Ideas and Innovations Reconstruction of the Nasolabial Fold Using a Fascia Lata Sheet Graft: A Modified Technique Kwok Hao Lie, M.A., M.B., B.Chir. G. Ian Taylor, A.O., M.D. Russell J. Corlett, M.B.B.S., F.R.A.C.S. Melbourne, Victoria, Australia
Summary: A refinement over existing static facial sling techniques to reconstruct the nasolabial fold in longstanding facial palsy is presented. The innovative use of fascia lata sheet graft instead of strips facilitates greater intraoperative control over the contour of the reconstructed fold and provides a wide area of attachments of the graft. This technique has a reduced incidence of complications and can be adjusted with minimal scarring as a secondary procedure if necessary. (Plast. Reconstr. Surg. 132: 1276, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
C
hanges in facial expression are reflected in the varying shape and curvature of the nasolabial fold. However, it is frequently obliterated in longstanding facial paralysis. Although dynamic facial reanimation is ideal, this option may not be indicated or available in every situation, especially in the elderly. Static reconstructions have much to offer in such cases. Fascia lata and other tendon graft slings are commonly used to reconstruct this fold1–5 but suffer from a number of well-recognized problems such as a “cheesecutter” effect on underlying tissues caused by high tension, and a high incidence of graft infections.4,6 We present an illustrative case from our series, conducted over the past 29 years, in which a modification of the established static fascia lata suspension technique is used to reconstruct the nasolabial fold.
SURGICAL TECHNIQUE The nasolabial fold is marked at rest as a curved ellipse 5 to 6 cm long on the affected side, the lateral margin of the ellipse is defined as a mirror image of the normal nasolabial fold, and the medial margin is 1 cm apart at its midpoint (Fig. 1, left). A second preauricular meloplasty incision is marked.
From the Taylor Lab, Department of Anatomy and Neuroscience, University of Melbourne, Royal Melbourne Hospital. Received for publication November 27, 2012; accepted May 23, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a4c22b
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The fascia lata graft is harvested by means of two transverse incisions, one 15 cm inferior to the greater trochanter and another 8 cm superior to the lateral aspect of the knee. Under general anaesthesia, the incisions and the intervening cheek are infiltrated with 1:100,000 adrenaline. The nasolabial ellipse is deepithelialized and then its lateral margin is deepened into the subcutaneous tissue. The meloplasty flap is raised to gain access to the temporalis fascia and mastoid process. These incisions are joined across the cheek using a no. 22 scalpel blade in one hand, and the other hand is placed on the outside of the cheek as a guide to control the depth and width of the tunnel for the subsequent 4- to 6-cm-wide fascia lata sheet (Fig. 2). The medial end of the fascial sheet is folded onto itself as a C to match the nasolabial fold. This folded margin, which prevents sutures cutting out, is attached with 6-0 monofilament nylon or Monocryl (Ethicon, Inc., Somerville, N.J.) buried sutures to the medial area of the deepithelialized ellipse to gain wider attachment of the graft (Fig. 3, left). The lateral end of the sheet is incised near the junction of the middle and lower thirds for 4 to 6 cm to provide two reins to control the shape of the nasolabial fold. Because the graft is attached to the medial margin of the ellipse, tension on either rein pulls this margin laterally beneath the cheek skin to provide a natural nasolabial fold (Fig. 2, right). The ends of the fascia lata sheet Disclosure: The authors have no competing financial interests in any of the materials referred to in this article.
www.PRSJournal.com
Volume 132, Number 5 • Nasolabial Fold Reconstruction
Fig. 1. Preoperative and postoperative photographs of a 72-year-old woman who presented with late facial palsy. (Left) The ellipse of skin within the white dashed lines is removed. Her nasolabial fold (medial dashed line) was reconstructed with a fascia lata sheet graft (right), with the result at 6 weeks shown.
are sutured to the temporalis fascia, the mastoid process, and the intervening parotid fascia after any excess graft is trimmed (Fig. 3, right). The wounds in the face and thigh are closed with suction drainage. The postoperative course in this patient, apart from some initial swelling, was uncomplicated. Preoperative photographs of our patient
demonstrated significant facial asymmetry, which was improved markedly after reconstruction (Fig. 1, right). Particularly pleasing is the symmetry of the nasolabial groove, which is a true fold and has the added benefit of supporting the nasal ala, which is often collapsed in facial palsy, and the wide sheet provides a “diaphragm” to buffer against during mastication.
Fig. 2. (Left) An anterior ellipse of skin extending 1 cm medial to the nasolabial fold was shaved of epidermis (white arrow). Posteriorly, a preauricular meloplasty incision was created and a subcutaneous tunnel developed between the two incisions. (Right) A broad, 5-cm-wide fascia lata sheet graft was placed in the tunnel and sutured along the anterior (medial) margin of the deepithelialized skin ellipse. Note the rolled-over new nasolabial fold with the graft under tension as the medial edge is pulled beneath the tethered margin of the ellipse. It was split posteriorly and the two “reins” adjusted to provide a natural curve, with the superior rein sutured to temporalis fascia and the inferior rein attached to the mastoid process.
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Plastic and Reconstructive Surgery • November 2013
Fig. 3. Illustration of surgical technique. The fascia lata sheet is placed through a subcutaneous tunnel and emerges posterior to the deepithelialized ellipse of nasolabial skin, as marked by the shaded region (left). The folded-over fascia lata sheet is sutured to the medial margin of the new nasolabial fold, as marked by the red arrow (left). The new nasolabial fold is subsequently closed with a running suture. Posteriorly, the fascia lata sheet is divided into two reins, which are then independently adjusted to provide a natural appearing nasolabial fold. The superior rein is sutured to temporalis fascia, and the inferior rein is sutured to the fascia over the mastoid process, as marked by red arrows (right).
The second and third authors (G.I.T. and R.J.C.) have used this technique for more than 30 years, usually in elderly patients with longstanding facial palsy or combined with a cross-facial nerve graft at the first stage. Infection has never been a problem, nor has extrusion of the graft. The only problem on occasion has been medial drift of the corner of the mouth caused by the skin and paralyzed orbicularis muscle stretching. This can be corrected under local anaesthesia by shaving a further medial skin ellipse and reattaching this to the graft edge.
DISCUSSION Many of the static procedures for lower facial palsy focus on suspension of the corner of the mouth with slings around the orbicularis oris and relatively little attention paid to reconstruction of the nasolabial fold.1,7 Given that the nasolabial fold is an animated, mobile, and changing structure that contributes to the anatomy of a normal smile, even achieving a good cosmetic result at rest goes a long way toward achieving the goal of a symmetrical face, especially if it helps prevent drift toward the opposite side during activity. Our technique represents a significant refinement of established static sling procedures involving suspension sutures,8,9 thinner segments of fascia,10 or other materials.11 These techniques spread tension in the slings over a much smaller
1278
surface area of attachment, dimpling, or an unsightly fold of skin. Our large broad fascial sheet also allows for a wide area of attachment and support. The medial edge of the fascial lata sheet is folded to avoid the problem of the sutures cutting through the graft edge when tension is applied. This leading edge is stitched also to the deepithelialized crescent of dermis, thereby providing attachment of the graft to an area rather than a linear skin margin. Splitting of the sheet posteriorly allows independent adjustment of the upper and lower halves of the nasolabial fold, thereby providing a natural shape and a true fold. Further refinements can be made with posterior sutures of the midportion of the graft to the parotid sheath. Another important feature of this technique is the ease with which postoperative adjustments can be made. If there is medial “drift” of the corner of the mouth, a further medial skin ellipse can be shaved as before and reattached to the medial edge of the graft. Functionally, the fascia lata sheet, rather than strip grafts, exhibits an added bonus during mastication by providing a relatively firm surface against which the food bolus can be pressed. In normal chewing, this surface is provided by tensing the buccinator muscle, which is flaccid in facial paralysis. An additional refinement that we have used is to attach the graft to temporalis and/or masseter to provide an active, dynamic reconstruction.
Volume 132, Number 5 • Nasolabial Fold Reconstruction SUMMARY We present a modified fascia lata sheet graft for facial palsy focused especially on reconstruction of a true nasolabial fold. G. Ian Taylor, A.O., M.D. Department of Anatomy and Neuroscience Room E533, Medical Building Grattan Street Parkville, Victoria 3010, Australia
PATIENT CONSENT
Patients provided written consent for the use of their images. REFERENCES 1. Clodius L. Reconstruction of the nasolabial fold. Plast Reconstr Surg. 1972;50:467–473. 2. Mclaughlin CR. Permanent facial paralysis; the role of surgical support. Lancet 1952;2:647–651.
3. McLaughlin CR. Surgical support in permanent facial paralysis. Plast Reconstr Surg (1946) 1953;11:302–314. 4. Alam D. Rehabilitation of long-standing facial nerve paralysis with percutaneous suture-based slings. Arch Facial Plast Surg. 2007;9:205–209. 5. Rose EH. Autogenous fascia lata grafts: Clinical applications in reanimation of the totally or partially paralyzed face. Plast Reconstr Surg. 2005;116:20–32; discussion 33. 6. Constantinides M, Galli SK, Miller PJ. Complications of static facial suspensions with expanded polytetrafluoroethylene (ePTFE). Laryngoscope 2001;111:2114–2121. 7. Cook JL. The undesirable influence of reconstructive procedures on the symmetry of the nasolabial folds. Dermatol Surg. 2005;31:1409–1416. 8. Robinson JK. Suspension sutures in facial reconstruction. Dermatol Surg. 2003;29:386–393. 9. Robinson JK. Suspension sutures aid facial reconstruction. Dermatol Surg. 1999;25:189–193; discussion 193. 10. Gillies H. Experiences with fascia lata grafts in the operative treatment of facial paralysis: (Section of otology and section of laryngology). Proc R Soc Med. 1934;27:1372–1382. 11. Fisher E, Frodel JL. Facial suspension with acellular human dermal allograft. Arch Facial Plast Surg. 1999;1:195–199.
FILLER-060
Plastic Surgery Level of Evidence Rating Scale—Prognostic/Risk Studies
Level of Evidence I II
III IV V
Qualifying Studies Highest-quality, multicentered or single-centered, prospective cohort or comparative study with adequate power; or a systematic review of these studies High-quality prospective cohort or comparative study; retrospective cohort or comparative study; untreated controls from a randomized controlled trial; or a systematic review of these studies Case-control study; or systematic review of these studies Case series with pre/post test; or only post test Expert opinion developed via consensus process; case report or clinical example; or evidence based on physiology, bench research, or “first principles”
Find out more from the “Evidence-Based Medicine: How-to Articles” Collection at www.PRSJournal.com
1279
Summary: A refinement over existing static facial sling techniques to reconstruct the nasolabial fold in longstanding facial palsy is presented. The innovative use of fascia lata sheet graft instead of strips facilitates greater intraoperative control over the contour of the reconstructed fold and provides a wide area of attachments of the graft. This technique has a reduced incidence of complications and can be adjusted with minimal scarring as a secondary procedure if necessary. (Plast. Reconstr. Surg. 132: 1276, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
C
hanges in facial expression are reflected in the varying shape and curvature of the nasolabial fold. However, it is frequently obliterated in longstanding facial paralysis. Although dynamic facial reanimation is ideal, this option may not be indicated or available in every situation, especially in the elderly. Static reconstructions have much to offer in such cases. Fascia lata and other tendon graft slings are commonly used to reconstruct this fold1–5 but suffer from a number of well-recognized problems such as a “cheesecutter” effect on underlying tissues caused by high tension, and a high incidence of graft infections.4,6 We present an illustrative case from our series, conducted over the past 29 years, in which a modification of the established static fascia lata suspension technique is used to reconstruct the nasolabial fold.
SURGICAL TECHNIQUE The nasolabial fold is marked at rest as a curved ellipse 5 to 6 cm long on the affected side, the lateral margin of the ellipse is defined as a mirror image of the normal nasolabial fold, and the medial margin is 1 cm apart at its midpoint (Fig. 1, left). A second preauricular meloplasty incision is marked.
From the Taylor Lab, Department of Anatomy and Neuroscience, University of Melbourne, Royal Melbourne Hospital. Received for publication November 27, 2012; accepted May 23, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a4c22b
1276
The fascia lata graft is harvested by means of two transverse incisions, one 15 cm inferior to the greater trochanter and another 8 cm superior to the lateral aspect of the knee. Under general anaesthesia, the incisions and the intervening cheek are infiltrated with 1:100,000 adrenaline. The nasolabial ellipse is deepithelialized and then its lateral margin is deepened into the subcutaneous tissue. The meloplasty flap is raised to gain access to the temporalis fascia and mastoid process. These incisions are joined across the cheek using a no. 22 scalpel blade in one hand, and the other hand is placed on the outside of the cheek as a guide to control the depth and width of the tunnel for the subsequent 4- to 6-cm-wide fascia lata sheet (Fig. 2). The medial end of the fascial sheet is folded onto itself as a C to match the nasolabial fold. This folded margin, which prevents sutures cutting out, is attached with 6-0 monofilament nylon or Monocryl (Ethicon, Inc., Somerville, N.J.) buried sutures to the medial area of the deepithelialized ellipse to gain wider attachment of the graft (Fig. 3, left). The lateral end of the sheet is incised near the junction of the middle and lower thirds for 4 to 6 cm to provide two reins to control the shape of the nasolabial fold. Because the graft is attached to the medial margin of the ellipse, tension on either rein pulls this margin laterally beneath the cheek skin to provide a natural nasolabial fold (Fig. 2, right). The ends of the fascia lata sheet Disclosure: The authors have no competing financial interests in any of the materials referred to in this article.
www.PRSJournal.com
Volume 132, Number 5 • Nasolabial Fold Reconstruction
Fig. 1. Preoperative and postoperative photographs of a 72-year-old woman who presented with late facial palsy. (Left) The ellipse of skin within the white dashed lines is removed. Her nasolabial fold (medial dashed line) was reconstructed with a fascia lata sheet graft (right), with the result at 6 weeks shown.
are sutured to the temporalis fascia, the mastoid process, and the intervening parotid fascia after any excess graft is trimmed (Fig. 3, right). The wounds in the face and thigh are closed with suction drainage. The postoperative course in this patient, apart from some initial swelling, was uncomplicated. Preoperative photographs of our patient
demonstrated significant facial asymmetry, which was improved markedly after reconstruction (Fig. 1, right). Particularly pleasing is the symmetry of the nasolabial groove, which is a true fold and has the added benefit of supporting the nasal ala, which is often collapsed in facial palsy, and the wide sheet provides a “diaphragm” to buffer against during mastication.
Fig. 2. (Left) An anterior ellipse of skin extending 1 cm medial to the nasolabial fold was shaved of epidermis (white arrow). Posteriorly, a preauricular meloplasty incision was created and a subcutaneous tunnel developed between the two incisions. (Right) A broad, 5-cm-wide fascia lata sheet graft was placed in the tunnel and sutured along the anterior (medial) margin of the deepithelialized skin ellipse. Note the rolled-over new nasolabial fold with the graft under tension as the medial edge is pulled beneath the tethered margin of the ellipse. It was split posteriorly and the two “reins” adjusted to provide a natural curve, with the superior rein sutured to temporalis fascia and the inferior rein attached to the mastoid process.
1277
Plastic and Reconstructive Surgery • November 2013
Fig. 3. Illustration of surgical technique. The fascia lata sheet is placed through a subcutaneous tunnel and emerges posterior to the deepithelialized ellipse of nasolabial skin, as marked by the shaded region (left). The folded-over fascia lata sheet is sutured to the medial margin of the new nasolabial fold, as marked by the red arrow (left). The new nasolabial fold is subsequently closed with a running suture. Posteriorly, the fascia lata sheet is divided into two reins, which are then independently adjusted to provide a natural appearing nasolabial fold. The superior rein is sutured to temporalis fascia, and the inferior rein is sutured to the fascia over the mastoid process, as marked by red arrows (right).
The second and third authors (G.I.T. and R.J.C.) have used this technique for more than 30 years, usually in elderly patients with longstanding facial palsy or combined with a cross-facial nerve graft at the first stage. Infection has never been a problem, nor has extrusion of the graft. The only problem on occasion has been medial drift of the corner of the mouth caused by the skin and paralyzed orbicularis muscle stretching. This can be corrected under local anaesthesia by shaving a further medial skin ellipse and reattaching this to the graft edge.
DISCUSSION Many of the static procedures for lower facial palsy focus on suspension of the corner of the mouth with slings around the orbicularis oris and relatively little attention paid to reconstruction of the nasolabial fold.1,7 Given that the nasolabial fold is an animated, mobile, and changing structure that contributes to the anatomy of a normal smile, even achieving a good cosmetic result at rest goes a long way toward achieving the goal of a symmetrical face, especially if it helps prevent drift toward the opposite side during activity. Our technique represents a significant refinement of established static sling procedures involving suspension sutures,8,9 thinner segments of fascia,10 or other materials.11 These techniques spread tension in the slings over a much smaller
1278
surface area of attachment, dimpling, or an unsightly fold of skin. Our large broad fascial sheet also allows for a wide area of attachment and support. The medial edge of the fascial lata sheet is folded to avoid the problem of the sutures cutting through the graft edge when tension is applied. This leading edge is stitched also to the deepithelialized crescent of dermis, thereby providing attachment of the graft to an area rather than a linear skin margin. Splitting of the sheet posteriorly allows independent adjustment of the upper and lower halves of the nasolabial fold, thereby providing a natural shape and a true fold. Further refinements can be made with posterior sutures of the midportion of the graft to the parotid sheath. Another important feature of this technique is the ease with which postoperative adjustments can be made. If there is medial “drift” of the corner of the mouth, a further medial skin ellipse can be shaved as before and reattached to the medial edge of the graft. Functionally, the fascia lata sheet, rather than strip grafts, exhibits an added bonus during mastication by providing a relatively firm surface against which the food bolus can be pressed. In normal chewing, this surface is provided by tensing the buccinator muscle, which is flaccid in facial paralysis. An additional refinement that we have used is to attach the graft to temporalis and/or masseter to provide an active, dynamic reconstruction.
Volume 132, Number 5 • Nasolabial Fold Reconstruction SUMMARY We present a modified fascia lata sheet graft for facial palsy focused especially on reconstruction of a true nasolabial fold. G. Ian Taylor, A.O., M.D. Department of Anatomy and Neuroscience Room E533, Medical Building Grattan Street Parkville, Victoria 3010, Australia
PATIENT CONSENT
Patients provided written consent for the use of their images. REFERENCES 1. Clodius L. Reconstruction of the nasolabial fold. Plast Reconstr Surg. 1972;50:467–473. 2. Mclaughlin CR. Permanent facial paralysis; the role of surgical support. Lancet 1952;2:647–651.
3. McLaughlin CR. Surgical support in permanent facial paralysis. Plast Reconstr Surg (1946) 1953;11:302–314. 4. Alam D. Rehabilitation of long-standing facial nerve paralysis with percutaneous suture-based slings. Arch Facial Plast Surg. 2007;9:205–209. 5. Rose EH. Autogenous fascia lata grafts: Clinical applications in reanimation of the totally or partially paralyzed face. Plast Reconstr Surg. 2005;116:20–32; discussion 33. 6. Constantinides M, Galli SK, Miller PJ. Complications of static facial suspensions with expanded polytetrafluoroethylene (ePTFE). Laryngoscope 2001;111:2114–2121. 7. Cook JL. The undesirable influence of reconstructive procedures on the symmetry of the nasolabial folds. Dermatol Surg. 2005;31:1409–1416. 8. Robinson JK. Suspension sutures in facial reconstruction. Dermatol Surg. 2003;29:386–393. 9. Robinson JK. Suspension sutures aid facial reconstruction. Dermatol Surg. 1999;25:189–193; discussion 193. 10. Gillies H. Experiences with fascia lata grafts in the operative treatment of facial paralysis: (Section of otology and section of laryngology). Proc R Soc Med. 1934;27:1372–1382. 11. Fisher E, Frodel JL. Facial suspension with acellular human dermal allograft. Arch Facial Plast Surg. 1999;1:195–199.
FILLER-060
Plastic Surgery Level of Evidence Rating Scale—Prognostic/Risk Studies
Level of Evidence I II
III IV V
Qualifying Studies Highest-quality, multicentered or single-centered, prospective cohort or comparative study with adequate power; or a systematic review of these studies High-quality prospective cohort or comparative study; retrospective cohort or comparative study; untreated controls from a randomized controlled trial; or a systematic review of these studies Case-control study; or systematic review of these studies Case series with pre/post test; or only post test Expert opinion developed via consensus process; case report or clinical example; or evidence based on physiology, bench research, or “first principles”
Find out more from the “Evidence-Based Medicine: How-to Articles” Collection at www.PRSJournal.com
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