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Special Communication Clinical Review & Education

A Contemporary Approach to Facial Reanimation

Figure 4. Static Reanimation Procedures in Flaccid Facial Palsy

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sition of theNLF for improved definition. 34 In patients with short life expectancies, NLF suspensionmay be achieved using local anesthe sia withmultiple 2-0 polypropylene sutures through the dermis and sub-SMASpassedsubcutaneously to the temporal regionwithaKeith needle (Figure 4E and F). 33 Suspension may be combined with sub SMAS plication for added midfacial support. Smile Dynamic reanimation of smile requires the reestablishment of vo litionally contractilemuscle. Options include regional muscle trans fer, free muscle with nerve transfer, or nerve transfer to native fa cial musculature. Temporalis Transfer Temporalis muscle transfer remains popular because of its ease of harvest, predictable anatomy, reliable blood supply, and low mor bidity. Temporalis transfersmay be antidromic or orthodromicwith regard to thenative vector of pull of themuscle. A supra-SMASplane is elevated using a preauricular incision extending from the point of attachment of the lobule to the temporal region. A temporopari etal fascia flap is carefully elevated off the true temporalis fascia and rotated posteriorly with preservation of the inferiorly based vascu lar pedicle. 35,36 In the antidromic approach, a 1.5-cm strip of tem poralismusclewith its true temporalis fascia is then elevated off the calvariumto the level of the zygomatic arch, reflected over the arch, and secured to themodiolus. Orthodromic approaches involvemo bilization of the tendon at the coronoid process through an intra oral or extraoral approach, with subsequent transfer to the modio lus using bridging fascia lata. 37 A sliding orthodromic approach has alsobeendescribed, which eliminates the adynamic segment. 38 For all approaches, the temporoparietal fascia flap may be used to re frank facial nerve invasion. No recovery of function was observed. E, Effacement of the nasolabial fold is demonstrated at rest with inferior malposition of the oral commissure. F, Facial symmetry at rest is improved two-weeks following minimally invasive suspension using polypropylene sutures passed subcutaneously using a long Keith needle under local anesthesia. D, Improvement is demonstrated 2 months following static fascia lata suspension. The patient reported substantial improvement in nasal breathing on the affected side. E and F, Static nasolabial fold suspension in flaccid facial palsy. The patient underwent a radical parotidectomy with interposition graft two years previously for a high-grade carcinoma ex pleomorphic adenoma with

general anesthesia to identify 4 or more FNbranches to the orbicu laris oculi using a nerve stimulator. Branches are isolated using ves sel loops, the ends of which are then delivered through stab inci sions in the overlying skin. After recovery from general anesthesia, the awake patient is asked to trigger the ocular synkinesis by smil ing, and branches are then divided in succession until a suitable de crease in synkinetic eye closure with smiling occurs without induc tion of lagophthalmos. The remaining branches are then released in continuity back through the stab incisions. Nasal Base External nasal valvecollapsemaybecorrectedusingalar battengrafts or a static fascia lata sling technique (Figure 4C and D). 32 An inci sion is made in the preauricular crease and carried superiorly into the temporal hairline, and a second incision is made in the alar crease. A subcutaneous tunnel is then developed through which a 1-cm-wide strip of fascia lata is passed. The fascia is secured medi ally to the dermis and accessory cartilages of the nasal ala using three 4-0 polypropylene or nylon sutures and laterally to the true temporalis fascia using 2-0 permanent sutures. Nasolabial Fold Static suspension using a 3-cm-wide strip of fascia lata may be used to improveNLFsymmetry. Thegraft is insetbelowthesub-SMASusing a preauricular incision extending to the temporal region. It is secured medially using 5 or 6 interrupted 4-0 polypropylene sutures placed through thedermis and sub-SMAS along a line immediatelymedial to thedesiredorientationof the fold. Laterally, thegraft is secured to the true temporalis fascia using three 2-0 polypropylene mattress sutures. 33 Inolder patients, a second skinexcisionmaybemadewith de-epithelization of a crescentic zone centered over the desired po A and B, Brow ptosis correction and lower lid tightening in flaccid facial palsy. The patient was seen with upper trunk paralysis secondary to a recurrent invasive basal cell carcinoma of the left cheek and subsequently underwent radical parotidectomy. A, On the affected side (asterisk), brow ptosis resulting in lateral hooding is noted together with lower lid ectropion. B, Correction of ectropion and lateral hooding is noted two-weeks following the lateral tarsal strip procedure and minimally invasive brow suspension using polypropylene sutures and a titanium plate. C and D, External nasal valve correction in flaccid facial palsy. The patient had undergone resection of an extensive glomus tumor with interposition grafting 20 years previously, without return of function. C, The external nasal valve is markedly narrowed at the base (arrowhead).

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

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