Smilow Cancer Hospital Town Hall | April 24, 2024

April 25, 2024

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New Clinical Announcements, Awards and Accolades, Advances in Facial Nerve Reconstruction, Q & A and Discussion

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00:00Well, good evening, everyone.
00:02Happy to have our community
00:05gathered for Town Hall.
00:09I'm privileged to have doctor Suresh
00:12Mohan with us as our special guest
00:15this evening from the section of Head
00:18and Neck Oncology in the division of
00:20Otolaryngology in the Department of Surgery.
00:25Terry, can you go ahead
00:26and put the agenda up?
00:32So I am flying solo today as your
00:36moderator, Tracy Carafino is on PTO.
00:40So you'll get me and our guest.
00:44I'm going to start with a number of awards
00:47and accolades and some clinical updates.
00:53You know, I I did want to take this
00:56opportunity in this presentation
00:59to remind our community that
01:02for many of our cancer patients,
01:05we as oncologists and cancer care clinicians
01:09serve as their primary care clinicians.
01:13And as such, it's really important that
01:16we both are aware of of shifting and
01:22evolving vaccination recommendations
01:25and we advance those recommendations
01:28and help our patients stay up to date.
01:31So I'm not going to read this
01:33table in its entirety.
01:34You can see that the complete
01:37guidelines are available and you
01:42can scan the QR code for those.
01:44They're also available through
01:46our website or pharmacy.
01:48But there are a number of key
01:54vaccinations that it's really
01:56important that our community stays
02:00current with COVID-19 has obviously
02:02got not gone away and there will
02:05be ongoing vaccinations for that
02:06as well as a variety of other
02:09viral and bacterial illnesses.
02:11So please stay abreast of the guidelines,
02:16next slide please.
02:19So it's really I think one of the things
02:23that is important and that I enjoy most is,
02:27is taking a few moments to recognize all
02:31of the great work that goes on through
02:34the Cancer Center and in Smilo and the
02:38remarkable group of people that do this work.
02:41And we did have the Yale Cancer
02:46Center Conclave, which is a annual
02:48gathering in which we reflect on our
02:51achievements across our missions,
02:54including clinical work,
02:55education as well as research both in
02:59the clinical and translational realms.
03:02And we recognize individuals who have
03:06made really major contributions in,
03:08in all of these areas.
03:11So I just want to take a few minutes
03:13to share some of these awardees with
03:16our community so that they are broadly
03:19recognized and our our teams that were not
03:21able to be at this event can be aware.
03:25So Terry,
03:26just flip back one one for me.
03:32Thank you. So great to recognize a
03:35lifetime of achievement by Doctor Ed
03:38Snyder who really was the pillar of
03:41our blood banking services for many,
03:44many years and definitely a role
03:47that is vitally important to the
03:49care of all of our patients.
03:51But Ed worked quietly behind the scenes
03:54to care for so many complex patients
03:56with ALL in collaboration with all
03:58of our teams and we wanted to provide
04:01a a special recognition for him.
04:03It was a real pleasure for me to see the
04:07recognition of two of my surgical partners,
04:10Doctor Jim Cloon and Doctor Kelly
04:13Olino here with Doctor Harriet
04:16Kluger for their work in leading
04:19the Melanoma clinical program.
04:21Doctor Cloon is a plastic surgeon.
04:24Doctor Olino is a surgical oncologist.
04:27And together they have created a unique
04:31collaborative care model for patients
04:34with Melanoma that often require the
04:37interdependent skills of plastic
04:39surgeons and surgical oncologists.
04:42And they have a service that it's recognized
04:45across the country for innovation,
04:48clinical research and outstanding surgical
04:50care of this complicated group of patients.
04:53So really well done,
04:55Kelly and Jim next.
04:59So as our audience knows,
05:03our advanced practice providers
05:06are in many ways the backbone of
05:09our clinical care both in the
05:11ambulatory and the inpatient arena.
05:13So annually the Ruth Mccorkle Oncology
05:16APP Award is given out and the winner
05:20this year was Ganesha Abraham and
05:22you see Ganesha with Tracy and Vana.
05:25So congratulations Ganesha
05:28efforts in diversity,
05:30equity and inclusion are central to our
05:33mission in the Cancer Center and in Smilo.
05:36And it was really a great joy to
05:38see Doctor Paris Butler recognized
05:40for his Seminole contributions in
05:42this area over the past year or two.
05:45Doctor Butler is a plastic surgeon
05:48in the Department of Surgery and
05:50is a national expert in brass
05:53reconstruction as well as advancing
05:55cancer care and cancer reconstruction
05:59for a diverse group with of women.
06:03Next slide please.
06:06So mentorship and faculty and
06:09staff development is another
06:11one of our guiding principles.
06:14This year we were really pleased
06:16to recognize Doctor Miriam Lesberg,
06:19Chief of the breast service for her
06:22outstanding contributions in mentorship.
06:24One of the things that is unique about
06:26Miriam is her broad mentorship platform.
06:29She not only supports the development
06:32of physicians and scientists,
06:35but nurses and advanced practice providers
06:38and a variety of other colleagues.
06:42Education is of also of course,
06:44central to all of our work.
06:46Doctor Mike Hurwitz, Gu medical oncologist,
06:50was recognized with the Yale Cancer
06:54Center Award for Teaching Excellence.
06:56Mike teaches at all levels from Med students,
06:59residents to fellows,
07:01and is recognized not only for
07:05his encyclopedic knowledge,
07:07but his unique teaching enthusiasm
07:10and skills.
07:11Next, please.
07:14So Doctor Weiner bestows several very
07:19specific directors awards related to
07:22outstanding service and contributions.
07:24The the individuals who received
07:27that award this year were Yang Zhao
07:31who serves as the Chief of Staff in
07:34the Director's office and does a
07:36host of things and was instrumental
07:37in the preparation of our Cancer
07:40Center support grant as well as Adam
07:43Roschka and then the entire CTO team
07:46which included which includes Dr.
07:48Ian Crop, Alyssa Gateman as well as Adam.
07:52Also in that picture service is
07:55part and parcel of who we are and
07:58what we do in a variety of ways.
08:00Crystal Esposito in the Director's office
08:04won the Service Excellence Award this
08:06year for her many many contributions
08:09organizing and developing a a variety
08:12of services in the Cancer Center.
08:15Next
08:19so science in the clinical,
08:25translational and basic science
08:27arena is foundational to our
08:30work advancing the field.
08:32Dr. Katarina Puliti won the
08:35Translational Research award.
08:38There was there's a special class of
08:4061 research award that was won by
08:42Nadia Dimitriova and Sarah Goldberg.
08:46Dr. Pam Kunz won the Clinical
08:49Science Research award for her
08:51work in Neuroniquin tumors.
08:52Alana Richmond Dr.
08:54Alana Richmond won the Population
08:56Science Research Award and
08:58Doctor Jason Schultzer,
08:59who is in the Department of Surgery,
09:02won the Basic Science Research Award next.
09:07So not only do we have outstanding
09:10people doing outstanding things,
09:12we have other programmatic
09:14achievements that we should all
09:17be aware of and be celebrating.
09:20All of our hospitals undergo an
09:22accreditation survey by the American
09:25College of Surgeons Commission on
09:27Cancer and I'm pleased to share
09:30that the Bridgeport Hospital team
09:32was just re accredited by the COC.
09:35It is hard to overstate the amount
09:37of work and preparation that goes
09:40into getting ready for these surveys.
09:43There are a lot of elements of the
09:45program that come under examination,
09:47including record keeping,
09:50survivorship programs,
09:51nutrition, physical therapy,
09:53compliance with College of American
09:57Pathologists, synoptic reporting.
10:00So the the group at Bridgeport
10:03did incredible work.
10:05Special thanks to Jean Brown for her
10:07leadership during the survey preparation.
10:10And of note,
10:11the surveyor did note particularly
10:13outstanding performance in
10:15several different areas,
10:16including quality, cancer,
10:18cancer registry,
10:19and survivorship.
10:22Next
10:24so Tracy, Renee, Eric Weiner, Lori Pickens,
10:30and myself all are committed to making
10:33this town hall a productive and informative
10:36and engaging forum for our community.
10:40We would like to get feedback from
10:43all of you about how we can best
10:47tailor the content and the time,
10:49the timing of this event.
10:51We know many people are able to access
10:53it later through the recorded version,
10:55but as much as possible,
10:57we'd like to make it an interactive event.
11:00So I would ask you please,
11:01please look for the survey of
11:06course is use the key QR code.
11:08Renee Gaudette has sent out emails.
11:12We will send out another round of
11:14emails looking for participation.
11:16But we would love your feedback.
11:18Please help us improve,
11:20suggest future topics and I promise you
11:24I know survey fatigue is a real thing,
11:27but this will take just a few minutes.
11:30Next slide please.
11:33So it's really a pleasure for
11:35me to introduce our speaker.
11:38And before I do that,
11:42I just want to tip my hat to Doctor
11:46Sarah Mara and Doctor Ben Judson
11:49for really developing a truly world
11:53class division of otolaryngology and
11:55section of head and neck surgery.
11:59You know head neck cancer is a
12:01uniquely challenging area that
12:03requires not only extraordinarily
12:06extraordinary technical surgical skill,
12:08but unique multidisciplinary
12:11collaboration across head neck surgery,
12:14medical oncology,
12:15radiation oncology as well as supportive
12:18services such as speech and swallow
12:22audiology, voice rehabilitation,
12:25physical therapy and nutritional support.
12:30So this team has really done amazing
12:34work and they are extending their reach
12:37across our entire cancer care enterprise.
12:40You know over the past couple
12:42of years there have been,
12:43there's been substantial growth
12:45in in this division.
12:48So you can see Doctor Ansley Roche
12:52came on about 3 1/2 years ago.
12:55Doctor Zafar Syed has joined
12:57in the past year.
12:59Avanti Verma who also spends time at
13:02the VA has been here about three years.
13:05We're just incredibly thrilled to re
13:09announce or remind the community of the
13:12riot of arrival of Doctor Sarah Pye
13:15who's a surgeon scientist who joined
13:17the faculty within the past year.
13:20And then our speaker today,
13:21Doctor Suresh Mohan who's a head
13:26and neck surgeon with expertise
13:28and facial nerve reconstruction
13:30who has just come on board.
13:33Doctor Mohan is going to be
13:35sharing with us his experience
13:37with facial nerve reconstruction.
13:39And you will begin to appreciate,
13:42as I have,
13:43that part of our work in the Cancer
13:45Center is not just treating disease
13:47and hopefully curing disease.
13:49It is doing it in a way that
13:51preserves the patient's quality
13:55of life as much as possible.
13:57And that is the work for all
14:00of us across the disciplines to
14:02not only treat and cure,
14:05but care and preserve,
14:06maintain the very best quality
14:08of life for our patients.
14:10And I think what you'll see is facial
14:12nerve reconstruction for head and neck
14:15cancer patients is a really exciting
14:18and prominent part of that goal.
14:21So without any further commentary,
14:22I'll kick it over to Doctor Milan.
14:24Thank you, Suresh.
14:26Thank you so much, Kevin.
14:28I am so excited to be here and can't
14:31thank you enough for the opportunity.
14:33Is everyone able to see my slides there?
14:37All right, perfect. All right.
14:38So like we heard from Doctor Billingsley,
14:42I just joined the head and neck cancers
14:44program here in the division of Auto
14:46Learning College in the past year.
14:48And my clinical interest is focused
14:51on facial paralysis or facial palsy.
14:55You'll hear hear me use
14:56the terms interchangeably.
14:57But I hope over the next few minutes to
15:03leave you with these three takeaways.
15:05And so I'll.
15:06I'll start with that 1st is that
15:08we typically hear a facial palsy
15:09as something that affects people's
15:11appearance and it it affects the way
15:14they interact with their environment.
15:16But truly there are several severe
15:19functional issues that that we
15:21seek to treat with what we do.
15:23And then also the psychological
15:25challenges that these patients go
15:27through I think are under appreciated.
15:29And so I hope to kind of illuminate some
15:31of of that as well in the next few minutes.
15:34Second take away is that
15:36sometimes I've heard patients say,
15:38you know my doctor said there
15:39was nothing to do,
15:40that there were no options for me.
15:41And I I hope to debunk that myth
15:43today and and convince you that pretty
15:45much every patient that has facial
15:47palsy given the plethora of options
15:49that we we have available to us now
15:52has something that we could do to
15:54improve their function or their form.
15:56And finally I hope to explain to
15:59you how facial reanimation surgery
16:01can re establish really functional
16:03parts of the face such as smile
16:05and blink the symmetry of the nose
16:07and the mouth and and on top of
16:09everything re establish a sense of
16:11self-confidence for the for the
16:13patients that suffer this condition.
16:17So I'd like to begin with the story
16:19this this is my patient Carol who
16:21kindly agreed to let me tell her story.
16:24But Carol was was living the prime of
16:27her life last year and and with a very
16:31vibrant family with her husband and
16:34grandkids and everything was going well.
16:36She had a facelift 2 years ago to
16:38make herself feel like the best
16:40version of herself.
16:41Life was going well until unfortunately
16:43she developed a terrible severe DLBCL
16:46of the of the head and neck and over
16:50the following six months with treatment
16:53not only did she lose severe amounts
16:56of of weight and it became cokectic,
17:00but she also developed involvement
17:02of the facial nerve.
17:04And what you see here is is how
17:07she presented when she when she
17:09came to my office.
17:10And so I want to,
17:11I want to want to leave this story
17:14in your mind as we kind of go through
17:17the options that we have today and
17:19and the opportunity that we have
17:21to to to help patients like Carol.
17:25So as we remember the facial nerve
17:27is involved of course in facial
17:29expression in in allowing us to
17:31communicate and express ourselves,
17:33but also turns out plays a critical role
17:35in corneal and hair cell protection.
17:38There's a muscle in the middle ear that's
17:41even innervated by the facial nerve.
17:43And of course the upper eyelid protects
17:46the cornea respiration through our nose,
17:50mastication with as we move our
17:52mouth and articulation as we speak.
17:55And when we have injury to the facial nerve,
17:58then we have not only appearance and
18:03aesthetic losses but also functional
18:05commutative and challenges with interacting.
18:08I have many patients that come
18:09in and tell me Doc, you know,
18:11I just stopped going out to eat.
18:12I can't.
18:13I can't sit there and have people
18:15see food fall out of my mouth and
18:17so it it affects their their social
18:19life and this leads to to worsening
18:21psychological stress as well.
18:26So to take a step back and just remind
18:28ourselves that the anatomy of course the
18:30facial nerve originates in the ponds
18:32where the facial nucleus is located and
18:35it travels through the facial canal in
18:37the temporal bone around the cochlea,
18:39exits the skull base at the stylo
18:42massive frame and just below the ear.
18:44And then as it enters the face,
18:45it spreads into several branches,
18:49most classically shown here, the frontal,
18:51the zygomatic towards the eye,
18:53the buckle towards the mouth,
18:54the marginal towards the lower lip,
18:55and the cervical into the neck,
18:59as shown here in this diagram.
19:04So what causes facial palsy?
19:05How do people get this condition?
19:07So the one that we probably all
19:09heard the most about, of course,
19:10is Bell's palsy or idiopathic facial palsy.
19:12So it turns out Bell's palsy is
19:14actually a diagnosis of exclusion.
19:16We have some theories about how it happens,
19:19but it is still not very well elucidated.
19:22For the purposes of this talk I'm
19:24going to focus of course on benign
19:27or malignant tumors and how this can
19:29lead to to facial palsy for patients.
19:31But it is important to understand
19:34that several causes can result in
19:36the same condition and and we see
19:39all these routinely at our center.
19:42So how does facial palsy progress?
19:46So the face is in its usual condition
19:48and there's an insult to the facial
19:51nerve which leads to complete
19:52complete facility of the face,
19:54so that the face goes completely
19:57weak If the insult was permanent
19:58or if there's an ongoing insult,
20:00for example a cancer or a a
20:03tumor compressing the nerve,
20:05then the face stays flaccid in in a
20:08chronic state and does not recover.
20:10Now if the insult for, for example,
20:13was inflammation,
20:14like we think happens in Bell's Palsy,
20:16then the nerve can actually
20:18regenerate back to normal.
20:20But sometimes in a subset of people,
20:22approximately 30% of patients,
20:23they can develop aberrant regeneration
20:26or misguided regeneration that results
20:28in something we call synkinesis or
20:30involuntary movement when you try
20:32to move another muscle. Now what?
20:35How does that manifest in the face?
20:37So on the left side we have a
20:39patient with flaccid facial palsy,
20:41and on the right we have a patient
20:43with synkinetic facial palsy.
20:44Now again,
20:45synchronesis is when you have
20:47involuntary facial movement
20:48accompanying voluntary movement.
20:50So for example, for the patient on the right,
20:53she's trying to smile,
20:54but her eye is closing.
20:55Why?
20:56Because when her facial nerve regenerated,
20:58some of the axons that were supposed to go
21:00to the mouth accidentally went to the eye,
21:01and vice versa.
21:02And so when she tries to close her eye,
21:05her mouth moves as well.
21:07And so this miswiring of the
21:09axons is what results in such a
21:13severe hyperkinetic state for the
21:15patients that develop synkinesis.
21:18And usually synkinesis starts about
21:20four months after the insult.
21:22So it's important conceptually
21:24to remember that we are treating
21:26both the flaccid facial plasty
21:27patients and we're treating the
21:29same kinetic facial plasty patients
21:30and they have very different
21:32paradigms of how we approach them.
21:36So this is a busy slide,
21:38but I put it in to kind of
21:41demonstrate how we think about
21:43addressing each aspect of the face.
21:45So for the flaccid patient
21:47on the disease side,
21:48we have several different
21:50procedures for each aspect of the
21:52face and we even have procedures
21:54we can do on the contralarial
21:56side of the face for symmetry.
21:58And similarly and we'll go into,
22:01I've selected a few of these to
22:03go into detail into shortly.
22:06When we look on at what we can
22:08do for the syn kinetic face,
22:10similarly there are several different
22:15procedures that we can do to improve
22:17the symmetry and the function and
22:20the hypertonicity of the face.
22:22And again we'll go into
22:24detail into this here.
22:26So the first step just like with
22:30rehabilitation of the limbs
22:31after injury or after surgery,
22:33the face is very similar.
22:35Turns out facial rehabilitation
22:37and neuromuscular retraining of
22:40the face is is critical in any
22:43nerve transfer procedures or nerve
22:45surgery in general that we do
22:46for patients with facial palsy.
22:48And so I'm just going to play a
22:50short video clip to to kind of
22:52demonstrate how this actually works
22:54and that and the way that the,
22:56this is a very specialized
22:59rehabilitation technique.
23:00And so we actually are fortunate
23:03to to be able to build that in
23:06conjunction with our physical therapy
23:07colleagues here at Yale, New Haven.
23:10So and we're going to try and
23:13balance your smile out by relaxing
23:15the tension in your eye and in your
23:18cheek and in your neck muscles.
23:20So form a small smile and at the
23:24same time you smile you're going to
23:27relax the tension around your eye
23:30and into your cheek focusing on the
23:33cheek muscles forming the smile motion.
23:36I think of it like your cheek
23:38balls trying to form.
23:39There you go that motion.
23:42Excellent.
23:43So we see here that it there's a
23:46lot of very nuanced attention to
23:49detail because these are fine,
23:52fine muscles of the face and
23:54trying to work with patients to
23:56to understand and control those
23:58movements takes a lot of time and
24:02patience and a dedicated effort.
24:04And so we're lucky to have a
24:06team directly focused on that.
24:10So the next level of treatment is
24:13actually with botulinum toxin injection.
24:15Of course we've we've heard of
24:17Botox for other cosmetic purposes
24:21as well As for hypertonicity in
24:24other parts of the body and even
24:27for central pathology.
24:28But in this case,
24:29it works extremely well for
24:32patients that have some kinesis
24:34after a facial nerve insult.
24:35So here on the left side is
24:37the patient before treatment.
24:39You can see she's developed
24:41some narrowing of the eye.
24:42And what's happening here is
24:44that the muscle around the eye
24:45is is the orbicularis oculi and
24:47it's a circular muscle so when it
24:48tightens it actually narrows the
24:50the aperture of the eye and and
24:53similarly in the chin or in the neck.
24:56You can see the tightness of
24:58the hypertonicity as these
25:00muscles all contract after some
25:02botulinum toxin injection,
25:04loosening and weakening of the
25:06muscle along with physical therapy of
25:08course you see a much more balanced
25:11appearance and less tension to the face.
25:13Now of course the downside of this
25:15is that the botulinum is a temporary
25:18treatment and so many times these there
25:21are patients that are stuck having to
25:23do this several times a year as the
25:26hypertonicity is is very persistent
25:30and comes back as the Botox wears off.
25:34This is another patient with a subtle
25:36results who had a chronic synchronesis
25:38of the left side and so we treated
25:41her with contralateral Botox because
25:43you can see the lip is pulling down
25:45here because of normal lip function,
25:47but on the weak side the lip is
25:49not pulling down.
25:50So if you weaken the healthy side,
25:52you can actually achieve a little
25:55bit better symmetry to the smile.
25:58And so the the botchline toxin
26:00offers an opportunity to intervene
26:02on both sides of the face.
26:07So probably the most important
26:10aspect of facial palsy care.
26:11As soon as the patient is diagnosed
26:13is taking care of the eye.
26:15As soon as the upper eyelid is unable
26:17to close and protect the cornea,
26:19the eye becomes at risk
26:22for exposure keratopathy,
26:23worsening paralytic glycophthalmos
26:25and so protecting the eye.
26:27It becomes the first priority.
26:30And how do we do that?
26:31So we start from it depends a
26:33lot on the patient's age and the
26:35laxity of the skin and the severity
26:38of the injury to the nerve.
26:40And so from a conservative to
26:42a more aggressive approach,
26:43we begin with physical therapy techniques
26:46such as stretching the eyelid,
26:47using an eye patch for community
26:49control to to maintain whatever
26:51community is possible and avoid
26:53drying out of the corneal epithelium.
26:58Another step up from that is
27:00called putting in a lid weight,
27:02which I'll show you shortly,
27:03where we can weigh down the
27:05upper lid to help close the eye,
27:07or we can tighten the lower lid
27:10with various strips or slings.
27:12And then we also have the opportunity
27:15to dynamically reanimate the upper
27:17lid and actually bring a nerve
27:19input into the muscle to help
27:21the eyelid start moving again.
27:23So let's look into that in more detail.
27:25So this is a platinum weight
27:27and the reason we use platinum,
27:30we used to use gold.
27:31I mean it's still used,
27:33but platinum offers a higher
27:35density and therefore it can be
27:37a thinner profile implant with
27:39less risk of extrusion in in the
27:42eyelid because the skin is so thin.
27:44So the way it's placed is it's first
27:47sized appropriately in terms of
27:50its weight for the the amount of
27:52depression of the upper lid that we need.
27:55And then a incision is made through
27:58the skin and muscle through the
28:00anterior lamella down to the tarsus
28:03or this is a little piece of basically
28:05cartilage that's in the upper eyelid.
28:07And so the weight goes
28:09just in a pretarsal plane.
28:10So there's the weight going in.
28:12It gets tacked down with some
28:15sutures and then and then the
28:18eyelid is now heavier and so the
28:20patient has an easier time closing
28:23the eye and protecting the cornea.
28:26Now what?
28:26What can we do for the lower eyelid?
28:28So this is called a lateral tarsal strip.
28:30And what it is,
28:32is when the lower lid loses its tone,
28:35it becomes LAX and the patient
28:36can develop a tropion or E
28:38version of the lower eyelid.
28:40And so way to treat that is by
28:42tightening the lower eyelid.
28:43And so here we make an incision on
28:46the outside of the eyelid and then
28:47we dissect down and do a canthotomy,
28:50cantholysis basically releasing
28:51the lower eyelid away.
28:53And then we shorten the lower tarsus
28:57here by trimming off the epithelium
29:00and then we bring it out laterally
29:03and secure it to the the orbital rim.
29:06And then by tightening the lower eyelid,
29:09this helps the eye close as well.
29:12There's also other techniques.
29:13So this is a a relatively recent technique
29:16described by one of my mentors in Boston
29:19where even though these two techniques
29:21that I just described, we use them.
29:22This is kind of the cutting edge in
29:25terms of when you can't correct the
29:27entire lid just by doing a lateral
29:29torsional strip or a lid weight.
29:31By putting a piece of fascia spanning
29:33across the entire lower eyelid,
29:35you can actually suspend the medial portion
29:37of the lid as well as the outer part.
29:39And so here you see we've borrowed
29:41a piece of fascia from the leg and
29:44then we're tunneling it through
29:46the lower eyelid across here.
29:47And then it acts as a belt to basically
29:51lift that or lower eyelid up and help
29:54the patient achieve better closure.
29:56You can see here there's a a narrower
29:58opening than when we started.
30:02So how about dynamic linker animation?
30:04What if I want to just be
30:06able to move my eyelid again?
30:08So turns out we have the
30:10ability to do that now too.
30:11So these are our photos from a colleague
30:14in Brazil who's it was actually the
30:16been popularizing this technique.
30:18So by bringing in a So this is a nerve
30:22graft that we've harvested from the
30:24leg and we connected to a from the
30:26healthy side to an eye branch that
30:29controls eyelid function on the good side.
30:31And then you tunnel that nerve
30:33branch over into the weak eyelid
30:36and then you come back several
30:38months later and put a little piece
30:40of muscle into the upper eyelid.
30:42And what happens is that direct
30:44neurotization or basically when
30:46axons grow into the muscle,
30:49then you have control to
30:52actually blink once again.
30:53And so it's a remarkable result and
30:56can be life changing for patients to go
30:58from never being able to move that eye
31:00to suddenly being able to blink again.
31:04So another technique as
31:05we move down the face.
31:07So we've talked about the eye,
31:08what about the mid face?
31:09And so this is a patient of
31:13mine from a few weeks ago.
31:14So this patient unfortunately had
31:17a terribly recurrent squamous cell
31:20carcinoma invading his parotid gland.
31:22And so it it already caused damage.
31:24This is him preoperatively and you can see
31:27that he's already had significant bratosis.
31:29He he has inferior scleral show of the eye.
31:32He's got increased watery eye.
31:35He's got a lot of mid face
31:37descent he can't smile.
31:38All of these things are direct
31:40sequela of the facial nerve injury
31:43and so he had a radical resection
31:45with a a free flap and at the same
31:47time along with dynamic techniques
31:49to restore smile static suspensions
31:51or slings are a big part of of
31:54re establishing facial symmetry.
31:56And so here we take fascia from the
31:59leg which basically acts as a non
32:03extensible stretch band and so you
32:07bring you bring the fascia into the
32:09face and here you see there's a band
32:11going to the corner of the lip into
32:13the nasal labial fold and here into
32:15the corner of the of the nose and we
32:18secure all that back to the the fascia.
32:23And so afterwards you see that
32:26he's has a better improved.
32:29Of course it's not perfect,
32:30but it certainly helps with the
32:33overall appearance and function.
32:35So it helps with drooling that commonly
32:38occurs here when you have this flaccid
32:41area of the corner of the mouth.
32:43And it could also help here when you
32:45look at the position of the nostril.
32:47So here,
32:48turns out when you lose your facial nerve,
32:51you actually stop being able to breathe
32:53through the nostril on that side.
32:54And so putting a band to the nostril
32:56actually brings that nostril and
32:57opens it so you can have air flow.
33:02So what about other techniques?
33:04How do we make smiles move? Again?
33:07The static suspension is a is
33:09a non dynamic approach but the
33:12mesoteric nerves are transfer.
33:13So when the facial nerves are not working,
33:16another way to keep those muscles
33:17of the face alive are to bring in
33:20donor nerves from other sources.
33:21So what if we took the mesoteric
33:23nerve which is a nerve that
33:25controls the bite muscle.
33:26So when you bike down,
33:27you should be able to feel the bulge
33:29of your master muscle on on both sides,
33:31and so that nerve can actually be
33:33transferred to connect to a facial
33:35muscle instead of the bite muscle.
33:37And when we do that,
33:40we actually can get remarkably
33:43improved smile results.
33:44So here the nice thing about the mesteric
33:47nerve transfer is that this surgery
33:50has a greater than 90% success rate,
33:53which is remarkable.
33:54There's also pretty minimal donor
33:56site morbidity because there's
33:58redundancy of that nerve and so you
34:00don't lose your ability to chew just
34:01because you transferred this nerve.
34:03You're still able to chew but
34:04then you're also able to smile.
34:06So in this patient who had
34:09facial palsy and had a 5,
34:11seven or a mesenteric nerve transfer,
34:13you can see when she bites down she can
34:16actually trigger movement of of the face.
34:19And of course this is a very critical
34:24the success of the separation is
34:25critical on on physical therapy
34:27because the patient has to learn
34:29the association that if I want
34:31to smile I need to bite down.
34:32And for young people turns out that's
34:34a pretty logical thing to learn.
34:36But it is certainly harder in the
34:39older population to kind of go that go
34:43through that neuroplasticity and the
34:44retraining in your mind to teach yourself,
34:46oh, if I want to smile,
34:47I need to do this unrelated
34:50movement to to be able to smile.
34:53The downside is of course that
34:54this is not a spontaneous smile.
34:57You know,
34:57when you or I look at something funny,
35:01our faces naturally break into a
35:03smile with that, with involuntarily.
35:05That's not something where you have to say,
35:07OK, ready, set, go,
35:07I'm going to smile now it's
35:09it happens involuntarily.
35:10But for the five,
35:12seven transfer,
35:13it's a voluntary movement so that
35:15the patient has to engage it to
35:17to be able to to see that smile.
35:19So even though it works really well,
35:21it's not spontaneous.
35:24So here's an example of a young
35:26girl who had an AV malformation,
35:28so you can see on the right
35:30side when she smiles,
35:31she has complete weakness on
35:32the right side of the face.
35:34And once we've done A57
35:36transfer and she's gone,
35:37undergone physical therapy,
35:41you can see here this is without
35:43engaging the bite.
35:44And then now she will engage the bites
35:46and you can see how she has a dramatic
35:49improvement in her smile there.
35:51And again,
35:52as with most things,
35:53kids are often the the best
35:55candidates for nerve transfer
35:57procedures. They just do remarkably well.
36:03So, OK, we talked about the masseteric nerve.
36:05What other nerves do we have available to us?
36:08So it turns out the hypoglossal nerve
36:09or the nerve that controls the movement
36:11of the tongue is also a great option.
36:14And so that's what's depicted here.
36:16The nerve, the facial nerve is transacted
36:19because of of some sort of central
36:22pathology and it can be brought down,
36:24sorry, more medial pathology
36:26to the the hearing organ.
36:28It can be swung down here,
36:30and then axons from the 12th or
36:33the hypoglossal nerve can actually
36:35innervate through the facial nerve.
36:37So how does that turn out into practice?
36:39The basically means when you move your
36:41tongue you'll be able to smile or at
36:44least you'll have some tone of the face
36:47from from the from the tongue axons.
36:49And of course if you're using
36:52the tongue nerve,
36:53then you worry about risks of the tongue.
36:55So tongue weakness or dysarthria,
36:57dysphasia,
36:58these are all risks that that can occur.
37:02This was a patient at our center
37:04here at Yale who had a weakness of
37:08the facial nerve after a parotid
37:11operation at an outside hospital.
37:14And she underwent a 12/7 transfer here.
37:17And you can see that her face is completely
37:19weak until she engages her tongue,
37:21and then she's able to actually
37:23get a pretty remarkable smile
37:25that looks natural here.
37:26So here's the video of her.
37:30So there's her we just engaging one
37:32side without the and then she moves
37:34her tongue and you can see how you can
37:36actually re establish smile there.
37:41And I will say this is one of the
37:42most gratifying things when you
37:44have a patient come in after this
37:46procedure you see him three months
37:48later and they just they break out
37:50into a smile for the first time.
37:51And and I think it was one of the first
37:54things that that made me fall into love.
37:56You know fall in love with this,
37:57with this field the ability to you
38:00just you see the confidence come back
38:02into their into their personas and it
38:04makes such a difference in their lives.
38:08OK so then we've talked about nerve
38:10transfers, we talked about static suspension.
38:12Now let's talk about probably the biggest
38:14procedure that we do and this is when this
38:16is a person that's had chronic facial palsy.
38:18So they the native musculature in the face
38:21after two years loses the ability to be
38:25reinnervated by nerve transfer procedures.
38:28And so in that case for the
38:29face to move after that,
38:31you need to bring in fresh muscle and fresh
38:34nerve to be able to re establish the smile.
38:37So it turns out the Gracilis muscle
38:39is probably the most commonly
38:41used muscle for smile reanimation.
38:42And so on the left side here we're
38:45seeing how we can take a piece of the
38:47gracilis muscle from the thigh along
38:49with the blood vessels and the nerve to
38:52operator and then we transplant that into
38:56the face and it's sutured to both the
38:59corner of the mouth and to the temple.
39:03And then the blood vessels are hooked
39:05up to blood vessels in the neck.
39:07And then with the nerves are hooked
39:09up to one of two sources either
39:12to the mesoteric nerve.
39:13So when they bite down,
39:14they'll be able to engage the muscle
39:16and smile or they get get connected to
39:19a cross faced nerve gaat which which is
39:22basically using the contralateral facial
39:24nerve to drive the the, the new muscle.
39:27So what does that look like?
39:29So here's a patient that had
39:31bracillus that was controlled by
39:34the mesoteric or the biting nerve.
39:36And so you can see here
39:38that when she bites down,
39:39she gets movement here on the left
39:42side that mirrors the healthy side.
39:44But again, this is voluntary,
39:45which is the downside.
39:46But the benefit of this approach
39:48is it's a single surgery.
39:49You don't need a separate surgery
39:51for the nerve graft and then a
39:53separate surgery for the muscle
39:55when we look at other options.
39:57So here again is a patient
39:59that had a 57 Gracillus.
40:01And so you can see she preoperatively
40:03has no movement on the right
40:06side and then with fresh muscle
40:08and biting down she's able to re
40:10engage and reestablish a smile.
40:12It's not perfect,
40:14but you can tell that she's trying
40:16to smile and and turns out we have
40:18great evidence to suggest that that a
40:21meaningful smile is the is the ultimate goal.
40:24It is is the person you're communicating
40:26with understanding that you were
40:28trying to smile and so that's a big
40:30outcome measure for these procedures.
40:34So the other option,
40:35like I mentioned,
40:35is if you use the contralateral facial nerve,
40:38the benefit of the contralar facial
40:40nerve is that it has spontaneity.
40:42So you don't have to think to smile.
40:44You can just smile like you would on the
40:46other side and this side will engage as well.
40:48So here's a young girl.
40:49You can see she's weak on the right side.
40:52And so she had two surgeries,
40:53the first surgery to put in a nerve graft,
40:55shown here in yellow.
40:57And then six months later,
40:59we came back and took the muscle
41:00from her leg and put it in her face.
41:02And this is a spontaneous smile.
41:04So we do a spontaneous smile assay where
41:07we show them funny videos to trigger
41:10a spontaneous smile and and they're
41:12on camera while they're doing it.
41:13And you can see how the benefit
41:16of a spontaneous smile is just
41:18it's remarkable and and life
41:19changing for for these children.
41:23So what is the latest in and greatest
41:26in terms of these procedures?
41:28So what if instead of just one
41:29nerve you hook it up to two nerves.
41:30So dual innovation of the Gracilis
41:34is slowly becoming more and more
41:37common and so that's basically when
41:38you do your your nerve graft across
41:40but then you also include the biting
41:42nerve just to make sure as it as an
41:45insurance policy to make sure that
41:46you the patient will end up with some
41:49movement from one of the two donors.
41:52Other thing you could do is we we talked
41:54about only a single vector Gracillus,
41:56what if we dissect out a portion of
41:58the Gracillus and we can actually
42:00do multi vector smile or animation.
42:01Turns out the face has multiple
42:04vectors that contribute to SMILES,
42:06so a single vector is pretty
42:08simplistic compared to if you can
42:10include multiple vectors.
42:11And so that's another.
42:13So you can see here it takes.
42:15It's a little bit more technical
42:17demand technically demanding
42:18because you need to have,
42:20you have to dissect out the pedicle
42:22to the the each part of the muscle.
42:25But for example here the muscles being
42:27attached to the lower lip so that the
42:29lower lip can depress like it like it
42:31naturally does when when you try to smile,
42:33smile.
42:34Of course there are increased complications
42:37as as it becomes more complex.
42:39So here at our facial nerve program
42:42we've had over 50 plus patients
42:44that come through our clinic in
42:46in the last six months and we
42:48we're continuing to rapidly grow.
42:50We've done 15 or so reanimation
42:53procedures already.
42:54We have clinics both at Smilo and Milford.
42:57We've set up a very standardized epic
43:00workflow for Botulinum toxin injection.
43:03We've partnered with the
43:04physical therapy department.
43:06We had a recent guest lectureship with
43:08training of of Southern Connecticut
43:10physical and speech language pathologists.
43:13And so we're on a pretty
43:15exciting trajectory right now.
43:17And so I'm very privileged and
43:19honored to be a part of this,
43:21this growth and I can't thank Ben Judson,
43:24Sarah Omera again Lee enough for for their
43:27support in in helping this program take off.
43:30And of course I want to thank Kevin again
43:33for the opportunity to present today.
43:35I leave you again with these three takeaways.
43:38Realizing that facial palsy
43:39is is not just aesthetic,
43:41it's functional, it's psychological.
43:43Every patient has an option and the
43:46surgery we do can really re establish
43:48function and form for for these patients.
43:50Thank you and I I'm happy
43:51to take any questions.
43:55So this is really inspiring.
43:59You know, I I will say I'm struck by
44:04the fact that you know our face is,
44:08you know the IT is the vehicle
44:10that we all use to communicate
44:12and engage with the world.
44:13And really it is how we
44:18facilitate relationships.
44:20And to you describe your experience
44:24with watching some of these
44:25patients after reanimation and
44:27just how gratifying that is.
44:28It is really a lifesaver in almost
44:32the same way any other cancer
44:34treatment is if not more so.
44:36The question I have Suresh is many
44:39of these patients appear to live
44:42through some extended period where
44:44they really are compromised in
44:46their ability to move their face to
44:50smile to engage what what kind of
44:53resources do we have or or should
44:57we be developing to support people
45:00in that in that period where they
45:03must feel incredibly isolated.
45:07Absolutely. You know I think the
45:10psychological component is is is
45:12it's a huge component and even and
45:15so there are you know I think that
45:18facial palsy is becoming more and
45:19more multidisciplinary as people
45:21realize that you cannot do it alone.
45:24You know it it takes a village and it
45:26and it takes a a people specialized
45:28in their own areas and so including
45:31psychiatrists or or therapists on the
45:34team is becoming much more common.
45:37And I think it is a really important
45:39part And and I think that's an
45:41area that we need to grow into and
45:43we haven't established that yet.
45:45But I'm really glad you brought that
45:46up because I think it's it's under,
45:50it's under addressed.
45:50You know and I have a lot of my patients
45:52that come in and they're you know they
45:54are glad that they survived their cancer.
45:56But now it's like you know they're
45:58they're walking around and they're
45:59like I I still don't feel great
46:01because of of this of this problem.
46:03And so another thing we're doing
46:05on the front end is when we had
46:07these cases where we know the facial
46:09nerves going to be sacrificed,
46:10we make it a a point to make sure we do
46:13upfront facial nerve reconstruction.
46:14It used to be that people would
46:16be like just get the cancer out,
46:17we'll deal with the nerve later,
46:19we'll we'll like,
46:19we'll take care of it later.
46:20But you know I think that ERA has,
46:22has is definitely coming to a close as
46:24we realize that we have an opportunity
46:27up front to prevent you know,
46:29severe sequelae for these patients.
46:31So.
46:33So thank you. So Doctor Mayer
46:37asks a question but yeah,
46:39what types of tumor and cancers
46:40are most common that need this
46:42is timing to referral important?
46:45Yeah, it's a great question.
46:46So you know I think the the the two
46:50most common I would say are either
46:52squamous cell carcinoma of of the
46:54parotid region that ends up requiring
46:57some sort of radical parotid ectomy
46:59and facial nerve sacrifice or two
47:03even vestibular schwannoma patients.
47:05So patients that undergo either
47:08surgery or or stereotactic radiation
47:09for treatment end up with a lot
47:12of facial nerves sequela and
47:16I think the sooner the better.
47:18I I I never say no to a new facial
47:21palsy referral and and usually the
47:23reason is because the sooner they
47:25they get plugged in they the the they
47:28don't even realize that there are all
47:30these resources that there's physical
47:31therapy available that there's even
47:33speech pathologist that can help with
47:35the this articulation issues And so
47:37early referral I think as soon as you
47:39have a patient that even and so we
47:41haven't even talked about Bell's palsy.
47:43But patients with Bell's palsy that
47:44don't recover after a couple of weeks,
47:46the sooner they get referred the
47:48better because we know that if you
47:50don't recover the the longer it
47:51takes you to recover the worse your
47:53long term facial function outcomes.
47:55So or early referrals is a big part of it.
48:05So I'm just going to ask one more question.
48:08I think we probably have a mixed audience
48:10who are overwhelmed and don't want to
48:12don't want to venture out there. But
48:15you know one
48:17of the things that we often struggle with
48:22in procedures that are not accentrative
48:27but are reconstructive is we sometimes
48:31battle with payers over the question
48:36of cosmesis versus real therapy.
48:39And I think what you've shown all of us in
48:43a really powerful way is that this is these,
48:47this is function and life saving therapy.
48:50Are there challenges we face with payers
48:54particularly for patients who are
48:56coming from outside of the system for
48:58these very specialized reconstructive
49:00procedures or is it generally OK
49:03you know the the good news is for
49:07most facial palsy related care
49:09most insurances will will cover
49:12even botulinum toxin injection and
49:15physical therapy referrals and and
49:17most surgeries get covered It it
49:21becomes tricky when you want to do
49:25something for the contralateral side.
49:26So for example somebody has a very
49:28weak face and they need you know they
49:30just have so much redundant skin that
49:32a facelift is part of what you need
49:34to do to to re establish the symmetry
49:37of the face it we run into these
49:39issues where then the other side looks
49:40you know it has normal aging and so
49:42they want to have a contralateral
49:44procedure and things like that.
49:45And so of course insurance is not going
49:47to cover that and so we just treat
49:49that as a as a cosmetic procedure
49:51if the patient's interested in that.
49:54But for most functional issues
49:56especially related to the eye
49:59related to drooling or facial,
50:02you know lack of smile,
50:04fortunately pairs are pretty
50:07supportive and it's becoming more
50:08and more recognized that this,
50:10this is necessary.
50:17Well I think it is really
50:19important for our community to
50:21to be aware of these incredible
50:24resources and it's exciting to see
50:26the work that's being gone going on.
50:29We're really glad to have you
50:30here in the head and neck team,
50:31including the medical oncologists
50:33and the radiation oncologists.
50:35And if there aren't other questions,
50:38we will wrap up and give people
50:40a few minutes back in there to
50:42enjoy their spring evening.
50:44So thanks so much everyone.
50:46Thanks Doctor Mohan.
50:47Thank you, Doctor Billingsley.
50:48Have a good night.