Static Suspension for Facial Paralysis Treatment & Management
- Author: Suzanne K Doud Galli, MD, PhD; Chief Editor: Arlen D Meyers, MD, MBA more...
No medical therapies to elicit functional facial reanimation exist. Antivirals and steroids, however, are in the armamentarium for acute onset of facial paralysis. Additionally, steroids in iatrogenic and traumatic facial nerve injury have a role.
Static Reanimation Technique
Facial deformities are divided into 2 main areas, as follows: (1) eyebrow, eyelids, and forehead (periorbital) and (2) cheek/lip (perioral). Regional deformities are addressed by multiple suspensions that provide cosmetic and functional therapy. Visual field deficits are restored, the cornea is protected, and nasal obstruction and oral incompetence are relieved. The forehead and brows can be addressed via multiple approaches ranging from direct brow lift to trichophytic, coronal, or endoscopic forehead/brow lifts. These procedures are detailed in the eMedicine topics Endoscopic Forehead Lift and Direct Brow Lift. Materials used in static reanimation techniques are discussed below.
Fascia has been used historically and extensively in correction of facial paralysis. Fascia can be harvested from the patient as an autograft or can remain in situ in a transposition technique. Fascia lata, for example, can be taken from the lateral thigh and divided into strips. Fascia lata is a good source for a substantial amount of fascia for use in multiple slings.
Temporalis fascia can be used in either dynamic or static reanimation techniques. Fascial grafts can augment muscle transfer techniques or, in staged procedures, refine or revise previous reanimation. Through specific skin incisions, fascial strips are anchored to the bone on one end and to subcutaneous tissue on the other end. Temporalis fascia can be applied to correct paralysis of the lower face and is used to elevate the lip. Temporalis fascia with or without muscle is applied to correct lagophthalmos. The fascia can be used to create 2 circumorbital slings that reconstitute the orbital sphincter.
In either case, the inferior edge is sutured to the subdermis, while the other edge remains attached in situ. Strips of fascia lata can be attached to add length. Either fascia lata or temporalis fascia carries the advantage of being a natural source for sling material. These techniques, however, carry the morbidity at the donor site with a separate leg incision for fascia lata and a potential scalp defect if muscle is taken with temporalis fascia.
This material has been used for facial reanimation for longer than 30 years. More recently, commercially available, freeze-dried, acellular human dermis (AlloDerm) has been used for facial slings in static reanimation. As with synthetic materials, the use of AlloDerm precludes a donor site harvest. AlloDerm is readily available and can be custom cut to create adequate facial slings. This product is real human dermis that eventually integrates into surrounding tissues. In the fascial sling technique, AlloDerm is suture-secured subdermally in the inferior position and is anchored to the malar bone in the superior position.
Expanded polytetrafluoroethylene (Gore-Tex)
Expanded polytetrafluoroethylene (e-PTFE), known commercially as Gore-Tex, is a synthetic material that has been used for static reanimation in facial paralysis. Gore-Tex is manufactured in thin (1-2 mm) sheets that can be cut to size. The use of Gore-Tex circumvents the need to harvest fascial material, thus eliminating donor site morbidity. The strips are implanted through specific facial incisions. The inferior ends are secured to the subcutaneous tissues with a nonabsorbable suture. The other end is secured to the malar bone by rigid fixation with microplates and screws. Gore-Tex has also been used in combination with temporalis muscle transfer to lengthen the muscle slips.
Suture technique has been described as another method to achieve static suspension. Through a multivector approach, sutures are placed, resulting in functional and aesthetic improvements. The suture technique is less invasive than other static techniques. It can be accomplished percutaneously and several types of suture have been employed for this method.
Historically, static facial slings have been implanted via a facelift approach. The strips of fascia or alloplast are sutured to the subdermis at the oral commissure and then fixated to the parotid fascia or superficial musculoaponeurotic system (SMAS) preauricularly. The superficial plane of implantation, however, has resulted in unnatural restoration of facial support and poor long-term results plagued with extrusion of the alloplast, specifically e-PTFE. Shumrick reports a more recent technique that places the alloplast (in this report, e-PTFE) deeper in the face.
In Constantinides' revised technique, the alloplast is secured to the malar eminence through a small incision in a natural crease with rigid 1.5-mm titanium screws. The alloplast is then tunneled along a plane just superficial to the zygomaticus major muscle to the oral commissure. Here, the alloplast is sewn to the deep surface of the orbicularis oris and the subdermis with 6-0 permanent monofilament sutures through small stab incisions in the melolabial folds. Additional strips can be brought to the alar crease to improve external nasal valve weakness and nasal obstruction.
The advantage of this technique is that it can be safely performed in conjunction with other facial animation techniques. The authors have successfully and simultaneously placed slings and hypoglossal-facial anastomoses with no interference in reinnervation. The patient benefits from immediate improvement in facial support and oral competence until the face is reinnervated.
Lagophthalmos and paralytic ectropion are complications of facial nerve paralysis. Because the orbicularis oculi does not contract, the eye does not close, the cornea is exposed, and corneal keratopathy can ensue. Placement of a gold weight in the upper eyelid can rectify lagophthalmos; medial and lateral canthoplasty are techniques for correction of ectropion. Commonly, a tarsal strip procedure is used to tighten and reposition the lax lower eyelid. Typically, indications for surgical therapy in the eyelid in facial paralysis include facial paralysis lasting longer than 6 months, no expected return of function, lagophthalmos of the upper eyelid, ectropion of the lower eyelid, poor tear function, and dry eye. The goal of therapy is to protect the cornea and to achieve aesthetic improvement. Placement of a gold weight is an easily reversed procedure.
Complications are encountered with static reanimation technique. The most important complication is loss of correction. Shumrick reports prestretching the e-PTFE preoperatively to reduce this problem. Despite vigorous prestretching, however, the authors have found continued problems with loss of support over time. Recently, the authors have had better early results with acellular human dermis (AlloDerm), with no loss of correction after 6 months.
Infection is another potential complication of static reanimation technique. Infection can occur early or late and usually requires removal of graft material.
May M. Facial paralysis, peripheral type: a proposed method of reporting. (Emphasis on diagnosis and prognosis, as well as electrical and chorda tympani nerve testing). Laryngoscope. 1970 Mar. 80(3):331-90. [Medline].
Citarella ER, Sterodimas A, Green AC, Sinder R, Pitanguy I. Use of triple-convergence polypropylene thread for the aesthetic correction of partial facial paralysis. Aesthetic Plast Surg. 2008 Jul. 32(4):688-91. [Medline].
Yu K, Kim AJ, Tadros M, Costantino PD. Mitek anchor-augmented static facial suspension. Arch Facial Plast Surg. 2010 May-Jun. 12(3):159-65. [Medline].
Henstrom DK, Lindsay RW, Cheney ML, Hadlock TA. Surgical treatment of the periocular complex and improvement of quality of life in patients with facial paralysis. Arch Facial Plast Surg. 2011 Mar-Apr. 13(2):125-8. [Medline].
Alam D. Rehabilitation of long-standing facial nerve paralysis with percutaneous suture-based slings. Arch Facial Plast Surg. 2007 May-Jun. 9(3):205-9. [Medline].
Alex JC, Nguyen DB. Multivectored suture suspension: a minimally invasive technique for reanimation of the paralyzed face. Arch Facial Plast Surg. 2004 May-Jun. 6(3):197-201. [Medline].
Biel MA. GORE-TEX graft midfacial suspension and upper eyelid gold-weight implantation in rehabilitation of the paralyzed face. Laryngoscope. 1995 Aug. 105(8 Pt 1):876-9. [Medline].
Brown JB, McDowell F. Support of the paralyzed face by fascia. JAMA. 1947. 135:18-22.
Chan JY, Byrne PJ. Management of facial paralysis in the 21st century. Facial Plast Surg. 2011 Aug. 27(4):346-57. [Medline].
Cheney ML, McKenna MJ, Megerian CA, Ojemann RG. Early temporalis muscle transposition for the management of facial paralysis. Laryngoscope. 1995 Sep. 105(9 Pt 1):993-1000. [Medline].
Coker NJ. Management of traumatic injuries to the facial nerve. Otolaryngol Clin North Am. 1991 Feb. 24(1):215-27. [Medline].
Conley J, Baker DC. The surgical treatment of extratemporal facial paralysis: an overview. Head Neck Surg. 1978 Sep-Oct. 1(1):12-23. [Medline].
Freeman MS, Thomas JR, Spector JG, Larrabee WF, Bowman CA. Surgical therapy of the eyelids in patients with facial paralysis. Laryngoscope. 1990 Oct. 100(10 Pt 1):1086-96. [Medline].
Freilinger G, Gruber H, Happak W, Pechmann U. Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg. 1987 Nov. 80(5):686-90. [Medline].
Hoffman WY. Reanimation of the paralyzed face. Otolaryngol Clin North Am. 1992 Jun. 25(3):649-67. [Medline].
Ibrahim AM, Rabie AN, Kim PS, Medina M, Upton J, Lee BT, et al. Static treatment modalities in facial paralysis: a review. J Reconstr Microsurg. 2013 May. 29(4):223-32. [Medline].
Kartush JM, Linstrom CJ, McCann PM, Graham MD. Early gold weight eyelid implantation for facial paralysis. Otolaryngol Head Neck Surg. 1990 Dec. 103(6):1016-23. [Medline].
Konior RJ. Facial paralysis reconstruction with Gore-Tex Soft-Tissue Patch. Arch Otolaryngol Head Neck Surg. 1992 Nov. 118(11):1188-94. [Medline].
Leventhal DD, Pribitkin EA. Static facial suspension with Surgisis ES (Enhanced Strength) sling. Laryngoscope. 2008 Jan. 118(1):20-3. [Medline].
Liu YM, Sherris DA. Static procedures for the management of the midface and lower face. Facial Plast Surg. 2008 May. 24(2):211-5. [Medline].
May M. Muscle transposition for facial reanimation. Facial Plast Surg. 1992 Apr. 8(2):115-20. [Medline].
May M, Drucker C. Temporalis muscle for facial reanimation. A 13-year experience with 224 procedures. Arch Otolaryngol Head Neck Surg. 1993 Apr. 119(4):378-82; discussion 383-4. [Medline].
Meltzer NE, Alam DS. Facial paralysis rehabilitation: state of the art. Curr Opin Otolaryngol Head Neck Surg. 2010 Aug. 18(4):232-7. [Medline].
Okamura H, Yanagihara N. Multiple facial suspensions in protracted facial palsy. Auris Nasus Larynx. 1987. 14(2):105-13. [Medline].
Ozaki M, Takushima A, Momosawa A, Kurita M, Harii K. Temporary suspension of acute facial paralysis using the S-S Cable Suture (Medical U&A, Tokyo, Japan). Ann Plast Surg. 2008 Jul. 61(1):61-7. [Medline].
Rose EH. Autogenous fascia lata grafts: clinical applications in reanimation of the totally or partially paralyzed face. Plast Reconstr Surg. 2005 Jul. 116(1):20-32; discussion 33-5. [Medline].
Snyderman RK, Ego-Acquirre E, Starzynski TE. The ultimate fate of freeze dried fascia: experience with its use in the correction of facial paralysis. Plast Reconstr Surg. 1966 Sep. 38(3):219-22. [Medline].
Spector JG, Thomas JR. Slings for static and dynamic facial reanimation. Laryngoscope. 1986 Feb. 96(2):217-21. [Medline].
Yoshimoto S, Sato N, Kuroki T, Rikihisa N, Ichinose M. Static reconstruction of malar region in facial paralysis: a new alternative technique for plasty of symmetric mouth appearance. J Plast Surg Hand Surg. 2013 Oct. 47(5):390-3. [Medline].