Title: Static Reanimation of the Paralyzed Face With an Acellular Dermal Allograft Sling
Abstract: Archives of Facial Plastic SurgeryVol. 3, No. 1 Fellow's PageFree AccessStatic Reanimation of the Paralyzed Face With an Acellular Dermal Allograft SlingCatherine P. Winslow, Tom D. Wang, and Mark K. WaxCatherine P. WinslowCorresponding author: Catherine P. Winslow, MD, Department of Surgery, Section of Otolaryngology–Facial Plastic Surgery, Walter Reed Army Medical Center, 6825 Georgia Ave, Washington, DC 20307 E-mail Address: [email protected] the Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University, Portland. Dr Winslow is now with the Department of Surgery, Section of Otolaryngology–Facial Plastic Surgery, Walter Reed Army Medical Center, Washington, DC.Search for more papers by this author, Tom D. WangFrom the Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University, Portland. Dr Winslow is now with the Department of Surgery, Section of Otolaryngology–Facial Plastic Surgery, Walter Reed Army Medical Center, Washington, DC.Search for more papers by this author, and Mark K. WaxFrom the Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University, Portland. Dr Winslow is now with the Department of Surgery, Section of Otolaryngology–Facial Plastic Surgery, Walter Reed Army Medical Center, Washington, DC.Search for more papers by this authorPublished Online:1 Jan 2001AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Facial paralysis results in profound functional and cosmetic disabililities. Early rehabilitation with nerve grafts is an excellent means of reanimating the face but is not always possible. Dynamic rehabilitation may be precluded by surgical disruption of the vascular supply or the intrinsic musculature. In these instances, static rehabilitation affords an alternative means of addressing the lower part of the face. Any synthetic foreign implant presents a potential for infection and extrusion. We describe a case of a static sling performed with acellular dermis (AlloDerm; LifeCell Corp, The Woodlands, Tex).REPORT OF A CASEA 79-year-old male physician presented with a recurrent neurotropic squamous cell carcinoma of the parotid gland. The skin carcinoma had become apparent 2 years earlier. The patient had undergone 2 previous excisions. He was referred after an ipsilateral progressive facial palsy was noted. A magnetic resonance imaging scan revealed enhancement of the nerve to the stylomastoid foramen. A fine-needle aspirate revealed recurrent carcinoma. The patient agreed to undergo tumor extirpation with facial rehabilitation. Anticipated ocular rehabilitation consisted of a gold weight placement, canthoplasty, and a browlift. The possibility of facial nerve grafting and dynamic or static oral reanimation was also discussed. Postoperative radiation therapy was planned.Intraoperatively, the tumor involved the facial nerve from the stylomastoid foramen to small distal branches. The superficial temporal artery and the masseter muscle were resected for oncologic reasons, precluding dynamic rehabilitation. Therefore, primary static rehabilitation, consisting of ipsilateral placement of a gold weight, browpexy, and lateral canthoplasty for the ocular effects of his facial paralysis, was performed. Acellular dermis was used to sling the oral commissure.The patient underwent an uncomplicated 6-week course of radiation therapy. He has been followed up for 6 months to date and has done well. He experienced some mucositis with therapy, but has had no extrusion or problems related to the acellular dermal sling. He has had no drooling or difficulty with chewing, and his speech is completely intelligible.PROCEDUREThe surgical approach was facilitated by the tumor extirpation. The preauricular incision provided access to the zygoma. A 3-0 polypropylene suture was placed circumzygomatically to anchor the graft laterally. Medial tunneling in the subcutaneous plane facilitated proper placement. Incisions in the vermilion border of the upper and lower lips were used to ensure proper attachments to this region. A dermal absorbable suture was used to anchor the graft to the melolabial fold. The acellular dermal graft was split to individually address the upper and lower lips. It was anchored medially and fed through the tunnel (Figure 1). The circumzygomatic suture was then tightened to the point of minimal elevation of the corner of the mouth (Figure 2). Drains were placed and incisions were closed. The patient did well postoperatively, with no complications. He demonstrated an appropriate amount of commissure elevation after surgery, which has not altered in 6 months (Figure 3).Figure 1. The acellular dermal (AlloDerm; LifeCell Corp, The Woodlands, Tex) graft is tunneled subcutaneously. Medially, the graft is split to allow for attachment to the upper and lower lips.Figure 2. The acellular dermal (AlloDerm; LifeCell Corp, The Woodlands, Tex) graft is then anchored and tightened appropriately via a circumzygomatic permanent suture. A slight elevation of the corner of the mouth is the desired end point.Figure 3. Six-month evaluation shows symmetry of the lip. The lip position has not changed during the postoperative period. Significant overcorrection is not necessary.COMMENTResection of the facial nerve leads to significant functional and cosmetic disabilities. The cosmetic changes are evident immediately. The asymmetry in the face worsens with time, as dynamic rhytids abate unilaterally. Functional issues include drooling, nasal valve collapse, visual obstruction, and corneal irritation. Inability to completely close the eye can lead to corneal scarring and eventual blindness.Reanimation with nerve grafts, cranial nerve XII to VII crossover, and microvascular nerve and muscle transfer techniques have all been described. Dynamic rehabilitation is possible with muscle transfer, such as that of temporalis or masseter muscle. However, patients who undergo resection of large facial or parotid carcinomas may not be candidates for such procedures. Compromise of the innervation or vasculature, in addition to muscle resection, makes dynamic rehabilitation an unsuitable option.Patients undergoing resection of the facial nerve for either recurrent or primary carcinoma are candidates for simultaneous reanimation. Protection of the eye, which is critical, can be provided by gold weight placement for the upper eyelid and canthoplasty, if necessary, for the lower eyelid. Alternatives include dynamic rehabilitation or spring placement. Browpexy can prevent visual obstruction caused by ptosis.Rehabilitation in cases in which there is a loss of oral competence presents a challenge. Lack of muscular control leads to depression of the lower lip, with subsequent drooling and difficulties with eating. This disability may be addressed at the time of initial resection (primary) or at a later date (secondary). Static fixation with fascia lata or expanded polytetrafluoroethylene (Gore-Tex; WL Gore & Assoc, Flagstaff, Ariz) has been described. Harvesting of fascia lata necessitates an incision on the leg and a second wound site. Expanded polytetrafluoroethylene slings are a viable option. Excellent results, with no extrusion, were noted in a series of 24 patients who underwent secondary reanimation, 14 of whom had undergone prior radiotherapy.1-1-1 Infection and extrusion have been seen in our patient population following primary expanded polytetrafluoroethylene sling rehabilitation of the oral commissure and postoperative radiotherapy. The sling is covered by thin skin with compromised vascularity from surgical manipulation and radiotherapy.An effort to develop an improved method of oral commissure suspension led to the use of freeze-dried acellular dermis that has been processed to rid the tissue of viral and immunogenic particles. It is available as dehydrated dermis in varying sizes. After 10 minutes of soaking in saline, the dehydrated dermis becomes soft and pliable. No specific immune response is generated, and revascularization and ingrowth of host cells can be demonstrated.1-1-2 It consistently integrates into native tissue.Although originally developed for use in burn patients, acellular dermis has been successfully used in otolaryngologic procedures. It has been described as a component of successful septal perforation repair.1-1-3 It also has been used as soft tissue filler and for resurfacing the intraoral cavity. It effectively replaces a dermal graft, with few risks. It is ideal in our patient population. The risks of foreign body reaction, infection, and extrusion are minimized. It has not stretched with time. A recent series of 10 patients were described in whom acellular dermal slings were used for oral commissure rehabilitation.1-1-4 Six (60%) of these patients received radiotherapy. However, no instances of infection or extrusion were noted. Nine (90%) of the patients in this series had excellent or good results with the sling. We have found that significant overcorrection, such as that needed with fascia and dynamic slings, is not necessary. The result has been a complication-free functional and cosmetic success.CONCLUSIONSReanimation of the face after facial nerve resection is challenging. Static rehabilitation of the oral commissure with an acellular dermal sling is described. This technique should be considered as an alternative for lower face suspension in cases in which there is a high risk for extrusion of implant materials.References1. Biel MA. Gore-Tex graft midfacial suspension and upper eyelid gold-weight implantation in rehabilitation of the paralyzed face. Laryngoscope. 1995;105:876-879. Google Scholar2. Wainwright DJ. Use of acellular allograft dermal matrix (AlloDerm) in the management of full-thickness burns. Burns. 1995;21:243-248. Google Scholar3. Kridel RWH, Foda H, Lunde KC. Septal perforation repair with acellular human dermal allograft. Arch Otolaryngol Head Neck Surg. 1998;124:73-78. Google Scholar4. Fisher E, Frodel JL. Facial suspension with acellular human dermal allograft. Arch Facial Plast Surg. 1999;1:195-199. Abstract, Google ScholarFiguresReferencesRelatedDetailsCited byFacial Suspension With Acellular Human Dermal Allograft John L. Frodel3 January 2011 | Archives of Facial Plastic Surgery, Vol. 13, No. 1Facial Reanimation An Invited Review and Commentary Tessa Hadlock and Mack L. Cheney3 November 2008 | Archives of Facial Plastic Surgery, Vol. 10, No. 6Multivectored Suture Suspension A Minimally Invasive Technique for Reanimation of the Paralyzed Face James C. Alex and Davis B. Nguyen1 May 2004 | Archives of Facial Plastic Surgery, Vol. 6, No. 3 Volume 3Issue 1Jan 2001 InformationCopyright 2001 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Catherine P. Winslow, Tom D. Wang, and Mark K. Wax.Static Reanimation of the Paralyzed Face With an Acellular Dermal Allograft Sling.Archives of Facial Plastic Surgery.Jan 2001.55-57.http://doi.org/10.1001/archfacial.qfp00002.55Published in Volume: 3 Issue 1: January 1, 2001PDF download
Publication Year: 2001
Publication Date: 2001-01-01
Language: en
Type: article
Indexed In: ['crossref', 'pubmed']
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Cited By Count: 16
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