xRead - May 2023

Special Communication Clinical Review & Education

A Contemporary Approach to Facial Reanimation

Figure 2. Focal Facial Nerve Transection Injury and Outcome Following Repair

A

B

C

D

E

F

G

H

I

J

jection, most commonly of the orbicularis oculi, mentalis, and pla tysma muscles. When ipsilateral frontalis or depressor labii inferio ris hypofunction exists, injection of botulinum toxin into the contralateral pairedmusclemay be used to camouflage facial asym metry. Gustatory tearing (Bogorad syndrome) is managed with lacrimal gland botulinum toxin injection. Following nerve-muscle transfer procedures, the toxin may be used to treat undesired hyperactivity such as mastication-induced twitching following trigeminal-facial (cranial nerve V-VII) nerve transfers. Brow The browmay be hyperelevated, balanced, or ptotic at rest. Hyper elevation is managed with botulinum toxin injection. When ptotic, correction improves ocular hygiene and facial symmetry. It may be performed using local anesthesia bymeans of a subgaleal temporal or endoscopic approach with a titanium bone anchor or a biode gradable polymeric device (Endotine; MicroAire Surgical Instru ments) ( Figure 4 A and B). Direct brow-lifting, midforehead brow lifting, and sutureelevationusinga titaniumplate are also reasonable options. Upper Lid Correctionof paralytic lagophthalmos inFFPmaybe achievedby tar sorrhaphy or placement of an eyelid spring or weight. Indications include poor prognosis for rapid recovery, inadequate Bell phenom enon, and absent recovery at 3 months. Placement of an eyelid weight should be considered as the first-line management. Plati num is preferred over gold due to its decreased allergenicity and large mid-facial branch. F and G, One year following direct end-to-end repair, facial symmetry is restored at rest (F), brow elevation remains symmetric (G), light-effort eye closure is improved but remains incomplete (H), smile symmetry is markedly improved (I), and near normal return of orbicularis oris function is noted (J). Left lower lip depressor weakness is also demonstrated (D and I), first noted following platysmaplasty at the same outside clinic several years prior.

A-E, The patient was seen 6 weeks following revision rhytidectomy performed at an outside clinic and reported immediate postoperative mid-facial ptosis that did not improve. The nasolabial fold on the affected (asterisk) side is effaced (A), while brow elevation remains intact and symmetric (B), light-effort eye closure is incomplete (C), zygomaticus function is absent with full-effort smile (D), upper orbicularis oris function is absent with lip pucker while lip depressor and platysmal function is noted to be intact (E). Exploration under general anesthesia seven weeks following insult revealed a complete transection of a

the proximal FN stump to upper, midfacial, or lower distal FN branches to provide resting tone.

Long-standing Facial Palsy Interventions Interventions for long-standing FFP and NFFP include physical therapy, injectables, and surgical reanimationprocedures. Interven tions are targeted to the type and degree of dysfunction specific to the facial zone (eTable in the Supplement and Figure 3 ). Compre hensive FN physical therapy consists of patient education, soft tissuemobilization, biofeedback, andneuromuscular retraining. 26,27 It is offered to all patients with NFFP and to those who have under gone dynamic reanimation surgery. The primary goals in the set ting of NFFP include reduction in mass movement on the affected side and reductionof compensatoryhyperactivityof thehealthy side to achieve improved balance and reduce symptoms of facial fa tigue. Following nerve or muscle transfer reanimation procedures, tailored physical therapy protocols are applied to optimize surgical outcomes. Injectable fillers and chemodenervation agents are useful ad juncts in the management of long-standing FP. 8 Volumizing fillers such as hyaluronic acid and fat grafts are beneficial in the midface and lips. In the patient with effacement of the NLF on the affected side, addingvolume to thecontralateral NLF results in improvedsym metry. Conversely, a trial of filler to the affected side should be con sidered when NFFP results in a deepened NLF. Botulinum toxin is used to reduce hyperactivity and synkinesis through targeted in

Downloaded by Ucsf Library University of California San Francisco from www.liebertpub.com at 08/19/21. For personal use only.

(Reprinted) JAMA Facial Plastic Surgery July/August 2015 Volume 17, Number 4

295

jamafacialplasticsurgery.com

Copyright 2015 American Medical Association. All rights reserved.