The brain while expanding pushes the skull outward in the same perpendicular to the closed structure. This will be marked by the occurrence of 'papilledema' 'pseudoproptosis' as also 'optic atrophy.' (39) This results in the orbital socket being smaller and the eyes getting 'protoposed'. The intercranial pressure is bound to be high. The symptoms in such cases will be optic atrophy, head ache and papilledema. Or in the case of 'Crouzon's disease' where occurs a marked hooked nose and a frontal lobe which makes the disease also called the parrot head disease. Surgery in both these types of situations become mandatory as the result of the cranial pressure could result in death. (39) Regarding the facial surgery discussions always centre on perfecting features and cosmetic changes. The debate must rather be on the goals of the surgery and the overall benefits that can accrue to the patient in terms of anatomical benefits. (7) in cases of adults and children different considerations of etiologies exist. For planned intervention and rehabilitation etiology is important. It is crucial that the etiology of the patient and associated problems be determined including the severity of the paralysis. In some cases etiology is apparent as in the case of a 'temporal bone fracture' or in 'partoid' cancer. Where it is obscure further tests may be necessary. In the absence of proper verification it may result in the deterioration of the patient's condition. (5)

All medical problems, and the time of onset of the paralysis is important along with the condition of the internal 'audiary canal'. MRI scan is helpful in diagnosis. A front cranial nerve examination and procedures like the 'hypoglossal facial anamostosis' need be conducted in cases where severe injuries in the cranial area are noted." (Park (5) p. 140) While assessing the anatomy of the patient, the forehead must be analyzed for cosmetic reasons. The degrees of the 'ptosis' of the brow along with eye examination are warranted. Regarding the eye it is important to observe for Bells disease, and the closure rate of the eye. Corneal anesthesia and dry eye are called Bad by Gulbor. Nasal functions and 'valve collapse' with or without 'septal' deformities must be noted. The depth of the 'septal' muscles and location are important. Similar examination of the mouth with particular notice to the mouth, upper and lower lips, dysfunction, dentures, drooling, biting etc. ought to be observed and recorded. (5)

Other tests that form the part of etiology are electrophysiological tests that help measure muscle dysfunction, and the maximal simulation test that determines the amount of facial nerve degeneration. Electromyography is used to find the 'depolarization' potentials of fibers and motor units. The patient may also be subjected to the nerve excitability test. Through this test we can obtain the current in amps that is necessary to obtain minimum 'facial movement'. (5) a difference to 3.5 amp between affected to the normal side will indicate a poor chance of recovery. To test the muscles an electrode stimulated record of muscle function is obtained by the 'electroneurography'. CT scans of the temporal bone helps in surgical planning. (5)

In short the necessary test for etiology may be summed up as "The history of the patient, Topognostic tests- Including hearing, stapes and schimers's tests, electrical tests - MST, EENG, and EMG tests, Radiographic study of chest, CAT Scan, magnetic resonance scan, and many laboratory tests needed for a surgical evaluation of the individual including lumbar puncture, WBC count, Mono spot tests, test for 'sarcodisis' and so on." (May, Schaitkin (6) p. 183) Bell's palsy is the most noted etiology, but there must be a diagnosis of exclusion all infections and congenital and developmental influences, and other causes must be ruled out. In a differential diagnosis for bell's palsy the diagnosis of exclusion works for 40% cases, the "chronic 'otitis media' may occur due to nerve compression from granulation tissue, or 'herpes 'zoster' 'oticus' which causes hearing problems with vertigo, and 'lyme disease' that forms after inoculation, and tumors - like temporal bone leukemia, fractures, and 'Melkwerson -Rosenthal Syndrome.'" (Kahan (10) p. 30)

In pediatric cases a surgical scoring system to asses the severity of the RRP disease is needed to track the course of the disease in the infant. (9) a case study of the etiology of a 3-day-old male child with left facial paralysis had the following history: The maternal history prior to delivery was normal, and the delivery was a 'vaginal delivery' without the use of forceps. There was mild facial asymmetry and no record of family inheritance of the disease. The physical examination did not show any abnormalities...

The etiology posed the problem of determining if it is traumatic, or congenital. Congenital facial paralysis can occur at the use of forceps caused by 'ecchymosis' or by indentation of the bony canal. In the case of paralysis with traumatic causes, the recovery can be better predicted. CT scan and other tests showed that this was a case of congenital unilateral facial paralysis of traumatic etiology. After three months full recovery of the patient was spontaneous and therefore no further intervention was necessary. (8)
The fact that natural recovery is possible without surgical intervention in case of infants with trauma, or facial paralysis owing to gynecological complications the case has to be studied in depth over time. In childhood the 'Acute lower motor neurone facial paralysis' is commonly observed and it is resolved in course of time naturally. (11) Some times conditions at the facial canal and mastoid cavity are the hot spots where the facial nerve which after leaving the pns at the 'pontomedullary junction' enters inside the skull through 'the internal auditory meatus' and the hot spots and problem areas may occur in these locations, along with the branches at the petrous temporal bone. (11)

In the case of the diseases that originate from malformities of the skull, 'Craniofacial techniques' are handy where the issue is an 'orbitofrontal fractures' and for 'post-traumatic sequelae', especially 'malar' and 'ethmoidal fractures'. "Craniofacial malformations' are very diverse and optimal timing for surgery is different from case to case." (39) the surgery is multidiscipline, spanning neurosurgery and plastic surgery. The amount of bone and soft tissue involvement in the deformities will determine the result of the surgery. Modern methods that involve the use of 'microplate' systems and computer aided imaging have gone a long way in aiding the surgery of the facial paralysis and anomalies. (39) the suggested etiology of the 'proptopsis' thus is a study of the history, physical records. The work-up for proptosis should begin with a complete history and physical, complete 'ophthalmic examination', 'orbital examination' with a record of palpitation, and proper imaging. Patients who show 'proptosis' "should have baseline thyroid function tests like TSH, free T3, free T4 and anti-thyroid antibodies are mandatory. Initial imaging should be in the form of a CT scan, followed by MRI if indicated." (Omer, Ozak, Ozgencl, Oouz, Faruk, Kamuran (38) p. 336)

Direct nerve to muscle neurotization of EYE SPHINCTER (orbicularis ori muscle, 12 LIPS DEPRESSOR, SMILE RESOTRATION and TONGUE specifically.

Disregarding the cause, whether by surgery or trauma, facial paralysis causes emotional disturbance in patients of any age group. It is the most outwardly identifiable trauma or surgery, exacts a dramatic physical and emotional toll from patients. The surgery for restoring the facial nerve must have created a difference in restoring tone, symmetry and simple voluntary motion. (14) the most important challenge in plastic surgery is reconstructing the eye and tongue movement which is a challenge to the surgical abilities and the nature of the process. The muscles used for facial surgery include "extensordigitorum brevis', Gracilis, 'Lassimus dorsi', 'Pectoralis major,' 'Rectus abdominis' and' Serratus anterior'." (Papel (17) p. 679) Surgeons speaking of the muscle nerve selection have the opinion that "muscle transfer should receive impulses from the uninjured facial nerve if a natural smiling response is to be provided." (Stone (16) p. 363)

The serious problem for the patient often is the inability to smile or move the lips. For the eye closure "free functional muscle transplantation offers a good solution for regaining near-normal eye protection without the need for implants." (Frey, Giovanoli, Tzou, Kropf, Friedl (12) p. 865) in an experiment wherein 42 of the patients with the issue of facial paralysis were being treated with the "Temporalis muscle transposition' to the eyes, in thirty four cases, free 'gracilis muscle transplant' with 'double cross-face nerve grafting' was resorted to." (Frey, Giovanoli, Tzou, Kropf, Friedl (12) p. 865) Further a study pertaining to "the preopertaion and post surgery details revealed that the 'gracilis muscle transplant' that was 'reinnervated by a 'zygomatic branch of the 'contralateral' through the nerve graft, changed the eyelid close count from 10.21 +/- 2.72 mm to 1.68 +/- 1.35 mm, compared with 13.70" (Frey, Giovanoli, Tzou, Kropf, Friedl (12) p. 865)

The techniques vary and there are variations that are caused by the mobility of donors in the case of 'hypoglossal-facial nerve repair'.…