eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Static Suspension for Facial Paralysis: Treatment

Author: Suzanne K Doud Galli, MD, PhD, Consulting Staff, Cosmetic Facial Surgery, Private Practice
Coauthor(s): Minas Constantinides, MD, Director of Facial Plastic and Reconstructive Surgery, Assistant Professor, Department of Otolaryngology, New York University School of Medicine
Contributor Information and Disclosures

Updated: Mar 24, 2009

Treatment

Medical Therapy

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.

Surgical Therapy

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

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.

Freeze-dried 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

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.

Intraoperative Details

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.

Postoperative Details

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.

Follow-up

Ocular considerations

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

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.

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