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Flashcards in Facial Plastics Deck (13):

Modiolus muscles

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

orbicularis oris,
levator anguli oris,
depressor anguli oris,
zygomaticus major,
levator labii superioris


Facial reanimation principles (4)

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


Dynamic Reanimation Categories

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


Dynamic Reanimation: 1st category and tx

1. Prox and distal systems intact

(ex. Disruption in temporal bone.

Repair w neurorraphy or graft)


Dynamic Reanimation: 2nd category and tx

2. Prox intact and distal not available

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


Dynamic Reanimation: 3rd category and tx

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


Dynamic Reanimation: 4th category and tx

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


Static Procedures

Independent or used in conjunction with dynamic procedures

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


Static Procedures: Smile

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


Static Procedures: Nasal obstruction

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


Static Procedures: Lower lip

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


Moe's Ectropion scale

Evaluadtion of the lower eyelid scale

0 to V scale
(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)


Upper eyelid evaluation in facial paralysis

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