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234
Fig. 17.7 Transection of
the masseteric nerve
Fig. 17.8 Nerve
reorientation for
neurorrhaphy
M. H. Hohman and A. G. Vincent
Fig. 17.9 Coaptation of
the buccal branch and
masseteric nerve
4. Coapt the nerves (Fig. 17.9) in an end-to-end fashion using ne sutures, such as
10-0 nylon, on a cutting needle. Only two or three interrupted stitches are usually
required, placed into the epineurium. Avoid overtightening and impacting or herniating the fascicles through the neurorrhaphy. Consider the application of brin
glue and/or a nerve protection sheath over the coaptation site.
17 Masseteric Nerve Transfer forFacial Reinnervation
235
Pearls
• Insist on the use of no long-acting paralytics during intubation for patients under-
going masseteric nerve transfer or, indeed, any facial nerve procedure. Loss of
stimulability of trigeminal and facial nerve branches during these cases may
increase the risk of iatrogenic injury.
• Avoid local anesthetic use in this procedure. The rate of metabolism of these
agents varies tremendously among patients, and stimulability of the relevant
nerve branches may be lost for hours following injection.
• Exposure of the masseteric nerve is more challenging in patients with synkinesis
than with accid paralysis because care must be taken to avoid injury to facial
nerve branches in the vicinity of the masseteric nerve when there is residual
mimetic function.
• Masseter muscle atrophy after masseteric nerve transfer is common, but fre-
quently resolves over several months. It does not usually affect mastication
because of redundant function in the temporalis and medial pterygoid muscles,
but it may cause noticeable facial asymmetry; counsel patients accordingly dur-
ing the preoperative visit.
• Transect the masseteric nerve as distally as possible to maximize the chance of
reecting the cut end out of the cavity in the masseter muscle, which in turn will
facilitate the neurorrhaphy.
References
1. Dusseldorp JR, van Veen MM, Guarin DL, Quatela O, Jowett N, Hadlock TA. Spontaneity
assessment in dually innervated gracilis smile reanimation surgery. JAMA Facial Plast Surg.
2019;21(6):551–7.
2. Borschel GH, Kawamura DH, Kasukurthi R, Hunter DA, Zuker RM, Woo AS.The motor nerve
to the masseter muscle: an anatomic and histomorphometric study to facilitate its use in facial
reanimation. J Plast Reconstr Aesthet Surg. 2011;65(3):363–6.
3. Pepper JP.Dual nerve transfer for facial reanimation. JAMA Facial Plast Surg. 2019;21(3):260–1.
4. Hohman MH, Hadlock TA. Microneurovascular free gracilis transfer for smile reanimation.
Oper Tech Otolaryngol Head Neck Surg. 2012;23(4):262–7.
5. Miller MQ, Hadlock TA.Beyond Botox: contemporary management of nonaccid facial palsy.
Fascial Plast Surg Aesthet Med. 2020;22(3):65–70.
6. Vincent AG, Bevans SE, Robitschek JM, Wind GG, Hohman MH.Masseteric nerve transfer
and selective neurectomy for rehabilitation of the synkinetic smile. JAMA Facial Plast Surg.
2019;21(6):504–10.
7. Dorafshar AH, Borsuk DE, Bojovic B, Brown EN, Manktelow RT, Zuker RM, Rodriguez ED,
Redett RJ. Surface anatomy of the middle division of the facial nerve: Zuker’s point. Plast
Reconstr Surg. 2013;131(2):253–7.
Outpatient Periocular Reanimation
18
MarcH.Hohman andAuroraG.Vincent
Introduction
The vast majority of patients with acute facial paralysis can be managed exclusively
with conservative therapy and oral medications. Bell’s palsy accounts for over 80%
of acute facial paralysis, and very few of these patients require operative intervention because 73–93% will return to premorbid facial function, or very close to it,
over the course of a year [1, 2]. The patients most in need of periocular procedures
are those who are anticipated to recover slowly or who will later require more denitive reinnervation or reanimation procedures. This group includes patients with
medical comorbidities or advanced age and complete hemifacial infectious paralysis (Bell’s palsy, Ramsay Hunt syndrome, Lyme disease, etc.), patients with poor
Bell’s phenomena or corneal anesthesia, and patients with known transection of the
facial nerve. Periocular procedures are also indicated in patients with milder presentations who nevertheless are unable to maintain ocular health and comfort with
drops, lubricant, taping, and eyelid stretching [3].
Multiple periocular procedures have been designed to improve eye closure,
among them upper eyelid loading and lower eyelid tightening. There are several
ways of performing both of these operations as well. Herein, the pretarsal approach
to eyelid weight placement is described, along with the lateral tarsal strip
M. H. Hohman
Baghdad Diplomatic Support Center, Baghdad, Iraq
Department of Surgery, Uniformed Services University of the Health Sciences,
Bethesda, MD, USA
e-mail: marc.h.hohman.mil@health.mil
A. G. Vincent (*)
Eisenhower Army Medical Center, Fort Gordon, GA, USA
e-mail: aurora.g.vincent.mil@health.mil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_18
237
238
M. H. Hohman and A. G. Vincent
canthoplasty. While preseptal placement of an upper eyelid weight may provide a
superior aesthetic result in many patients, the more inferior location of the weight
resulting from a pretarsal placement increases the mechanical advantage, particularly at night when the patient is supine and makes eye closure more complete. The
choice of implant will depend on surgeon preference and patient factors. Platinum
has a lower tissue reactivity rate than gold and has a lower prole under the skin
because of its slightly higher density, and chains are less likely to cause clinically
signicant astigmatism than solid weights but are more likely to extrude in the long
run [4, 5]. Ideally, one would apply adhesive weights of varying masses to the
patient’s affected eyelid to determine the ideal size of the implant preoperatively,
but a good starting place for most patients is 1.2g. In most cases, there will not be
an ideal mass that permits complete eye closure without causing any blepharoptosis; therefore, the weight selected should balance the two competing factors.
Lateral tarsal strip canthoplasty is also a straightforward clinic procedure sufcient for alleviating most cases of minor paralytic ectropion, particularly when performed under local anesthesia in the same session as upper eyelid loading. Medial
canthopexy and lower lid suspension can be added for more severe cases, particularly in older patients with chronic accid paralysis, but these procedures are typically performed under general anesthesia because of the extent of surgery and care
necessary to avoid damage to the lacrimal system.
Pretarsal Upper Eyelid Weight Placement
1. While the patient is upright, mark the upper eyelid crease incision (Fig.18.1),
roughly the length of the weight and centered just lateral to the medial limbus or
wherever the lagophthalmos is greatest. In patients with multiple creases, choose
one roughly 8mm above the lash line. Inject local anesthetic with epinephrine
just under the skin to avoid a hematoma; place a substantial amount medially
because the infratrochlear nerve is often under-anesthetized, and this frequently
causes the patient discomfort during surgery. Prep the skin with 5% povidone-
Fig. 18.1 Eyelid marking
18 Outpatient Periocular Reanimation
239
iodine solution, taking care to avoid disrupting the surgical markings. Below, the
medial and lateral vertical lines are the anticipated medial and lateral extents of
the incision, and the central vertical line is where the lagophthalmos is most
pronounced.
2. Incise through the skin with a #15 blade (Fig.18.2), stopping at the surface of the
orbicularis oculi muscle.
3. Dissect sharply with ne scissors through the orbicularis oculi (Fig. 18.3),
angled inferiorly toward the tarsal plate, avoiding dissection superior to the tarsal plate, which can injure the aponeurosis of the levator palpebrae superioris muscle.
4. Identify and skeletonize the tarsal plate (Fig. 18.4), extending the dissection
medially and laterally as necessary to allow placement of the weight roughly
2mm superior and parallel to the lash line. Obtain hemostasis with bipolar electrocautery on a low setting, such as 10–12 watts.
Fig. 18.2 Eyelid incision
Fig. 18.3 Sharp dissection
through orbicularis oculi
240
Fig. 18.4 Tarsal plate
Fig. 18.5 Securing the
implant with a partialthickness suture through
the tarsal plate
M. H. Hohman and A. G. Vincent
5. After conrming that the pocket is large enough to accommodate the weight in
the desired position, suture it to the tarsal plate using a clear 6-0 nonabsorbable
monolament suture (Fig.18.5). The needle should only be passed partial thickness through the tarsal plate to avoid injuring the cornea either during surgery or
afterwards if the suture material were to cause an abrasion. Displace the eyelid
off the globe prior to passing the suture by applying tension as the patient looks
downwards. The assistant should provide conrmation that the needle has not
violated the conjunctiva by examining the everted eyelid while the needle is still
in the tarsal plate (Fig.18.6). Place the sutures at the inferior border of the weight
rst and then the superior border. Take care to ensure the knots pass perpendicularly across the edges of the plate so that there is no slack in the sutures so that
the weight will be less likely to shift postoperatively.
6. Close in two layers, with buried 5-0 absorbable sutures in the orbicularis oculi
and 6-0 interrupted absorbable sutures in the skin (Fig.18.7). Apply ophthalmic
antibiotic ointment and a cold pack.
18 Outpatient Periocular Reanimation
Fig. 18.6 Checking to
make sure the suture has
not violated the
conjunctiva before pulling
it through
Fig. 18.7 Suture closure
241
Lateral Tarsal Strip Canthoplasty
1. Perform a lateral canthotomy with ne scissors out to the lateral orbital rim
(Fig.18.8), using a crow’s foot wrinkle, if practical.
2. Retract the lateral lower eyelid and perform a complete inferior cantholysis
(Fig. 18.9), dividing all of the palpable inferior bers of the lateral canthal
ligament.
3. Make a back-cut incision in the lateral lower eyelid (Fig.18.10) just below the
inferior border of the inferior tarsal plate, roughly 5 mm long and 4mm below
the lash line.
4. Denude the gray line parallel to the back cut (Fig.18.11).
5. Elevate the skin and orbicularis oculi muscle off the tarsal strip (Fig.18.12).
6. Scrape the conjunctiva off the tarsal strip with a #15 blade (Fig.18.13).
7. Place a lateral canthal reapproximation suture (Fig.18.14) using a 5-0 absorb-
able suture running parallel to the gray line, with the knot oriented laterally, then
242
Fig. 18.8 Lateral
canthotomy
Fig. 18.9 Inferior
cantholysis
M. H. Hohman and A. G. Vincent
Fig. 18.10 Back cut of
the lower eyelid
18 Outpatient Periocular Reanimation
Fig. 18.11 Denuding the
gray line
Fig. 18.12 Elevation of
the skin and orbicularis
oculi
243
Fig. 18.13 Scraping off
the conjunctiva
244
Fig. 18.14 Lateral canthal
reapproximation suture
Fig. 18.15 Lateral tarsal
strip suture placement
M. H. Hohman and A. G. Vincent
reect the suture medially with a clamp; this stitch is placed prior to suspending
the tarsal strip because it is more challenging to place afterwards.
8. Place a double-armed 4-0 polyester suture (Fig.18.15) into the lateral aspect of
the tarsal strip with both needles passing deep to supercial, one superior to the
other. Then, displacing the globe medially with an empty scalpel handle or a
malleable retractor, pass the needles deep to supercial through the periorbita
roughly 2mm superior to the level of the medial canthus, keeping the needles
and suture passes parallel to each other. Tie the suture tightly enough to overcorrect by 10–20%.
9. Tie down the lateral canthal reapproximation suture to create a sharp, natural-
appearing canthus (Fig.18.16), and then close in layers, using the remnant of the
canthus suture to close the orbicularis oculi and 6-0 interrupted absorbable
suture for the skin. Trim any excess lower eyelid skin as necessary.