Smilow Cancer Hospital Town Hall | April 24, 2024

Transcript

• 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.