Facial animation surgery with neuromuscular transplants has become a standard procedure for the treatment of facial palsies. However, the forehead, periocular complex, nasal base area, and inferior lip are secondary sites that also need to be considered in the complete rehabilitation of a flaccid facial palsy.
Materials and Methods
A total of 136 ancillary procedures were performed in 49 patients between 2003 and 2013 and consisted of eyebrow suspensions (11), upper eyelid loading with a platinum chain (39), inferior palpebral suspension with fascia lata (22), nasal base suspension with fascia lata (26), and botulinum toxin injection (38).
Cosmetic results were good and excellent in 30.7% and 63.2% of the procedures, respectively. Functionally, periocular complex rehabilitation and nasal base suspension led to excellent improvements in function in 87.2% and 73.1% of the patients, respectively.
The use of ancillary procedures can improve the functional and esthetic results of facial animation surgery.
Facial paralysis patients are affected by a complex condition that involves not only the inability to smile, but also several additional deformities that could represent major issues for both the patient and the surgeon. Facial animation surgery, consisting of neuromuscular transplants to restore the ability to smile, today represents a well-defined approach for established or congenital facial palsies, and over the past 20 years, it has gradually replaced static procedures. Despite the desirable results achievable with these techniques, the use of neuromuscular transplants alone should today be considered inadequate for the complete management of a paralyzed face. The forehead, periocular complex, nasal base area, and inferior lip are secondary sites that also need to be considered in the complete rehabilitation of a flaccid facial palsy. Thus careful examination of the patient and a comprehensive approach should be followed when a facial animation program is planned. In this article we discuss our approach to these neglected areas, presenting some reliable ancillary procedures to complete the rehabilitation of facial palsy patients treated with neuromuscular transplantation.
Materials and Methods
Local anesthesia is administered 15 minutes before surgery in the paralyzed forehead, eyebrow, and hairline. A small incision, measuring approximately 2 cm, is performed horizontally at the hairline to reach the subperiosteal plane. Three small horizontal incisions are made in the upper margin of the eyebrow, exposing the subdermal plane, approximately at its midline and at the medial and lateral limit. Additional incision(s) can be added if other area(s) of the brow also need suspension. A No. 2-0 Prolene suture (Ethicon, Somerville, NJ) is placed in the subcutaneous plane of the eyebrow, and a tunnel is created subcutaneously from the incision at the hairline to the first incision in the eyebrow: A periosteal plane is usually chosen to reduce bleeding and swelling. In our experience a Klemmer forceps is the ideal instrument. The suture is transferred in the hairline incision through the tunnel. The same procedure is repeated for the other anchorage points. Selected tension is provided to the sutures to correct the ptosis, taking care to provide a little overcorrection to prevent insufficient suspension after soft tissue adjustment. A microplate is fixed in the frontal bone using 2 microscrews, and the suspending sutures are fixed to the plate to prevent detachment. Finally, a standard suture is placed to close the cutaneous wounds ( Fig 1 ).
Platinum Chain Eyelid Positioning
After local anesthesia, a linear incision is made in a superior palpebral wrinkle. The tarsal plane is reached through blunt dissection, and the tarsal plate is exposed. Accurate hemostasis is performed to prevent postoperative bleeding and hematomas. A platinum eyelid chain load is then placed in the eyelid pocket and fixed using a Prolene suture, securing all of the holes of the chain ( Figs 2A, C, D ). The assistant usually checks the conjunctival plane to verify whether suture has accidentally gone too deep. Finally, a standard suture is used to close the incision line. We usually provide immediate ice packing to prevent excessive swelling of the lid.
Inferior Palpebral Suspension With Fascia Lata
A small incision (approximately 1 cm) is performed in the lateral aspect of the thigh, and the fascia lata plane is reached through blunt dissection. The fascia lata is then incised, and a neural stripper is used to harvest the fascia through blind stripping. Once an adequate length is achieved, a small incision (<1 cm) is made and blind cutting is performed over the stripper. The strip of fascia is finally removed from the thigh. In the meantime, another team works on the inferior eyelid: A small incision is made at the level of the lateral cantus, and the lateral wall of the orbit is reached. At this level, a hole is made, taking care to protect the eye during drilling. Another small incision is made in the medial cantus; this is identified and dissected, and a tarsal tunnel is harvested in a blunt and blind fashion. The fascia strip is then passed through the tunnel and fixed with a Prolene suture to the medial cantus. The strip is pulled until adequate tension is provided and satisfactory suspension of the eyelid is obtained ( Figs 2B, D ). The fascia strip is finally fixed to the bone with a Prolene suture through the previously prepared hole. Standard sutures are then used for skin wound closure.
Nasal Base Suspension With Fascia Lata
This procedure is usually performed simultaneously with a neuromuscular transplant for facial animation surgery. A fascia lata sheet is harvested with an open approach or with a fascia lata stripper from the lateral aspect of the thigh. At the same time, during facial pocket harvesting, the nasal base is reached in the same subcutaneous plane where the facial vessels are dissected and the neuromuscular transplant is placed, and a skin incision is performed at the base of the nasal ala. The fascia lata sheet is fixed with 2 or 3 Prolene suture stitches to the base of the nasal alar cartilage; the fascia is pulled until adequate tension has been provided and the nasal base has reached the desired position and is finally fixed to the temporalis fascia: Precise vector of tension has to be evaluated to maximize nasal widening and, at the same time, prevent distortion of the nasolabial philtrum ( Fig 3 ). Before fixation of the fascia lata sheet, it is important to complete the suture of the nasal base skin to prevent distortion of the skin during suture. The neuromuscular transplant will be placed over the fascia sheet. Overcorrection is mandatory to prevent an insufficient result due to adjustment of tension in the postoperative period.