Webinar date: Thursday, April 8, 2021 | 9am PST
With guest speaker Peter C. Revenaugh, MD is head of the Section of Facial Plastic and Reconstructive Surgery and the Patient Safety and Quality Improvement Officer for the Department of Otorhinolaryngology at Rush Medical College, Chicago. He has authored numerous journal articles and book chapters and has a passion for humanitarian work providing surgical care to areas of the developing world.
His team specializes in noninvasive and minimally invasive cosmetic procedures for facial rejuvenation, cosmetic and functional nasal surgery, rehabilitation for facial paralysis, and advanced facial reconstructive and microvascular surgery following head and neck cancer.
Amit Kochhar, MD
Facial Plastic & Reconstructive Surgery, Pacific Neuroscience Institute Dr. Amit Kochhar, MD, is double board-certified in Otolaryngology, Head and Neck Surgery, and Facial Plastic and Reconstructive Surgery. He is the director of the Facial Nerve Disorders Program at Pacific Eye, Ear & Skull Base Center, Pacific Neuroscience Institute, Providence Saint John’s Health Center in Santa Monica. Dr. Kochhar is one of a few select surgeons who perform complex (microvascular) head and neck reconstruction following cancer resections and facial trauma, as well as for the rehabilitation of facial paralysis, an area in which he has specific clinical expertise and research interest.
For more information
310-829-8701 | https://pacificneuro.org/facialnerve I'm happy to um to be able to um give any information to patients providers or whomever out there. Um I have no disclosures, no um industry ties or anything like that. Um A little disclaimer at the bottom obviously this is meant to be informational and not intended as medical advice. Um Some of the information on here may actually be just my own opinion um about um certain things obviously I'll state medical um but they're also not the opinions of my employer here at Rush University Medical Center either um we do have a great um facial paralysis and and rehabilitation team here myself and Mark Wyatt who is a neuropsychologist had the team and then we have great partners in neurosurgery neurology um Ocular plastics, other facial plastic surgeons and of course um the nursing support staff um physical therapy and all those that that really make it make it possible. Um Dr kota charges already mentioned my my kind of background training it at um Cleveland clinic at johns Hopkins before coming here. Um The things we'll talk about today um I think and that's our hospital there just on the west side of Chicago. Um But um things we'll talk about are the concepts of facial perception which I think are important to understand anytime we're talking about facial paralysis and then treatment options for facial paralysis treatment options for sync genesis and then some future directions are things that we might be thinking about um things I always like to to mention at the beginning of any talk when it comes to facial paralysis and or psychokinesis is really the um the five facts um of facial paralysis in genesis. So number one, um the cause and presentation of this or you know how people are affected by it is highly variable and anybody that is affected or works with patients that are um would be would would easily notice that it is an extremely personal and life altering experience to have weakness of the face. Um Paralysis of the face or even just synchronicities, which I shouldn't say just sink. Genesis can be incredibly um life altering and bothersome. There are no minimally or maximal or no minimal or maximal times for treatment. Um so even if you had facial process 35 years ago, um there may be things that we can do that can that can help um your experience with it. I put some stars there because as we do um go through um time out from treatment options do change. And so that's important to note and important to to see somebody well versed in facial paralysis early on. Um So you can kind of talk about what options you might have um from the beginning. Um it is uniquely individualized since the cause and presentation is variable, so is the treatment for it. Um and so of course of action may be very different one patient to the next and then research and treatment options are rapidly growing. So as I mentioned, things years ago that we did may still be options now and or we may have more options than we did then. So as far as the concept of facial perception, um I always put this um statement in my talks to, you know, faces, one of the most important stimuli that carries social meaning and the primary means of social communication. And and and I'm sure everyone realizes this and some people have told me in the past years, well, you know, virtual communication or texting and things like that has taken over. Um and and and maybe the face isn't so important. Um I would say it's it's just as important um because you can see here emojis are faces that we send to each other with emotions or with um expressions on them. And then of course there's a blurry picture of a zoom meeting which we're all very familiar with. Obviously we're on one now um where we're looking at other faces and communicating with with facial um emotion and um and movements in social cognitive science. Um in 100 milliseconds we will see someone else's face assign meaning to it. And and and and basically judge it. Um To put that in context. And 3 to 400 milliseconds is an eye blink. So in a fraction of an eye blink we can see somebody and decide are they a threat, are they mad? Are they happy? Are they sad? Um And facial paralysis or sink genesis can disrupt that a little bit. Um and and and cause us to be confused by what we see or two, perhaps even judge somebody negatively. Our brains are highly tuned to this, to the appearance of people's faces and the expressions of people's faces. Um I always like to talk about how this might be an innate thing. Um that's a picture of my son just after he was born. Um but as early as 30 minutes after birth, babies will pay more attention to faces. If you show them a face versus a picture of a car, they'll pay more attention to that face. As early as three days after birth, they'll pay more attention to their mother. Um So they obviously know that that face is more important than other faces, so there's probably something innate with our ability to recognize and judge faces. In fact, infants tend to look more often or longer at symmetric faces. Um and so um obviously symmetry or asymmetry and faces can be can be a problem. And and um there's this idea that that beautiful people or um the most acceptable faces are average, so they're symmetric. Um they're an average of other faces. And if there's a symmetries, we assign almost a social penalty to that, we judge them differently. So the face is a very complex intersection of, of form and function. We just mentioned that asymmetry um is a big deal when it comes to faces. Um but certainly um the face is also very important for for everything we do day to day for eating, for speaking, um things that are important for communication as well, intake of senses, so, you know, vision um is obviously important and affected by or can be affected by facial paralysis, um hearing, smelling all that um is in section of form and function. And then obviously when someone has facial paralysis like this picture here, um not only is form altered and we noticed that right away and everybody quickly notices that something is wrong here, but then her function is dramatically altered in many ways. I think an important thing about this talk because um I was asked to talk about paralysis and sink genesis so important thing is to have that. Well, what is the difference. Um and and it can be very difficult for um trained physicians to tell which one is going on. Um and certainly for for patients or patients, families or friends, um it can be very difficult to separate the two. So I'll give my kind of simple ideas of definition. So paralysis or paralysis, which processes is just paralysis that may get better. Um Paralysis I think of as its permanent is not going to get better, but um either one of them is an irreversible or reversible loss of movement. So those muscles cannot move or are very weak in moving, that's paralysis and paralysis sink in genesis on the other hand, is abnormal movement of those muscles or abnormal tension of the muscles. So they're abnormally um taught and and many times I'll see psychokinesis patients and they say, well I'm paralyzed, I can't move. And that that may be quite true, but they may have abnormal tone of those muscles. Um So sometimes it's very difficult to separate the two, but it's it's very important because it makes a difference in treatment options and just another example of facial tone, because sometimes that's a concept that can be difficult tone is just the resting kind of tightness of muscles. Um And I tell patients all the time that we all have facial tone all the time, even if we're just sitting here, if we didn't, all of our faces will be just drooping down, but we all have tone in the face. And then when you have synchronous is that tone it can be altered. And so the face can be tighter in certain areas um than in other areas. And that's where a lot of symptoms can come from. Just to review again, start with basics um The facial nerve is basically a nerve that comes out of the brain stem through the skull behind the ear and then spreads out into the face. Um like this cartoon here. Um and when it spreads out into the face. These signals that come down through the nerve that we see with this arrow here um can go to all these little muscles that we see in the face and provide movement um to those facial muscles and those muscles all do different things to um portray the complex amount of emotions that we can on our faces. Even at the muscular level. Those little yellow nerve branches go down and um uh sensationalize right to those little different muscle fibers. Um And so anywhere along that pathway, if that nerve or that that wire is I think of it is um disrupted. It can cause problems with facial movement. So we'll touch on Bell's palsy because Bell's palsy is the most common cause of facial paralysis and synchronous is so vast. Majority of my patients that I see in the office um for either synchronous or facial paralysis, it's because of Bell's palsy and that's basically an unexplained loss of movement of the face. Um it happens um at a frequency of 20 or 30 per 100,000 people per year. Um It's more common in pregnant women during the 1st and 3rd trimester. And there's even a little bit of a difference, at least that I've seen with um at which trimester and how good their recovery will be. Um 3rd trimester tends to not recover as well um and it can be on both sides um in a very small amount of cases, people that see a lot of facial process has definitely seen cases of bilateral I have a feeling my practice, but it's it's more rare than than than one side and the prevailing thought is that it is related to a viral cause, although that's never been definitively proven. So um in medicine we call it idiopathic facial paralysis, meaning we don't know why the face isn't moving. Um But it's important to uh to know that it has a pretty common presentation. So it's a sudden onset of loss of movement in all our parts of the face and and suddenly the keyword. Um So it's usually over the course of hours, most patients will say I went to bed, I woke up and I tried to brush my teeth or drink a glass of water and and things fell out of my mouth and that's how I noticed it, but it happens quickly like that or it happened over the course of a day. Um It's sometimes associated with other symptoms like pain in or around the ear loss of alteration of taste or sensitivity to sounds. Um treatment options. Um For Bell's palsy um I would say the most important treatment option is prompt medical evaluation. Um Because there Bell's palsy, as I mentioned, is idiopathic, we don't know why. So you have to figure out is there any of those other things that could be and make sure that it's not. Um It's important that you see someone well versed in facial paralysis as early as possible. So if you go to the emergency department, you wake up in your face isn't moving and you go to the emergency department, that's great. Um They'll rule out all those really bad things. But then I think it's very important that that patients get in to see somebody that knows about facial paralysis because um not everyone treats initial Bell's palsy the same. Um and there are some differences in initial treatment that could make a difference in the final outcome. And then certainly you want someone that is going to more thoroughly look through things and follow you throughout your course and make sure things get better and that there isn't something else going on. Other testing or intervention may be indicated based upon that initial evaluation or subsequent evaluation. Um People that have Bells oral steroids and anti virals are really the mainstay of initial treatment. Um usually high dose oral steroids if the patient can can tolerate that. Um And then antivirals have been kind of controversial. I would say most people nowadays would use um use that at the initial um Bells presentation as we mentioned is a diagnosis of exclusion though. So these are the some of the other things or some of the other more common things that can cause facial paralysis. Um Certainly you want to rule any of these out because their treatment and and um kind of timeline of of improvement are very different than Bells. We want to make sure there isn't something else going on and then I usually um tell patients or other medical doctors that I'm talking to about um about facial paralysis that these types of warning signs. You really want to see somebody sooner rather than later. So if it happens slowly, if the if you were diagnosed with Bell's palsy and it happened over the course of a few days or a couple of weeks, well that is probably not Bell's palsy. Um If it only involves one area, the face um that is of concern. So if only the eye isn't working or only the corner of the mouth isn't working. But the eye is those are also concerning issues. Um If there is facial twitching that accompany that, especially happening days before that is a problem and probably not Bell's palsy. Um Other symptoms we mentioned, it can be accompanied by facial pain. Um numbness is rare, um weakness of other areas. The body is rare. Even if you have any other symptoms, probably seeing someone again that sees a lot of facial paralysis is important to make sure that that's really all you're dealing with. This is a patient will play her video um that presented to me for um was diagnosed with Bell's palsy. Um But she had a very atypical presentation. It happened over the course of um of days and weeks. Um and it happened to be unfortunately a skin cancer that um was affecting the nerve. Um Deep down. Um She was treated for it is doing quite well now, but it's important to know that, do you really want to rule out all the other things before you get onto that, A lot of my patients now will say, what about the COVID-19 vaccines or vaccines in general related to Bell's palsy? And so I just put a couple of things up here because I'm constantly talking to patients about this day to day um in the in the clinical trials for the two most common vaccines used now in the currently United States, the Fighter and the Moderna. Um There were reports and and that of people with Bell's palsy. Um they reported six cases in nearly 34,000 patients in that initial study. Um If we remember back, Bell's palsy will occur normally um in 2 to 3 out of 100,000. So if we break that down, um we would expect um I'm sorry, 2 to 3, but in 20 to 30 and 100,000, 2 to 3 and 10,000. So in 30,000 we'd expect 6 to 9 cases of Bell's palsy and that's exactly what they saw. So, most people think this is probably just what we would expect to see. People just randomly getting Bell's palsy and not related to the vaccine. And certainly the american Academy of otolaryngology has come out and said that um people that have previously had Bells should still get a vaccine. There doesn't seem to be any relation to them getting recurrent Bell's palsy. Um and then it doesn't seem to cause Bell's palsy higher than the we expect in the population. Um when the flu vaccines first came out, this was also a hotly contested thing. People thought it was causing Bell's policy. It turns out Same thing. It seems to be related to the population average of people getting it. So probably unrelated to the vaccine. And certainly with COVID-19. Um the potential um issues with getting it probably outweigh any potential risks of the vaccine. So I advise my patients that they should they should strongly consider getting the vaccine. So let's talk about facial paralysis. Um And then we'll go on to talk about synchronicities with the time we have left. Um So we mentioned there are variables and outcome timeline and treatment options based on the cause of the of the paralysis or paralysis. So, for example, if a nervous cutting surgery, um we want to fix that right away um Within, within the first couple of days if we can um if the nerve is weak from the surgery. So you had a surgery on your spit gland or on a tumor um near the brain. Um and the surgeries week after. But the surgeon was very confident that that he or she did not um cut the nerve and then it's it's reasonable to observe, observe the patient closely with, with a plan for further work up our surgery as time goes on. If the nervous week from Bells that we just started to finish talking about or other medical causes Lyme disease or things like that. Then you want to promptly treat that cause um and then follow the patient closely and so we'll talk about some of those things um in a little bit. Um This is just a list of things that that I've done last year for treatment of our last couple years for treatment of facial paralysis or paralysis. So you can see the list is very long. Um There's lots of options, meaning that there's no one magic bullet either. Um and also meaning that the presentation of the way people experience that are very different. Um and so um it's important that that you work with your physician to to figure out what is what is the best course of treatment. So we'll go through some of those things I mentioned. So the immediate issue the nervous cut during trauma. So here's a little cartoon, let's say the nerve got cut here. The patient was in a car accident, gunshot wound. Um You know, various other injuries. Can can cause problems with the nerve. Well then you want to do what's called a primary anastomosis or sew it back together as quickly as you can, that's going to get the best The best outcome for the patient um usually wants to do it in the 1st 72 hours because that's the timeline that we can still um stimulate the nerve and look at the nerve. Be able to find it easily. So here's an example of a patient that that I saw on on the left hand side of the screen there you see he's trying to move the face around but he's weak on the right side of his middle part of his face. And when you get back to the beginning here you'll see that again. Um He can't kind of get that cheek up his high. So he had a piece of glass fall on his face at work. Um And he came in and the nerve could not move. So we explored it. We hooked on her back together and you can see the other video. Now he has much more movement of that right side of the face. If you look very closely you may notice some subtle differences the amount of movement that he has. Um And that's because again um Maybe not again but um showing the nerve back together can get very good results but it doesn't get us perfect results. Um There's really nothing that can at least yet that can completely um make a nerve that was damaged to that degree um completely healed back to normal. Um Let's say the nerve had to be cut during surgery. Um So the surgeon to remove a tumor had to cut the nerve. If you can sew it back together. You can many times though the nerve has been cut in two separate areas. Um And those nerve branches or ends can't get back together. So in that case you can um put a nerve graft. Er I think it was a little piece of wire that you're stringing between those two ends um from another nerve somewhere else in the body. You can also use a nerve transfer or another nearby nerve. That can be another source of power to kind of hook into that nerve um to make it work. Um So here's an example of both of those things. So this patient had a tumor on the left side of her face and you can see that it looks different. But now she's kind of biting her teeth together and she she's getting movement of the face. Now most of her facial nerve was removed. Um And part of it was reconstructed with a nerve graft and part of it was reconstructed with a a nerve transfer from her chewing nerves so she can get reasonably normal facial symmetry. Um And and you can see her movement is a little asymmetric and and and um not coordinated well with the other side but but that's one of the best things we can get with a nerve transfer. So looking at longer term issues, let's say the nerve had to be cut during surgery. Um Or there was a trauma involved as I mentioned gunshot wounds, car accident but now it's been over a year we usually think of as one year as kind of the point where some of these nerve things that I just showed, The nerve transfers nerve grafts and things no longer will be working. Um And that's because the the nerve ending right near the the level of the muscle and the muscle um kind of shrinks down over that year and just like if you didn't walk on your leg for a year, um that muscle shrinks down, but the facial muscles don't come back if you start stimulating them again or start exercising them again. So um if you haven't had signals going to them for over a year, oftentimes you won't be able to use another nerve to kind of re plug it back in. So they rely on these techniques here static sling. We kind of just pull up the face temperatures Tendon where we use a nearby muscle um to pull up the corner of the mouth that doesn't move very much. Um the some of the studies show that, yeah, you can get it to move if you're very, very good. Um but even with that, most patients will get about three of movement, which is not a lot. Um and there's aggressiveness muscle that we can take from the leg. Um and we can use that, that gets a lot of movement. It's a rather big surgery. Um and I'll show you some examples the movement is always a little off. I mean, even in the best of hands, you can pick out which side has the Godzilla's on which side is the normal side. Um Here's a couple examples static sling. So this is a patient that had a tumor removed. She has paralysis on the right side of the face. There was no nerve available and she was not a great candidate for a Godzilla's. So we take little strips of muscle covering. Um It looks kind of like fabric and we string them underneath. And you can see we can get a reasonable symmetry of the face. You notice there's not a video here of her face because there really isn't much movement to see actually no movement to see. It's really just kind of pulling up and getting symmetry in the face there. The temperatures tendon transfer that nearby muscle. It I mentioned you can see in this picture here that chewing muscle that goes over the side of the head and down to the jaw where it attaches to the jaw. We can remove it and bring it out to the front of the face. Um as depicted in this cartoon here, um and connect it to the corner of the lip. And so that can get pretty good um symmetry of the face. Again, it doesn't move a whole lot. So I never promised patients that it's going to move a lot and really get them symmetric movement if it does then. And I count that as a win. But um we really do it to establish symmetry of the face. And so here's a couple of gentlemen um where I did this where we did a temporal tendon transfer um and pulled up the paralyzed in the face is the right side. Obviously in both of these patients, they both had had prior surgery years before and it gets pretty good symmetry, so they look normal when they're just sitting there in a waiting room on a bus. Um But you will notice in this picture there's another gentleman that had the same thing done and you can see on the right hand video um he's going to start moving the face around here in a minute. Um and we'll see that he's paralyzed on the right side. Um But we'll see um in the video, after the temporal attendant transfer things look more symmetric and a little scar on his cheek there where the or the tendon was attached. But we just don't see a lot of lot of movement in that middle part of the face, even when he's trying to bite down and show us movement. We can see a little hint of it more than when he was completely paralyzed, but we just don't see a lot of movement. And that's kind of very typical of the temporal, this tendon transfer. The Godzilla's micro neurovascular transfer of brazil's flap and some people will call it. Um This is a cartoon. I pulled from a paper I'd written years ago with with dr byrne um about you know how we actually do this procedure. This is a little better cartoon that I took off a website on different surgical techniques. And and you can see the idea that it's depicting here is that this muscle is stretched between the lip and the side of the cheek, that that kind of um red area there and you can see the blood vessels that are feeding that muscle. And that's what we we do. That's the micro neurovascular portion. We use a microscope to hook those blood vessels together as well as the nerve. And you can get really lots and lots of movement with this, but you have to expertly attach it to the corner of the mouth to get it to move in the same position as the other side of the face. And oftentimes it does not move exactly the same. Um Here at Russia and many other centers we harvest a nerve graft if we need to use a nerve to the other side of the face. Through an endoscopic techniques. This is myself, my partner, just harvesting one here. It can lead to a single incision behind the ankle and then you can bring that through the face from the normal side of the face to the affected side underneath the lip. Um And that could be used to help power or um only power the muscle or you can use a chewing nerve to add into it. Um Here's a picture of that muscle um sitting on the back table and that's how it is in a the markings on a patient, how we would implant it into the face. And you can see that muscle picture there, it looks like a little bit like a steak. Um And you can see the two things kind of coming off and those are the blood vessels and the nerve that would use to get it both blood supply and power. So there's a gentleman that had a trauma. You can see there's other scars on his face. Um But he had a grocery list on the left side of his face. You can see he can get some movement Um that he can match with the other side of his face. You notice that coordination of that movement is difficult. Here's another patient that had a um a surgery years ago and then we did a Godzilla's about 20 years later and you can see you can get some movement of that, that right cheek, but again coordination and symmetry is not exactly there, but he definitely has a lot more movement than the patients were seeing before with those other techniques. Here's another gentleman um recently um He's less than a year out from his grace still is and you can see him paralyzed before there and then here's him moving after um showing us a smile that he can get um coordinating that um That priscilla's um free flap there. So um you can see you can get pretty good smiling with it and facial symmetry. So I think what we see more commonly than these long term issues um is kind of the medium term issue. The nerve is um week from surgery but the the surgery wasn't, the nerve wasn't cut. And an example that many people may be familiar with is an acoustic neuroma of vestibular Schwann oma. So um this is a benign tumor that affects or near is near the hearing or facial nerves. Um And um surgery can sometimes affect the tumor itself can affect the facial nerve. These patients we watch very closely. If we don't say meaningful movement before a year then we'll do one of those nerve transfers or using another nearby nerve to to plug into it. Um that we talked about before. Um Some people will consider some off label medications um for for nerve healing in these patients. And and I know some centers are starting to use calcium channel blockers. Um There's been some indication in animal models and and very limited human studies that that these basically blood pressure medications may help with nerve healing. So if it's not contraindicated sometimes will offer this to patients. Um The issue with this is that recovery in these in these patients will come in different groups and you see this little square here um Some patients have immediate recovery. Obviously we don't worry about. Those patients will have the week after surgery but within a few weeks they start to recover or um they'll have delayed recovery, may take weeks to months. But then they get you know, a reasonable recovery. And these patients on the bottom that have a delayed recovery and maybe just have a little bit of tone in the face but can't move it or patients that are frankly, you know, still droopy or flaccid and and cannot move the face at all. Um Those patients are the ones that we really want to try and intervene on. Um And unfortunately um I guess fortunately now it's a little bit better that there's facial nerve centers around the country but but years ago most patients did not even get to a facial nerve um expert um within that year. So um some of the options I'm about to present warrant options for them, but now they are. And so again it's important that if um even if a patient's had a surgery and we expect the nerve to recover that they're followed closely because if it doesn't recover by one year um we want to really intervene pretty quickly to get them some uh some movement. So here's a patient uh very patient. So he had an acoustic neuroma surgery, the nerve was intact but he's not showing any improvement um in the right side of his face beyond maybe a little bit of tone if you look very closely. Um And so this is kind of our algorithm that we use here. Um uh there's a bunch of red question marks in there and that means that these are decision points or controversies. So um areas that we could kind of go either way or we have areas where we have to make a decision. Um This was a study published out of the group at Hopkins um that showed that with these patients that have acoustic neuroma or similar type tumors. If you don't do anything by about or they I guess if they don't show movement by about six or eight months, they won't get movement. Um And so their argument was, well we should intervene in these patients sooner um than a year because they may get better results. And and if they're not saying we're not seeing anything by that time, then then um we should do something. And so I kind of agree um I tend to wait a little bit longer um in some patients because I have seen some improvement. Um but but I will agree that if we're not getting close to that year and not seeing any any meaningful recovery, we won't Um and so again, 6-8 months is kind of what that article quotes, I tend to wait, you know, a little bit longer, but we definitely start having those conversations. If we're at 6-8 months and we haven't seen any improvement. So we can kind of skip over this for the sake of time. Just basically saying that we don't have any ideal reanimation techniques that can do all of these things. We cannot replace um normal facial movement um in a patient that the nerve has been dramatically damaged. We can get close but we can't ever make it completely normal someday. We will be able to do that. But unfortunately um we have to rely on techniques that are not quite as good um but can get us reasonable results. Um So what nerves do we use for these transfers? Well there's a whole bunch of different ones that we use. Um uh Hipaa glassell nerve or the tongue nerve um was very popular years ago. Um The massacre nerve and that's a different chewing muscle. The face was popularized About 15 years ago. Um spinal accessory has been used um combination is what's kind of more and more used nowadays. And that's what we we tend to do here at rush. Um So there's all these different interventions we can do and really want to figure out what's going to be the best for the patient and work with them. That decision is really made um on the age of the patient um how much surgery they want to have or how much of a candidate they are for for more surgery and other medical problems. But since none of the nerve transfers ideal, we really try to harness um the advantages of more than one. Um And we just have a published that paper that was published last month looking at the two different main types of nerve transfers. The massacre nerve transfer. The hipaa glassell as to which one is better. And there really is a toss up. The massacre nerve shows improvement much quicker. Um But in my mind and what some of the studies have shown that it does not seem to produce as much tone or kind of resting tone in the face if you look very closely at it as like a hippo glassell jump graph. Now again this is a very debated topic and we may see other papers that come out that that can look at it closer but the available evidence we have shows that you know neither one is completely ideal. So we say well then until we have greater evidence and and there's not much problem um or difficulty for the patient, maybe we should use both. And so that's what we do. So here's a patient he had a master nerve grafts. So you see um obviously this week on the left side but when he bites his teeth together he can get pretty darn symmetric. Um So and that's great I mean he has great movement much more than we would ever get from any of the other techniques and it looks very natural matching the other side of the face. He does have to clench his teeth but unfortunately he's not clenching his teeth when he just as weak. Um The other side does not look um does not look uh matching the other side. Here's a patient that had a combination of nerve transfers. So a hipaa glassell and a master nerve. And you see even at rest she looks very normal when she bites her teeth together she can get that side of the face to move quite a bit. Um And she can um she's not very good at coordinating it yet but she can get a reasonable smile from what was a completely paralyzed face. I mean here's the gentleman we saw earlier. Um So he was paralyzed on the right side after his surgery. Um We did a combination nerve graft and you can see he has tone and then when he bites together he can match a smile pretty well to the other side of the face. And he's now showing me that he can actually do different things. Um So when he bites his teeth together he'll think it'll loop back here when he bites his teeth together. He can get a very nice smile and the tone is there and he can actually move his tongue. He gets a different amount of movement or tone in the face by moving his tongue. It's just showing that both of those nerve grafts actually did do something different. They both grew in and are affecting the facial nerve. Um So let's say it wasn't a surgery but maybe it was Bells or another medical cause that that causes issue. Well then the chances of recovery are much better. Um But that doesn't mean the patient shouldn't be followed. So we shouldn't say well as Bell's palsy we'll see you later, you're going to get better because there's other things that can happen. Um So these are the patients that commonly develops in kinesis. Um And so these are the patients that I hold really closely, we see them every three months because of synchronicities starts to develop. We want to have a plan together and how we're going to treat that. Um And we also aren't sure that intervening earlier in psychokinesis um may prevent it from getting worse. Um And hopefully we'll know some of that in the next few years in the first year. You can try other things though. Um So facial massage acupuncture, facial retraining. Now none of this has been shown to to necessarily help more so than just leaving it alone. And and but there hasn't been great studies. Um But also none of it has been shown to hurt. Um And I definitely have patients that have undergone acupuncture and think that it helped quite a bit um in their overall um pain or tightness or even sing kinesis. Um I have the fortunate experience to work with several great facial retraining therapists. Um There's some great ones in Chicago. Um Jackie deals who's a leader in the field um is a few hours away and and Madison Wisconsin and her and I share a number of patients. Um And so I think there's a definite benefit to facial retraining both early on and then after intervention especially. And I mentioned some off label medication uses. Um So um I mentioned before calcium channel blockers, some centers are using um longer term antivirals, especially in patients that may have had like a um herpes zoster type of paralysis. Um There may be some some used to this now there's there's pros and cons. So um and it's an off label use. So you definitely want to discuss with your with your doctor and make sure that um it is something that would benefit you and not cause any undue risk. Um So the last few minutes I have left, I'll talk about synchronicities. So um this is probably one of the most bothersome symptoms in patients after Bell's um or other facial nerve injuries. And you notice in this in this video here as this gentleman is moving his face, um there's certain things that are happening when the other side um um is moving when he's closing his eyes and the mouth is moving. He's actually was paralyzed on the right side. But you notice that side seams increases seem deeper um and when he moves his eye, his mouth moves and these are the things that patients commonly talked about so synchronicities. My simplistic way of thinking about it because we don't really know exactly what's happening is that those signals that go down the facial nerve um instead of going in the in the direction they should be. Um Sometimes those signals whether it be from nerve regeneration um Or or or or or signaling transfer are getting crossed over and are kind of turning around and signals meant for the I. R. Going to the mouth or vice versa or signals are just more amplified to the face um than they should be. So those facial muscles, like we said instead of being droopy are actually more tight. And so patients will notice that that side of the face and the creases are actually deeper. Um But the muscles aren't moving as much and so that's where the confusion can come in while my face is paralyzed. But actually it's not it is just pulling so hard that it can't pull anymore and we can't get movement. So these statements are things that I hear every every week from patients. Um And these are the common things that we'll see with with with with synchronous is so your eye closes when when when they smile or eat or or pucker their lips um their their mouth or cheek moves when they blink. Um there's bands or tightness or lines on one side of the neck and not the other. Um The lines on one side of the face are deeper than the other one or the the eyebrows in a different position. Um That though it doesn't move, it may even be in a higher position on one side that the affected side but it's not moving. Um There's there's pain, there's cram penis, there's tightness or the one that I find that if you talk to enough patients you'll listen and most of them is that there's just an awareness of that affected side of the face. Not even that it hurts. Not even that it's cramping, not even it's tight but that they just can feel that that side that had bells is different than the other side and they feel it all day every day. And that can be a very very concerning thing for patients and and unfortunately they'll see doctors and and and they'll look at them and say well your face looks fine. Um And it may look fine but um but that feeling can be very disruptive to patients. Um This is a little cartoon I pulled off a United Kingdom um advertisement for Botox for for psychokinesis. But it kinda in cartoon form kind of shows some of those ideas that you know my muscles are fighting each other or my um talking makes my face hurt or by the end of the day everything is really tight and cramped e um you know there's twitching feelings or my eye closes. Um But I think the thing that they're not mentioning here which is very important is that just that awareness of of one side being different. Um Again it's not often easily noticed by most people. Um Patients with synchronous is often will say well you know my friends or family say they don't notice it but but but it drives me crazy. Um um So that doesn't mean even if it can't be seen doesn't mean it does not create a significant issue luckily Insurance um is increasingly recognizing this and paying for treatments force in genesis. So we have several research projects that are kind of looking at the effect of psychokinesis on people. Um But the first line therapy for this is really Botox or botulinum Botox and Botox is just one brand. Um There's other ones like Ze Mn or dis sport um And basically it it works at that muscular level. So we mentioned those nerves go down and attach right to the muscle and send little signals across there. What what botulinum toxin or Botox does is basically just blocks those signals. So it stops muscles from working. Um So it doesn't help on the side in people that are paralyzed because it paralyzes muscles. So if you already paralyzed doesn't help but people that have synchronous is where the muscles are moving abnormally or maybe are moving too much or too tight. Um It can be very helpful and relaxing. Um Both kinds of patients paralysis or sink kinesis can benefit from Botox on the other side of the face because it can help just provide balance to those muscles on the on the unaffected side. That might just be moving more than the other side. Um It can help just provide balance and symmetry to the face. Um Pros and cons of of botulinum toxin therapy. Well the pros are it's very safe. It's been used for years and years for many indications there's no evidence of you know, build up over time in the body. Um It only acts where you inject it. So if you inject it somewhere you you know you didn't mean to it's not going to go into the bloodstream and affect anywhere else in the body. Um And it only acts that that that nerve muscular junction. So if you took a bunch of Botox and injected it right into the facial nerve it would do nothing because it has to be right at that nerve muscular junction. Um It is reversible with time. So you can't reverse it with any medication. But if you just wait, usually it's three or four months it will wear off universally. It wears off. So that's a pro and a con because if it's helpful um it will wear off and you'll have to do it again um It's very good at treating the eye symptoms. So the eye closure symptoms are the um blinking that people get. Um It's also very good at creating that treating that tightness of the neck or of the face. Um It's not so good as far as the cons as as getting improved lip movement. And that can be sometimes the most concerning thing for patients that have since genesis is the amount that their upper lip moves. Um The reason it's really hard to get consistent results and good results with that. It's because there's about seven muscles around the corner of the mouth that that make that corner of the mouth move and all have to coordinate themselves together when you're smiling or moving your mouth. Um And Botox is a little non selective. It doesn't affect areas that you don't inject it but the muscles are so close together there that when you inject it you may catch another one of the muscles and and cause something that you didn't intend to. Um And again I mentioned it's reversible with time. But but that could be a problem because um people don't like to get come in every three or four months for injections. Um But I would say most patients are happy to do that if they get relief from it. So here's the patient again with with synchronicity you see on the left side of her face when she's trying to smile that the lip isn't really moving up but her eyes closing. Um you're seeing some tightness of that side of the face. Um And she has tightness in her neck and things that we can't see um that bother her. Um some of the tightness in the face. Um it can be relieved by a simple injection inside the mouth. Um this is something this was described well in the literature in 2017. So really just five years ago we started doing this um in a really meaningful way or four years ago. Um and this can help tremendously with patients tightness or pain in the face. So that just kind of highlights that this is still very evolving field. And so um continually following up for for discussion of treatment options can be helpful because new ones do show up um that we can incorporate into people's treatment. This is just a diagram that Jackie deals who I mentioned is a great facial retraining expert. Um The patients that we work with together, she'll send me these diagrams and they walk in my office these diagrams of where she thinks the Botox is the most effective and what dose um and will often do exactly that and patients get good relief. Sometimes I'll add things in, sometimes I'll subtract things but we'll all work together to get the patient the best the best possible result selectively innovations the last few minutes I'll talk about this. Um So this is the the newest thing out there for patients with psychokinesis. Um It was well described in an article by Dr Aziz a day um That was published last year. Um but basically because the idea behind psychokinesis is that these muscles are getting too much signal, are are moving when they shouldn't be or getting confusing signals. We might be able to go in there and find those little nerve branches and cut the ones that are misbehaving, leaving the normal ones there. And I described this to patients, a lot of them look at me um and with disbelief saying you're gonna go in and cut these nerve branches when my face didn't move for for 369 months. Um I don't know about that. Um And I agree with that. You have to be very careful. Um It can be very helpful for smile improvement. Um It can be very helpful for tightness in the neck and the cheek if you are able to identify those nerves and cut them and they can get patients a lot of relief. Um It's kind of a big surgery in the classic way that is described. Um It involves in a facelift incision around the ear. Um You lift up all the skin off that side of the face and you find those nerve branches um and and cut them. So that does involve an incision around the ear. Now, um many um doctors that that perform this procedure procedure also performed facelifts. So they're very good at hiding scars and we can make this car look very good, but it still is a scar um that that we have to create in the face. Um The classic technique is not designed or isn't good yet at improving i symptoms. Um So I tell most patients that we're talking about it that this isn't going to make the eye symptoms better. So you're probably still gonna need some some Botox to help our botulinum to help the eye symptoms. And so that's an important thing to note that this isn't going to necessarily make the patient free of needing botulinum injections. So that shouldn't be the goal of surgery but it can dramatically reduce the amount of injections we have to do. Um patients need to be well selected. Again it's good for certain things and not others. So we want to make sure that we're seeing which patients going to benefit and and and they know what the benefit is going to be. Um It can recur I know a group um that does a lot of these surgeries working on their recurrence rate. Um So if if you don't cut enough of the nerve or sometimes the nerve can just be very tenacious and can regrow and find the other end and and it can come back. Um I usually will put clips on either side of the nerve and remove a pretty good section of nerve to make sure that it doesn't come back. Other groups will wrap the nerves so that it can't be re growth but it can still happen. Um And sometimes it needs revision. Um So sometimes we don't get quite as much as we want and probably that's because we are cutting normal nerves and so um we're very selective and careful about it but also we don't want to do anything harmful. So oftentimes you know we may not get exactly the result we wanted if there's room for improvement, some patients will require revision where you go back and find those branches again. Here's just a video of us doing one. There might be some uh sound there um As we're kind of stimulating these nerves and you can see little vessel loops around the different branches of nerves that we're going to cut. There's a handful of centers in the country, obviously there's several in southern California. There dr Kochar performs these types of surgeries. And so you can um make sure that you you know that your surgeons have done a few of these um because it is kind of a technical surgery and you want to make sure that you're gonna get the results. You can um One thing that we're starting to do here um over the last year is is uh we're kind of turning a minimally invasive my Autumn E and selective innovation. So we're finding that one of the muscles that's misbehaving the depression, anxiety oris muscle that misbehaving and corner of mouth movement and also finding some nerve branches and cutting them as well. Um The pros of it are it's it's very helpful. It seems to be very helpful for smile improvement. Again, that's one of the biggest concerns for patients. So I think it's very helpful for that. Um It can also be helpful for tightness in the cheek area that buck senator muscle we're talking about. We can um disrupt some of the tightness there. Um It's not very good for the neck tightness. So if patients a lot of neck tightness um then I usually tell that this surgery is probably not going to help them. And and and then we'll talk about the the you know, the more traditional selectively innovation um procedure. Um But another pro of the minimally invasive one. There is pretty minimal downtime. So patients don't have to have an incision in front of the ear or any incision on the outside really. It doesn't involve as much skin or soft tissue movement. Um So they can really get back to their normal activities pretty quickly. Um It's not designed to improve the eye symptoms, just like your your classics selected Innovation. Um So patients will still usually need some Botox either around the eye or the neck because it's not designed to fix that either. You have to be very selective in these patients because only certain ones will um will improve from this and some will not. Um And so those are important things to mention. Um Here's just a video of uh this is actually just a few days ago, one that we're doing. And so we're showing uh an artery there that were moving out of the way and then deep down our branches to the facial nerve there. Um and we're gonna lift those up and we're going to stimulate them to ensure that they're the ones going to the muscles that we hope they are. Um And and you have to variably dissect these out because there's one muscle, especially in saying kinetic patients around the corner of the lip there that you don't want to disrupt. So if we accidentally um cut the nerve to that we may have a result that we're not happy with. And so you see we're putting uh some clips on the nerve here. Um We'll cut it in just a minute. You know, here's the nerve model to go off as we as we put the nirvana or the clips on it. Um And then after we cut it here we will um then just cut it in a minute and then we'll retract the muscle is actually retracted out laterally. That depression anger the Oris muscle um is under the uh blue um loop that you see there. Um And we're going to retract it back in in just a moment here after the nerve is cut. Um And then we're gonna cut that mosque. So um and we'll then show you the result of a patient on just a minute here of kind of what this procedure can accomplish. So we'll kind of bring that muscle back over and then we will um cut through it with an electric artery to make sure the ends don't don't regrow and then we'll close that. So it's all done through an incision inside the mouth. Um So here's a patient that um on the side of the screen here you'll see this is just immediately post op. So you see um and she's smiling there, you see on the left side of her face that that the smile just does not get as high. Um She has these strange dimpling around the corner of her mouth and her chin over there. Um And so the picture on the right side. We'll put the video here in just a minute. Um This is one week after her um procedure. So one week so she importantly I like to point out that she has her I. D. Card on. So she was at work and she popped over from work but just one week later um we can see that you know there's still a symmetry in the movement of her lips. But when she tries to smile we see much more of her teeth on that left side than we do on the right side. And that kind of loop around, we'll show you that again. Um And so this is just from a simple less than hour procedure um with minimal downtime. Um And she's back in the office within a week. Um And so I think that's definitely the benefit of it versus the the more traditional surgery you can see around the corner of her eye though she had no Botox onboard because she's just immediately post op here. So her I shall need some Botox on the either, she's still a little dimple in the chin and we didn't quite get the entire um mentalist muscle de innovated but um a little bit of Botox in those areas. I think she'll be very happy with for that improved smile that she got. Um So lastly outcomes measures um I talk about this any chance I can get and this is a rare diagnosis. It's hard for us to get in the numbers of patients um to um to really show big differences. We don't have consistent outcomes. Any good center that you go to will do these things, they'll do pictures, they'll do videos, they'll ask you to fill out forms um about how you're feeling. Um They'll do their own measurement tools just to really try and get a standardized way to do this. So every place around the country that is really a good facial nerve center will do these things. Um And so make sure your doctors are doing it is an article that we published showing that we've been bad about really objectively looking at how our results are. So our program dr Kochar program um Many other programs in the country are really trying to offer um the full gamut of procedures but also collect these data so we can look at them together and figure out how we're doing and how we can help patients. Um And so um I'm more than happy to answer any questions at this time. All right, thank you. Dr Evan on that was excellent. Um So we do have opportunity for questions and there's a couple of comments that were made um here. So just so everyone knows um please put your questions in the in the chat box to uh for security purposes. Um We can um I can stop sharing my screen. There we go. Great. Um And uh for hipAA and security purposes we're going to hold off on questions, hold off on showing people's faces. Um One comment here was regarding um you know emergency room sending patients to neurologists and not specialize in facial paralysis. I think that that is something that is slowly changing and evolving as emergency rooms are becoming more understanding of. Bell's palsy and facial nerve experts in areas are are growing. I'm not sure what the algorithm is for you dr cavanaugh in Chicago but I've certainly been seeing a lot more patients recently diagnosed with Bell's palsy in my clinic than before. Have you noticed any changes? Yeah, I think we've we've noticed some changes. Actually my partner dr smith is in the process of kind of getting up and running a an acute facial nerve um Kind of center so we can really go out to the emergency departments and neurologists and say hey any patients that show up that have just had bells or acute paralysis send them over. You know we'll get unplugged in. Many of them won't need anything and we get that. Um But some of them will need things down the line and so having them plugged in early so we can get those interventions and the information to them I think is very important. Excellent. Um One person mentioned facial massages helpless in kinesis. I think facial massage if done by an expert in facial retraining is a great avenue for part of the physical therapy process. Um The key that in that sense I think should be facial nerve expert. There are a lot of doctors or physical therapists out there who offer treatment for facial paralysis. Um But I would suggest certain things you want to shy away from any electrical stimulation especially early on down the road after treatment. Um I found some of it useful but some things you do want to be careful for regarding matter, just making sure the person has experience taking care of patients with facial paralysis. Um In terms of vaccinated Botox. The question here, does the boxer later Botox injection effect the lip going up. Can you do you have any any any thoughts on that in terms of what the bucks in your book it can and it can. So that's a that's a tough question. Um Bucks nater Botox can be really helpful in. Um I find it most helpful in tightness but it can be helpful in getting the lip a little bit more elevated because it's one of those muscles that it pulls kind of in a in a you know it's a muscle that helps you push food into your teeth. And so um it kind of pulls in and down to the lip. Um So in some patients I've seen improvement um it kind of selling it as it's going to improve the corner of mouth movement. I would say I haven't seen it dramatically improve it. Um It can affect it negatively if you do too much in the Botox or get it too close to the corner of the mouth, it can negatively affected. And so um most people will do a very small amount to start and then if there is a benefit start to kind of decide how much you can go up with that. Okay great. Um There's one other question patient um describes getting Botox in their eyelid and having it negatively reflect their blink. Um They couldn't blink for three months. Um Is this common? It made me nervous to do it again. How would you counsel that patient in your office dr even? Oh yeah I would say it's not super common. Um And you can share your experience in in a second but um I think um causing it to not be able to blink. I would say that probably maybe there was a little too much Botox used because I haven't seen many patients not be able to blink now. Some patients will cause maybe a little more dryness of the eye if we're really aggressive with it. Um I think you know one issue that comes that we see more than not being able to blink is that it can make the upper lid a little bit low especially if you're doing upper lip injections. Which that's another thing you should definitely do with somebody that that kind of knows what they're doing because the upper lid is a real risky area to inject into. Um I can understand why that would make a patient nervous. Um You know and and just like with the sink genesis surgical treatments you know we can't forget that patients have had paralysis before so they know what that is like and and to have this something not move again like it did before um And thinking gosh is just going to stay like this that can be really traumatic. Um I would say um you could do Botox injections again and I think you probably have a better experience um doing them again and so make sure you see somebody that that does a lot of it know what they're doing but I think you'd have a better experience with another round? Okay. Um and are at rush, are you seeing remote consultations or telemedicine consultations for first time patients? Absolutely, yep. Um Just like anywhere in the country this pandemic has changed the way that we do that, but um we definitely do virtual visits and and virtual video visits, obviously, maybe not obviously, but throughout the country it does depend on your insurance whether or not you can um see us for a virtual visit um and but if you call in to to arrange it, they can certainly help um uh sort through all that. Okay, great. Um just a couple of points that I wanted to touch upon that dr revenue brought up. Um You know, I think all of us who take care of patients facial paralysis agree that this is extremely personal. Um It does have a life altering effect, whether you have a brain tumor or Bell's palsy um depending on no matter what age or sex you are. So our goal is to get patients to the right place. And so when patients call me from Chicago, I almost automatically refer them to the revenue or his colleague um dr smith and to anyone at Rush. And so likewise our goal is to not promote ourselves but to promote the best treatment for patients. Um But and I would highly recommend anyone in the midwest seek out dr revenue and his colleagues because he's done tremendous work in just a short amount of time. Um One last question is regarding facial tightness for patients who feel that they're they're not so much concerned about their asymmetry, but they just feel the tightness in their face. Do you feel that botulinum toxin um with or without physical therapy is is beneficial or is there something else that you would recommend for those patients? Oh yeah, absolutely, that's probably the most beneficial thing. And certainly the thing that I would start with um you know, facial massage retraining can help with that tremendously. I have a lot of patients that just remembering to stretch it out, just like other muscles in your body stretch that out in the evenings may help. Um but it's certainly worth a trial of botulinum to see if, if you can get additional benefit or or long term benefit and and have to do less massage. So either thing that can be helpful and combined together maybe the most help. Great. Um well we're out of time but dr revenue, thank you so much for joining us. We were going to record this and we'll share it on our platform on our facebook site as well as on other social media avenues and will also allow people to share it and download it as wanted um I think and the slides will also be available on that video. So for anybody who has questions, please reach out to myself or doctor rev in awe. Um will be sure to share our professional emails with you as well. And if you need to look up dr revenue, you can find him at Rush Medical College or Rush University Medical College in Chicago. Thank you very much. Have a wonderful day. Thank you. Have a good one. Okay.