Novel Free Tissue Transfer Brings a Smile to Facial Paralysis Patients

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology, head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on Twitter @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology, Head and Neck Surgery by following at @CleClinicHNI. That's C-L-E, clinic, H-N-I.

Today, I'm excited to talk with Dr. Patrick Byrne, a facial plastic and reconstructive surgeon and Chairman of the Head and Neck Institute. You can follow him on Twitter and across many social media channels @pjbyrnemd. That's at P-J-B-Y-R-N-E-M-D.

Dr. Byrne, welcome to Head and Neck Innovations.

Patrick Byrne: Thank you very much, Paul. It's great to be here.

Paul Bryson: Well, let's start by having you share some of your background to our listeners, where you're from, where you trained, how you've come to Cleveland Clinic and what you've been up to.

Patrick Byrne: I'm from California and did all of my training, was born and raised there, and went to UC San Diego for medical school and residency. Then did my fellowship in the Midwest, in Minnesota, and I spent my first almost two decades at Johns Hopkins, where I've always focused on facial plastic and reconstructive surgery and got involved in a variety of interesting things there and had a wonderful number of years there. And in 2020 I came to Cleveland Clinic to serve as Chair of the Head and Neck Institute.

Paul Bryson: From your prior work in rehabilitation of facial paralysis, I understand there's been quite a bit of exciting developments, surgical innovation. Can you give the listeners some more information and updates on your team's recent publication on the tri-vector gracilis flap procedure?

Patrick Byrne: I can give you a little anecdote to share. What's amazing about facial paralysis treatment is really just how much has changed over the past 20 years. I had this experience as a resident where I attended this full day symposium on every aspect of facial plastic surgery, and it was like 10 different speakers, and it was so exciting. As a junior resident, I was psyched thinking, that's what I want to do. And maybe 15 or so years later, I was one of the lecturers at that same annual symposium, and so I sat in, and most of the topics were the exact same lectures that I had heard 15 years before. And that's not a criticism of any other niche subspecialty, it's just often things don't change a whole lot in surgical disciplines. But the facial paralysis one was totally different, because it's changing incredibly rapidly.

So, the brief story of the tri-vector is we've realized for many years now that we can reanimate a face that's been paralyzed for a long time by taking muscle from the leg, the gracilis muscle, and reanimate it, and connecting the vessels and the nerves, and it can wake up.

What we've been experimenting and refining over the last seven or eight years quite a bit, is pushing the boundaries of what we can achieve with that gracilis muscle from the legs. So, the main innovations have been we've learned that we can separate the muscle into little slips and still preserve the neurovascular supply to the individual strips of muscle. And we're able to re-vascularize it and re-innervate it typically with multiple nerves now instead of a single nerve.

This combination of splitting the nerve into multiple strips, providing it with multiple nerve supplies, has improved our outcomes. We're able to create more natural appearing smiles, we're able to restore some movement around the eyes, which a natural smile always has. And so, it's been pretty cool to see these patients do better than they did in the past, before we started. And it's not just myself, lots of innovative people around the country and some spots in the world have been working on this in recent years.

Paul Bryson: What makes the gracilis so special? How did you settle on that muscle? Lots of muscles.

Patrick Byrne: That's a good question, Paul Bryson. There's a lot of muscle options in the body, and several have been tried. There are actually some strap muscles, for example, in the neck that have higher percentage of fast twitch fibers, and so in some ways are much more replicative of the facial mimetic muscles. And so, the sternohyoid and omohyoid have been used.

The challenge there is the donor site would require you to make a pretty substantial neck incision, so I think the attributes that we're looking for are minimal donor site morbidity in terms of function but also cosmesis, and then optionality in terms of effective force transmission to the structures that we're trying to move, the corner of the mouth, the upper lip, the eyelids. And so gracilis turns out it works out. I don't know that it's perfect, it's definitely not perfect, but it's a great option. And rather than seek new muscles, which is something in parallel we're also doing, we've focused on, well, what more can we get out of this muscle? And it turns out it's got a pretty rich network of neurovascular supply and we're able to push the envelope more than we realized a few years ago.

Paul Bryson: Without getting too far afield, people will talk about the concept of synkinesis and re-innervation that's not productive for function. What's that experience like in the face?

Patrick Byrne: It's a huge deal. So, there's a big distinction we make between flaccid and non-flaccid facial paralysis. And in many ways, flaccid is simpler. You have a patient who maybe from a tumor, acoustic neuroma, or a parotid cancer, or a trauma, some cases congenital, they have no function in the face. And by and large for those patients, synkinesis is not a concern. Really, the concern for synkinesis arises typically in non-flaccid cases, in most of which the facial nerve is anatomically intact. It's been injured, but it's intact. And during the process of regeneration, well, the sequela is, things don't work the way you want them to, there's multiple muscles firing at once or muscles firing that you don't want to fire. And so, it's those cases that are actually much more challenging to deal with.

Bell's palsy is the classic example. It's a massive group of patients every year who develop Bell's palsy, and maybe 10 percent of them end up with long-term sequela. It's pretty frustrating. And much of that frustration in the clinical manifestation is due to synkinesis, all these muscles pulling tightly at the same time. And because of that, you're not getting the desired outcome, the movement of the eye, the movement of the lips, that you want. And so that's a whole other field in terms of how we're evolving in our management of synkinesis.

Paul Bryson: Now, I appreciate that. It's a problem that we experience in the larynx, and I'm certain there's other groups that we would interface with that have a similar opportunity to share experience.

Patrick Byrne: So, in the larynx, do you have synkinesis in which opposing muscles are firing at once?

Paul Bryson: Yeah. We'll see it with, the worst example is probably bilateral vocal cord paralysis, where you have the respiratory function of the vocal folds to open during breathing, they're not firing appropriately, and there's only one muscle on each side that fires for that. And so, you have a stronger abductor compartment that closes. And so, for example, after a thyroidectomy or something like that, you'll get synkinesis and the vocal folds will just rest in the midline in not a very great position for breathing. And so, some of the re-innervation strategies and things like that, the opportunity would be to reestablish a respiratory pattern.

Patrick Byrne: Well, are you familiar with the selective necrectomy approach in Bell's Palsy now?

Paul Bryson: I'm familiar from training, but not in clinical practice.

Patrick Byrne: Because it's pretty recent.

Paul Bryson: I don't know much about that.

Patrick Byrne: Well, just to throw out there in this conversation, as dear listener, it often does when Paul Bryson and I sit together, we will veer off into interesting subjects, but that's fun. But in Bell's now we think that by taking some of the neural supply offline intentionally, we can unlock function. So, a big game-changing procedure of the last five years, it really wasn't being used in this manner before, has been to identify nerves that are supplying muscles that are counterproductive to the desired function, and actually removing them. I don't know if there's an analogy in the larynx, but the analogy would be, instead of augmenting function, actually removing some function so that seesaw or tug of war is engineered better in the patient's favor. Maybe it makes no sense for larynx.

Paul Bryson: No, it makes sense. People have not talked about that yet in the larynx. It's always about reestablishing a nerve supply that's more directional or purposeful. But I guess the example would be removing some abductor function, and people have not talked about that in our area. It's more of how can we perhaps use the phrenic nerve to have the respiratory function pathway regenerated.

Patrick Byrne: To augment the abductor.

Paul Bryson: Yes. But then they would try to take the abductors offline by bringing in perhaps ansa cervicalis to have tone, but to dig out the recurrent and the scar bed from the thyroidectomy is often a challenge. So, I'll definitely take a look at some of that Bell's palsy work. That's pretty interesting.

I wanted to go back. Going back to the gracilis, when would you recommend this procedure versus other treatment options for facial paralysis?

Patrick Byrne: For flaccid paralysis of long-standing duration, it's hard to come about a better option, so I would say most patients, kids, senior citizens. Used to be thought that these sort of reanimation techniques didn't so work so well in senior citizens, but we've shown that that's not true. They tend to do quite well. So that's really the sweet spot.

We apply it more broadly. There are absolutely cases with non-flaccid paralysis in which we will use the gracilis, it's just a more complex decision around pros and cons. Because when a patient has some reasonable symmetry at rest and some movement, then it's not always the case that adding a muscle to the face, which invariably causes at least some amount of morphologic change, and this is all an aesthetic procedure, so every little detail matters, that calculus doesn't always work out. More often we're going to try other measures, maybe select a myectomy or nerve re-innervation techniques, and so it's a subset of the non-flaccid paralysis patients we do gracilis on.

Paul Bryson: You recently performed perhaps one of the first of these gracilis procedures on a pediatric patient, and I encourage everyone to check out our social media or visit our website to read the patient's story. Are there any specific considerations or changes to the procedure in a younger patient or perhaps even an older patient?

Patrick Byrne: Yeah, well, I think the tri-vector is getting a lot of attention. The specific advantage of the tri-vector, why it's getting some attention in facial paralysis circles worldwide, is because there haven't been described procedures before that do link some contraction of the muscles around the eye with the smile. And so, we call that Duchenne smile, which is a natural smile. When we intentionally smile, not emotionally, but we just force a smile, we can do so quite well except for one part, which is there's not going to be any contraction of the lateral aspect of the muscle surrounding your eye, the orbicularis oculi. You have to learn and intentionally do that to produce a smile that can be passed off as a natural mimetic smile by someone who knows what they're looking for.

So, this tri-vector, it's simply the additional third slip of muscle that is placed underneath the eyelid, around the medial part, we call it the medial canthus, attached to the lateral part, the lateral canthus, so that every time the mouth lifts in a smile, the eyelid contracts a little bit.

It's that crow's feet. When you think of people smiling, you see their little crow's feet wrinkles around the eye. It's amazing how much more natural smile looks when that happens than when it doesn't. And so that's why the tri-vector is different than our previous multi-vector flap, which we described, I think, in 2017 or 18, which is also an advance.

So, this kid is the first child to have it done. I've done it now in maybe about 10 patients total, so we're still learning about this technique. But the results are pretty spectacular. She has a pretty extraordinary smile of her mouth, but also, she smiles around her eyes, so it's really amazing to see.

Paul Bryson: Like you said, we're in the beginning stages of this technique and the refinement of it. What are the next things that you might be exploring?

Patrick Byrne: I feel like in comparison to decades ago, the results we can get now are dramatically better. At the same time, it's still the case that most of these patients don't look normal, if we're being really honest with our outcomes. They're dramatically improved over their preoperative state, but if they're in a room around others for any length of time, it's probably going to be noticeable to somebody.

I think the future state that we're committed to is, well, how do we get results that are so amazing that nobody ever tells? And in some fields, in facial plastic and reconstructive surgery, we achieve that pretty routinely. Nasal reconstruction would be one, where our techniques have gotten so good, we can more often than not achieve an outcome that's not detectable by other people, at least not routinely. And so, we're going to have to keep developing better techniques.

My guess is that the surgical refinements will continue. I'm hopeful we'll solve for eyebrow elevation, for example, which is something we've been working on, and greater spontaneity, more predictability of re-innervation through probably the application of some sort of biologics, we're experiment that. We're doing a study now on intraoperative electrical stimulation to nerves, which has been shown in animals to enhance regeneration.

In terms of prevention, I think that's probably where one of the biggest opportunities lies. We should be able to develop pharmacological interventions that can prevent some of the injury cascade of events that results in synkinesis, so we would treat Bell's palsy, or other forms of facial nerve injury, early, with either an injectable or systemic medication of some sort that can limit the amount of synaptic stripping in the brainstem and aberrant regeneration. I feel like there's enormous room for improvement in our outcomes in this field.

Paul Bryson: I really appreciate you sharing all of this exciting surgical development and patient outcomes. It's been great. I wanted to ask just for the listener, if someone wants to refer a patient to our center for facial reconstruction and other facial nerve disorders, what can they expect in terms of that experience for the referrer and for the patient?

Patrick Byrne: Well, the most amazing thing is that here it is, 2023 now, and I'm kind of amazed that not a month goes by still, and I was amazed saying this 10 years ago, that we don't meet a patient from somewhere who is seeking help for their facial dysfunction, facial nerve injury, paralysis, be it partial or otherwise, because they've been told that there's nothing that can be done. All over the country, there are patients with facial paralysis of variety of severities who are being told there's nothing that can be done. That's almost never the case. There's almost always something that can be done that can help you improve at least some, and usually a meaningful amount. And I think that's the most important take on whether you're a physician listening or if there's the random non-physician listening to our podcast here, just give us a call, because we probably can help you get better. Not perfect, but better than you are now. And that's meaningful to patients.

Paul Bryson: It's amazing, I think, what just a bit of function can do for somebody's quality of life and just the way that they face the world. No pun intended. It can mean a lot.

Patrick Byrne: I totally agree. We've seen it thousands of times, that people can regain their confidence, they feel more comfortable in social situations, focus on it less, become a little less obsessive, regain comfort in their lives. And it improves mood, we've shown that too, actually. So yeah, anything we can do to help. We want to be there for people.

Paul Bryson: For more information on facial paralysis, facial nerve disorders, and reconstructive treatments at Cleveland Clinic, please visit clevelandclinic.org/facialreconstruction. That's clevelandclinic.org/facialreconstruction. And to speak with a specialist or submit a referral, please call 216.445.9259. That's 216.445.9259. Finally, follow us on Instagram at Cleveland Clinic Facial Plastic Surgery. Dr. Byrne, thanks for joining Head and Neck Innovations.

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