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19 Static Facial Suspension withFascia Lata
Fig. 19.14 Fascia lata
(blue arrow) in place
overlying a sternoomohyoid free muscle ap
Fig. 19.15 Tacking of
fascia lata to temporalis
fascia
255
Pearls
• Mark the nasolabial fold on the paralyzed side preoperatively with the patient
sitting upright, using the nasolabial fold on the unaffected side as a template.
• Make the posterior fascia lata harvest incision before the anterior one to prevent
vastus lateralis herniation from obstructing the view of the fascia.
• Bury all knots underneath the ribbons of fascia lata to prevent them from becom-
ing palpable.
• Close the alar-facial incision prior to applying tension to the fascia in order to
save time and effort.
• When performing a minimally invasive nasolabial fold suspension, do not over-
tighten the knots that secure the fascia lata to the dermis, as this will cause dim-
pling in the skin.
• Overcorrect facial suspension by roughly 20% and counsel patients accordingly
in order to prevent postoperative dissatisfaction.
256
M. H. Hohman and A. G. Vincent
• If periocular procedures are performed concomitantly with nasal base suspen-
sion, anticipate prolonged infraorbital edema due to interruption of lymphatic
drainage by the fascia lata.
• If performing static suspension and muscle transfer, place the fascial ribbons
supercial to the transferred muscle to act as a glide plane under the skin and
prevent muscle tethering to the dermis.
References
1. Hadlock TA, Greeneld LJ, Wernick-Robinson M, Cheney ML.Multimodality approach to
management of the paralyzed face. Laryngoscope. 2006;116(8):1385–9.
2. Hohman MH, Bhama PK, Hadlock TA.Epidemiology of iatrogenic facial neve injury: a decade
of experience. Laryngoscope. 2014;124(1):260–5.
3. Kiefer J, Braig D, Thiele JR, Bannasch H, Stark GB, Eisenhardt SU.Comparison of sym-
metry after smile reconstruction for accid facial paralysis with combined fascia lata grafts
and functional gracilis transfer for statis suspension or gracilis transfer alone. Microsurgery.
2018;38(6):634–42.
4. Faris C, Heiser A, Jowett N, Hadlock T.Minimal nasolabial incision technique for nasolabial
fold modication in patients with facial paralysis. JAMA Facial Plast Surg. 2018;20(2):148–53.
Functional Sterno-omohyoid Free
Muscle Transfer forFacial Reanimation
MarcH.Hohman andAuroraG.Vincent
Introduction
When patients with chronic facial paralysis of greater than 1–2years in duration
desire dynamic rehabilitation, the mimetic muscles have typically atrophied and are
no longer able to accept reinnervation for these patients and for patients with congenital facial palsy who were born with decient mimetic musculature, replacement
of the muscles as well as their motor nerves is required. Additionally, patients with
severe synkinesis may be candidates for functional free muscle transfer, which can
provide improved function and cosmesis by bypassing the injured facial nerve [1].
The choice of donor muscle is determined by patient requirements and goals,
anatomical considerations, and surgeon preference; numerous options are available.
The latissimus dorsi can provide a substantial amount of bulk, as well as overlying
skin, if necessary. The pectoralis minor is substantially slimmer and is very popular
but has a notoriously variable venous outow pattern. The gracilis muscle, rst
reported as a facial reanimation option in 1976, is the most commonly used donor
muscle for functional free tissue transfer in North America, because of its anatomical
consistency and the ease with which it can be harvested while facial surgery is
ongoing [2].
20
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_20
257
258
M. H. Hohman and A. G. Vincent
Despite its reliability, the gracilis lacks two major features possessed by native
facial muscles: low volume and the ability to contract rapidly. It is a large postural
muscle, and when transferred to the face, it must rst undergo substantial debulking
to avoid adding noticeable excess subcutaneous volume. Aggressive debulking
removes the muscle’s fascial layer and potentially increases the chance of dermal
tethering; more importantly, debulking risks denervating the muscle and compromising its contractility. The speed with which facial muscles contract is one of their
dening characteristics however. Histologically, facial muscles have low mitochondrial counts and comprise largely type II “fast twitch” bers, in contrast to the gracilis’ high mitochondrial count “slow twitch” architecture [3]. Similar to the facial
muscles, the anterior cervical strap muscles are also made up primarily of type II
bers, and they have the advantage of being comparatively slim without requiring
debulking.
The other advantage provided by strap muscles is that more than one belly can
be harvested based on the same nerve and vascular pedicle. Transferring the sternohyoid and omohyoid together permits replacement of the zygomaticus major and
levator labii superioris simultaneously, providing a more natural, dentate smile than
can be achieved with methods that replace only the zygomaticus major muscle, such
as temporalis or traditional gracilis transfer [4]. More recently, the gracilis has been
divided into multiple individual slips of functional muscle in order to provide multiple vectors of facial movement, but doing so risks denervation and requires a large
volume of muscle [5, 6]. Likewise, the serratus anterior muscle is naturally congured with multiple slips that correspond to different ribs; however, like the gracilis,
it is much larger than native facial muscles [7]. The ability of the sterno-omohyoid
ap to produce dual-vector smile reanimation using slim, fast twitch muscles is a
major advantage. Lastly, the neural input to the strap muscle ap is the ansa cervicalis, which is long and possesses two major branches for input; both can be coapted
to the masseteric nerve to maximize reliability of the ap, or one end of the ansa
may be sutured to the masseteric nerve and the other to a cross-face nerve graft,
which potentially improves spontaneity and symmetry of the smile [8]. Loss of the
ansa cervicalis along with two strap muscles from one side of the neck has not
resulted in any reports of postoperative speech or swallowing difculties.
Despite seeming like an ideal reconstructive option, the strap ap does have two
notable disadvantages. The rst is that because it is harvested ipsilaterally to the
facial paralysis, simultaneous harvest and recipient site preparation is challenging.
The second is that the vascular anatomy is variable, and while the superior thyroid
artery is generally reliably located, the venous outow is highly variable as it is with
the pectoralis minor ap. Outow typically drains through the vena comitans of the
superior thyroid artery, the superior thyroid vein, the middle thyroid vein, or a ranine
vein. Herein, the technique of sterno-omohyoid harvest and inset as well as sural
nerve harvest and cross-face nerve graft placement are detailed. For a description of
masseteric nerve dissection for innervation of the strap ap, please see Chap. 17.
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
259
Recipient Site Preparation
Ensure that no long-acting paralytic agents will be used during induction of general
anesthesia, and inject the face with plain epinephrine for hemostasis, avoiding any
local anesthetic in order to prevent loss of nerve stimulation. Add 1mL of 1:1000
(1mg/mL) epinephrine to a 100mL bag of normal saline to produce plain 1:101,000
epinephrine. Mark the letter “P” on the paralyzed side of the face to avoid confusion
while the patient remains under general anesthesia.
1. Make a modied Blair incision, running from within the temporal hair tuft down
to the lobule and then down the lateral neck, joining a transverse skin crease to
travel to the midline, approximately 2cm superior to the clavicle. Then, raise a
sub-SMAS (supercial musculoaponeurotic system) ap (Fig.20.1) extending
to the oral commissure and around the upper lip, exposing the orbicularis oris
muscle; continue the ap elevation in a subplatysmal plane 2–3cm past the midline of the neck.
2. Identify and isolate the recipient vessels (Fig.20.2), preferably the distal facial
artery and vein superior to the inferior margin of the mandible. The supercial
temporal vessels and/or the external jugular vein are viable alternatives.
3. Place a 6-hole titanium miniplate at the inferior orbital rim via a preseptal, trans-
conjunctival approach.
(a) Incise the conjunctiva 2–3mm below the inferior margin of the tarsal plate,
from the punctum medially out to the lateral canthus. Carry the incision
through the capsulopalpebral fascia (Fig.20.3).
(b) Place a tension suture through the capsulopalpebral fascia and retract it over
the cornea with a hemostat, then continue the dissection, separating the orbicularis oculi muscle from the orbital septum (Fig.20.4) until the infraorbital
rim is reached.
(c) Expose the maxilla and place the 6-hole titanium miniplate just inferior to
the infraorbital rim (Fig.20.5), but do not tighten the screws completely,
leaving room for needle and suture passage later in the operation.
Fig. 20.1 Flap elevation
260
Fig. 20.2 Recipient vessel
isolation
Fig. 20.3 Incision through
conjunctiva and
capsulopalpebral fascia
M. H. Hohman and A. G. Vincent
Fig. 20.4 Dissection
between orbicularis oculi
and orbital septum to
orbital rim
4. Place 2-0 braided, absorbable inset sutures: one at the modiolus of the oral com-
missure, one just inferior to it, and one just superior to it, then two more farther
medially along the orbicularis oris muscle of the upper lip. Apply superolateral
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
Fig. 20.5 Titanium plate
placement
Fig. 20.6 Adjustment of
suture placement until the
appearance of the smile is
appropriate and there is
neither unnatural dimpling
of the skin nor eversion of
the lip
261
tension to the three lateral sutures towards the superior margin of the auricular
helix while applying tension to the two medial sutures over the infraorbital miniplate; adjust suture placement until the appearance of the smile is appropriate
and there is neither unnatural dimpling of the skin nor eversion of the lip
(Fig.20.6).
5. Identify and isolate the masseteric nerve, as described in Chap. 17 (Fig.20.7).
262
Fig. 20.7 Identication of
the masseteric nerve
M. H. Hohman and A. G. Vincent
Optional: Sural Nerve Harvest andCross-Face Nerve Grafting
forDual Innervation oftheFlap
Sural Nerve Harvest
1. Make a transverse incision 1cm superior and 1cm posterior to the lateral mal-
leolus of the ankle and identify the lesser saphenous vein within the wound .
Retract the vein and isolate the underlying sural nerve (Fig.20.8).
2. Divide the sural nerve as inferiorly as possible, but superior to its branch point,
and then pass the nerve through a tendon stripper (Fig.20.9). Maintain tension
on the nerve while advancing the stripper, gently twisting back and forth.
Resistance will be encountered when the nerve branches over the gastrocnemius
muscle. Once the stripper has been advanced roughly 30cm up the leg, it can be
twisted sharply to divide the nerve; alternatively, a stab incision over the end of
the stripper will provide access to the sural nerve for transection.
3. Retrieve the stripper and leave a hemostat on the inferior/distal end of the nerve
(Fig.20.10).
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
Fig. 20.8 Isolation of the
sural nerve
Fig. 20.9 Tendonstripper- assisted harvest of
the sural nerve
263
Fig. 20.10 Harvested
sural nerve with hemostat
identifying the distal end
264
M. H. Hohman and A. G. Vincent
Cross-Face Nerve Grafting
1. Isolate the primary branch to the zygomaticus major on the non-paralyzed side
(Fig. 20.11), according to the instructions in Chap. 17, section on “Buccal
Branch Identication”.
2. Make a stab incision in the superior gingivolabial sulcus, superior to the canine,
and advance a Wright fascia passer needle through it and into the wound on the
non-paralyzed side of the face, then suture the proximal end of the sural nerve
graft to the tip of the needle and retract the end of the nerve out through the stab
wound (Fig.20.12).
Fig. 20.11 Buccal branch
isolation
Fig. 20.12 Passing the
sural nerve across the face