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Clinical Review & Education Special Communication

A Contemporary Approach to Facial Reanimation

Figure 3. Management Options for Flaccid Facial Palsy and Nonflaccid Facial Palsy by Facial Zone and Side

Flaccid Facial Palsy

Diseased Side

Healthy Side

Frontalis chemodenervation

Brow ptosis correction

Brow

Lubrication and night taping Physical therapy (lid stretching) Upper lid weight/spring/tarsorrhaphy Lower lid tightening/suspension Nerve transfer to orbicularis oculi

Periocular

Nasal valve correction NLF suspension Rhytidectomy

Midface

Fillers to NLF

Fillers to upper lip Oral commissure suspension Nerve transfer to zygomaticus Functional muscle transfer Semidynamic fascia graft Functional muscle transfer

Smile

DLI chemodenervation DLI resection

Lower Lip Chin

Neck

Physical therapy (patient education) Medical therapy (immunosuppressants/ antivirals/antibiotics) Surgical decompression or exploration Direct or interposition-graft repair

Global

Nonflaccid Facial Palsy

Brow ptosis correction (if depressed) Frontalis chemodenervation (if elevated) Diseased Side

Healthy Side

Frontalis chemodenervation

Brow

Physical therapy (lid stretching) Orbicularis oculi chemodenervation Highly selective neurectomy

Periocular

Midface chemodenervation

Midface

Fillers to NLF

Nerve transfer to zygomaticus Functional muscle transfer Semidynamic fascia graft Functional muscle transfer Mentalis chemodenervation

Smile

DLI chemodenervation DLI resection

Lower Lip Chin

Platysma chemodenervation Platysmectomy

Neck

Physical therapy (patient education, soft tissue mobilization and relaxation, biofeedback, and neuromuscular retraining)

Global

DLI indicates depressor labii inferioris; NLF, nasolabial fold.

higher density, which allows for thinner profile weights. 28 The pro cedure is performed using local anesthesia. An incision is made in the supratarsal crease, and a plane is developed deep to the orbi cularis oculi, exposing the anterior surface of the tarsal plate. The implant is centered between the pupil and themedial limbus and is secured to the tarsal plate with three 6-0 clear nylon sutures. The weight may be removed without aesthetic consequence if recov ery ensues. Lower Lid Tightening of the lower lidmay be achievedby the lateral tarsal strip procedure (Figure 4A and B) with or without medial canthal ten don plication. The lateral tarsal strip procedure involves a 10-mm in cision along a horizontal crow’s-foot line through skin and orbicu larismuscle, followedby canthotomy, cantholysis, de-epithelization of the gray line along the desired length to be tightened, and secur

ing of the lower tarsal plate to the lateral orbital rim using a nonab sorbable suture. 29 Complications includehemorrhage, recurrent lax ity, and lateralization of the lacrimal punctum. An alternative approach is placement of an autologous fascia lata lower eyelid sling. 30 In this procedure, a small strip of fascia lata is tunneledwith a needle through the lower eyelid and anchored to the nasal bone medially and superolateral orbital rim laterally with bone anchors. The fascia is tensioned, andbone anchor positions are selected such that the lower lid margin rises to the level of the lower limbus. Periocular Synkinesis Physical therapy and chemodenervation are used to manage peri ocular synkinesis in NFFP. When these fail, permanent orbicularis oculi denervation via a 2-step highly selective neurectomy may be performed. 31 The first step involves a preauricular incisionwith sub superficialmusculoaponeurotic system(sub-SMAS) dissectionusing

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

jamafacialplasticsurgery.com

Copyright 2015 American Medical Association. All rights reserved.

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