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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “Good morning, young man.”
Patient: “Good morning.”Dr. Joel Aronowitz: “Do you want to take off your mask and show us what's going on here? Now, I'm noticing that on the left side of your face, your eye is watery. It's more open than the right side of your face, and your face seems to be drooping on that side. Do you want to smile for me? Yeah. So we have not as much movement on the left hand side of your face, and we have... Do it one more time. You can see this little tremor going on here, the circulation of that muscle. It's trying its best to contract, and you've had numerous surgeries on your face. Do you want to explain to us what's going on here and why you're having those problems? You want the rest of the story. And now for the rest of the story, right. And you have a good sense of humor, so thank you. I'll start with the acoustic neuroma, which was removed in 02.
So an acoustic neuroma is a benign tumor of the... Around the bundle of nerves behind the ear, especially the acoustic nerve. It damaged that nerve was gone completely. When that surgery was done, they cut the facial nerve, cleaning up the... The acoustic neuroma. The neuroma, taking it out to get everything cleaned up. With that, I lost... The whole side of my face was paralyzed. It took about three years to get some movement back. Almost right on three years, I started getting movement back. And the reason that nerve gets damaged is because they're operating inside this bone behind the ear called the mastoid bone, and everything is very tight. And the blood supply to the nerve is tenuous. And if the nerve loses blood supply, it's like if our brain loses blood supply, we're out of luck. And if the nerve loses blood supply, the nerve is badly damaged or dies. And the facial nerve is the nerve of facial expression, the fifth cranial nerve, seventh cranial nerve. And the muscles of facial expression don't work. Now, the muscles of chewing, muscles of mastication, they work because that's a different nerve. And the sensation, the fifth cranial nerve, that works. So you have sensation. You're welcome. Thank you, doctor. I'm saying that for the benefit... We have a lot of our followers are in the medical profession or hoping to go into the medical profession. And so I like to explain it a little bit. Now, why is your eye more open? It would seem like if the nerve is not working, then that eye would be more closed. Okay. The day, I believe it was the day after the original surgery, Dr. Levine came in and made a spring, a little clamshell type of spring. So that little spring, you can see it here. There's a little weight there. I think that's actually not the weight. That's the dead rod catch holding the spring down. But the spring, the idea of the spring is to keep his eye closed because his eye is too open because the muscle that goes around our eye is sort of like a sphincter, like the one going around her mouth and other places. It keeps the eye more closed. And because it's paralyzed, it allows the eye to open more. And if the eye is excessively open, then it dries out. Also looks a little bit scary because you see too much of the eye.”
Patient: “Yes.”
Dr. Joel Aronowitz: “And Dr. Levine has put in a piece of plastic along the bottom side of the lid. A few years back, that was to hold it in place a little bit better.
Because as the face is paralyzed and it falls, it pulls the lower eyelid down. Looks like an old hound dog. I think we're both going to look like old hound dogs anyway. Yeah. Well, that's the goal. Yes, exactly. Exactly. So he's put that in there and even that is beginning to sag now. So he's going to pull that up and tighten it up. Yes. And stop that. Now, the, I don't know, the side of the eyeball may or may not have a little bit of red on it right now. There are days that with wind and dry, I look up in the desert and, you know, 7% humidity and things like that. So it allows the eyeball to dry out a lot more. That eyeball will be bright red at night. And what will happen is the lower eyelid should be right up against the eyeball. And if you, Chloe, if you look over here, when the eye, when that eyelid comes away from the eyeball, you see that red and there's not a lot of tension holding that eyelid up against the eyeball. So as the facial paralysis causes the face to come down, it pulls it away and that causes his eye to be more exposed. And it also causes that red, which looks a little scary.”
Patient: “What also happens is, and Dr. Levine explained it to me, is the way that cup is holding the tears. What I have found is if I'm reading or I look down, if I got tears in there, I end up ripping all the tears out. And so that's part of the reason it's drying out also.”
Dr. Joel Aronowitz: “Is that normal tear gutter is not working? No. Because the tears are starting up here, starting up here, coming down and across diagonally and they're being collected in a little, opening here and on the top of the upper lid and on the lower lid. There are two little dots and those are little openings for the gutter to drain in and go back down and drains into your, where do the tears end up? I don't know. It's a mystery. So that's going to be, that's going to be question number one is, where did the tears end up? Ever thought about that? Your tears have to go somewhere. Okay. So now let's look at the mouth. So give me a kiss. All right. Now relax. Do you see how the midline has moved over toward me, toward the good side? Because what's happening is there's more tension over here pulling and there's nothing opposing, not much opposing on this side. So over time, everything moves toward the good side. So it's gradually, here's the philtrum, philtrum of the upper lip should be here, but it's moved over and the same with the lower lip. That's because there's that oppositional force from the opposite side is out of balance. It should be like that. So we're going to try to correct some of this and I can't replace the nerve and I can't replace the muscle, which is really what needs to be done. So a sling will create a, will create some of that counter tension and give some support here to the cheek so that Dr. Levine has an easier time supporting your lower eyelid. And that doesn't help you spontaneously smile better, but at rest it's better.
So it's kind of the principle of even broken watches right twice a day. So sometimes that's the best we can do and maybe somebody will invent a little device that we can implant that will move your face, the same as the opposite side and be able to offer that to patients someday. So if we inspire somebody to do that, then maybe we've done some good in the world today. Okay, so we will see you all in surgery in a little bit and we'll explain how we're going to do everything. We'll see a little bit of Dr. Levine's portion of the operation if he will let us and thank you for sharing these problems and explaining it to us. Unfortunately, you're an expert at this stage. Well, yeah, no more than common. So the other question I'm going to have for everybody is the difference between Bell's palsy and this acoustic neuroma problem, because they seem to create similar problems and it's a question that always comes up. You have something to say about Bell's palsy? Don't give away the answer though.”
Patient: “Well, I had a doctor, he was my primary doctor when all this happened, and he still got on all my charts that this is Bell's palsy, and I've asked him about it, and this is the symptoms that's, it's just commonly known that way.”
Dr. Joel Aronowitz: “So we'll talk about the real difference between Bell's palsy and facial paralysis due to acoustic neuroma. It's basically the same thing caused by two different problems, but it's an important differentiation. It should be called by the proper name. That's what my English teacher, Mrs. Nelson, said in the fourth grade, and I agree. Okay, we'll see you all in the back. Okay, thank you, Dr. Levine. All right, Dr. Levine. We're in the first part of the case now where Dr. Levine is doing the eyelid. Let's see what's happening.”
Dr. Levine: “Closing up. We're done.”
Dr. Joel Aronowitz: “So what have you done, Dr. Levine?”
Dr. Levine: “What have I done? I put the lid back up a little bit.”
Dr. Joel Aronowitz: “And you did that how?”
Dr. Levine: “Medial camphor palsy, lateral camphor palsy. He had a piece of med port in that was overriding parses, so I put it back in. I also put an endotine under his nail complex here. Okay. I'll show everybody what an endotine looks like. And we will do, you want to hold it on the blue so you can see it. And um there are little pines there. Maybe just turn it a little bit so you can see the the sharp points. Yeah, so those sharp points attach to the tissue and then you can pull and hold the tissue and that's helping hold the cheek up. Correct. Correct. It takes the weight off the tissue so it doesn't undo the other thing that I've done. And then that's made out of material that gradually dissolves over time. Right. It's rateable in about a year.”
Dr. Joel Aronowitz: “Very good. Thank you for showing us that. So just scrubbing in on this face and what we're going to do is now the secondpart after Dr. Levine finished this part. So that consists of opening the temple through the existing scar in the temple where he's been opened before. I'll dissect the flaps and identify the existing sling which is a artificial material, a polymaterial, and see if any of those slings are useful to tighten up and use again. I'll probably put a little piece of material in the temple to help anchor it better so there's a little strength. And then I'll feed the new slings down and out with a taster device and then secure everything up in the temple again. And then when we're securing it I'll try to over-correct it just enough figuring I'm losing a little bit of the correction to laxity over time. So just kind of a judgment call there. So I'll show you all this when we get in there and meanwhile we'll rinse off. Okay so let's review what we're going to do. This is a passer. It's like I think of it as a knitting needle. It's a long pin called a k-wire and it has a little tiny hole in the end. I'll take that without the wind holder. And what we're going to do is we're going to put our sling suture right here. We're going to feed it through the end of the knitting needle there. So now now we have that stitch on the passer or the knitting needle. So I'm going to pass this in. I'm going to retrieve it from the mouth. And then I'm going to pass the passer back through another path. I'm going to then attach the suture again like so. And then I will bring it out this way so that by the time I'm done, what I've accomplished is a loop that goes like this and allows me to pull up the nasolabial fold here and help support the lower face. That'll also make him look better. It'll also help support the repair the Dr. Levine distance. So that's going to be a facial.”
And right here you can see the superficial temporal artery right here. So so this is a little draft I'm going to put in to reinforce my anchor point in the superficial temporal fashion. And that way I've got something a little more essential to sew to.
And that will be incorporated into the patient's own fashion within a relatively short time. So this is made out of the hemorrhagic sac. It's very well tolerated by the bodies. you can see this is loose. This is the one of the slain features that I was talking about. It's already there, but it's becoming effective because it's coming loose. All righty. So now if you look down at the face, you can bring that out. So I can move the lower face with my little puppet string here and that's what we're going to put a couple more of these and we're going to tighten this one up.
Here's another one. It is not as loose, but we want to tighten that one up as well. So we're going to go ahead and do that and then we're going to anchor all of them down here to our new graph. So here's our slain feature. We're going to use our passer. We're going to go simultaneously and here's the tip of my tassel. I'm going to try to catch a little bit of that close by and come out through the mouth. Pick out my stitch.
Now I'm going to withdraw that passer and come out in a slightly different area so that I can create a little loop. There we go. Nathan, you want to thread that through for me? Beautiful. Now this is going to disappear into the mouth and it's going to reappear up here in the temple and what we're going to have is a sling and the sling is pulling. They're going to have nasolabial nose to lip, I guess, nasolabial fold and that will help pull everything back toward the midline. So we're going to do one more of those before we sew this into place. Put this at rest and we'll take one more sling. Now our needle holder. Now we're going to sew our sling into place up here in the temple. Now we're going to, we have our sling sutures in place here. Looks like we have a little stuff. So, we're going to, because this young fellow comes from out of town, we're going to close this with a septum-ticular suture, so he doesn't have to worry about taking stitches out. And I'm going to use a stitch that dissolves and bury my stitches under the surface of this. Not always how we close, but today we're going to close that way as a convenience for the patient so that if, when I see him post-op, if his stitches aren't ready to come out, he doesn't have to go and see his local doctor to get them removed. So, to close septum-ticular, here's the needle coming out in the dermis, superficially, and then when I go back in, I want to go in at the same level so that the suture pulls the skin together like that. Now, I came out deeply in the deep layer, so I go in the deep layer, and again, I come out superficially, and I'm going to go in superficially and then come out deep so that all the wound comes together properly.
And each one of those loops is called a bite, so I'm taking a bite now, the tissue, and I want to have a generous bite so that the tissue can be held together with minimal amount of tension and won't give way and come apart. It's not pleasant as you can imagine. Lonnie, we're going to be done here in about 10 minutes. I'm going to give you a warning so that you're not keeping the patient asleep for longer than is necessary while you figure out that the operation is over.
Closing the skin now. Here's my repair through the existing scar, and I closed it with a subcuticular suture so that he doesn't have to worry about having stitches removed from his out of town, his hometown doctor since he's an out of town patient. You can see the correction of the nasolabial fold here and how I brought the midline structure back across the midline, and we've put this in with a good bit of, a little bit of overcorrection and reinforced the anchor point so that the repair should be able to last longer. And he'll have a little bit of pain, but we've put a line acting pain medication in so that when he wakes up, he won't have as much discomfort. And that is a static facial sling for facial nerve paralysis. The paralysis causes a lot of problems due to problems with the eye, problems with the mouth and speech, and probably the most cruel problem is the social problems of trying to interact socially with people when you look funny because one side of your face doesn't move. And as you're talking to people, people are trying to figure out what's the matter, and everything you do to correct it is just overcorrecting, making it look worse because you're exercising the intact side too much. So facial paralysis and Bell's palsy. The Bell's palsy refers to a viral infection involving the nerve swelling inside the bone that causes the nerve to malfunction for a period of time. Sometimes it's permanent, but usually it comes back quickly. Acoustic neuroma, though, is an actual benign tumor that usually doesn't affect directly the facial nerve typically, but it causes injury to the nerve either from the tumor itself or the surgery that's done. So two different causes of the same thing, facial nerve paralysis. And Lonnie, you're making a lot of noise there.”
Lonnie: “Sorry, sir.”
Dr. Joel Aronowitz: “Okay, we're all done. We will see you all later, direct from not Lonnie land, not Hale land, directly from Aronowitzland.”
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