facial paralysis reconstruction

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FACIAL PARALYSIS RECONSTRUCTION

BOBBY SWADHARMA PUTRA (BSP)Surabaya, 28 Februari 2011

Pendahuluan

► Facial paralysis adalah kondisi dimana terjadi deformitas disebabkan paralisis struktur pada wajah yang diinervasi oleh n. facialis.

► Not an aesthetic issue Functional disability

► Pada otot wajah fungsi yang bisa terganggu adalah proteksi mata, jalan nafas, fungsi makan dan berbicara

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Klasifikasi

Berdasarkan penyebab :► Kongenital► Trauma► Infeksi ► Neoplasma► Idiopatik► Toxic► Iatrogenik

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Berdasarkan anatomi :• Extratemporal• Intratemporal• Intracranial

Berdasarkan sisi wajah yang terkena : Bilateral Unilateral

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Anatomi

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18 paired muscle animate the face

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Pemeriksaan Klinis► Anamnesa

Keluhan pada mata seperti mata kering atau air

mata berlebihan, kelopak mata tidak bisa menutup

Keluhan pada nasal airway

Bentuk mulut yang tidak simetris, gangguan bicara

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Eye symptoms: dryness, excessive tearing, incomplete closure, outdoor discomfort, use of artificial

tears.

Pemeriksaan Fisik

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Snap test

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Nasal airway obstruction :

due to the paralysis muscles and the sagging of the cheek, forced inspiration leading to collapse of the

nostril.

12Oral symptoms: continence problems, speech.

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Psychological status & level of difficulty to communicate (happiness, anger & sadness)

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Examination:Brow, eye, upper, lower

lid, position of the inf.canalicular punctum,

corneal ulcerations, philtrum, depression of commisure, nasolabial

fold, sagging of the cheek.

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Synkinesis: simultaneous

contraction of two or more muscle groups

which should not contract togather

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Pemeriksaan fisik dimulai dengan meminta pasien

mengangkat alis, menutup mata, tersenyum, dan mengerucutkan bibir.

Tatalaksana►Secara umum bertujuan :

Proteksi mata

Mengembalikan posisi simetri wajah

Mengembalikan fungsi gerakan wajahEkspresi wajah ( senyum )

Konseling pasien diperlukan oleh karena

sulit mengembalikan semua fungsi dan

bentuk wajah seperti semula

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Tatalaksana

► Non surgical

Sering diterapkan untuk kelainan pada mata,

seperti lid taping, eye lubrication, eye patches

Melatih pergerakan otot wajah (rehabilitasi

medik)

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Tatalaksana► Surgical Treatment

Alis : Direct brow lift, coronal brow lift, endoscopic brow lift

Kelopak mata atas (lagophtalmus) : Gold weight, temporalis transplantation, spring, tarsoraphy

Kelopak mata bawah (ektropion) : Tendon sling, lateral canthoplasty, horizontal lid shortening, termporalis lid transplatation, cartilage graft

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Surgical Treatment

Nasal airway : Static sling, alar base elevation, septoplasty

Bibir atas & pipi:Muscle transplantation with use of ipsilateral 7th nerve, cross facial nerve graft, or other cranial nerve for motor inervation, temporalis transplantation with or without masseter transplantation, static sling, soft tissue balancing procedure

Bibir bawah :Depressor labii inferioris resection, muscle transplantation (digastric platysma ), wedge excision

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Alis

►Direct Incision►Insisi koronal►Endoscopic Brow Lift

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Direct brow lift

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Direct brow lift

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Coronal Brow lift

Endoscopic Brow lift

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Kelopak Mata Atas

►Lid Loading (gold prothese)►Pemasangan Palpebral Spring►Transfer m. temporalis►Free Platysma transfer

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Lid Loading

Early technique– Incision in the supratarsal crease– Subcutaneous pocket – Insert weight– Close skin

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Gold Weight

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Surgical Procedures

Gold weight implant-placed beneath levator

aponeurosis

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Gold Weight

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Gold Weight Placement

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Combination of Gold Weight and Lower Lid Shortening

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Combination of Gold Weight and Lower Lid Shortening

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Platinum Chain

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Palpebral Spring

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Kelopak Mata Bawah

►Static Sling►Cartilage graft to

tarsal plate jarang dilakukan

►Wedge Incision

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Tendon sling placement

37Horizontal lid shortening

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Lower lid shortening– Wedge excision with

lateral canthopexy– Used in combination

with gold weight implantation

39Temporalis Muscle Transplantation

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Tarsorrhaphy

41Lateral canthorhaphy

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Nasal

►Elevasi ala nasi, kemudian dilakukan pemasangan sling dari tendon.

►Septoplasty bila perlu

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Bibir & PipiRekonstruksi dibagi 2 : Static pemasangan sling (fascia, tendon,

goretex) Dynamic pemindahan otot :

Regional : temporalis, masseterCross facial nerve graftcoaptation to masseter motor

branch

- Free muscle transplantation

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Regional Muscle Transfer

M. temporalis M. masseter

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Free muscle transplantation

Free muscle transplantation

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Cross Facial Nerve Graft

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Bibir Bawah

► Reseksi otot m. depressor labii inferior

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Resection of the depressor labii inferioris of the normal side

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Resection of the depressor labii inferioris of the normal side

Algoritma

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Surgical management

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Tow stage Microneurovascular muscle transplantation

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Dissection of the facial nerve branches on the normal side

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Mapping of the facial nerve branches

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Mapping of the facial nerve branches

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Sural nerve harvesting with a nerve stripper

58Gracilis muscle harvesting

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Placement and

anastomosis of the

pedicle

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Placement and

anastomosis of the

pedicle

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Temporalis & masseter muscle transplantation

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Static tendon slings placement

Daftar Pustaka

Leedy, E. Jason : Facial Reanimation. Essentials of Plastic Surgery. QMP Publishing. 2007; 347-361

Neligan, C. Peter; Zuker, M.Ronald : Facial Paralysis Reconstruction. Grabb & Smith’s Plastic Surgery 6th edition. Lippincott Williams & Wilkins. 2007; 417-427

Zuker, M.Ronald ; Manktelow, T. Ralph; Hussain, Gazi : Facial Paralysis. Mathes’ Plastic Surgery Volume 3. 2006; 883-915

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TERIMA KASIH