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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4479_Библиотеки_им_академика_М_И_Перельмана.pdf
18 Outpatient Periocular Reanimation
Fig. 18.16 Tying down
the canthal sutures
245
Pearls
• There is no perfect weight that will produce complete eye closure without bleph-
aroptosis, so counsel patients accordingly. The correct eyelid weight will mini-
mize or eliminate the requirement for eyedrops and ointment without causing
bothersome blepharoptosis, but patients will still often notice incomplete eye
closure on windy days or when washing their hair in the shower. When in doubt,
a 1.2g weight works in most cases.
• Avoid dissection superior to the tarsal plate, as this can injure the levator aponeu-
rosis and cause blepharoptosis.
• To avoid corneal abrasions, conrm that the sutures used to secure the weight are
placed only in partial thickness through the tarsal plate.
• Place the lateral canthal approximation suture prior to suspending the tarsal strip
to save time and effort.
• Reduce the risk of producing bradycardia via the oculocardic reex by minimiz-
ing time spent applying pressure to the globe when suspending the tarsal strip.
• Ensure patients plan to be driven home, even if the operation is performed under
local anesthesia, because operated eyes will likely be swollen and blurry by the
time of discharge.
References
1. Escalante DA, Malka RE, Wilson AG, Nygren ZS, Radcliffe KA, Ruhl DS, Vincent AG,
Hohman MH.Determining the prognosis of Bell’s palsy based on severity at presentation and
electroneuronography [published online ahead of print March 30, 2021]. Otolaryngol Head
Neck Surg. 2022;166(1):151–7.
246
2. Sullivan FM, Swan IC, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale
LD, Clarkson JE, Hammersley V, Hayavi S, McAteer A, Stewart K, Daly F.Early treatment
with prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007;357(16):1598–607.
3. Hohman MH, Hadlock TA. Etiology, diagnosis, and management of facial paralysis: 2000
patients at a facial nerve center. Laryngoscope. 2014;124(7):e283–93.
4. Silver A, Lindsay R, Cheney M, Hadlock T.Thin prole platinum eyelid weighting: a superior
option in the paralyzed eye. Plast Reconstr Surg. 2009;123(6):1697–703.
5. Pausch NC, Kunht CP, Halam D.Upper-eyelid weight implants for patients with lagophthalmos-
comparison of rigid and exible implants. J Craniomaxillofac Surg. 2018;46(10):1843–9.
M. H. Hohman and A. G. Vincent
Static Facial Suspension withFascia Lata
19
MarcH.Hohman andAuroraG.Vincent
Introduction
Facial paralysis affects multiple different aspects of mimetic function, including
smile symmetry and resting oral commissure position, nasolabial fold depth and
orientation, and external nasal valve patency [1]. While the majority of facial paralysis will either resolve spontaneously or ultimately result in hypertonicity, tumor
resection and nerve transection will often result in long-term accid facial palsy [2].
The gold standard for these patients should be dynamic reanimation with functional
muscle; however, not all patients are appropriate candidates for lengthy microvascular procedures. When multiple medical comorbidities, anatomical considerations,
or patient preferences contraindicate muscle transfer, static suspension may be an
acceptable alternative. Additionally, static suspension may be employed to augment
results obtained with functional muscle transfer [3].
Common materials used for facial suspension include fascia lata, expanded
polytetrauoroethylene, and nonabsorbable suture; these can all be employed at
multiple locations within the face, including the oral commissure, the nasolabial
fold, and the nasal base. While addressing all three of these targets simultaneously
may be an attractive option for a patient who requires a minimally-invasive facial
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_19
247
248
M. H. Hohman and A. G. Vincent
reanimation solution, suspension of the nasal base and/or the nasolabial fold may
provide additional improvement of resting symmetry for patients undergoing
dynamic reanimation, such as sterno-omohyoid free muscle transfer for smile
rehabilitation.
There are myriad approaches to suspension of the nasal base, nasolabial fold, and
oral commissure; herein, a limited-access technique is described, involving a short
alar groove incision, percutaneous stab incisions at the nasolabial fold, and an
abbreviated Blair preauricular incision. An alternative method employing a fulllength nasolabial fold skin excision is also detailed. Similarly, there are several
methods of harvesting fascia lata; the open harvest is presented here, as it provides
optimal exposure and visualization, but a variant that uses short transverse incisions
is discussed as well [4].
Fascia Lata Harvest
1. Mark the groove on the lateral thigh that runs between the quadriceps and ham-
string muscles (vastus lateralis and biceps femoris) roughly halfway down the
thigh. Making the incision too far superiorly will expose the tensor fasciae latae
muscle rather than the desired fascia itself. If the incision is made longitudinally,
it will be 8–10cm in length to permit harvest of 12–14cm of fascia, as shown.
If incisions are made to limit incision length (dashed black lines) transversely,
they should be separated by 12–14cm to allow harvest of a sufcient length of
tissue (Fig.19.1).
2. Dissect down to the fascia lata through fat and a thin band of fascia (Fig.19.2).
The true fascia lata will be a very apparent white, brous layer. Use a sponge to
wipe the fat off its surface and expose the necessary amount of fascia. If performing three-level suspension, a piece 14cm long by 8cm wide should sufce
for most patients. If suspending the nasal base, a 1.5cm wide piece is required;
4cm of width is adequate for the nasolabial fold, and 2cm sufces for the oral
commissure.
Fig. 19.1 Incision
markings, both transverse
(black dashed lines) and
longitudinal (marker)
approaches
19 Static Facial Suspension withFascia Lata
Fig. 19.2 Exposure of
fascia lata
Fig. 19.3 Incision through
fascia lata completed with
blunt-tipped scissors
249
3. Make a stab incision with a #15 blade parallel to the bers of the fascia, and then
complete the incision with blunt-tipped scissors to avoid injuring the underlying
muscle (Fig.19.3). Make the posterior incision rst. Otherwise, the vastus lateralis will herniate through the incision and displace the fascia posteriorly, which
will impede access.
4. Mobilize the deep surface of the fascia (Fig.19.4) from the underlying muscle
with a nger sweep and then make the transverse incisions to complete the harvest. A right-angled scissor, like a Jorgensen, can help ensure an even cut. Apply
tension to the fascia when making the nal incision to prevent retraction and
harvest of a shorter piece than planned.
5. Obtain hemostasis and close in layers. If only a narrow strip of fascia lata was
harvested, it may be possible to close the fascia and prevent muscle herniation.
Take care to close the dead space and consider suction drain placement, although
a drain is not usually necessary if hemostasis is adequate and a pressure dressing
is applied. Divide the fascia into ribbons of appropriate width: 1.5cm for nasal
base suspension, 4cm for nasolabial fold suspension, and 2cm for oral commissure suspension (Fig.19.5).
250
Fig. 19.4 Deep
mobilization of the fascia
Fig. 19.5 Harvested
fascia lata cut into
appropriate strips
M. H. Hohman and A. G. Vincent
Static Facial Suspension
1. Mark the alar-facial incision (Fig.19.6) just lateral to the alar-facial junction,
meeting the superior aspect of the nasolabial fold to create a naturally-appearing
nasofacial isthmus. The nasolabial fold should be marked preoperatively while
the patient is upright. Roughly 2mm anterior to the nasolabial fold, 10–12 percutaneous stab incisions should be marked as well. Mark the letter “P” on the
paralyzed side of the face to avoid confusion while the patient remains under
general anesthesia.
2. Make an abbreviated preauricular Blair incision, running from high within the
temporal hair tuft down to the lobule, and raise a sub-SMAS (supercial musculoaponeurotic system) ap (Fig.19.7) extending to the nasolabial fold and the
modiolus of the oral commissure, where the zygomaticus major muscle inserts
onto the orbicularis oris muscle.
3. Make the nasolabial fold stab incisions with a #11 blade, then tailor the 4 cm
wide band of fascia lata with a gentle curve on the anterior edge to parallel the
nasolabial fold (Fig.19.8). Place the fascia under the facial ap and insert it into
19 Static Facial Suspension withFascia Lata
Fig. 19.6 Alar-facial
incision marking
Fig. 19.7 Sub-SMAS
elevation
251
the nasolabial fold using 3-0 polypropylene sutures with double-armed straight
needles as follows: the rst needle is passed through the stab incision into the
facial wound; the second needle is then passed from the rst stab incision through
the dermis and into the adjacent stab incision, where it is retrieved, reloaded on
the needle driver, and then passed through the stab incision and into the facial
wound (Fig.19.9). Repeat with each of the stab incisions. The number of sutures
required is n–1, in which n is the number of stab incisions; for 10 stab incisions,
9 sutures (18 needles) are required. It is critical to keep all of the needles in order
and avoid twisting the sutures. Placing the needles point down into a suture
booklet may be helpful. Once the sutures have all been passed through the stab
incisions, the needles can be passed through the fascial band at regular intervals
along its anterior edge, and the fascia advanced into the facial wound until its
edge rests immediately subjacent to the dermis of the nasolabial fold. The sutures
are then tied with the knots buried under the fascia. Do not overtighten the knots,
or the skin will dimple unnaturally. The tension on the fascia itself will create the
nasolabial fold, not the tension on the knots.
252
Fig. 19.8 Fascia lata
tailoring to t the face.
This patient is undergoing
nasolabial fold and alar
base suspension in addition
to sterno-omohyoid
functional free muscle
transfer
M. H. Hohman and A. G. Vincent
Fig. 19.9 Illustration of
the suture topology.
Placing the sutures through
stab incisions allows them
to bury while avoiding a
noticeable scar. The knots
are tied beneath the fascia
lata to prevent them from
becoming palpable
4. Alternatively, an incision can be made directly in the nasolabial fold and a trian-
gular section of dermis inferomedial to it deepithelialized (Fig. 19.10); this
inferiorly- based dermal tab is afxed to the fascia lata with buried 3-0 nonabsorbable sutures, and the fascia then passed into the facial wound (Fig.19.11).
The fascia lata should be sutured to the undersurface of the dermal tab, with the
knots located deep to the fascia to prevent them from being palpable. This
method leaves a visible scar but is technically more straightforward than the
minimally invasive technique described previously.
19 Static Facial Suspension withFascia Lata
Fig. 19.10 Alternative
direct nasolabial fold
incision
Fig. 19.11 Afxed fascia
lata graft to be passed into
the face. (Photograph
courtesy of Tessa A
Hadlock, MD)
253
5. Make the alar-facial incision and tailor the 1.5cm wide fascial ribbon to parallel
the curve of the alar-facial junction (Fig.19.12). Secure the fascia to the deep
brous tissue and sesamoid cartilages of the ala using 3-0 nonabsorbable suture
while the fascia is draped across the contralateral side of the face. This arrangement will bury the knots once the fascia is passed into the face.
6. Secure the 2cm wide fascial ribbon to the modiolus of the oral commissure with
3-0 nonabsorbable suture, taking care to place the knots deep into the fascia.
Figure19.13 depicts the inset of all three ribbons of fascia lata via a nasolabial
incision, and Fig.19.14 depicts the nal position in the face. If no nasolabial
incision is used, the oral commissure and nasolabial ribbons will be located
under the facial ap. Using a long clamp, tunnel from the facial incision to the
alar-facial incision and pass the nasal base fascial ribbon back under the ap,
taking care to avoid twisting it. Close the alar-facial incision with 6-0 absorbable
suture prior to applying tension to the fascia. Otherwise, the incision invaginates
and becomes very challenging to suture.
7. Apply tension and tack the fascia lata strips to the temporalis fascia with 2-0
nonabsorbable suture (Fig.19.15), starting with the oral commissure ribbon just
254
Fig. 19.12 Estimation of
fascia lata position through
alar-facial incision
Fig. 19.13 Inset of all
three ribbons of fascia lata
via a nasolabial incision
M. H. Hohman and A. G. Vincent
superior to the auricle, then the nasolabial fold ribbon superior to that, and then
the nasal base ribbon in the most superior position. Overcorrect by approximately 20% to avoid loss of suspension in the early postoperative period. Close
in layers over a drain and apply a pressure dressing unless a fresh microvascular
anastomosis is present.