid paralysis is shown on the picture here on the left Where you have a patient that has parallel paralysis of the left side of her face this is a patient where the The left side of the face is completely droopy and so patients like this will say oh it looked like I've had a stroke They're going to also complain of issues related to function around the eye This is where you're at really significant risk for the the corny of the eye to dry out You're going to have some vision loss related to just droopiness of the eyebrow You'll have some drooling and some oral incompetence Especially when it comes to speech is falling problems Compared to the non-flaccid facial paralysis patient Which is what's shown on the picture on the right and so in this patient You're actually going to have overactivity in certain areas You're going to have other areas that have decreased activity. You're going to have tightness in the face You're going to have narrowing in the eye opening Sometimes you'll have excessive tearing and you'll have this entity called synkinesis Which we're going to talk a little bit more about Now some patients can have a mixed picture They can have areas of the face such as the eyebrow that are more droopy Which is what you would see in the flaccid patient versus areas that are more elevated and more tight and more frozen Which is what you'd see in the non-flaccid patient So synkinesis which ordinarily is seen in the non-flaccid paralysis Is defined as unintentional motion in one area of the face resulting in Occurring at during intentional motion in another area So the picture on the right shows some arrows And so when you have a person that's trying to them move their mouth Which is what the intended motion is you're going to have unintentional motion of the eye What shown in the second figure is this gentleman is raising his eyebrows And so he has the intended motion of raising the eyebrows You have the unintended motion of lifting the corner of the mouth So synkinesis develops during the process of nerve recovery or nerve injury It's not universal, but it can develop in you know 20 percent of patients 40 percent patients depending on what study you read the Development of synkinesis usually occurs around two to three to six months after the injury of the facial nerve It can be very debilitating aesthetically as well as functionally and so if you have the What's shown here the situation where whenever you move, you know One part of the face such as your mouth or your eyebrows any of unintended movement You can see in this patient when she's puckering or moving her mouth She's having significant closure of the eye and so as you can imagine This can have significant functional consequences when it comes to your vision So when you come to a facial nerve center, you undergo a lot of photos and videos And so we take this in order to help us educate ourselves and to educate the patients in terms their progress in terms of treatments progress and recovery progress and so it's it's periodically I'll review Patients photos and videos Just to kind of get a sense of where we've come and also to get a sense of what Treatments we have now at this point that we can improve any particulars patients facial function So let's switch gears here and talk about more treatment So as I mentioned, there's kind of two tasks determine the etiology and directing treatment toward that etiology But then also what I call the treatment triangle, which is really addressing The functional aesthetic issues that are resulting from the facial weakness or paralysis The treatment triangle can be summarized as a combination of medical treatment physical therapy or surgical treatment so medical treatment are things like Injections injections of chemo denervation agents or injection of fillers Versus surgical treatments, which I'm going to talk about briefly a subset of treatments that are available to help patients In certain situations get more Movement of the face in terms of physical therapy, which is a very important Branch of that treatment triangle the current physical therapy techniques Incorporate selective exercises of the face facial massage and relaxation techniques combined with biofeedback Neuro facial neuromuscular retraining is a type of therapy that facial physical therapists Especially trained and taking care of patients with this facial paralysis tend to employ what is the hope is that through Aggressive education and directed exercises with the patients therapists are able to help patients control their facial movement and compensate for the loss that they may have on one side or the other and What's been shown in the literature is that this type of therapy actually improves facial function as well as aesthetics Mirror fire biofeedback is another technique that's very commonly Utilized by physical therapists where they use mirrors and ask patients to do various facial Exercises to help them regain some control of the face and then ultimately use that Those exercises to help improve facial function So let's talk about some medical treatments So one of the common medical treatments that we deliver at the facial nerve center is Injection of dermal fillers and this is used to improve facial symmetry as well as facial function so my go-to filler is the use of hyaluronic acid fillers and this is because this is a material that's readily found in people's bodies, so we're injecting Agents or medication that is already found in your body. So it's a little bit safer and well more well tolerated It also has a lower rate of complications compared to some of the other fillers that are available in the market Now the other nice part about this is that it's reversible and so if we don't like the effect There's a medication that we can give that will reverse some of the effects of the filler Now as you can imagine That these these filler agents are not permanent And so you will require periodic repeat injections to continue to realize the benefit so a common treatment that I use for patients that have Oral incompetence after a facial paralysis is using filler to give some volume into the upper and lower lip and so in this patient on the left you can see that When they pucker or purse their lips they're going to have a little bit of a gap that exists Because of the loss of some of the muscle ability By putting a filler or hyaluronic acid into the lip it gives that volume and takes the place of some of the loss thereby allowing some patients to purse their lips keep their food or saliva In their mouths when they're eating or speaking Other uses of fillers especially in the patients that have the non flaccid type of facial paralysis. They tend to very deep very They tend to create very deep smile lines or folds in the area of the paralysis And so by using hyaluronic acid fillers, you are able to result in some improved symmetry Auteo grosso and colleagues recently in 2020 actually described in their paper that dermal fillers and patients with facial paralysis Can improve facial symmetry and improve psychological well-being therefore improve quality of life just after one treatment Now the other very common medical treatment for patients that have facial paralysis is the use of chemo denervation agents So such as botulism Botulism or just in generically speaking botox can be given and it's one of the more common things that's Given here at our facial nerve center and a big part of it is because it's minimally invasive And it can result in significant improvement of facial function aesthetic as well as quality of life Now botox just to say in layman's term produces Chemical denervation of muscles by blocking release of a neurotransmitter the acetylcholine at the junction between the nerve and the muscle So now this is a permanent denervation that occurs However, your body has the ability to regrow these nerve endings between the muscle and the nerve and so as a result At about three months you start Developing return of function of these muscles and so that explains why you have to undergo repeat treatments at times So botox is frequently used cosmetically to help soften wrinkles as shown here in this patient Where you have forehead wrinkles you can inject in the forehead you can soften some of these wrinkles You can also inject in your 11 lines Which are the lines that end up forming as we age between our eyebrows So you can see after a standard injection you can get softening That occurs because you're having paralyzed you're having paralysis of these muscles So these cosmetic indications these situations the exact dosing the locations well very well described and very generalizable generalizable across patient to patient However in the facial paralysis patient Um, this is not as well generalizable And so this is where we have an opportunity to really tailor the treatment to any particular patient's facial problem So let me talk about a couple of the problems that we commonly see So first is the lower lip the lower lip by symmetry is very common in patients that facial paralysis We can actually inject specific groups of muscle in order to achieve improved facial symmetry and improve function And so what's shown here in the picture on on the right you have Uh, the lack of lower lip pull down with smile in the paralyzed side So this patient has left sided lower lip paralysis And so with specific injections to some of the lower lip depressors You can actually paralyze the non paralyzed side Then resulting in better symmetry As shown here after injection with a very much more symmetric smile and the ability to kind of bring the lips together The other common area that we see in patients and inject is the platysma This is the large muscle in the neck that's right underneath the skin And in general patients that have non flaccid paralysis type tend to have a lot of tension pain and spasm in this muscle That's a very frequent and common complaint at their center So the muscle also is involved in pulling the corner of the mouth and the lower lip downward And so injecting Botox This chemo denervation agent into the muscle you can see will relax this muscle As shown from the picture on the left to the right where you can see the relaxation of the the muscle band that's there What it also tends to do Is relieve some of this spasm that twitching and the tension and the pain that patients feel in this area Additionally since it's also used to bring some of the lower lip down by paralyzing it You can actually get some improvement in some patients in in terms of their smile or uplift of their smile So synkinesis we've talked about that how you have unintended movement to one side of the face while you're moving some other and so Treatment with chemo denervation agents is really one of the gold standards One of the easiest ways that we have to improve this sequela facial paralysis And so as you can see in this patient where you have closure of where you have puckering of the mouth results in closure of the eye area with selective specific Injections around the eyelid around the eye As well as other areas of the face you can achieve what's shown here Where now the eye is not closing with that pucker or with that movement of the of the mouth So this is an example of A pattern of injections that we will do depending on The the problem areas and so in this particular person that had this map, you know They had problem areas in the forehead around the eyes. They wanted some lower lip symmetry now. This is not Standard between each patient and so we're armed with the task of figuring out kind of the facial injection map Between sessions and so what's exciting is the patient I get to know each other We get to figure out what areas are the problem areas what areas don't bother them and we direct injections toward those areas to calm down those problem areas So let's switch gears a little bit and talk about some surgical options On that treatment triangle that we have that are available for facial dysfunction So one of the areas one of the problem areas, especially in patients that have flaccid paralysis is they have incomplete eye closure And so this is a big problem because If you're not able to close your eye, you're not able to lubricate the eyeball the cornea And that's the seeing part of the eye or the colored part of the eye as shown here If you're not lubricating it, you're kind of putting yourself at risk of drying pain and Eventually blindness and so we take the eye area and patients with facial paralysis exceptionally serious and so Initially the management is medical management of using things like artificial tears lack or lube ointment, which is more viscous Taping the eye shut in specific areas lifting the lower eyelid with tape or taping the eye shut at night specifically to make sure the eyeball is getting adequate lubrication All additionally we can use things like a moisture chamber which is shown on the right Which is an alternative to do the taping when you put the moisture chamber It creates a micro environment where the eye is more Moisturized after you put all your drops of lubrication in so there's an alternative to taping at night now This is what you will see in flaccid paralysis close your eyes Relax Where you can see you don't have the ability to close the eyelid to cover your your eyeball You also have some droopiness of your lower eyelid as well as the eyebrow itself all can limit eye function and vision so in terms of surgical options As we've talked about some medical options related to the eye area is really implantation of these eyelid weights and so After about a month if you're still not recovering some of that function around the eye We would talk about inserting one of these eyelid weights to help With the management of the eye. It's a short surgery that can be done It's a common kind of come-and-go outpatient type procedure Which will allow someone to now be able to Volitionally close their eye when they need to so for example in this patient Closure eye when you ask to close their eye You're not able to achieve that now after undergoing eyelid weight implantation into the eyelid In addition to a brow lift and a lower eyelid lift you can see what can be achieved Which is improved eye closure and so This will help patients This has been shown in multiple studies to improve quality of life because it's one less thing that the patients have to Deal with as they're addressing the rest of their face Now a new surgical tool that's been recently added to our armamentarium is called modified selective norectomy Uh, and this is can be combined combined with platysmal excision Which is recently described in 2019 by babacus these days out in los angeles Um, this is really a nice addition to our Toolbox Because for patients that have non flaccid paralysis Prior to this we are primarily treating with a chemo denervation agents as well as facial dermal fillers Since the description of the surgery and now really the Use of the surgery in patients. It's really helped some improve their facial function specifically around smiling The way this surgery is performed This is done through a facelift type incision So it's a well hidden incisions During the procedure we go in and selectively find nerves That are us are what we call the problem nerves So these nerves are supplying muscles that are doing actions that they're not intending to do So for example when you're trying to smile You're trying to have your muscles above the corner mouth lift the corner of the mouth so you can smile But there are some nerves and muscles that are now counteracting that Uplift and so as a result if you can go in and selectively find that nerve and muscle And cut that you can potentially result in a better smile better function decrease incisions, and that's what we've shown here So let me give you an example And so this is from his paper. We can see the patient has a kind of lower downturn corner of the mouth Less dental show and a lot more asymmetry. So after undergoing this modified selective urectomy This is what's shown in the bottom bottom picture is something that can be potentially achieved And this is in one of my patients that had long-standing facial paralysis non flaccid after vellus palsy This is the type of smile that he had So you can see the asymmetry That's on the left side. He has minimal function More pulling out To the side and very little dental show. So now after this modified selective urectomy This is just a couple months out I take back a couple weeks out you can see much more dental show much more smile You know, he reports to me that he's felt like for many many years over a decade He's not had an appropriate smile And so after undergoing this procedure, he feels that him and his family kind of see a much more improved And he's happy with the smile that he can achieve Now the final technique that i'm going to discuss in this talk Can be used in patients that have flaccid paralysis So for example after patients that have trauma to the facial nerve After fractures of the the head or the ear bone or if a gunshot wound or after removal of a tumor This is where one of the techniques that come in Also, this can be applied in patients that have Uh a problem that's more long standing that they haven't gotten recovery of facial function And so what we do here what has been described is the technique of transplanting nerves So taking nerves from the arm or the leg Uh and then rerouting them in the face and then also rerouting local nerves So specifically the nerve that used to control one of the muscles of biting So the masseter muscle you can actually reroute that and reroute it specifically to the nerve branch that controls smile And so by doing this combination therapy, we're actually able to achieve significant improvement in facial function Giving people the ability to smile which we were not able to do many years ago Because of the advances in the technology that's that's come about And so this is an example of a person that underwent removal of a cancer and we did some of this combination nerve grafting taking nerve from the leg As well as rerouting taking the nerve from the bite muscle And reconnecting into the facial nerve And so this is uh immediately right after surgery you can see The paralysis the lack of movement that is present When the person tries to smile now this is four months after surgery Uh and we're going to show you uh smiling with biting down because that's where the rerouting comes into place So when you now clench you're able to smile and then also clenching and smiling On on command Okay And then Okay And so you can see this is a much more meaningful smile that we can achieve what's your techniques because of these new Uh kind of revolutionary nerve-based techniques that we have now which we did even have uh, you know five ten years ago All right, and so these are my references and so i'll conclude Uh, so understanding the facial nerve and facial muscle anatomy is crucial Determining, uh, the etiology is important because that's a big part of the treatment Uh of the facial paralysis Remembering the treatment triangle, which is a combination of physical therapy medical therapy and surgical therapy And really using combined treatments now can help patients maximize their facial function and ultimately improve their quality of life Well, I want to thank everyone for tuning in and I appreciate Appreciate everyone's attention and we'll open up the floor for any questions