Facial Plastics

Question 1

Modiolus muscles

Answer 1

chiasma of facial muscles held together by fibrous tissue, located lateral and slightly superior to each angle of the mouth

orbicularis oris, 
buccinator, 
levator anguli oris, 
depressor anguli oris, 
zygomaticus major, 
risorius, 
platysma, 
levator labii superioris

Question 2

Facial reanimation principles (4)

Answer 2

1. Reannimate facial muscles ASAP
2. Eye and face should be done separately
3. Combination of static and dynamic procedures produces the best result
4. Each procedure is individualized

Question 3

Dynamic Reanimation Categories

Answer 3

Proximal system= Facial nerve nucleus
Distal system= Facial n musculature

1. Prox and distal systems intact
2. Prox intact and distal not available
3. Prox unavailable and distal intact
4. Neither system available

Question 4

Dynamic Reanimation: 1st category and tx

Answer 4

1. Prox and distal systems intact
   (ex. Disruption in temporal bone.

Repair w neurorraphy or graft)

Question 5

Dynamic Reanimation: 2nd category and tx

Answer 5

2. Prox intact and distal not available

(ex. facial n invasion by cancer.
Prox facial n. can innervate free flap)

Question 6

Dynamic Reanimation: 3rd category and tx

Answer 6

3. Prox unavailable and distal intact (Acoustic neuromas. Best tx w dynamic innervation via nerve subtituition w a CNXII jump graft or cross facial nerve graft).

Best done in first year of paralysis

Question 7

Dynamic Reanimation: 4th category and tx

Answer 7

4. Neither system available (ex. pt w radial parotid surgery for cancer who presents years later for reanimation)
   Two dynamic options

Temporalis muscle transposition

Innervated free flap based on another CN (V, contralat VII, XI, XII)

–> often gracilis is anchored to the modiolus to give an active smile
Helps to have static support as nerve graft may not be fx for 18 months

Question 8

Static Procedures

Answer 8

Independent or used in conjunction with dynamic procedures

MC procedures: Brow lift, nasal alar lateralization, suspension of the oral commissure, digastric muscle transposition

Question 9

Static Procedures: Smile

Answer 9

Support of the modiolus
Materials: suture, fascia lata, palmaris longus tendon, cadaver and collagen products
For fascia lata:
Take measurement from zygomatic arch to modiolus
2.5 cm wide segment of fascia lata taken. Tunnel it from nasolabial fold or lip skin junction to incision in the hairline. Mimic the contralateral side

Nasolabial fold incisions work best in older patients w/ deep folds on the normal side

Question 10

Static Procedures: Nasal obstruction

Answer 10

Loss of facial tone causes a shift of the central upper lip filtrum and collapses the ipsi nasal alae.

When suspending the smile, you can use a portion of that material to lateralize the nasal ale through an alar incision. Suspend the ala to a lateral position of the front face of the maxilla w/ a surgical anchor

Question 11

Static Procedures: Lower lip

Answer 11

Isolated Ramus mandibularis defect can be treated with lip plication or digastric muscle transposition

Digastric muscle transposition: mobilize digastric from posterior aspect. do NOT use in total facial paralysis. Can decrease oral competence

Lip plication: Lower lip wedge resection: horizontally shortens lip allowing improved speech and oral competence and better symmetry. Take less than 1/3 of lip to avoid microstomia

Question 12

Moe’s Ectropion scale

Answer 12

Evaluadtion of the lower eyelid scale

0 to V scale
Determinants:
(1) eyelid appearance

(2) eyelid laxity on examination
(3) eversion of lower eyelid
(4) complications (conjunctival metaplasia, stenosis of lacrimal duct, retraction of anterior lamella, other)

Question 13

Upper eyelid evaluation in facial paralysis

Answer 13

Objectively compared with normal side by using medial and lateral measurements of the distance between the eyelids in the closed position