Craniofacial Muscles

276 A.O. Grobbelaar and A.C.S. Woollard
patient. The fi nal plan must be tailored through detailed discussion between surgeon
and patient as to the desired end point. The overall aims focus on protection of the
cornea, resting symmetry and tone, and a dynamic symmetrical smile.
15.7 Nonsurgical Management
The nonsurgical approach really centers around prophylactic measures to reduce the
incidence of sequelae around the eye, predominantly corneal abrasions. Arti fi cial
tears such as hydroxypropyl methylcellulose can help to lubricate the eye. At night
a more viscous, petrolatum-based ointment in combination with taping down of the
upper lid can reduce the chances of a corneal ulcer.
Chemodenervation of the active facial muscles with botulinum A toxin can be
used to create a more symmetrical face. This must be administered 2–3 times per
year. It can help both with the static position and to reduce the twitching of synkinesis.
It is also possible to improve the symmetry of a smile in a partial paralysis
through careful denervation of small muscle groups around the mouth to in fl uence
the vector of the smile (Bulstrode and Harrison 2005 ) . Some physicians offer neuromuscular
retraining with specialist physiotherapists to improve dynamic motion,
but this is more usually in association with a functional muscle transfer.
15.8 Acute Surgical Management
Early repair of a nerve after transection improves the fi nal outcome. In a trauma scenario
with a grossly contaminated wound, the ends should be tagged and repaired as
soon as adequate debridement and infection control has been established, ideally
within 30 days. A nerve that has been accidentally divided during surgery should be
repaired immediately. If a segment of the nerve is invaded by a tumor, proximal and
distal ends can be sent for fresh frozen section and once con fi rmed clear can be
repaired or bridged with a cable graft (usually sural). A more distal division tends to
be compensated for by the cross-arborization of the buccal and zygomatic branches.
More proximal injuries also suffer from increased incidence of synkinesis as they
recover (Coker et al. 1987 ) . In cases where the proximal facial nerve is not suitable
for repair it is possible to perform an immediate mini-hypoglossal transfer to the
distal branches of the facial nerve at the same time as a cross-facial nerve graft that
can be coapted at a later date to augment the axonal load (Terzis and Tzafetta 2009 ) .
15.9 Chronic Surgical Management
As previously mentioned the goals of surgical reconstruction are tailored to the
needs of the individual patient. The procedures can be divided into static vs. dynamic
and by which area of the face they are trying to improve: the forehead; the upper and