AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

Facial paralysis is a debilitating condition that induces enormous functional, psychological, and cosmetic problems. The surgical team has an armamentarium of surgical strategies for facial reanimation. These options can be categorized as either dynamic reanimation or static procedures. The surgeon can decide on the most appropriate reconstruction for the patient after performing a detailed evaluation and assessment that includes determination of etiology, duration of paralysis, extent or degree of paralysis, and the patient's age and overall health.

Facial nerve injury paralysis can be demarcated by the following:

• Facial laxity
• Asymmetrical smile
• Droopiness of the commissure (due to the weakened zygomatic major and minor)
• Inspiratory nasal collapse
• Oral incompetence
• Lower lip asymmetry
• Lower eyelid ectropion or laxity
• Lagophthalmos

Therefore, the goals of reconstruction of the paralyzed face are as follows:

• Facial symmetry at rest
• Oral competence and eye closure
• Voluntary facial movements with spontaneous facial expression
• Minimal to absent synkinesis and mass movement

Dynamic procedures can restore movement to the face and should be considered in every patient with facial paralysis. Static techniques support and suspend soft tissue structures of the face but do not provide facial reanimation. Static procedures are often adjunctive maneuvers (in conjunction with dynamic techniques) to enhance facial symmetry, particularly in treating lagophthalmos and lower lid laxity. These static procedures are most suitable for patients who are not candidates for dynamic reconstructive efforts because of debilitation, advanced age, or poor health.

Indications for static procedures

Sometimes, dynamic facial reanimation is not possible or indicated (eg, in elderly patients). Goals of static procedures are to protect the cornea, restore facial symmetry at rest, and correct functional disability. These static procedures include the following:

• Brow lift
• Lower lid shortening/tightening (Kuhnt-Szymanowski procedure)
• Shortening and thickening of the upper and lower lip with commissure preservation
• Repositioning of the nasal alar base
• Recreation of the nasolabial fold

EVALUATION

Section 3 of 8  

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

Evaluation of a patient with facial paralysis commences with a thorough and detailed history and physical examination.

History

Etiology is the most important factor in determining the timing and choice of reconstructive technique. Bell palsy is an idiopathic form of facial paralysis and is a diagnosis of exclusion. Trauma is the second most common cause of facial paralysis.

A thorough history includes the onset of paralysis, initial degree of paralysis, duration of paralysis, and associated symptoms. These details can often help identify the etiology. Facial nerve injuries from Bell palsy, trauma, and malignant neoplasm need to be identified. The reconstructive efforts and interventions need to be tailored appropriately based on the etiology of the disorder. The etiology of the denervation also dictates the timing of surgical treatment, if any is to be done. If spontaneous recovery is possible, such as in a patient with Bell palsy, an irreversible technique to reanimate the face may not be the best choice.

The patient's overall health, psychological stability, and life expectancy are significant considerations. Patients with significant health risks and medical problems are not appropriate candidates for invasive reconstructive operations in which results do not manifest for 2-3 years postoperatively.

The surgeon must discover the psychological impact of the paralysis on the patient and discuss the patient's expectations. During this patient education, the physician should establish realistic expectations and determine if the patient can expend the time and finances for multiple procedures and revisions in order to guarantee successful results.

Physical examination

The surgeon must perform a comprehensive physical examination of the patient with facial paralysis, scrutinizing the face at rest and during voluntary and reflex emotional movement. The physician must determine the involvement of unilateral or bilateral facial nerves and facial asymmetries. The degree of brow ptosis, ectropion, and lid laxity, as well as oral laxity, skin laxity, or commissure incompetence must also be noted. The surgeon must identify the presence of other cranial facial or neurologic deficits or anomalies.

The eye condition must be carefully inspected to assess eye closure, ectropion, lower lid laxity, corneal irritation/ulceration, and tear production. The cornea can be inspected by fluorescein and a Wood lamp for exposure keratitis or corneal ulceration. The surgical team must record objective measures of facial motion and movement with digital images (either with photography or video recordings). This assists with preoperative evaluation and postoperative assessment of outcomes.

MANAGEMENT OF THE EYE IN FACIAL PARALYSIS

Section 4 of 8  

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

Paralysis of the upper branches of the facial nerve results in disorders of the eyelid and lacrimal function. Sequelae include incomplete closure of the eye with corneal exposure, lower lid ectropion with epiphora, decreased tear production, and loss of the corneal squeegee effect. These factors contribute to inadequate corneal protection, which can result in exposure keratitis, corneal ulceration, and blindness.

Eyelid and Lacrimal Function

Management Strategy

Management of the eye in a patient with facial paralysis centers on corneal protection. The patient should use artificial tears during the day and lubricating ointment at night. Taping the eyelids can assist with eye closure. Patching is not recommended since it does not protect the cornea from trauma or ulceration. The surgeon must examine the cornea frequently to rule out injury and irritation.

Tarsorrhaphy

Tarsorrhaphy is a popular and effective method of eye protection in facial paralysis. A central tarsorrhaphy completely impairs vision and is not cosmetically acceptable as a permanent procedure. It should be used as a tool for temporary eye protection.

A lateral tarsorrhaphy is preferred, but it also limits peripheral vision and does not provide a cosmetically acceptable long-term result. Permanent tarsorrhaphy should never be entertained; moreover, tarsorrhaphy should never be a first line of treatment because of the functional and aesthetic downfall and drawbacks.

Permanent lateral tarsorrhaphy is not generally recommended but can be used for eye protection in the severely debilitated patient who is not a candidate for other procedures. In this approach, the lateral aspects of the upper and lower lid are de-epithelialized and then approximated with sutures.

Gold weight lid loading

Gold weight lid loading is an invaluable technique for the treatment of the paralyzed upper eyelid. A weight in the upper eyelid causes greater gravitational pull, passively closing the lid. Gold is the material of choice for lid weighting because of its high density, relative inertness, and color, which blends with most skin tones.

Commercially manufactured gold implants are available in a wide range of weights. The most suitable weight is determined by taping different weights to the patient's upper lid to assess which weight provides the most suitable eye closure in upright and supine positions.

Placement of a gold weight lid load is a simple procedure that is performed under local anesthesia. A supratarsal crease incision is made and dissection is carried down to the tarsus. Disruption of the levator aponeurosis must be avoided. A pretarsal pocket is created, in which the selected gold weight is centered and secured to the tarsus with an absorbable suture.

May reports a 90% success rate in 482 gold weight lid loading procedures with a 5% rate of persistent lagophthalmos. Complication rates are generally low. Potential complications of lid loading include incomplete closure, displacement or migration of the weight, foreign body reaction, cosmetic lid deformity, shifts in the astigmatic axis of refraction, and extrusion. Careful attention to pocket size and to securing the implant to the tarsus can minimize complications of migration. Closing the orbicularis and subcutaneous tissue over the implant reduces the risk of extrusion. If necessary, revision procedures can be performed to reposition or replace the implant with a different weight. Removal of the implant is simple, and postremoval sequelae have not been described.

Early use of gold weight lid loading is espoused and can be performed at the time of the initial facial nerve injury. In situations of nerve repair or grafting, recovery of facial nerve function may take several months. Lid loading provides corneal protection during the recovery period, and with return of facial nerve function, the lid load is removed easily. For surgeons who prefer autologous material, conchal cartilage grafts are an alternative treatment for lagophthalmos.

Lower lid procedures

Loss of orbicularis tone in the lower lid results in ectropion and problems of lid closure and lacrimal drainage. Techniques to reanimate the lower lid include canthoplasty, lid tightening procedures, and lid suspension.

A lid shortening procedure does not adequately address medial canthal laxity. The classic technique, the Collin medial canthoplasty, involves exposure of the canthal tendon through upper and lower incisions just medial to the puncta. The surgeon needs to approximate the 2 arms of the tendon with a mattress suture in order to tighten it. This technique is appropriate for treatment of mild-to-moderate medial canthal laxity.

Crawford et al report that 90% of patients with paralytic medial ectropion treated in this fashion experience complete relief of symptoms.¹ A potential complication of the medial canthoplasty is inferior canaliculus scarring with inexorable epiphora.

Lateral lid laxity can be addressed by lid shortening or lateral canthoplasty procedures. Lid shortening is accomplished by a full-thickness wedge resection of the lower lid through a subciliary skin incision. A full thickness incision is made at the lateral limbus, followed by overlapping of the cut ends and wedge excision. Overcorrection should be done, and the tarsal plate is reapproximated with a nonabsorbable suture.

The lateral canthoplasty corrects canthal tendon laxity and shortens the lower lid. The tarsal strip procedure is a powerful procedure, where a lateral canthotomy is executed and the inferior portion of the lateral canthal tendon is released from its insertion at the lateral orbital wall. The tarsal strip is de-epithelialized and elevated and suspended to the periosteum of the orbital wall to produce sufficient lower lid tightening.

Ellis describes using a sling to suspend the medial lower lid. In this technique, tunnel a Gore-Tex (WL Gore and Associates, Newark, Del) strip subcutaneously from the anterior lacrimal crest to the zygomatic process.² Tension on the sling elevates the lid and positions the punctum against the globe. Excess lid laxity often needs to be addressed with a lid-shortening procedure in conjunction with the sling.

Lower lid sagging can recur following lid shortening and tightening procedures because of poor orbicularis tone. Numerous grafts (eg, septal and conchal cartilage, hard palate mucosa, contralateral tarsal plate), secured to the lower tarsal border, can bolster the lower lid. Cartilage is harvested easily from either the septum or the fossa triangularis. Conchal cartilage is thinner and more elastic than septal cartilage, lending itself to more facile molding and shaping. The cartilage graft is tailored to fit the convexity of the globe and the inferior border of the tarsus. After a subciliary incision or transconjunctival incision, the depressors/lower lid retractors are released, the lower edge of the tarsus is identified, and a pocket is created. The graft is sutured and secured within this pocket to the lower tarsal border.

More recently, Li and Shorr describe their experience with AlloDerm (LifeCell, Branchburg, NJ) versus hard palate graft for lower lid retraction.³ They report equal success for both materials in treating ectropion and elevating the lower lid. In any case, this procedure is easily combined with other lower lid procedures, including the lateral tarsal strip. May implanted the lower lids of 51 patients with auricular cartilage and reported improvement in lid position in 100%.⁴ He reported no extrusions and only 2 cases of implant migration.

STATIC RECONSTRUCTION OF THE LOWER FACE

Section 5 of 8  

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

Static techniques generally are unsatisfactory as a single modality for rehabilitation of the paralyzed lower face. They should not be used as a primary modality of reconstruction. However, static procedures are most appropriate for debilitated patients who are unable or unwilling to endure the extensive operations of dynamic reanimation or those who are not expected to have a life expectancy beyond the nerve and muscle recovery of dynamic strategies. Static techniques can also enhance dynamic reanimation by augmenting facial symmetry.

Most static procedures involve suspension of a part of the face by a sling. The most commonly used materials are fascia lata and the palmaris longus tendon. Both grafts are easily harvested and afford adequate length and strength. The fascia lata is preferred because multiple strips can be acquired. Initial overcorrection is necessary to compensate for the stretching that occurs with autologous grafts.

Alloplastic materials for facial suspension include polypropylene mesh and the polytetrafluoroethylene patch. Advantages of these alloplasts include elimination of donor site morbidity and minimal stretching and laxity. However, because alloplasts are foreign material, they have higher complication rates due to infection and extrusion. Another option is AlloDerm, which has tensile strength similar to that of alloplasts but does not exude any of the foreign body reactions. AlloDerm slings have shown significant improvements in oral commissure position and oral competence. Unlike Gore-Tex, AlloDerm slings can also be used in patients who are undergoing radiation therapy.

Oral commissure and lip suspension

Drooping of the oral commissure secondary to facial paralysis can be aesthetically and functionally problematic. Static suspension of the commissure can reestablish symmetry and enhance oral competence. The sling involves suspension of autologous or alloplastic materials from the orbicularis oris muscle to either the zygomatic arch or the orbital rim.

Sundry surgical approaches and incisions are used in facial suspension. A standard rhytidectomy incision and dissection provides excellent exposure to the entire hemi-face. Moreover, exposure of the oral commissure can be achieved via incisions at the vermillion border of the upper and lower lip or at the nasolabial fold. An extended subciliary incision or a vertical incision anterior to the sideburn provides exposure to the orbital rim and zygomatic arch.

The sling is sutured to the modiolus or split it into 2 tongues and fixed to orbicular fibers of the upper and lower lip. By analyzing the position of the mouth on the unaffected side, the suspension vector is determined and the free end of the sling is suspended and fixed to the zygomatic arch or infraorbital rim by a permanent suture, Mitek screw (Mitek Surgical Products, Westwood, Mass), or miniplate. Multiple strips of sling material can be used to create different vectors of suspension for the upper and lower lip. Some degree of overcorrection is necessary to account for postoperative relaxation and laxity, especially when using autologous material such as fascia lata.

Nasal lateralization

Buccal branch denervation induces paralysis of nasalis muscles and subsequent nostril collapse. Patients may experience unilateral nasal airway obstruction and internal valve collapse. This can be corrected by a lateralization procedure in which a sling of fascia or alloplast is secured to the deep tissue of the lateral alar base and suspended lateral to the ascending maxillary buttress with a nonabsorbable suture, an anchoring suture, or a titanium plate/screw.

Other anchoring techniques

Surgeons have developed other stratagems because of their dissatisfaction with autologous fascia and alloplasts. These surgeons are opposed to the resorption, scarring, and laxity of fascial slings as well as the complication rates and foreign body response to alloplasts.

Seeley and To describe a system where they suspend the face, commissure, and mid face in multiple vectors.⁵ They developed a static, multivector, bone-anchored system of resuspension with braided sutures depressing the lower lip with anchor to the mentum, elevation of the lower face with an anchor to the angle of the mandible, and resuspension of the lip/nasolabial region and mid face with an anchor to the lateral canthal region. The multivector suspension restored nasal breathing, improved drooling, restored normal speech, and enhanced cosmetic results and symmetry with minimal operative time and morbidity.

Similarly, Horlock and Sanders improve on oral competence and oral asymmetry at rest and movement with a suborbicularis oculi fat (SOOF) lift and subperiosteal midface lift.⁶ Their approach achieves improved resting symmetrical tone and spontaneous synchronization. This technique is generally not indicated for patients with poor mouth excursion or with severe static asymmetry identified preoperatively.

Cheiloplasty

The corner of the mouth can be resuspended by either dynamic or static techniques, but residual lip asymmetry with loss of tone and gapping often occurs. In cheiloplasty, the redundant paralyzed lip tissue is resected and exchanged for normal orbicularis and lip from the contralateral unaffected side. The lip resection should be achieved with a full-thickness V or W wedge. As much as one third of both the upper and lower lip can be excised and closed primarily. The goal of this rotation and transfer of normal tissue is to reestablish a dynamic sphincter. Cheiloplasty can improve speech, eating, commissure competence, and appearance.

ADJUNCTIVE PROCEDURES

Section 6 of 8  

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

Soft tissue descent and ptosis may not manifest until well after 9-12 months after the onset of facial nerve denervation. The surgeon should wait at least 12 months before considering any mode of cosmetic suspension or rehabilitation. The cosmetic or adjunctive techniques should be postponed until all necessary reconstruction and muscle/nerve recovery is realized. This is paramount for free muscle transfer for facial reanimation since restoration of neurotization and muscle function can take 2-3 years.

Browlift, blepharoplasty, and rhytidectomy procedures can be used in various configurations to battle soft tissue changes and descent that occur in the paralyzed face.

SUMMARY

Section 7 of 8  

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

Facial nerve paralysis results in significant functional, psychological, and cosmetic difficulties for the patient and poses inexorable challenges to the surgeon. Dynamic and static procedures can be performed for facial reanimation. Although dynamic procedures provide the best functional and cosmetic results for the paralyzed face, they may not be suitable for a patient who is debilitated or terminally ill. Static procedures are valuable tools in the management of eye protection, lid laxity, and lagophthalmos. They can also serve as adjunctive modalities to achieve better facial symmetry and cosmesis. The plastic surgeon, with other specialists, must incorporate static procedures with advanced dynamic muscle transfers into their palette of facial nerve reconstruction.

REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Evaluation
• Management of the Eye in Facial Paralysis
• Static Reconstruction of the Lower Face
• Adjunctive Procedures
• Summary
• References

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4. May M, Hoffmann DF, Buerger GF Jr, Soll DB. Management of the paralyzed lower eyelid by implanting auricular cartilage. Arch Otolaryngol Head Neck Surg. Jul 1990;116(7):786-8. [Medline].
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6. Horlock N, Sanders R, Harrison DH. The SOOF lift: its role in correcting midfacial and lower facial asymmetry in patients with partial facial palsy. Plast Reconstr Surg. Mar 2002;109(3):839-49; discussion 850-4. [Medline].
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Article Last Updated: Sep 14, 2007