145
Contemporary Facial Reanimation Tessa A. Hadlock, MD1
1 Division of Facial Plastic and Reconstructive Surgery, Department of
Otolaryngology, Harvard Medical School/Massachusetts Eye and Ear Infirmary, Facial Nerve Center, Boston, Massachusetts Facial Plast Surg 2014;30:145–151.
Abstract
Keywords
► facial paralysis ► facial nerve ► reanimation
Address for correspondence Prabhat K. Bhama, MD, MPH, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Harvard Medical School/Massachusetts Eye and Ear Infirmary, 243 Charles Street, 9th Floor, Facial Nerve Center, Boston, MA 02117 (e-mail: [email protected]).
The facial nerve is the most commonly paralyzed nerve in the human body. Facial paralysis affects aesthetic appearance, and it has a profound effect on function and quality of life. Management of patients with facial paralysis requires a multidisciplinary approach, including otolaryngologists, plastic surgeons, ophthalmologists, and physical therapists. Regardless of etiology, patients with facial paralysis should be evaluated systematically, with initial efforts focused upon establishing proper diagnosis. Management should proceed with attention to facial zones, including the brow and periocular region, the midface and oral commissure, the lower lip and chin, and the neck. To effectively compare contemporary facial reanimation strategies, it is essential to employ objective intake assessment methods, and standard reassessment schemas during the entire management period.
The management of facial paralysis is extraordinarily complex and often requires input from multiple disciplines. The key initial step to proper management is meticulous data collection during patient intake and assessment (►Fig. 1). When a patient presents with facial paralysis, assessment must be completely codified,1 and should include a quality of life (e.g., Facial Clinimetric Evaluation Scale)2 assessment, static and dynamic facial movement analysis (►Fig. 2), and a “lay-person” assessment of overall facial harmony. In selected cases, assessment may also involve symptom-related patientreported outcome measures, such as the Nasal Obstruction Symptom Evaluation Scale,3 or the Synkinesis Assessment Questionnaire,4 or assessments of smile spontaneity. Once patient intake has been completed comprehensively and systematically,1 management evolves from the captured data.5 For example, patients with specific ocular symptoms related to malposition of the eyebrow or eyelids require periocular reanimation. Patients who experience difficulties with smiling need intervention with static, regional, or free tissue techniques to correct oral commissure malposition. Thus, the management plan must follow a formalized, systematic, and comprehensive assessment.
Issue Theme 11th International Symposium of Facial Plastic Surgery; Guest Editors, Jonathan M. Sykes, MD, FACS, and Anthony P. Sclafani, MD, FACS.
General Concepts Once facial nerve insult has occurred, it is paramount to establish an environment where optimal reinnervation can occur. In cases of nerve transection, coaptation of the cut ends of the nerve using 10–0 nylon epineural sutures is indicated. If the transected ends of the nerve cannot be repaired without tension, then a cable graft is used to appose the ends. If primary nerve repair or cable graft cannot be performed, preservation of native facial musculature is the next crucial step in facial rehabilitation. Although free tissue transfer and regional muscle transfers can mimic the action of native smile musculature, they do not emulate the exact movements of the native musculature. Therefore, if the patient presents within 2 years of loss of facial muscle function, a nerve transfer to preserve facial muscle tone, and possibly movement can be considered. Typically, the hypoglossal nerve or the masseteric branch of the trigeminal nerve serves as a donor nerve, though using the latter precludes later use during free tissue transfer. Deep temporal nerve branches are also an option for use as donor nerves, but are of limited caliber and length, which can make coaptation to smile branches challenging.
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1371900. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Prabhat K. Bhama, MD, MPH1
Contemporary Facial Reanimation
Bhama, Hadlock
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146
Fig. 1 Scale for physical examination of the patient with facial paralysis.
Cross-face nerve grafting to the native distal branches of the facial nerve is another option for patients who desire emotive dynamic facial movement. As described above, these procedures are typically reserved for Facial Plastic Surgery
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those patients whose facial musculature is receptive to reinnervation. This condition exists in recently denervated muscle, and in muscle which has been aberrantly innervated.
Bhama, Hadlock
147
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Contemporary Facial Reanimation
Fig. 2 Massachusetts Eye and Ear Infirmary Face-GRAM program for analyzing facial movement.
Fig. 3 Securing miniplate to frontal calvarium during brow lift.
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Contemporary Facial Reanimation
Bhama, Hadlock
Fig. 6 Highly selective neurectomy for ocular synkinesis. Selected facial nerve branches are delivered transcutaneously through stab incisions for neurectomy once the patient is awake.
Fig. 4 Placement of platinum eyelid weight.
Management of the Paralyzed Face by Zone Brow Brow Lift The brow can be variably malpositioned in the patient with facial paralysis. Most commonly, the brow is ptotic at rest, but it may also be balanced or paradoxically hyperelevated. The ptotic brow causes disfigurement and may result in desquamation of epithelial cells onto the cornea, resulting in ocular irritation. Brow ptosis can also contribute to a peripheral visual field deficit, if dermatochalasis is present. Elevation of the brow can be performed by any number of surgical approaches.6,7 Recently, an efficient and reliable method to lift the brow was described6 using a miniplate and monofilament nonabsorbable suture. The procedure is performed in the clinic setting under local anesthetic. An incision to calvarium centered in the midpupillary line is made in within the hairline of the frontal scalp and the pericranium is elevated just enough to accommodate a reconstruction plate. Three stab incisions are made in the eyebrow itself to permit passage of a straight
needle between the incisions in the subcutaneous plane. The sutures are passed transcutaneously into the subperiosteal space of the forehead, and delivered through the scalp incision, and secured to the calvarium with a miniplate (►Fig. 3). Selected patients with unilateral brow paralysis can be treated by injecting the contralateral frontalis muscle with botulinum toxin to create a more symmetric look. The paradoxically hyperelevated brow may also be corrected via injection into the depressors of the contralateral brow. Patients typically require repeated visits every 4 to 6 months.
Periocular Upper Eyelid Techniques Lagophthalmos results from denervation of the orbicularis oculi muscle, and must be treated to avoid exposure keratopathy, and even blindness. Aggressive lubrication and taping the eye shut at night should be employed in the acute setting. Tarsorrhaphy can attenuate symptoms in these patients, but it often yields a poor esthetic result, and can cause visual field deficits. Lid loading is an effective management strategy, though the successful use of palpebral springs has also been reported.8,9 Eyelid weight placement augments gravity-assisted closure of the upper eyelid (►Fig. 4). Thin-profile platinum eyelid weights are preferred over gold weights because they have a lower risk of extrusion, reduced bulk, and decreased risk of allergic reaction.10
Lower Eyelid Tightening
Fig. 5 Suturing tarsal plate to medial aspect of lateral orbital rim.
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Paralysis of the lower lid orbicularis oculi can result in lower lid malposition, causing scleral show and exacerbating lagophthalmos. Elevation of the lower lid is often used in conjunction with upper eyelid weighting to achieve full eye closure. The procedure begins with lateral canthotomy, followed by inferior cantholysis. Five millimeters of lateral tarsal plate are then isolated by removing the overlying anterior lamella and underlying palpebral conjunctiva. The lateral 2 mm of the plate are trimmed sharply. The gray line of the inferior and superior lids are then denuded, and approximated to one another using 5–0 polyglactin suture. A 4–0 braided nonabsorbable polytetrafluoroethylene coated suture is then
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inferior flap deep to the superior flap, and establishment of a neonasolabial fold.
Flaccid paralysis leads to a characteristic blunting of the nasal sill region on basal view, secondary to deviation of the nasal base to the normal side. Symptomatically, this presents as nasal obstruction, and may be addressed by making in incision in the nasofacial crease and securing a strip of fascia lata to the sesamoid cartilage and fibrofatty tissue of the lateral nasal ala (►Fig. 7). The superior end of the fascia lata is tunneled subdermally and secured to the deep temporal fascia under tension to lateralize the ala and open the nasal valve.13
Smile Fig. 7 Schematic for suspension of external nasal valve with fascia lata sling. Note the placement of alar batten graft is performed only in selected patients with external nasal valve collapse refractory to static suspension.
used to secure the tarsal plate to the periosteum of the medial aspect of the lateral orbital rim (►Fig. 5). The wound is then closed with 6–0 fast absorbing plain gut sutures.
Smile reanimation is perhaps the biggest target of facial reanimation surgeons. Regional muscle transfer is appropriate in patients with a poor prognosis or the elderly, but it provides limited excursion of the oral commissure. Free tissue transfer permits the surgeon to engineer the vector of the resultant smile, and limit the amount of bulk transferred to the face, and has thus become the gold standard for smile reanimation. Of the muscles described for smile reanimation, gracilis is the most widely employed.14
Highly Selective Neurectomy Symptomatic periocular synkinesis is treated using botulinum toxin injections. Antibody development to botulinum toxin has been described11 and results in poor response to continued injections. For these patients, highly selective neurectomy is often useful. The procedure is performed in two stages—the first stage under general anesthetic and the second with the patient completely awake. Under general anesthesia, facial nerve branches innervating the orbicularis oculi are identified, isolated with vessel loops, and delivered transcutaneously through stab incisions in the skin (►Fig. 6). The wound is then closed. Once the patient is awake, branches that induce eye closure with voluntary smile are divided until the desired effect is reached without creating lagophthalmos.12
Midface and Nasal Base Nasolabial Fold Effacement of the nasolabial fold (NLF) at rest is an obvious source of asymmetry in the patient with flaccid paralysis. Static suspension of the oral commissure may help to reestablish the inferior aspect of the NLF, but it does little to recreate the superior portion of the NLF. A neo-NLF can be created by making an incision where the NLF should rest. A sub-SMAS flap is then raised superiorly, and a triangular portion of the inferior flap is deepithelialized. A segment of fascia lata equal in width to the triangular strip created in the prior step is then harvested from the thigh and sutured to the deep aspect of the triangular strip of dermis using 4–0 monofilament nonabsorbable suture. The fascia is tunneled subdermally and secured to the deep temporal fascia under tension. This results in retraction of the dermal tab of the
Technique for Microvascular Free Gracilis Transfer The recipient site is prepared by making a modified Blair incision on the paralyzed side of the face and elevating a subSMAS flap anteriorly. Once the anterior border of the parotid gland is reached, care is taken to avoid damaging native functioning branches of the facial nerve, if present. The modiolus is identified by tracing the facial artery from the inferior border of the mandible anteriorly to the oral commissure, and by identifying the zygomaticus major muscle and tracing it inferomedially to its insertion. The donor nerve is then identified. In patients undergoing cross-face nerve grafting, the nerve is typically left in the submucosal plane of the upper lip. In patients who will have a trigeminally innervated gracilis, the masseteric branch of the trigeminal nerve is dissected from within the masseter muscle and reflected superficially. The gracilis muscle is harvested via an incision placed in the medial thigh, approximately 12 to 15 cm in length. The gracilis muscle is identified, and the plane between the adductor longus and magnus muscles is developed to permit adequate dissection of the neurovascular pedicle. The length of muscle harvested is calculated by measuring from the free edge of the tragus to the oral commissure and adding 2 cm. Typically, 50% of the width of the muscle is harvested. The harvested segment is trimmed extensively to minimize the amount of bulk transferred into the face; a final weigh of 6 to 18 g is desirable. The gracilis muscle is inset medially to the modiolus using 0 polyglactin suture to achieve minimal overcorrection of the oral commissure. Then, microvascular anastomosis and neural coaptation are performed. The superior aspect of the gracilis is then affixed to the deep temporal fascia using 0 Facial Plastic Surgery
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External Nasal Valve
Contemporary Facial Reanimation
Bhama, Hadlock Platysmectomy Platysmectomy is ordinarily performed in the clinic setting using local anesthesia. The patient is asked to close their eyes or perform any other facial movement that causes unwanted platysmal contraction. The medial and lateral edges of the platysma are marked. A 1 cm incision is made in a natural neck crease well inferior to the lower border of the mandible to avoid injury to the marginal mandibular branch of the facial nerve. The platysma muscle is then identified, and blunt dissection is used to expose the deep and superficial borders of the muscle. The medial and lateral borders of the platysma are dissected, and a 1 cm strip of muscle is excised using bipolar electrocautery (►Fig. 8).19
Fig. 8 Platysmectomy. A 1 cm band of platymsa muscle is resected to prevent readhesion of cut ends of muscle.
polyglactin suture. After perfusion of the flap is confirmed and hemostasis achieved, the wound is closed.15
Lower Lip and Chin Lower Lip Asymmetry Management Paralysis of the depressor anguli oris and depressor labii inferioris results in inadequate downward displacement of the affected lower lip during smile and speech, particularly in the patient with a “full-denture” smile. Digastric muscle transposition has been described as an option for surgical rehabilitation of the lower lip,16 but satisfactory results can often be obtained by using contralateral chemodenervation techniques. Injection of botulinum toxin into the contralateral depressor labii inferioris creates a more symmetric smile by inhibiting inferior displacement of the unaffected lower lip. This procedure can be repeated every 4 to 6 months for two to three treatments. If the patient desires a more permanent solution, resection of the depressor labii inferioris via an incision in the sublabial mucosa of the lower lip can be considered.17 Chemodenervation for Mentalis Dimpling Synkinesis of the mentalis muscle can cause inappropriate dimpling of the chin with facial movement. This is addressed with local injection of botulinum toxin, which is typically repeated every 4 to 6 months. The use of botulinum toxin has been shown to improve quality of life scores in patients with hypertonic facial paralysis.18
Platysmal Denervation If platysmectomy fails to attenuate symptoms of hypertonic paralysis, denervation of the platysma can be considered. The procedure is performed via a modified Blair incision on the affected side. A sub-SMAS flap is raised and the anterior border of the parotid gland is identified. Facial nerve branches along the inferior aspect of the face are then carefully dissected as they exit the anterior border of the parotid. If a nerve exclusively innervating the platysma is identified, a 1 cm length is transected.
Conclusion Comprehensive rehabilitation of the paralyzed face must involve rigorous use of validated assessment tools at intake, and following recovery and treatment. Each zone of the face must be carefully considered. Zonal facial assessment leads to identification of targets for the facial reanimation surgeon, and each intervention should be followed by repeat assessments, demonstrating the QOL benefits and subjective or objective changes following the intervention.
References 1 Bhama P, Gliklich RE, Weinberg JS, Hadlock TA, Lindsay RW.
2
3
Neck Chemodenervation Platysmal synkinesis can result in unsightly and uncomfortable vertical banding of the neck during dynamic facial expressions. Involuntary contraction of the platysma may also restrict oral commissure movement by pulling the lower lip inferiorly during smiling, and yields excessive pulling and tension in the neck. Chemodenervation using botulinum toxin injection is typically the first step in addressing platysmal synkinesis refractory to physical therapy. Injections are typically repeated every 4 to 6 months. If the patient requests a more permanent solution, platysmectomy can be performed.19 Facial Plastic Surgery
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5
6
7
Optimizing Total Facial Nerve Patient Management for Effective Clinical Outcomes Research. JAMA Facial Plast Surg 2014;16(1): 9–14 Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB, McKenna MJ. Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale. Laryngoscope 2001; 111(3):387–398 Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004; 130(2):157–163 Mehta RP, WernickRobinson M, Hadlock TA. Validation of the Synkinesis Assessment Questionnaire. Laryngoscope 2007; 117(5):923–926 Hohman MH, Bhama PK, Hadlock TA. Epidemiology of iatrogenic facial nerve injury: A decade of experience. Laryngoscope 2014; 124(1):260–265 Hohman MH, Silver AL, Henstrom DK, Cheney ML, Hadlock TA. The “Power” Brow Lift: Efficient Correction of the Paralyzed Brow. ISRN Plastic Surgery 2013;2013:1–4 Quatela VC, Graham H, Sabini P. Rejuvination of the brow and midface. In: Papel I, ed. Facial Plastic and Reconstructive Surgery. New York, NY: Thieme Medical Publishers, Inc.; 2002
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8 Demirci H, Frueh BR. Palpebral spring in the management of
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12
13
lagophthalmos and exposure keratopathy secondary to facial nerve palsy. Ophthal Plast Reconstr Surg 2009;25(4): 270–275 Fay A, Santiago YM. A modified levine palpebral spring for the treatment of myogenic ptosis. Ophthal Plast Reconstr Surg 2012; 28(5):372–375 Silver AL, Lindsay RW, Cheney ML, Hadlock TA. Thin-profile platinum eyelid weighting: a superior option in the paralyzed eye. Plast Reconstr Surg 2009;123(6):1697–1703 Göschel H, Wohlfarth K, Frevert J, Dengler R, Bigalke H. Botulinum A toxin therapy: neutralizing and nonneutralizing antibodies—therapeutic consequences. Exp Neurol 1997;147(1): 96–102 Hohman MH, Lee LN, Hadlock TA. Two-step highly selective neurectomy for refractory periocular synkinesis. Laryngoscope 2013;123(6):1385–1388 Lindsay RW, Smitson C, Edwards C, Cheney ML, Hadlock TA. Correction of the nasal base in the flaccidly paralyzed face: an
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orphaned problem in facial paralysis. Plast Reconstr Surg 2010; 126(4):185e–186e Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 1976;57(2):133–143 Hohman MH, Hadlock TA. Microneurovascular free gracilis transfer for smile reanimation. Operative Techniques Otolaryngology 2012;23(4):262–267 Conley J, Baker DC, Selfe RW. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg 1982;70(5):569–577 Lindsay RW, Edwards C, Smitson C, Cheney ML, Hadlock TA. A systematic algorithm for the management of lower lip asymmetry. Am J Otolaryngol 2011;32(1):1–7 Mehta RP, Hadlock TA. Botulinum toxin and quality of life in patients with facial paralysis. Arch Facial Plast Surg 2008;10(2): 84–87 Henstrom DK, Malo JS, Cheney ML, Hadlock TA. Platysmectomy: an effective intervention for facial synkinesis and hypertonicity. Arch Facial Plast Surg 2011;13(4):239–243
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Contemporary Facial Reanimation Tessa A. Hadlock, MD1
1 Division of Facial Plastic and Reconstructive Surgery, Department of
Otolaryngology, Harvard Medical School/Massachusetts Eye and Ear Infirmary, Facial Nerve Center, Boston, Massachusetts Facial Plast Surg 2014;30:145–151.
Abstract
Keywords
► facial paralysis ► facial nerve ► reanimation
Address for correspondence Prabhat K. Bhama, MD, MPH, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Harvard Medical School/Massachusetts Eye and Ear Infirmary, 243 Charles Street, 9th Floor, Facial Nerve Center, Boston, MA 02117 (e-mail: [email protected]).
The facial nerve is the most commonly paralyzed nerve in the human body. Facial paralysis affects aesthetic appearance, and it has a profound effect on function and quality of life. Management of patients with facial paralysis requires a multidisciplinary approach, including otolaryngologists, plastic surgeons, ophthalmologists, and physical therapists. Regardless of etiology, patients with facial paralysis should be evaluated systematically, with initial efforts focused upon establishing proper diagnosis. Management should proceed with attention to facial zones, including the brow and periocular region, the midface and oral commissure, the lower lip and chin, and the neck. To effectively compare contemporary facial reanimation strategies, it is essential to employ objective intake assessment methods, and standard reassessment schemas during the entire management period.
The management of facial paralysis is extraordinarily complex and often requires input from multiple disciplines. The key initial step to proper management is meticulous data collection during patient intake and assessment (►Fig. 1). When a patient presents with facial paralysis, assessment must be completely codified,1 and should include a quality of life (e.g., Facial Clinimetric Evaluation Scale)2 assessment, static and dynamic facial movement analysis (►Fig. 2), and a “lay-person” assessment of overall facial harmony. In selected cases, assessment may also involve symptom-related patientreported outcome measures, such as the Nasal Obstruction Symptom Evaluation Scale,3 or the Synkinesis Assessment Questionnaire,4 or assessments of smile spontaneity. Once patient intake has been completed comprehensively and systematically,1 management evolves from the captured data.5 For example, patients with specific ocular symptoms related to malposition of the eyebrow or eyelids require periocular reanimation. Patients who experience difficulties with smiling need intervention with static, regional, or free tissue techniques to correct oral commissure malposition. Thus, the management plan must follow a formalized, systematic, and comprehensive assessment.
Issue Theme 11th International Symposium of Facial Plastic Surgery; Guest Editors, Jonathan M. Sykes, MD, FACS, and Anthony P. Sclafani, MD, FACS.
General Concepts Once facial nerve insult has occurred, it is paramount to establish an environment where optimal reinnervation can occur. In cases of nerve transection, coaptation of the cut ends of the nerve using 10–0 nylon epineural sutures is indicated. If the transected ends of the nerve cannot be repaired without tension, then a cable graft is used to appose the ends. If primary nerve repair or cable graft cannot be performed, preservation of native facial musculature is the next crucial step in facial rehabilitation. Although free tissue transfer and regional muscle transfers can mimic the action of native smile musculature, they do not emulate the exact movements of the native musculature. Therefore, if the patient presents within 2 years of loss of facial muscle function, a nerve transfer to preserve facial muscle tone, and possibly movement can be considered. Typically, the hypoglossal nerve or the masseteric branch of the trigeminal nerve serves as a donor nerve, though using the latter precludes later use during free tissue transfer. Deep temporal nerve branches are also an option for use as donor nerves, but are of limited caliber and length, which can make coaptation to smile branches challenging.
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1371900. ISSN 0736-6825.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Prabhat K. Bhama, MD, MPH1
Contemporary Facial Reanimation
Bhama, Hadlock
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146
Fig. 1 Scale for physical examination of the patient with facial paralysis.
Cross-face nerve grafting to the native distal branches of the facial nerve is another option for patients who desire emotive dynamic facial movement. As described above, these procedures are typically reserved for Facial Plastic Surgery
Vol. 30
No. 2/2014
those patients whose facial musculature is receptive to reinnervation. This condition exists in recently denervated muscle, and in muscle which has been aberrantly innervated.
Bhama, Hadlock
147
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Contemporary Facial Reanimation
Fig. 2 Massachusetts Eye and Ear Infirmary Face-GRAM program for analyzing facial movement.
Fig. 3 Securing miniplate to frontal calvarium during brow lift.
Facial Plastic Surgery
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Contemporary Facial Reanimation
Bhama, Hadlock
Fig. 6 Highly selective neurectomy for ocular synkinesis. Selected facial nerve branches are delivered transcutaneously through stab incisions for neurectomy once the patient is awake.
Fig. 4 Placement of platinum eyelid weight.
Management of the Paralyzed Face by Zone Brow Brow Lift The brow can be variably malpositioned in the patient with facial paralysis. Most commonly, the brow is ptotic at rest, but it may also be balanced or paradoxically hyperelevated. The ptotic brow causes disfigurement and may result in desquamation of epithelial cells onto the cornea, resulting in ocular irritation. Brow ptosis can also contribute to a peripheral visual field deficit, if dermatochalasis is present. Elevation of the brow can be performed by any number of surgical approaches.6,7 Recently, an efficient and reliable method to lift the brow was described6 using a miniplate and monofilament nonabsorbable suture. The procedure is performed in the clinic setting under local anesthetic. An incision to calvarium centered in the midpupillary line is made in within the hairline of the frontal scalp and the pericranium is elevated just enough to accommodate a reconstruction plate. Three stab incisions are made in the eyebrow itself to permit passage of a straight
needle between the incisions in the subcutaneous plane. The sutures are passed transcutaneously into the subperiosteal space of the forehead, and delivered through the scalp incision, and secured to the calvarium with a miniplate (►Fig. 3). Selected patients with unilateral brow paralysis can be treated by injecting the contralateral frontalis muscle with botulinum toxin to create a more symmetric look. The paradoxically hyperelevated brow may also be corrected via injection into the depressors of the contralateral brow. Patients typically require repeated visits every 4 to 6 months.
Periocular Upper Eyelid Techniques Lagophthalmos results from denervation of the orbicularis oculi muscle, and must be treated to avoid exposure keratopathy, and even blindness. Aggressive lubrication and taping the eye shut at night should be employed in the acute setting. Tarsorrhaphy can attenuate symptoms in these patients, but it often yields a poor esthetic result, and can cause visual field deficits. Lid loading is an effective management strategy, though the successful use of palpebral springs has also been reported.8,9 Eyelid weight placement augments gravity-assisted closure of the upper eyelid (►Fig. 4). Thin-profile platinum eyelid weights are preferred over gold weights because they have a lower risk of extrusion, reduced bulk, and decreased risk of allergic reaction.10
Lower Eyelid Tightening
Fig. 5 Suturing tarsal plate to medial aspect of lateral orbital rim.
Facial Plastic Surgery
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Paralysis of the lower lid orbicularis oculi can result in lower lid malposition, causing scleral show and exacerbating lagophthalmos. Elevation of the lower lid is often used in conjunction with upper eyelid weighting to achieve full eye closure. The procedure begins with lateral canthotomy, followed by inferior cantholysis. Five millimeters of lateral tarsal plate are then isolated by removing the overlying anterior lamella and underlying palpebral conjunctiva. The lateral 2 mm of the plate are trimmed sharply. The gray line of the inferior and superior lids are then denuded, and approximated to one another using 5–0 polyglactin suture. A 4–0 braided nonabsorbable polytetrafluoroethylene coated suture is then
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
148
Contemporary Facial Reanimation
Bhama, Hadlock
149
inferior flap deep to the superior flap, and establishment of a neonasolabial fold.
Flaccid paralysis leads to a characteristic blunting of the nasal sill region on basal view, secondary to deviation of the nasal base to the normal side. Symptomatically, this presents as nasal obstruction, and may be addressed by making in incision in the nasofacial crease and securing a strip of fascia lata to the sesamoid cartilage and fibrofatty tissue of the lateral nasal ala (►Fig. 7). The superior end of the fascia lata is tunneled subdermally and secured to the deep temporal fascia under tension to lateralize the ala and open the nasal valve.13
Smile Fig. 7 Schematic for suspension of external nasal valve with fascia lata sling. Note the placement of alar batten graft is performed only in selected patients with external nasal valve collapse refractory to static suspension.
used to secure the tarsal plate to the periosteum of the medial aspect of the lateral orbital rim (►Fig. 5). The wound is then closed with 6–0 fast absorbing plain gut sutures.
Smile reanimation is perhaps the biggest target of facial reanimation surgeons. Regional muscle transfer is appropriate in patients with a poor prognosis or the elderly, but it provides limited excursion of the oral commissure. Free tissue transfer permits the surgeon to engineer the vector of the resultant smile, and limit the amount of bulk transferred to the face, and has thus become the gold standard for smile reanimation. Of the muscles described for smile reanimation, gracilis is the most widely employed.14
Highly Selective Neurectomy Symptomatic periocular synkinesis is treated using botulinum toxin injections. Antibody development to botulinum toxin has been described11 and results in poor response to continued injections. For these patients, highly selective neurectomy is often useful. The procedure is performed in two stages—the first stage under general anesthetic and the second with the patient completely awake. Under general anesthesia, facial nerve branches innervating the orbicularis oculi are identified, isolated with vessel loops, and delivered transcutaneously through stab incisions in the skin (►Fig. 6). The wound is then closed. Once the patient is awake, branches that induce eye closure with voluntary smile are divided until the desired effect is reached without creating lagophthalmos.12
Midface and Nasal Base Nasolabial Fold Effacement of the nasolabial fold (NLF) at rest is an obvious source of asymmetry in the patient with flaccid paralysis. Static suspension of the oral commissure may help to reestablish the inferior aspect of the NLF, but it does little to recreate the superior portion of the NLF. A neo-NLF can be created by making an incision where the NLF should rest. A sub-SMAS flap is then raised superiorly, and a triangular portion of the inferior flap is deepithelialized. A segment of fascia lata equal in width to the triangular strip created in the prior step is then harvested from the thigh and sutured to the deep aspect of the triangular strip of dermis using 4–0 monofilament nonabsorbable suture. The fascia is tunneled subdermally and secured to the deep temporal fascia under tension. This results in retraction of the dermal tab of the
Technique for Microvascular Free Gracilis Transfer The recipient site is prepared by making a modified Blair incision on the paralyzed side of the face and elevating a subSMAS flap anteriorly. Once the anterior border of the parotid gland is reached, care is taken to avoid damaging native functioning branches of the facial nerve, if present. The modiolus is identified by tracing the facial artery from the inferior border of the mandible anteriorly to the oral commissure, and by identifying the zygomaticus major muscle and tracing it inferomedially to its insertion. The donor nerve is then identified. In patients undergoing cross-face nerve grafting, the nerve is typically left in the submucosal plane of the upper lip. In patients who will have a trigeminally innervated gracilis, the masseteric branch of the trigeminal nerve is dissected from within the masseter muscle and reflected superficially. The gracilis muscle is harvested via an incision placed in the medial thigh, approximately 12 to 15 cm in length. The gracilis muscle is identified, and the plane between the adductor longus and magnus muscles is developed to permit adequate dissection of the neurovascular pedicle. The length of muscle harvested is calculated by measuring from the free edge of the tragus to the oral commissure and adding 2 cm. Typically, 50% of the width of the muscle is harvested. The harvested segment is trimmed extensively to minimize the amount of bulk transferred into the face; a final weigh of 6 to 18 g is desirable. The gracilis muscle is inset medially to the modiolus using 0 polyglactin suture to achieve minimal overcorrection of the oral commissure. Then, microvascular anastomosis and neural coaptation are performed. The superior aspect of the gracilis is then affixed to the deep temporal fascia using 0 Facial Plastic Surgery
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External Nasal Valve
Contemporary Facial Reanimation
Bhama, Hadlock Platysmectomy Platysmectomy is ordinarily performed in the clinic setting using local anesthesia. The patient is asked to close their eyes or perform any other facial movement that causes unwanted platysmal contraction. The medial and lateral edges of the platysma are marked. A 1 cm incision is made in a natural neck crease well inferior to the lower border of the mandible to avoid injury to the marginal mandibular branch of the facial nerve. The platysma muscle is then identified, and blunt dissection is used to expose the deep and superficial borders of the muscle. The medial and lateral borders of the platysma are dissected, and a 1 cm strip of muscle is excised using bipolar electrocautery (►Fig. 8).19
Fig. 8 Platysmectomy. A 1 cm band of platymsa muscle is resected to prevent readhesion of cut ends of muscle.
polyglactin suture. After perfusion of the flap is confirmed and hemostasis achieved, the wound is closed.15
Lower Lip and Chin Lower Lip Asymmetry Management Paralysis of the depressor anguli oris and depressor labii inferioris results in inadequate downward displacement of the affected lower lip during smile and speech, particularly in the patient with a “full-denture” smile. Digastric muscle transposition has been described as an option for surgical rehabilitation of the lower lip,16 but satisfactory results can often be obtained by using contralateral chemodenervation techniques. Injection of botulinum toxin into the contralateral depressor labii inferioris creates a more symmetric smile by inhibiting inferior displacement of the unaffected lower lip. This procedure can be repeated every 4 to 6 months for two to three treatments. If the patient desires a more permanent solution, resection of the depressor labii inferioris via an incision in the sublabial mucosa of the lower lip can be considered.17 Chemodenervation for Mentalis Dimpling Synkinesis of the mentalis muscle can cause inappropriate dimpling of the chin with facial movement. This is addressed with local injection of botulinum toxin, which is typically repeated every 4 to 6 months. The use of botulinum toxin has been shown to improve quality of life scores in patients with hypertonic facial paralysis.18
Platysmal Denervation If platysmectomy fails to attenuate symptoms of hypertonic paralysis, denervation of the platysma can be considered. The procedure is performed via a modified Blair incision on the affected side. A sub-SMAS flap is raised and the anterior border of the parotid gland is identified. Facial nerve branches along the inferior aspect of the face are then carefully dissected as they exit the anterior border of the parotid. If a nerve exclusively innervating the platysma is identified, a 1 cm length is transected.
Conclusion Comprehensive rehabilitation of the paralyzed face must involve rigorous use of validated assessment tools at intake, and following recovery and treatment. Each zone of the face must be carefully considered. Zonal facial assessment leads to identification of targets for the facial reanimation surgeon, and each intervention should be followed by repeat assessments, demonstrating the QOL benefits and subjective or objective changes following the intervention.
References 1 Bhama P, Gliklich RE, Weinberg JS, Hadlock TA, Lindsay RW.
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Neck Chemodenervation Platysmal synkinesis can result in unsightly and uncomfortable vertical banding of the neck during dynamic facial expressions. Involuntary contraction of the platysma may also restrict oral commissure movement by pulling the lower lip inferiorly during smiling, and yields excessive pulling and tension in the neck. Chemodenervation using botulinum toxin injection is typically the first step in addressing platysmal synkinesis refractory to physical therapy. Injections are typically repeated every 4 to 6 months. If the patient requests a more permanent solution, platysmectomy can be performed.19 Facial Plastic Surgery
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Optimizing Total Facial Nerve Patient Management for Effective Clinical Outcomes Research. JAMA Facial Plast Surg 2014;16(1): 9–14 Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB, McKenna MJ. Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale. Laryngoscope 2001; 111(3):387–398 Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004; 130(2):157–163 Mehta RP, WernickRobinson M, Hadlock TA. Validation of the Synkinesis Assessment Questionnaire. Laryngoscope 2007; 117(5):923–926 Hohman MH, Bhama PK, Hadlock TA. Epidemiology of iatrogenic facial nerve injury: A decade of experience. Laryngoscope 2014; 124(1):260–265 Hohman MH, Silver AL, Henstrom DK, Cheney ML, Hadlock TA. The “Power” Brow Lift: Efficient Correction of the Paralyzed Brow. ISRN Plastic Surgery 2013;2013:1–4 Quatela VC, Graham H, Sabini P. Rejuvination of the brow and midface. In: Papel I, ed. Facial Plastic and Reconstructive Surgery. New York, NY: Thieme Medical Publishers, Inc.; 2002
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lagophthalmos and exposure keratopathy secondary to facial nerve palsy. Ophthal Plast Reconstr Surg 2009;25(4): 270–275 Fay A, Santiago YM. A modified levine palpebral spring for the treatment of myogenic ptosis. Ophthal Plast Reconstr Surg 2012; 28(5):372–375 Silver AL, Lindsay RW, Cheney ML, Hadlock TA. Thin-profile platinum eyelid weighting: a superior option in the paralyzed eye. Plast Reconstr Surg 2009;123(6):1697–1703 Göschel H, Wohlfarth K, Frevert J, Dengler R, Bigalke H. Botulinum A toxin therapy: neutralizing and nonneutralizing antibodies—therapeutic consequences. Exp Neurol 1997;147(1): 96–102 Hohman MH, Lee LN, Hadlock TA. Two-step highly selective neurectomy for refractory periocular synkinesis. Laryngoscope 2013;123(6):1385–1388 Lindsay RW, Smitson C, Edwards C, Cheney ML, Hadlock TA. Correction of the nasal base in the flaccidly paralyzed face: an
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orphaned problem in facial paralysis. Plast Reconstr Surg 2010; 126(4):185e–186e Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 1976;57(2):133–143 Hohman MH, Hadlock TA. Microneurovascular free gracilis transfer for smile reanimation. Operative Techniques Otolaryngology 2012;23(4):262–267 Conley J, Baker DC, Selfe RW. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg 1982;70(5):569–577 Lindsay RW, Edwards C, Smitson C, Cheney ML, Hadlock TA. A systematic algorithm for the management of lower lip asymmetry. Am J Otolaryngol 2011;32(1):1–7 Mehta RP, Hadlock TA. Botulinum toxin and quality of life in patients with facial paralysis. Arch Facial Plast Surg 2008;10(2): 84–87 Henstrom DK, Malo JS, Cheney ML, Hadlock TA. Platysmectomy: an effective intervention for facial synkinesis and hypertonicity. Arch Facial Plast Surg 2011;13(4):239–243
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