From Mark 6: 31-32 “He said to them, “Come with me by yourselves to a quiet place and get some rest.””
Oh do I ever need some rest! Yesterday’s appointment was some good and some not so good. But I have options for further treatments! I mean, that IS a positive right?
My new doctor/surgeon came in and immediately said, “I am so sorry for everything you have been through the past two years. I am glad you are here though. I remember how worried your boys were about you while you were in the hospital.”
He knows my medical hardships, but not my emotional hardships. They really are hardships and for anyone here to minimize that and tell me that I’m not the only one affected by my injury…well, I’m glad you made your choice then. You are now living the consequences of your actions. I have my God and my little family. I turn to God for everything. I challenge God, too. But he accepts me. All of me. He will never forsake me or leave me.
My doctor goes on to explain that my case is very complex and unique. It’s unlike anything you’ll find from a textbook. So we need to take this on in phases. He goes on to say that he can’t recover all of my mobility and give me a perfect face again. I shook my head in understanding. Even after he helps me with a couple of things, I still might have paralysis in some places.
Here I some of what he said to start us off:
Duration: 24 mos
Etiology: Temporal bone trauma
Side affected: Both
Extent: Mixed
With it being two years since my injury, it is more than likely some of the muscles in my face won’t start working again. The paralysis has become permanent.
And then he goes on to state part of my complex case. There is definitely way more to it than this!
Per chart review, she had an unwitnessed fall at work with a resultant traumatic brain injury in the spring of 2022. She was hospitalized here at UVA, and her injuries included a skull fracture and subarachnoid hemorrhage. She required a bilateral frontal craniotomy, tracheostomy, and placement of a PEG tube. Her hospital course was complicated by a DVT and pulmonary embolus as well. The subarachnoid hemorrhage was felt to be traumatic as an initial CT of the head was negative for aneurysm. Due to concern for an unwitnessed seizure, she had been treated with Keppra XR, and after going through a course of rehabilitation, she has significantly improved from a neurological standpoint. She has been left with multiple cranial nerve injuries and recently underwent gold weight right eyelid placement (1.4g) with lateral tarsorrhaphy on 02/19/24 and later left strabismus surgery on 02/27/24, both with Dr. James Gigantelli. He is also planning for a left eyelid gold weight placement (1.6g).
Why did I come see him? I found out about facial reanimation and that UVA has a great program and I wanted to see if he could help me!!
Today, she presents to discuss potential facial reanimation procedures. She gets incomplete closure with her right eye but notes that it is much improved than prior to the eyelid weight placement. She also bites her left lower lip while eating and is more bothered by oral incompetence as she has to push her left face up while eating and drinking and hold a napkin near her neck in case of spill.
She also has some periorbital erythema which has been present since her injury but not previously. She says Dr. Gigantelli recommended she switch to a different eye drop to reduce possible irritation.
See there have been some issues that you may not have know about. I don’t want this done because I want to be beautiful again. I NEED this done so it can help improve some of the day to day things that I do.
General: Alert and oriented in no acute distress
Head and Face: Normocephaic, atraumatic
Neurological: Cranial nerves II-XII are intact except bilateral facial nerves. Temporalis and masseter function are intact bilaterally
This is why I have facial nerve palsy. It’s not completely paralyzed!! But my five other nerves are paralyzed in my face. The following is my facial nerve exam. The doctor’s notes will be in bold and mine will be italicized.
Facial nerve exam:
Forehead: Brow position is asymmetric. Right brow movement is absent. Left brow movement is normal.
My right brow hangs lower then my left brow. It also doesn’t move…at all. I can raise my left brow all day long, but not my right brow.
Eyes: Upper lid position is symmetric. Right eye closure is incomplete. Left eye closure is incomplete. Bell's phenomenon is intact. Corneal sensation is intact. Eye vector is normal. Lower lid position is asymmetric. Lid turgor is decreased and laxity is present entire lid on left. Right eye s/p partial tarsorrhaphy and weight placement, no lower lid laxity noted.
Both eye closures are incomplete. I cannot close my eyes. This is why I am still having surgeries. The surgeries don’t fix it, but they close a lot farther than they have previously. Saying bells phenomenon is intact is what some of the other doctors refer to when they say I can roll my eyes very well! I still have vertical movement of my eyes, just not horizontal. When I blink, it looks like I’m rolling my eyes. My lower lid on the left side pulls away from my eye. So it’s droopy. It is also very dry or ‘dehydrated.’ But the upcoming surgery will fix the droopiness…surgically though by sewing it to my upper eyelid.
Midface: The nasolabial fold is diminished on the right and diminished on the left. Midfacial movement is diminished on the right and diminished on the left.
I do not have smile or laugh lines and there are no movements to my mid face. So when he asks me to curl my upper lip like Elvis, I can’t. When he tells me to scrunch my nose like a bunny, I can’t.
Mouth: Oral commissures are asymmetric. Excursion of the right commissure is diminished and lip levators are diminished. Excursion of the left commissure is diminished and lip levators are absent. Air escape is present at the left commissure with bilabial plosives. Dynamic lower lip pull to the right with weakened pucker on left.
The corners of my mouth are not equal! One is lower than the other. On the right side I can’t smile. It does not pull upwards. It goes down instead. On the left side, I can’t do anything! I can’t close my lips together, so air flows freely outward when I try to hold air in my mouth and when I speak and say the ‘p’ and ‘b’ sounds, air escapes my mouth as well. He told me to pucker, and I did. Well…I tried to…my right side over-exaggerates in the pucker and my left side can’t pucker at all! Giving a kiss to my kids and husband is a HUGE challenge! I typically make the kissing sound so they know I’m giving them a kiss.
Neck: Activation of the platysma is intact on the right and intact on the left. Platysmal bands are absent.
Oh, the platysmal bands… You know how when you tense up the vertical bones in your neck stick out? Yeah…I can’t do that. I can’t make the bones in my neck stick out. He asked me a couple of times to try it and I did. He felt around my neck and could feel they were still there, I just couldn’t make it known by showing them.
Synkinesis: Right mentalis synkinesis with smile
oh joy I have synkinesis! This is when I try to smile, my eyelids involuntarily scrunch together.
Next up…the grading scale!!
I had about five different scores, but the important one is the overall score. Sunny room has a facial scale of 0-100. 0 being complete paralysis and 100 being a normal function of the face. My score…a 24.
Now the House-Blackman score…is a 5. This means…Moderately severe dysfunction (obvious and disfiguring asymmetry, significant synkinesis) Incomplete eye closure, moderate forehead movement.
I know, I know…all good things! Right? Well here are a few good things:
Skin: Skin texture is thick rated as Fitzpatrick 2
Eyes: EOMI, sclera clear, periorbital and lid erythema with some scaling and blepharitis. Right brow lower than left.
Ears: Pinna are normal in shape and position
Nose: Dorsum is midline.
Oral cavity and Oropharynx: Mucous membranes moist without lesions present.
Neck: Supple without LAD.
Lungs: Breathing comfortably
Psychiatric: Mood and affect are normal
Now the overall assessment:
ASSESSMENT:
1.Facial nerve palsy
2.Oral phase dysphagia
3.Facial paralysis on left side
4.Facial paralysis on right side
5.Synkinesis
6.Brow ptosis
7.Paralytic lagophthalmos right upper eyelid
8.Paralytic lagophthalmos of left upper eyelid
So what is the plan after I get the beat down by Goliath? Shall I walk up to him with a stone?! I’m going to approach this with a David mentality and entire faith in God. This is just another giant that I need to take down in my journey. Another hurdle. The steps I need to follow are not easy by any means. But with God, all things are possible.
Jessica presents today for initial evaluation of facial paralysis with noticeable movement present on exam. While she will unfortunately not see complete motion recovery, reassured her there are several treatment options to improve her facial symmetry along with function. We reviewed the goals of facial reanimation are to optimize her residual facial motion then discussed various treatment options. Recommended she first start working with Helen for specialized facial PT. This can help her learn to optimize the extent of facial movement she does have.
We also discussed use of chemodenervation to improve spasms, tightness, synkinesis, and facial symmetry. Also reviewed the Botox effects timeline. For longer term benefit, we discussed more invasive procedures including a selective myectomy, masseter to facial nerve transfer to improve midfacial motion, and gracilis muscle transfer from the leg to face for maximal smile improvement. As these are more invasive procedures, advised that we will start with PT for now as she continues to recover.
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