In-Service Exam
Facial - Palsy - 2003





A 32-year-old woman has near complete paralysis of the lower portion of the left side of the face three years after onset of Bell's palsy. There has been no return of nerve function for the past year. Examination shows adequate function of the orbicularis oculi muscle and a good Bell's reflex.

Which of the following is the most appropriate management?

(A) Continued observation
(B) Hypoglossal nerve transfer
(C) Placement of a gold weight in the eyelid and static browlifting
(D) Neurotized free muscle transfer using innervation from cross-face grafts
(E) Temporalis muscle transfer to the upper and lower eyelids

The correct response is Option D.

Significant muscle atrophy is likely in a patient who has had facial paralysis for longer than 18 months. Because cross-face nerve grafting is a staged procedure that may not be completed for an additional year, it is not suggested in this patient who would almost certainly have atrophy of the native muscles. Neurotized free muscle transfer is the most appropriate option for restoring dynamic function of the lower left side of the face. This technique can be accomplished by using a cross-face nerve graft or the hypoglossal nerve as a donor.

Observation is inappropriate because the paralysis will not resolve spontaneously. Transfer of the hypoglossal nerve would merely innervate the atrophied muscle. Although placement of a gold weight in the eyelid is a recommended treatment for facial paralysis, it is not the procedure of choice in this patient who has function of the orbicularis oculi muscle and a good Bell's reflex, indicating that the cornea is adequately protected. Similarly, temporalis muscle transfer would also address the eye but not the paralyzed lower portion of the face.

References
1. Bove A, Chiarini S, D'Andrea V, et al. Facial nerve palsy: which flap? Microsurgical, anatomical, and functional considerations. Microsurg. 1998;18:286-289.
2. Snyder MC, Johnson PJ, Moore GF, et al. Early versus late gold weight implantation for rehabilitation of the paralyzed eyelid. Laryngoscope. 2001;111:2109-2113.
3. Wei W, Zuoliang Q, Xiaoxi L, et al. Free split and segmental latissimus dorsi muscle transfer in one stage for facial reanimation. Plast Reconstr Surg. 1999;103:473-482.

A 42-year-old woman who has excess skin and subcutaneous tissue of the lower buttocks is scheduled to undergo excisional lipectomy with the incisions parallel to the gluteal fold. Which of the following is the most likely adverse effect?

(A) Dimpling of the buttocks
(B) Fat necrosis
(C) Flattening of the gluteal fold
(D) Painful scarring
(E) Widening of the gluteal cleft

The correct response is Option C.

Adverse effects reported with transverse excision lipectomy include flattening and asymmetry of the buttocks and hypertrophic scarring. Dimpling of the buttocks is more commonly associated with suction lipectomy in the region overlying the gluteal muscles because of the large amount of fibrous septa between the fascia and skin. Widening of the gluteal cleft is uncommon because the incision is made parallel to the gluteal fold.

Fat necrosis does not generally occur in the buttocks because of the good vascularity in this region. Long-term painful scarring is also rare.

References
1. Mladick RA. Body contouring of the abdomen, thighs, hips and buttocks. In: Georgiade GS, Riefkohl R, Levin LS, eds. Textbook of Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:674.
2. Pittman GH. Liposuction and Aesthetic Surgery. Saint Louis, Mo: Quality Medical Publishing, Inc; 1993:169.