A New Paradigm of Surgical Management of the Atonic Face

Abstract

Introduction: Consequences of facial paralysis are functionally and cosmetically debilitating. Surgical facial suspension in patients with facial nerve palsy is characterized by inexorable recurrent descent of the atonic tissues. Despite numerous variations on techniques that have been attempted over the years, including muscle and fascia flaps, deep plane or periosteal dissection, and multiple vector fixation, we have been disappointed to note substantial or complete loss of improvement effect over 1–2 years. This experience has allowed us to reassess the basic philosophy of rehabilitation for patients with facial paralysis. If the most robust and invasive surgeries are not adequately permanent to avoid the need for frequent reoperation, then perhaps a rational approach is to accept and anticipate the need for repeat procedures and use minimally invasive procedures that are designed for maintenance reoperations. Materials and Methods/Results: We report our experience with a layered multivector cable suture suspension technique to address the atonic descent of the eyebrow, eyelid, midface, and lower face in patients with facial palsy. We describe 2 approaches, a Keith needle with either Gortex or a nylon suture passed from nasolabial fold to deep temporalis fascia and a procedure involving multivector cables. To address the ocular complications in the atonic face, we review upper and lower eyelid adjunctive techniques. For facial paralysis, solutions to address ocular issues include placement of gold weight to upper eyelid, skin graft to upper eyelid, midface-lift, and lower eyelid slings. Finally, to address the lateral oral commissure droop, we discuss a localized technique involving upward positioning of the area by removal of an ellipse of tissue down to the level of the orbicularis oris muscle. Discussion: We discuss our experiences in addressing the upper face, midface, and lower face regarding static reanimation surgery of the atonic face with multivector cables and other modalities to provide a systematic approach. Many of these techniques can be used on the cosmetic patient as well.