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| Dr. Joel Aronowitz |
Jody Brown: Figure out where he was he came in two hours late and and when he finally came in where have you been and he said this one required much prayer. (laughter) He said he had been off praying all morning which probably was quite accurate turned out great in was when he came up with the idea for the Dacron sleeve because mine had poked through and he was trying to figure out a solution yeah and so that's when he started doing the sleeve around the end of the spring.
Dr. Joel Aronowitz: "Hello and welcome back to Aronowitzland. Today's video is about facial paralysis.Facial paralysis is a relatively unusual problem but not rare and it involves the facial nerve it's a nerve that comes up directly from the brain through the skull and into the face it splits into five branches here just in front of the ear it primarily provides innervation or control of the muscles of facial expression so all the smile and grimacing and sneering and normal muscles that we use on our face to let others know how we're feeling and express our emotions those muscles are paralyzed by loss of the facial nerve there are a couple of other things that the facial nerve controls as well but the main problem that people have when they lose that nerve is inability to control the muscles of facial expression it causes a lot of functional problems one of which is that the eye is too open because the closure is affected by the paralysis and also it causes a lot of problems functioning in society because the appearance is typically very asymmetric and disfigured looking and others who don't know how to process the difference in one side of the face versus another don't really know how to react to that individual so without further ado i will let our patient describe the problem herself this patient is a lovely woman who's very very generous in allowing us to share her story.
I'm going to show you her interview include Dr. Robert Levine, a long time oculoplastic surgeon who's done a lot of groundbreaking work in this field and I've worked with I've had the pleasure and privilege of working with for many many years and then I'll catch you on the back end."
Interviewer: "Okay so thanks for agreeing to share your story with everyone else can you tell us uh who you are a little bit about yourself and then about uh what happened to you?"
Jody Brown: "Sure my name is Jody brown and I am wife mother four kids uh professional speaker and and about 15 years ago I had a brain tumor between the end of my ear canal and wrapped around my brain stem and in the process of removing that tumor it left my face paralyzed. I had a spinal fluid leak, I lost my hearing had oh all sorts of fun complications but the one that has lasted the longest are the effects of facial paralysis so in the last 15 years I have undergone I think we're at 17 surgeries now to try to fix all of the complications and side effects."
Interviewer: "Why people with an acoustic neuroma which is a type of tumor you had why they have problems with the with the face because it's not in the brain and do you want to tell us a little bit about why this is a very common problem?"
Jody Brown: "Sure, so in the process of removal because of the nerves that are all right there i had issues with my fifth seventh and eighth cranial nerves and each of those cranial nerves are related to a different part of functionality and when you hit seventh and eighth cranial nerves that's when you start to have problems with different parts of your face and so depending on where the tumor is and what the situation is and taking it out you can end up having facial palsy facial paralysis when you have facial paralysis it's usually one-sided because the tumor is on one side and they take it out and that then makes it so you don't have control over anything on that side of your face so no controlling the food and fluids in your mouth i used to drool and have things drip out in my mouth all the time very difficult to eat and to drink can't open and close your eyes normally and it's a little different from case to case depending on what the exact circumstances are for me my eye just stayed in a permanently wide open position and i couldn't close it i also don't produce very many tears i only produce about three tears per minute and the drain doesn't work and so when anything accumulates it just all accumulates right there in the eye and so in a course of trying to alleviate as many of these issues as possible I've undergone a series of different procedures most of them have involved my eye."
Interviewer: "So why does the eye stay open too much if you have a paralysis?"
Jody Brown: "Because the eye stays open because the muscle that closes the eye no longer works that's where the paralysis comes.
Interviewer: "That's the orbicularis the one that orbits or goes around the eyeball."
Jody Brown: "I'll take your word for it that that's the name for it but yes so that when that muscle stops working then you are no longer able to close your eye so my eye was very big and wide open always causing problems i have had a spring in my eyelid for 14 years I wore an eye patch on and off for the better part of a year to two years as we were getting trying to figure out how to manage it so the initial solution was a gold weight but the size that we would need of a gold weight for gravity to do its job and keep it closed was was much too large for me and my body size and for the nature of my paralysis and so after having a gold weight for about a year my neuro ent recommended that I come to sunny Southern California to meet with Doctor Robert Levine to have a palpable spring implanted into my eyelid so my first spring was put in 14 years ago the way that a spring works is it functions very much like a safety pin it's got the top part the little spring in the corner and then it comes over and that is attached to the the top bone right here this corner of the spring comes over and then it goes across the middle of the eyelid and is implanted into the muscle so that when the eye relaxes a little bit it actually helps to close the eye so it gives you a little bit of hopefully a lot of closure but it depends on you know how well everything's working and how well it's implanted I have had great success far more success with the spring than I ever had with the gold weight."
Interviewer: "So the spring is quite a lengthy operation and you're awake part of the time why why would you need to be awake?"
Jody Brown: "No one likes to be awake during surgery; let's face it but you have to be awake because they have to see if it's implanted in the right place so that they know if you're getting the kind of closure that you need because they want you to have as much and as tight closure as possible for functionality purposes but also to protect the eye and so in the course of having the spring implanted they have to figure out if it's in the right place and also they need to make sure that it is the curvature that they've got it fixed so that it fits the curvature of your eye because they want it to have a nice tight fit and not have any parts that will be able to come loose or break through if it's created and fitted appropriately it should last for years and years and gives you much greater closure than you could have otherwise this particular spring i have had for 10 years however this is my second spring the first one only lasted a few years and it started to move out of place and so we came and had to have it surgically not replaced but adjusted and put into a better location in the second round of having a spring the Dr. Levine was very very intentional and methodical and actually came up with kind of a new solution so that not only when he implanted the spring did he put it in the right spot for closure but he also put it inside of a little sleeve so that it would better protect the eye and not have as great of likelihood to poke through the eyelid when it did wear out and you think about the fact that you have up to 14 000 blinks in any given day and that is working on repeat it just simply is going to wear out so i'm very fortunate i got 10 great years out of the spring and now we are going to replace that spring and do a little packing of some fat around my eye to help fill in some of the hollowness in my face that has naturally occurred over the course of 15 years of paralysis."
Interviewer: "Dr. Levine can you explain a little bit to us about how you began doing palpebral springs and where your interest came from in that operation?"
Dr. Robert Levine: "When I was a chief resident at Bellevue Hospital at the NYU Medical Center Professor Laurel Fasher who came up with the idea of putting a little wider spring in an eyelid to make it blink again taught us about his procedure and as it turned out I had a patient who needed that operation and did the first one at Bellevue Hospital way back when. When I came out to California I was a heat fellow at the Delaney Foundation at the time I had a conversation in the doctor's lounge with Dr. Bill House who had pioneered the new approach at that time to acoustic tumor surgery as a result of which the morbidity which had been around 15 percent or higher went down to nearly zero making LA a mecca for acoustic tumor surgery and so Dr. House and Dr. Hitzelberger his neurosurgical colleague were doing many many cases on a routine basis day in and day out and he said to me you know have you ever heard about the spring operation that was invented in France? I said actually I did one when I was chief resident he said we better start doing them here because we're having a terrible time managing the eye complications in our acoustic tumor patients.
We published the first 22 cases in the eye literature in the American Journal of Ophthalmology that was authored by myself Dr. House and Dr. Hitzelberger and now more than 2,000 springs later still doing them. It turns out of all the things that have been thought up over the years to try to manage that very difficult problem the spring has been the best. Gold weights work if you're sitting up; gold weights don't work at all if you're lying down so you have a part-time solution and not a full-time solution even with a successful so-called gold weight or platinum chain operation since they're gravity independent.
The spring works in all positions and so is a much better solution."
Interviewer: "So what kind of problems do you have functionally from having the eye open too much? It would seem like it would be pretty simple to wear a patch or to tape the eye."
Jody Brown: "It might seem like those are simple or good solutions but they're not. It's really tricky because if you think about it you think about the number of times a day that you blink upwards of 14,000 times you are constantly that means your eye is getting lubricated it's being protected you're getting that closure when your eye is open all the time you are you are a target the wind blows and something gets in your eye and you can't protect it anything happens and there are things that are accumulating in your eye there's dust there's debris it becomes uncomfortable it becomes painful then you have also the chance that something's going to scratch your eye your cornea gets damaged and it really is quite an uncomfortable situation. I have tried every method of taping on the planet I think and it's just not a great solution because especially in my case where my eye wanted to stay in the open position that meant that after some period of time whatever kind of tape you had on the eye would still start to open and I'd wake up in the middle of the night and I have the tape over my eye but my eye is open underneath. With a patch, a patch helps because it takes the pressure off your eye from having to function and so it does help a little bit with with a dry eye it helps a little bit with the protection but then you also have there's quite a bit of stigma and not everyone is very nice about, it but it also does limit your perception your depth perception and it still doesn't solve the underlying problem.
So I do still use a patch from time to time when my eye is exhausted and when I just don't have any other solution sometimes I'll still pop a patch on top of there just to give it a little bit of a break because if it can't get the closure it needs or if there's some other irritation sometimes just giving the eye a break will help."
Interviewer: "Dr. Levine, do you want to comment on measures that can be taken to protect the eye when there's excess opening such as in facial paralysis?
Dr. Robert Levine: "Another device that's very useful is a moisture changer which is basically a one-sided gobble with a little foam around it and that creates a moist space."
Interviewer: "Is that something that a patient would wear during the day or only when they're asleep?"
Dr. Robert Levine: "Primarily for sleep but you can wear it during the day as a temporary measure it's not easy to deal with device in a lot of circumstances in that you can't fit glasses over it so easily if you're wearing glasses unless you use an anti-fog solution on the inside because it's moist. it's going to fog up.
Interviewer: "Also use a contact lens do you want to tell us about that?"
Dr. Robert Levine: "Yeah so the contact lens is a adjunctive device that we can use if you have a reasonable amount of closure but even with a 24 hour lens that can be put in and left in for a long period of time because it has a good oxygen transmission. Those lenses tend to dry out and then pop out of the eye unless there's some reasonable amount of closure and blinking to begin with. So when somebody who's got a weakness but some degree of closure that's a very good thing and somebody who's already got even good closure but a dry eye because the basic pathology has also affected the tear system.
By that I mean if the if you have a brain tumor like an acoustic tumor located such that it also involves the branches to the tear system the eye produces zero tears and so that's its own issue."
Jody Brown: "I have used every one of the options that Dr. Levine has mentioned. I had the moisture chamber in the hospital that is effective to a certain point and nowadays there's also moisture chamber sunglasses that you can buy that have a protective covering in the outside so that they they protect you a little bit from the outside wind and things getting in any kind of debris getting in.
Those I have I used that for a number of years they did finally wear out but that there are options out there that will help but with all of these different things I would say they're all temporary until you have something like a spring that can actually provide you with true functionality. All of the others are like band-aid fixes but really you need something that's going to give you the functionality that will help you be able to live your day-to-day life without the constant pressure and hassle and frustration of realizing every moment of every day that you've got something wrong with you. There have been many many times in the last dozen plus years where I've had great days gone through lived totally normal life without having to think about the fact that my face was paralyzed because I've had solutions that have really worked for me and my family and that is the best that is the best solution you can possibly have."
Dr. Joel Aronowitz: "Well I hope you enjoyed that interview with Jodi. She's really a very special person and really shows you how when life gives you lemons you can make lemonade. I hope it gives you a little insight into the challenges that our facial paralysis patients face and why doctors like Dr. Levine and myself and many others are very dedicated to trying to help people that suffer from this malady.
There are many causes of facial paralysis. Many people have a benign brain tumor and acoustic neuroma like Jodi but many others have a Bell's palsy that just didn't get better like 80 or 90 percent of them do. Some people have trauma from surgery or trauma from other accidents that sort of thing.
There's a wide variety of causes but the problems that people face are all very similar. They're social in facing the stigma of not being able to properly express your emotions on your face as well as the lack of understanding of the public about what's going on with this face that looks really distorted and then there are a host of functional problems as well. The surgery itself, the spring and other operations for this problem we'll deal with in a second video but I wanted to make this one just about Jodi so that you could have some insight into why this is a very compelling problem.
So thanks so much to Jodi for sharing her story and thanks to you for watching."
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