Dr. Jacob Dey is a Facial Plastic & Reconstructive Surgeon and expert in facial reanimation. Dr. Eric Moore is a Head & Neck Surgeon and expert in the management of complex parotid tumors. They discussed the latest innovations to optimize the outcomes for patients with complex parotid gland tumors and associated facial paralysis.
Learning Objectives:
Understand how complex parotid tumors and their treatment can lead to injury of the facial nerve.
Learn how the Mayo Clinic model of care and innovative treatment options for patients with complex parotid tumors maximize both cancer treatment and optimization of facial nerve outcomes.
Speakers:
Jacob K. Dey , M.D., Facial Plastic and Reconstructivce Surgeon, Mayo ClinicEric J. Moore , M.D., Head and Neck Surgeon, Mayo Clinic
Welcome. And thank you for joining us for the future of facial nerve care for patients with complex parad tumors webinar. We're glad to have you with us today and look forward to a great discussion. I'm pleased to introduce the speakers for today's webinar. Please join me in welcoming Doctor Jacob Day, a facial plastic and reconstructive surgeon and an expert in facial reanimation. Doctor Eric Moore is a head and neck surgeon and expert in managing complex parad tumors. Thank you both for joining us today and with that, I'll turn the presentation over to you. Great. Thank you and thank you all for taking time out of your evening to join us as we discuss the future of facial nerve care for patients with complex prod tumors. Uh I'm Jacob Day and on behalf of myself and doctor Moore, uh We really look forward to sharing information about this topic that we're very passionate about. Uh We have no disclosures and no financial conflicts of interest. Uh Our hope uh this evening and with this webinar is to share information about how complex broad tumors are thought about and managed and how their treatment can often involve involvement or injury to the facial nerve and how we approach the reconstruction of that. Uh We also hope to highlight our innovative model of care at Mayo Clinic with our complex prod tumor, facial nerve multidisciplinary practice. Uh where we help patients with tough complex parad tumors to both maximize their cancer treatment and to optimize their facial nerve outcomes. An overview of our topics, we'll start by uh talking about prod tumors and then give a little background information on facial paralysis. And they really use a couple of cases to highlight some of our innovative approaches to treating these complex tumors at reconstructions. Uh So with that, I'll turn it over to Doctor Moore to uh discuss prod tumors. Thanks Jacob and thanks everybody for joining us. Um The last century saw the majority of the development of how we moderately and think uh treat and think about froid tumors in the facial nerve within the period gland. The first facial nerve preservation uh uh and removal of a pro tumor was in 19 07. And it was very, unlike what we do with most parad tumors today, it was done under local anesthesia. There was poor classification of the different tumor types at that time and it was largely in a Nucleation of the tumor. Uh recognizing that the facial nerve was nearby and trying to bluntly dissect around that there's been uh then very rapidly after that. Um a couple of key recognitions, one that that technique led to a high recurrence rate. And so, an an interest in trying to more completely resect parad tumors. Uh but also the separation anatomically of the para gland into what we we today colloquial describe as the lobes based on the fact that the facial nerve runs through the period gland separated into a superficial portion and a deep portion or those portions that are lateral to the facial nerve and those portions of the para gland that are deep to the facial nerve at our own institution. Uh About 20 years after that, uh was a nice description of the fact that most para tumors uh could be removed by superficial para me. That's because the majority of the gland sits lateral to the tumor. Uh but for those tumors that were more aggressive, those tumors that sat deep to the facial nerve, uh or those tumors that were known to be highly malignant. Complete para me with preservation of the facial nerve. Uh was possible. The fact that the facial nerve is so intimately in play in periodic gland surgery is is nicely outlined by this. This was a study uh 10 years ago, looking at uh a decade and a half of medical legal um complaints related to salivary gland surgery. And there were 26 medical legal cases that were pulled out of West law in the previous decade uh that involved the the salivary glands and salivary gland surgery. Of those 26 cases. Uh 99 of 16 of them involve the para gland, but nine of them were um involved facial paralysis that occurred after para toy. And I point this out just because it's intimately important to the patient and very important to the surgeon, how to identify and protect the, the facial nerve during even routine para. So how do you do that? Well, I think it starts with both good image study and just anticipation of where the tumor is gonna lie in relationships with the facial nerve. So I'll show some examples of how I typically do that based on common imaging techniques and how to anticipate and predict where the facial nerve is going to sit. And what's its relationship it gonna be to the period to the para tumor specifically, is the tumor gonna be above or deep to the facial nerve or is there going to be tumor at the stylomastoid frame? And that's gonna make identification of the facial nerve in the classic uh ways that we do it uh difficult. You need an organized identification technique of the facial nerve and then you need an a traumatic technique. So this CT scan on the left side shows per a cross section or axial view of the parada glands. And uh most importantly, it shows two vessels that sit basically at that two thirds, one third, lateral and medial junction of the period gland because you can't see the facial nerve Well, in imaging studies, you need a surrogate marker for where the facial nerve is gonna be. And the retro mandibular vein and the external carotid arteries, of course is through the parodic gland are a great surrogate marker. So I try to look at how much gland is, is or how much tumor is sitting lateral to those structures or is the tumor sitting medial to those structures. And that gives me a rough approximation of whether it's going to be a superficial or a flow parade tumor. The view on the right just shows the facial nerve with the dissected superficial paradac. And again, it shows those vessels that sit very, very close to the facial nerve. So the retro Mendu vein and the external crowd artery sit just behind the facial nerve and are a good surrogate approximated for it on the imaging studies. So this is again an axial ct scan and the para gland on the patient's left side or the right side of the view is deep to that surrogate marker, deep to that external carotid arteries, of course, is through the gland, the majority of the tumor sits medial to that marker. So you can anticipate that this is likely going to sit also deep to the facial nerve. Knowing that uh ahead of time allows you to have a really great discussion with the patient or what's going to be involved in facial dissection to remove their tumor and gives the surgeon some advanced notice of what they're gonna have to do to approach the tumor and how they're going to have to manage the facial nerve. And then how do you identify the facial nerve during product surgery? This is a review for most people, but it, but it always is uh bears repeating to point out the facial nerve. You can go ahead and advance the slide. There comes out of the stylomastoid for ramen and that stylomastoid frame and is not visible typically during para toy. But what is visible is the Timpani ring mastoid tip groove. So that green arrow there is showing the junction of the timpani portion of the temporal bone and the mastoid portion of the temporal bone. And that Tian ma tempo mastoid groove which you can see and feel during parade surgery leads directly to the stylomastoid forin. What's the significance of that can advance the slide there, that ring and that groove is going to be a great approximated for the course of the facial nerve. So as the facial nerve comes out of the style of asteroid frame and go ahead and advance the slide there. It has to course across the man the mandible to get to the midface and innervate the muscles of facial expression. So that tiano mastoid groove and the para gland directly anterior to it is a great approximated for where the facial nerve is gonna sit during period. Again, in this patient, you can see the sort of depression uh up by the ear between the mastoid tip and the tympanic ring. And if you draw a line directly and cheer to that depression, that approximates the course of the facial nerve trunk. How do you identify the facial nerve during protid toy? Well, classically, you do Trump dissection and then follow the nerve and grade out through the para gland. But sometimes you're not able to do that because of where the tumor sits. I'll show you some examples of that and you have to perform retrograde dissection. So you have to find the facial nerve most commonly, the inferior division as it courses over the facial artery and vein at the, at the notch of the mandible is a good place to identify it distally and then follow it retrograde back to the trunk or you can follow the frontal branch or the zygomatic branch back to the trunk and get to the facial nerve that way. And finally, sometimes when the tumor completely surrounds or encases those structures, you'll have to identify it within the mastery bone or Intropin identification. For classic trunk identification, we teach, find that Timpano mastoid suture line or groove that gives you the rough horizontal or superior, inferior location of the facial or trunk. Identify the trigo pointer, which is a portion of the tragus, which forms sort of a triangular point which points right to again that Timpano master groove typically and leads you to the trunk as it exits the style of an aid and find the digastric muscle because where the digastric muscle inserts into the Timpani rain and that gives you the depth you can go ahead and advance there. So here's a, here's a classic example of a tumor that's sitting in the deep low, but that you can still use those techniques to find trunk and dissect intra grade. So we've identified the trunk on the right side at that Tiano mastoid groove where the trail pointer points. And we've followed that atra grade out through the period gland to lift the para gland up. And then we're seeing the Pez and serena. So the superior and inferior division that course is directly over the course of the tumor. Most para gland tumors are benign identification of the facial nerve uh correctly. And, and with those techniques allows you to see the relationship of the gl- of the gland of the gland and the nerve and the tumor. And then most of the time you can bluntly and carefully dissect the tumor off the nerve or the nerve off the tumor in this case and preserve it um quite nicely. Here's another example of identification of the trunk, lifting the tumor off the trunk and the inferior division in the Pez with the parada gland with a traumatic technique allowing you to preserve the patient nerve carefully. And this is the total superficial perect toy again where the tumor and the gland have been dissected off the nerve and the superior and inferior division leaving that basically pristine and untouched with careful blunt technique. But a careful identification, the patient number is the key to that. Here's a case where it might be a little more difficult to dissect in the classic trunk fashion. So this is a deep low carotid tumor. Again, from this axial scan, we see it sitting deep to the external carotid artery and retro manar vein as they course through the gland, I wasn't able to identify the trunk because the majority of the tumor sat directly on top of and and over the trunk. So I dissected the facial nerve out distantly and followed it retrograde over the tumor. And then once I, once I could see the entire facial nerve could dissect the tumor off of it. Next slide, here's an example of that. There's the tumor on the left sitting intimately associated with the trunk. The schematic gives you a view of what we're looking here. The trunk is coursing partially over, partially under the tumor with the tumor surrounding it. And once we've identified the facial nerve distantly and traced it back to the trunk, then we can carefully dissect the tumor off that facial nerve. Again, most benign froid tumors and even low grade malignancies are not intimately associated with the trunk where you can dissect them off. And finally, here's a patient that's going to be impossible. We'll get to this again later on in the top of our case example, where it's gonna be impossible to identify both the trunk or really the distal segments very well because the tumor encases off all of them. And this is a case where we might drill out the mastoid bone and identify the facial nerve intra tian and then follow it out distally to the style of asteroid frame and to gain our bearings. Great. So I just want to give an overview about the facial nerve and facial paralysis to kind of lay the groundwork in the foundation as we approach these cases, uh and thinking about facial reanimation. So as many of you know, the facial nerve is the seventh cranial nerve and has very intricate and complex anatomy. It exits the skull base um and goes through the temporal bone, sorry e exits the brain stem at the pontomedullary junction, goes through the temporal bone behind the ear, exits through the stylomastoid for amen. And then as you saw from uh many of those pictures with doctor Moore goes through the product gland dividing it into deep and superficial lobes, making its first branch point at the Pez anus into an upper and lower division and then five main facial nerve branches uh and then it just continues to branch and branch and branch as you can see from this diagram here. And it goes to innervate or drive all of the muscles of facial expression. And that's complex. There are about 20 muscles on each half of the face uh that help us make facial expressions and blink and move the mouth and smile. And that's one of the most important functions of the facial nerve. But the facial nerve has other functions that we don't always think about including special sensory functions and parasympathetic functions. There are many sources of injury to the facial nerve. And in my practice, I see a lot of patients with facial paralysis and the most common cause of facial paralysis is viral injury to the facial nerve such as Bell's Palsy or Ramsey hunt. Um but other common causes of facial paralysis include tumors along the course of the facial nerve, uh or tumors of the facial nerve. And commonly those are in the para gland, which is the focus of this talk, uh or skull based tumors. And there are many other causes of injury to the facial nerve when there's been injury to the facial nerve clinically that presents as facial paralysis. And this is my framework for thinking about facial paralysis. When I see a new facial paralysis, consult, I like to place the patient into one of these four categories because it informs me on what their likely symptoms are and what the treatment options are. And so I think you can take any facial paralysis patient and put them into one of these four categories. So the first category is complete acid facial paralysis. So all of these patients have paralysis on their right side. And so this woman has a complete placid facial paralysis. This is what happens after a facial nerve is initially injured. Uh It presents this facial flad paralysis, uh where there is tosis to the face at rest. And it's characterized by lack of muscle movement, depending on the severity of that injury. It can either be complete or incomplete, which is our next patient category. Again, this is a type of facial paralysis characterized by lack of facial muscle movement. Um but it's incomplete. So this patient is still getting some degree of facial movement. Uh It's just not as much as the other side. Our next patient uh is a good example of another category of facial paralysis, uh which I call aberrant reinnervation syndrome or A RS. And so any time a facial nerve is injured. Like I said, the initial presentation of that injury is going to be a flad facial paralysis. However, if the facial nerve remains intact or if an injured facial nerve is reconstructed, it has the ability to regenerate, which is great. Um but sometimes depending on the severity and location of that injury, that recovery of facial function, that reinnervation and new axonal growth doesn't necessarily happen in the correct way. And that's what aberrant reinnervation syndrome is. It's patients presenting with facial synkinesis, facial muscle tightness or hypertonicity and facial muscle spasm and twitching. It's a very bothersome subtype of facial paralysis, but a very different subtype than flad. And then the last category is a patient who has uh had injury to the facial nerve followed by recovery uh and still has components of facial muscle weakness. So still has an incomplete flad, facial paralysis, but also has components of aberrate reinnervation syndrome. And I think it's important to note that a patient can evolve over the course of their injury and recovery uh through many of these different subtypes of facial paralysis. So, if a patient has a severe injury to the facial nerve, they can have initially a complete placid, facial paralysis and then progress and recover over time to incomplete placid and then recover uh even more but maybe develop aberrant reinnervation. So this is the framework that I use in my mind when I'm approaching patients with facial paralysis and trying to figure out uh what treatment options are available. So then when we talk about treatment of facial paralysis, the uh the real oh sorry, the treatment is facial reanimation and facial reanimation. For me is an umbrella term. It describes numerous non-surgical and surgical treatments that we have to treat patients with facial paralysis. Now, the ultimate goal of facial reanimation is to uh improve facial symmetry and facial function in patients who have facial paralysis. But it's a long list of things that, that we have available and this is a list that's constantly growing as we innovate. And we understand more about facial nerve injury and recovery and develop new techniques to further improve facial symmetry and function for these patients. So, with that background, uh Doctor Moore and I will go through uh a couple of cases here uh that we've worked on together uh in our complex uh prodded tumor facial nerve multidisciplinary clinic. Uh So that's a a clinic we're very excited to have here uh at Mayo in Rochester where for these patients with really complicated parad tumors that are uh have either caused a facial paralysis or all wrapped around the facial nerve and are threatening the facial nerve. We can work together as a team. So, Doctor Moore is the head and neck cancer surgeon with expertise and uh para gland surgery and myself as a facial places, surgeon with expertise and facial reanimation and then a host of others uh who are part of our team, radiologists who are specialized in head and neck radiology, pathologists who have years and a lot of experience in period gland pathology, which is Doctor Moore will talk about has many nuances to it, radiation oncologists, medical oncologists important uh to help me. Uh and the patient with recovery of facial function is facial physical therapy. We have a great nursing uh team and care coordinators and then can involve as needed, ophthalmologists and speech language pathologists and dental specialists. So we really have the luxury here of uh a broad uh team of experts that we can call upon to help patients with these complex tumors. And ultimately, our goals are to optimize the cancer treatment with a goal of curing the patient if at all possible uh as well as maximizing facial nerve outcomes. So we're working to give each patient the best facial function possible and working as a multidisciplinary team. Uh and kind of the magic of Mayo clinic. I think we're able to provide really well coordinated care for patients uh and give them world class care and an elevated patient care experience. And it's really for me personally, also just fun to work with such talented colleagues in all of these areas as we approach these difficult problems from my perspective. Uh So I do a lot of facial reanimation, but I think these cases are some of the most challenging cases when it comes to facial reanimation because the amount of injury with some of these tumors to the facial nerve can be extensive. And we're not just dealing with facial nerve reconstruction, but pro bed defect reconstruction and some of our common options that I would call upon for facial reanimation may be off the table because of the tumor. And so I think uh to approach these cases from a facial reanimation standpoint, you really need to have all the tools available to you in your, in your toolbox. Um And so with that, I will turn it over to Doctor Moore to go through a case. So there there's a number of ways that the facial nerve can interplay with para tumors. And um there's a lot of different situations that can happen and that makes that makes treatment of para tumors extremely challenging and also extremely rewarding because as Dr Damon and you have to have a whole lot of potential tools at your disposal. And as much as we try to anticipate and um predict what we're going to encounter and then plan out how we're going to adequately rehabilitate it. You can sometimes run into situations intraoperatively, even that you didn't anticipate that can cause you or, or, or require you to adjust on the fly. But uh here's, here's a case example that we treated uh that illustrates a whole bunch of the nuances in para tumor and cancer uh interplay with the facial nerve. So this is a 48 year old woman who had a history for parad surgery for the most common parad tumor that you can, you can acquire, which is pleomorphic Anoma, a benign tumor in 1990 in California. One of the reasons that we tell people that they need to have pleomorphic Anoma treated, even though it's a benign tumor is that will, it will slowly and inexorably grow over time. So it can go from a small tumor to a medium sized tumor to a large tumor, to an enormous tumor if left alone. But the other reason that we tell them that they need treatment for para tumor, uh is because it can transform into a malignant tumor as we'll see here. So, this patient developed a recurrent mass in her period gland 10 years after undergoing treatment because it was a recurrent tumor and a benign tumor. And she already undergone previous parad surgery. Revision surgery is more complex. Revision surgery puts the facial nerve more at risk. She decided to slowly to observe her tumor over time thinking I don't have to do anything about this because it's a benign tumor, it's slowly enlarged and she didn't have any facial weakness associated with it. And she was relatively non bothered by it by the, except for the fact that she could feel nodules within her per bed. In 2023 she underwent an MRI scan of her face because it grew a little bit more rapidly than she was acc accountant to. And she underwent a biopsy with a final aspiration that was suspicious for carcinoma. And she presented to us for treatment, we're gonna see a tumor within her per bed on the left side. And it's multifocal, meaning there's multiple tumors. There are multiple masses that's very typical of recurrent pleomorphic Anoma, recurrent pleomorphic Anoma most classically is thought to recur um uh because of tumor that is outside the capsule of the tumor when it's removed. So any release of tumor outside the capsule during removal has the potential to recur as multiple masses. And so this is what it typically looks like when it occurs even as a benign tumor. But there's heterogeneity in these tumor masses. They don't all enhance the same and look the same, which is a sign of potential malignant degeneration of some. This patient has normal facial function, no facial nerve weakness associated with this. So we think we're dealing with recurrent pleomorphic Anoma and some malignant transformation in some of those nodules based on that. And with her imaging and with her, with her treatment um plan, we went to the operating room and performed total perect toy. During the course of that total para we did rebiopsy and find that we were encountering malignant transformation or my carcinoma within pleomorphic Anoma. We anticipated possible facial nerve sacrifice because of the intimate association of the tumor nodules with the nerve. And we anticipated that we might have to approach that nerve further up into the mastoid to get a clean margin around it. Common reconstruction options for the facial nerve that we can employ are greater irregular nerve graph or interpositional grafting. As Doctor Day will show you we have other at our disposal also for interposition grafting. And then we want to fill in the para defect. We're dealing with both an oncologic process and a cosmetic process. An ideal management that is complete adequate oncologic removal of the tumor management of any lympha Andy that may occur within the bed, complete margin, negative resection of the tumor. But also then rehabilitation of the patient's facial nerve and their contour defect to try to achieve an ideal result. In this particular case, we're gonna show motor nerve to vastu for interpositional grafting. And why we chose that ma or zygomatic facial nerve reims estos. So dividing up the facial nerve into an upper facial nerve function and a lower facial nerve function to try to decrease some of the effect of that apparent reinnervation that Doctor Day called about. We love using the an trilateral thigh for a filler graph because it gives us contour, low morbidity of donor site tissue that we can model and mold into the product defect, it's vascularized. So it holds up to radiotherapy and subsequent healing afterwards. And it also gives us the ability to harvest that motor nerve at the same time in one donor site defect. And then we'll show you a couple of adjunctive maneuvers also in facial reinnervation. So this is that patients uh tumor as it's coming out, this whole mass is multiple recurrent product tumors, many of which have carcinoma pleomorphic Anoma within them. It's a conglomerate mass, impossible to completely free up her facial nerve from this mass. This is the difference between benign recurrent pleomorphic Anoma and malignant transformation with benign recurrent pleomorphic Anoma. You can often find a plane and preserve the facial nerve with removal of the tumor nodules. In this patient, we could not find any plane to separate the facial nerve from the tumor nodules, which is a good sign of malignant transformation. So this is the bad, sorry ja this is the bed when we're all finished, where we've resected the tumor. We're gonna point out that we have distal and proximal facial nerve edges and blood vessels that are e clipped here in preparation for soft tissue reconstruction. So once the uh ablated portion of the surgery was done, then we worked on reconstructing and like Doctor Moore had mentioned, we kind of approach these in in two ways, one, we have a pro bed defect that needs to be reconstructed from a facial contour, uh standpoint. And the other is the facial nerve reconstruction and the facial reanimation. So in this case, we're left with a total pro defect. So a significant facial volume defect and we're left with the need to do facial reanimation, what informs us on our decisions there. One this patient had normal facial function going into the case. So I know her native facial muscles are intact and they're working well. And then it really just depends on our options at that point with what nerve are we left with after we've cleared the cancer and the margins. And so in this case, uh we called upon one of our ologists who drilled uh the mastoid identified the proximal facial nerve in the mastoid segment and we had cleared a tumor margin on the nerve in that area. So that was my proximal. So I had a stump of proximal facial nerve in the mastoid. And then in this case, it's, it's a tough case, you know, sometimes we then distally I have a main trunk before Pez or I have the nerve at the Pez or uh I have an upper and lower division that are separated. But in this case, really, the tumor was extended out to where I was just left with the five main branches of the facial nerve. And so then we really have to think about uh the optimal way to reconstruct uh to optimize the patient's facial function. And like Doctor Moore mentioned, minimize aberrant reinnervation and facial synkinesis. And so, uh and, and then Doctor Moore had also identified as you can see with the um clips here in the neck uh vessels in the neck, teeing us up for our adipo facial uh free tissue transfer for pro bed reconstruction. So that I would say that is our favorite approach for these cases where we're going to do nerve grafting and nerve transfers. We have a total fraud defect to fill and the patient is likely going to need radiation postoperatively. Um And for a couple of reasons like Doctor Moore had mentioned one, I feel that the adipo facial tissue transfer which is vascularized holds up better to radiation than just a free fat graft. I think if this patient did not need radiation, an abdominal dermal fat graft would be just fine uh and, and work well. But with radiation, I like the vascularity of the tissue because it really preserves the contour of the face. The other reason I like that is as we'll get to in a few slides, harvesting the adipo facial uh free flap allows me in the same location to have a great nerve, the motor nerve de vastu that I can use for interposition, grafting of the facial nerve. And the last reason I like it is, I feel like the vascularized tissue protects the nerve graphs to some degree from radiation change. Um And, and damage to the nerve graphs, potential damage with radiation. It's something that uh we'll talk about. We're doing active investigation and we follow patients over time and track their outcomes. Uh So we're really excited to, to see what this innovative approach holds for these patients. But I feel like intuitively, it makes sense that if we're able to cover our nerve graphs with vascularized tissue, it's going to protect them uh to some degree from the radiation change that they will experience. So for all those reasons, we uh chose to do uh adipo facial uh free tissue transfer and uh facial reanimation. So to do that flap, it's uh basically harvested very similar to any a lt free tissue transfer. So on the antri lateral thigh, relying on the lateral circuplex for moral vessels. You don't need to harvest it with a skin paddle. Uh Sometimes we will harvest it with a really narrow skin paddle just for ease of elevation of the flap. But really, you're harvesting, vascularized fat and fascia uh over the vastest lateralis muscle, capturing the perforators off the lateral circum memorial. And uh conveniently running along the lateral circum flex, femoral uh is the motor nerve to the vastest muscle, which you can uh take a segment of as you can see here, which we did in the case, uh with no uh significant morbidity to the leg. And this is a great nerve graft for interposition, grafting for the facial nerve. Uh If you, I think it's probably one of the best um because it's a large diameter nerve that matches uh very well the diameter of the facial nerve and it's a motor nerve, it's not a sensory nerve. So it's architecture uh on a microscopic level is set up very similar to the facial nerve, which is also a motor nerve. So we harvested motor nerve to vastus and the au facial free tissue flat from the thigh and then proceeded back up to the face. So this is a photograph showing the proximal facial nerve coming out of the mastoid. And so I uh did micro surgical anastomosis of the motor nerve to vastus to that proximal facial nerve. I use nino nylon sutures. And this is a collagen nerve wrap that's on that to support the connection. We then went and said which branches. So this is an interesting thing because then now we have to decide which branches in the face are we going to prioritize and which branches are we gonna uh target for primary interposition grafting? And the way I think about this is the most important branches from the patient's perspective. And a functional standpoint that I want to prioritize are the facial or branches that are helping them blink and close the eye and the branches that are helping them smile and move them out. Um So let's say in a case like this, I was able to divide up all the face of this motor nerve to vastu and plug them all in and do five nerve connections to all the five main branches of the facial nerve, even if I could do that, I wouldn't do it. Um And the reason is, yeah, it may look nice. It may look like I've kind of reconstructed the facial nerve, but I can't control where the axons as they regenerate through that nerve graft are gonna go. So I can't control if an axon that elevates the brow goes down to the mouth or not. And so if I do that in a case like this, I I'm gonna probably give the patient bad aberrant reinnervation and synesis. And I'm taking away valuable axons from the nerve branches that I really care most about and want to target, which are the Zygomatic and the buckle branches. Uh So in this case, I uh identified Doctor Moore had teed up for me, the main buckle branch here, you can see just above that, a couple of Zygomatic branches. So here's one smaller one and there's one just down from that. And so we took uh so in addition to that, then we also uh dissected out and identified the mater nerve. So the maser nerve is a powerful motor nerve that I commonly use for facial reanimation. It's a great nerve because it's powerful. It has a lot, it's a strong motor nerve and it has a lot of axons that we can use to supercharge and plug into the facial nerve. And it happens to be easily available in the surgical field. In these cases. There are some cases where uh there's the tumor and the proto gland is very invasive and invades into the mater. And this nerve option is off the table. But thankfully in this patient, it was preserved. And so I identified the mater nerve coursing through the sub zygomatic triangle and infra temporal fossa and through the Massar muscle identified, as you can see here, the dominant descending branch of the maso nerve. And that's another great nerve that we can use for facial reanimation. So now I've got primary interposition grafting from the main trunk of the facial nerve. And I've got this maso nerve which patients can easily use with facial physical therapy, learning to put their teeth together to trigger a smile. And so Now, I've got these two new sources of innovation as we think about uh facial reanimation. So what I did in this case, so this is showing the motor nerve to vastu interposition graft going down from the proximal facial and the mastoid segment going up uh through the proto bed defect up over the edge of the mandible and over the mater muscle. And then I did an end to end anastomosis of that nerve graph to the main buckle branch. And in this case, because the facial patient's facial function was intact. Prior to surgery, I could use a nerve stimulator and stimulate these branches and watch the facial movement, which is very helpful in deciding where do I want to target the precious resource of these nerve graphs. Um And so this buckle branch produced a really nice strong smile and uh move including movement of the comma and upper lip. So that was a target. I also had a nice Zygomatic branch here. So I again uh targeted these really important mid facial branches and did an side anastomosis. As you can see here of that motor nerve tava. Now carrying the main uh facial nerve axons to both buckle and Zygomatic branches. And this, I feel very safe about doing and not causing significance in kinesis because there's so much redundancy and cross talk and overlap between the mid facial branches natively uh that uh this produces typically a very good result. And then just to supercharge things and give the patient as much as we could. Uh as far as facial reanimation, we connected one of the other zygomatic branches to the mater nerve uh as you can see here. So after all of that facial nerve reconstruction, then we were able to do microvascular anastomosis. And Dr Moore had the terminal external carotid artery as is often available in these cases in the facial vein, available for an osmosis. And we did microvascular and aosis and then inset this flap. And so here you can see the adipo facial a lt free flap. Uh and uh it's nicely covering all those nerve graphs that's filling the pro bed defect. Uh and uh it's well vascular. So you can see the fat and a little bit of the facial outta here. Uh So it, it really reconstructs the the bed well. So that is a good example of a malignancy, a clear malignancy of the para gland that required facial nerve resection and then elegant uh rehabilitation of the patient with interpositional graphs using two different uh nerves. And again, we, we um have a multifocal goal here which is what makes this, this uh treatment fascinating. We want to cure the para tumors. We plow of our oncologic pro um uh uh goals of complete tumor section management of, of peroral invasion, management of extra product extension, management of um lymphatic uh spread um potentially uh adjuvant therapy. Uh And then also um uh give the patient the best potential cosmetic outcome. Um We're gonna show you another case example here. This is a patient um also that has recurrent period uh pleomorphic Anoma. She had surgery many years ago. She's had slowly progressive multifocal lobular masses within her para para bed. Uh no signs of facial um weakness and um uh FN A uh uh elsewhere showed pleomorphic Anoma, but this patient has just massive pleomorphic Anoma. It's, she's had several different treatments of this in the past. Uh We're gonna, we know we're gonna be into scar tissue from a reoperative para bed, but she also has just innumerable amounts of tumor and these patients. Uh I talked to them about the fact that she's young. We don't want to just leave this alone and leave it there. We're going to have to treat this at some point either preemptively or later when it starts to progress and grow and cause mass effect or hopefully, unlike that other uh per patient is transformed into a malignant tumor. And we know we're gonna potentially get some facial weakness out of this operation. We're gonna try to preserve as much facial function as possible. But we know there's a high possibility that we're gonna get some weakness with this extents of a tumor. Hm. A common approach for this would be to wait until the tumor causes facial paralysis, then remove it and reconstruct it. But we don't really like to wait until someone develops a malignancy or until they develop the sequoia that we'd like to do something preemptively particularly on younger and healthier patients. And this is a very innovative approach that Doctor Day has presented and is going to show you where we're going to do some pre facial reanimation, followed by a period of recovery and then tumor removal in 6 to 9 months. What is the advantage of this? We think that if we re innovate those mid facial branches, it'll soften the blow for the patient of complete resection, leading to potential facial paralysis and then, and then reconstruction and then having to wait for all that to take place. So we're trying to get some facial function into the mid face um um uh particularly preemptively so that if we go in and remove tumor and cause facial paralysis by, by um having to remove any facial nerve and have to do interpositional grafting at that point that we will set the patient up for a faster recovery by doing some preemptive facial re animation. Great. So, uh I wanted to talk a little bit about this um because it's something that I'm very interested in and uh I really enjoy working with Doctor Moore on these cases. Uh As we think, what can we do to further enhance the patient's outcome? You know, obviously, I, no question that Doctor Moore is going to do great surgery and treat the tumor and give the patient a great outcome from that standpoint. But what else can we do? How can we push the envelope to try to give these patients at the same time as getting good, great tumor control, great facial function. Um And so that's where preemptive facial reanimation comes into play. Preemptive facial reanimation is not a new technique. It's using all the techniques that have been well described and developed and that I use regularly in my facial reanimation practice. The innovation is how we apply it. And as Doctor Moore uh alluded to it's it's applying it prior to the facial nerve injury. So it's useful in cases of patients with benign tumors of the product of the facial nerve such as a facial nerve schwa noma or patients with benign tumors all around the facial nerve like this case that we presented and we know likely at some point along the course of that tumor and the treatment the facial nerve is going to be injured. So what can we do ahead of time to both as Doctor Moore said, soften the blow, minimize the morbidity of facial paralysis associated with treatment of the tumor as well as to enhance the patient's recovery and shorten the time of that recovery. And so that's the thought behind preemptive facial animation. We're employing the similar techniques of nerve transfers. Uh but we're employing them prior to injury of the facial nerve. And I think in my mind, there are many benefits of doing this in the setting of a benign tumor. Uh for patients, one is yes, you're gonna hopefully decrease the length of time that that patient has a complete or very significant facial paralysis. Secondly, when a patient has a facial nerve injury, if that's a complete flad paralysis, the facial muscle for a period of time, 69 months is going without innervation. And during that time, there is a degree of muscle atrophy. So if we're able to prevent that period, that downtime of the facial muscle prevent that atrophy, perhaps we can give them a better ultimate facial reconstruction rehabilitation. So I think some those are some of the reasons that uh we're excited about this. Some of the techniques that we use for preemptive facial animation. Like Doctor Moore said, we're targeting those really important mid facial branches that are helping with quality of life things for patients blinking, smiling, movement of the mouth, which helps with eating and speaking clearly. And common techniques that I'll use are cross facial nerve grafting and mater nerve transfer and sometimes hypoglossal nerve transfer. And we're not in these cases targeting or plugging into the main trunk of the facial nerve. I want to preserve the current function that the patient has but enhance it by plugging in new axons from other locations so that when it comes time to treat the tumor, their face doesn't go completely out. They don't have a complete facial paralysis. So I'm targeting those facial nerve branches uh more distantly out in the face and finding the high value ones to add additional axons too. And so we can harvest sural nerve from the leg and do cross facial nerve grafting. And as shown in the previous example, we can do Masar nerve transfer to a Zygomatic branch or buckle branch helping with smile or hypoglossal nerve transfer or multiple of those options. Most commonly in my practice, I will do both cross facial nerve grafting and mass to facial nerve grafting or both or just one of them, depending on the patient's uh situation and how much time they have prior to treatment of the tumor. Typically with mater to facial nerve transfer. The time from doing that surgery before we see an effect or see the axons growing into the facial nerve musculature is between four and six months with an average of about five months for the masci to facial. For cross facial. It's a longer distance and nerves grow slowly about a millimeter a day. It takes about 7 to 9 months. Uh after that surgery before we see activity of those new axons being plugged into the face. So in this patient, uh we did uh both cross facial and maser to facial nerve transfer demonstrating both options for preemptive facial reanimation. So by making two small incisions on the back of the leg, we can harvest the cl nerve which is a sensory nerve. This is well tolerated by patients, they get a patch of numbness on the back of the leg, but it doesn't affect their ability to walk or move or use the leg. And so, uh it's uh something that patients are willing to do for the ability to reanimate their face. We can get a really long nerve graft here uh over 30 centimeters if needed. Typically, it's between 25 and uh 28 centimeters to be adequate for cross facial grafting for cross facial, I then make a limited face lift incision. As you can see in this picture on the normal side, the functioning side of the face or the side without the tumor. And uh do a deep plane dissection just over the level of the Prado masic fat and then identify those zygomatic and buckle branches and use a nerve stimulator inter operatively to identify nerve branches that help produce a nice smile with good upper lip elevation, maybe even a little bit of lower eyelid contraction. And then I'm tracing those branches under the microscope to find two branches of the midface that do the exact same function. Uh because that makes me know that I can safely take one of those branches to connect to the cross face nerve graph without causing a facial nerve paralysis on the normal side. So we then do the cross nerve graph to a really small incision under the upper lip as shown here. And I have a nerve passing instrument that allows me to subcutaneously pass the nerve from the face lift incision on one side of the face. To this incision under the lip and then to the face lift incision on the other side of the face, this is on the functional uh side of the face. You can see I've identified a Zygomatic facial nerve branch that we're gonna use for cross nerve grafting. You can see the sural nerve, you can see the end of it with a lot of nice healthy fales and we're getting ready to do uh uh micro Anestis of that nerve. So this is showing that uh Zygomatic facial nerve approximately going into the cross facial nerve graft uh ours nerve, which is then tunneled to the other side of the face. So then it's pulled to the other side of the face. Again, a similar face lift incision on this side. And then I'm mapping facial nerve branches on the side that's affected the tumor on the side where there's a tumor and deciding which branches do I want to plug this cross facial graft in and which ones do we want to plug the mater nerve transfer in? Again, we're trying to optimize blinking, eye closure, smiling. Uh And so this shows the mater to zygomatic uh nerve connection and transfer as well. So, uh I think that's uh highlights something that we're interested in um continuing to progress and innovate and figure out what we can do uh to help further the outcomes of our patients from both the perspective of tumor treatment and facial reconstruction and facial reanimation. Uh An outcomes assessment is really important to us and that's also part of our multidisciplinary clinic uh because it's our outcomes assessment that allows us to identify what are the areas for improvement. So our outcomes assessment fuels our innovation. And so we are on all of the patients who come and see us. We're doing good oncologic screening. We're doing expert evaluations of their facial function, very nuanced evaluations. We're very fortunate to have great standardized photography and videography here to document patients progress over time. But we collect from the perspective of the patient, uh patient reported outcomes metrics to assess the impact of the tumor and facial paralysis on their quality of life and daily activities. And we're taking all this data and working together Dr Moore and I and the rest of the team, we're talking all the time about patients and cases and outcomes and what we can do to, to create better outcomes for patients and coming up with new and innovative technique. So it's a really exciting area uh to be a part of and fortunate to have great colleagues. So uh thank you all for uh spending time with us. Uh If Dr Moore has anything else to add, uh otherwise we'd like to open it up for questions. Oh, fantastic Doctor Day. I, I'd love to see if there's any questions and see, see how we can provide some answers. Well, thank you very much. Uh, both of you for the Informative presentation. We do have a handful of questions from the audience and we'll try to get through as many of them as we can. I'll look to you doctors to determine who best to answer the questions as they come in. The first one that we have is what are some of the most common risk factors for some of the more aggressive parad tumors? Yeah. II I think that para tumors unfortunately have a lot of unknown causes or sporadic causes. But um radiation therapy either either um as part of treatment for some other kind of tumor earlier in life or childhood uh or exposures from environmental or, or job related things is associated with para tumors. And so um we see para malignancies associated with radiation therapy, uh typical carcinogens for other head and neck tumors also initiate some parad tumors. So smoking has been associated with para tumors and then there are some hormonal influences also that are associated with parad tumors. It's a, it's a kind of a mixed bag depending on what tumor type we're talking about. But I'd say radiation therapy is probably the best associated. Ok, thank you. Uh The second question is how long after nerve reconstruction is it safe to receive radiotherapy to minimize radiation nerve damage? Well, we, we, we typically think that although it may not be the most ideal situation. A lot of the nerve grafting that we do is um sort of reliable enough and, and durable enough that it can still re innovate through radiation therapy. So we usually plan our radiation therapy more on the oncologic time frame and principles. So we try to get those patients typically into radiation therapy by four weeks and no later than six weeks after the surgical procedure, we do all of this tumor removal and reconstruction in the same operative setting. So that's post operative day zero. And then we try to start radiation therapy within 4 to 6 weeks afterwards, aiming for that window of completing radiation therapy. Well, within the 12 week kind of oncologic window that's historically associated with better outcomes from a tumor standpoint. And we just do that in spite of the nerve grafting with the expectation, we have a lot of experience with this, that those nerve graphs will regenerate even though we did radiation therapy. Yeah, that's my approach on it. It's a question that comes up often I just talk to a patient about it today. Uh And they say, you know, should I do radiation? When should I do radiation? And first of all, I defer to the oncology team, but I tell them, you know, radiation is life saving. Our number one goal is we want to cure this tumor. We don't want it to recur because even if you have the best outcome possible from a facial reanimation standpoint. If you get recurrent tumor, we've got to go back in and Doctor Moore's got to take it out and re operate and that's gonna uh you know, ruin the great outcome that you had from a facial reanimation standpoint. So first and foremost, pursue radiation like Doctor Moore said, we let some initial healing happen but then want to pursue that 4 to 6 weeks. Um You know, is there some effect on nerve regeneration from radiation? Yes. Uh But uh we've had good long term outcomes with these patients despite radiation. So I always recommend that if that's the recommendation of the oncology team and I give patients some reassurance that we're really um hopeful. Uh And what we're seeing so far is that with this innovative technique of using vascularized tissue to cover the nerves that can act as a further uh barrier of protection to those nerve transfers and nerve graphs uh during radiation therapy. So that's a great question. Thank you. The next question that came in is what is the role of cranial nerve monitoring in your center? Do you use it for every case of prod and tumors or only on complex cases? We use cranial nerve facial nerve monitoring by at least two lead and sometimes four lead electrodes to the face for every para in case. Um I I think that it gives sometimes some really valuable information, sometimes some really reassuring information that you've dissected this tumor up and you can stimulate the nerves and they stimulate well at low ampage, you can predict that they're gonna work well. But I think that, that also we, we do it somewhat from um, both a protective uh course and that, you know, in the event that you had at untoward facial nerve injury and you weren't using monitoring. I think the first question would come up of why weren't you using monitoring? And so we do it just routinely we're a residency training program as well. So uh we get people comfortable with all the feedback from the facial nerve monitor and how to interpret that information. So it's a valuable part of our teaching process. And finally, as, as Dr day mentioned in one of these cases, you know, many times using nerve stimulation can help you really decide which nerve branches are playing a significant role in this spacial motion and can give you some really valuable inter operative information that can guide you in your reconstruction. So long, long answer. But the short answer is we use it on every case. And how long does it take for typical facial nerve grafting to function? Yeah, that's a great question. It's a little nuanced and that it depends on which nerve graft or nerve transfer you did. But of the common ones, if you did interposition, grafting of the facial nerves. So the main uh proximal facial nerve coming out of the stylomastoid frame and going into the pro like we presented on the first case with that motor nerve to vastu where we had done the interposition grafting that I expect 6 to 9 months. Uh before we see uh facial movement and recovery from that as those axons regenerate through that cable graph or that interposition graph that we did from masci nerve to facial nerve transfer because it's closer to the target. Uh On average five months can be as early as four months, as late as six months. And for cross facial grafting typically 7 to 9 months. And those are factors that we consider uh when we're deciding on treatment options as well for the patient. But I, I like to talk to patients about that because I wish it was as easy as we put the nerves back together and the patient wakes up from surgery and it works. Uh but the nerves take time to grow. I like to describe it to patients as the nerve reconstruction is kind of like the highway has been disrupted and I'm reconstructing the highway and uh the cars are like the axons, they're the nerve cells, they are what actually going in and driving the muscle movement. And so what we're doing in surgery is I'm reconstructing the highway, but then those cars are driving slow, they're following the speed limit. And so they take time about a millimeter a day of growth. And so that's what takes time uh before we see uh facial movement and recovery after this. And it's at that point that facial physical therapy becomes really helpful. So we have a great team here of uh well trained uh facial physical therapists, trained in uh facial rehabilitation, neuromuscular retraining and really work closely with our patients to help optimize their outcomes after we see facial movement. Thank you very much. Um More questions still coming in. So why don't we keep going? Uh Do you recommend any physiotherapy for people after nerve grafting? Yeah, that kind of got to just the last part of what I was saying. So the physiotherapy or or facial physical therapy is extremely helpful and um just like facial plastic surgeon, not all facial plastic surgeons do facial reanimation. Not all physical therapists are specialized in facial physical therapy for patients with facial paralysis. So you're unlikely to find somebody who's an expert in this, in your local community. But uh here, because of our practice, we're very fortunate to have team of uh physical therapists with special training and expertise in facial uh physical therapy. And so uh like I said, as soon as we see some early movement of the face from these nerve reconstructions that we do, we get patients in to see those specialists and start doing uh facial retraining. Thank you. And and what adjunctive measures are available to treat unwanted facial motion after grafting. Yeah. So that is what Doctor Moore and I were talking about with aberrant reinnervation or spacial synkinesis. So that's the thought that after injury to a facial nerve, uh thankfully, nerve cells can regenerate. But unfortunately, we can't control the path they take along regeneration. And so uh you can get bothersome symptoms like synchs, which is unintentional facial movement. Uh facial muscle tightness, patients will say I just my eye is more closed, my face feels more tight or facial muscle spasm and twitching. And so thankfully, there are good treatments for aberrant reinnervation syndrome. Uh And we start with non-surgical uh which is Botox injections and a special type of facial physical therapy called neuromuscular retraining. And we're able to use Botox, which is a very safe injectable botulinum toxin. It's a protein that you can inject in facial muscle to temporarily weaken it. And we can do that to select highly selectively weaken certain muscles that are working against the patient and causing facial asymmetry and dysfunction. And the goal of that Botox treatment combined with neuromuscular facial retraining is to deal with those bothersome symptoms and improve facial symmetry and function. And then for some patients who over the course of time because the downside of Botox is it's not permanent, it's temporary um who get a series of injections and like the effect but want something more long lasting. We have surgical options such as select neurectomy, select myectomy to help with that. So long story short, that thankfully there are many treatment options. Well, thank you very much, Doctor Day and thank you both Doctor Day and Doctor Moore for your time this evening and for the wonderful presentation, I like to also take the time to thank all of you for joining us this evening. Great questions, great conversation and great de great dialogue and a very important topic. So thank you to all and we hope you all have a wonderful evening. Thanks for joining us. Thank you.
