English

07. Correction of facial paralysis by means of the elastic thread and two-tipped needle

KEYWORDS: facial paralysis, elastic thread, atraumatic two-tipped needle.

Facial paralysis can easily be corrected by means of the new elastic thread (Elasticum, Korpo srl) equipped with an atraumatic two-tipped needle. The two-tipped needle enables permanent volumetric lifting to be carried out exactly where it is needed.
This patient had undergone removal of the parotid gland and requested plastic correction for the ensuing paralysis of the facial nerve. In this procedure, the pathway of the elastic threads is drawn on the patient's face. Five threads will be implanted: one to lift the outer corner of the eyebrow, one to lift the cheek, two for the nasolabial fold and one to lift the orbital/malar region. The operation is carried out under local anaesthesia. First, a minimal MACS lift incision is made, which stops at the tragus. A small flap is then dissected above the superficial temporal fascia; alternatively, dissection may be performed at the level of the deep temporal fascia.
On completion of the temporal dissection, which, as can be seen, is very limited, a flap of skin is removed from above the eyebrow and the first Elasticum® thread is implanted in order to lift the corner of the eyebrow. This thread is fixed to the deep temporal fascia. A double-layered suture is used to close the breach in the skin above the eyebrow.
The next step is to lift the cheek. For this purpose, the elastic thread is fixed in the temporal fascia and the Jano needle® is inserted. The route taken by the two-tipped needle must not be too superficial. The needle emerges at the pre-established point and the thread is pulled through. The needle is not completely extracted; the posterior tip remains in the tissues at a depth of about 5 mm and subsequently becomes anterior. The needle travels in the direction of the temporal wound, where it emerges. The elastic thread is then knotted.
At this point, the third elastic thread is implanted. The Jano needle® passes through the deep temporal fascia in order to fix the elastic thread. The two-tipped needle is then inserted in the direction of the lip, in order to lift the nasolabial fold. Once the pre-established point has been reached, the needle emerges and the thread is pulled through. The depth indicators on the shaft of the needle enable the posterior tip to be kept at a depth of about 5 mm from the surface of the skin. The posterior tip now becomes anterior and is directed towards the temporal wound, where it emerges. As the points of entry and arrival of the thread are fairly far apart the elastic thread is again anchored in the deep temporal fascia and then knotted.
The fourth thread is implanted parallel to the third, in accordance with the preoperative design. The tip of the needle emerges at the pre-established point on the nasolabial fold. The needle is partially extracted and the thread pulled through. The depth indicators are used in order to keep the tip of the needle at a depth of 5 mm. The needle then returns in the opposite direction, emerges from the wound and again passes through the deep temporal fascia. The elastic thread is knotted.
The fifth and final elastic thread is now implanted; this lifts the malar region, reducing scleral show. The elastic thread is fixed in the deep temporal fascia. The needle is partially extracted and the elastic thread is pulled through. The needle then returns in the opposite direction (the posterior tip now becoming anterior) in order to anchor the upper portion of the malar region. In this case, the malar anchorage point is high because two elastic threads have been implanted in the nasolabial fold. Normally, the malar anchorage point is situated at the intersection between a horizontal line running below the wings of the nose and a vertical line descending from the outer canthus.
The last elastic thread is knotted.
Excess skin is removed and the skin is sutured.
The operation is completed by the subperiosteal dissection of the malar region. Local anaesthesia is performed. The syringe is perpendicular and the needle is in contact with the periosteum. A small incision is made in the gingival fornix at the level of the canine tooth. The periosteal dissector is inserted and the malar region and the lower orbital border dissected. Placing a finger on the point of emergence of the infraorbital nerve avoids damage to this nerve.
Once dissection has been completed, the elasticity of the implanted thread under traction immediately and stably lifts the malar region. The small breach in the vestibular fornix is sutured with a stitch. On completion of the operation, the patient is made to sit up in order to check the result. The threads shown in the preoperative design are sufficient to achieve very good lifting. The long-term result, after the disappearance of oedema and surgical artefacts, is also very good.

Correction of facial nerve paralysis by means of the elastic thread and two-tipped atraumatic needle. Five Elasticum® threads have been implanted: one lifts the corner of the eyebrow, one the cheek, two the nasolabial fold and one the orbital/malar region.

Rava C. (2009): Correction of facial paralysis by means of the elastic thread and two-tipped needle. CRPUB Medical Video Journal. Elastic Plastic Surgery section. http://www.crpub.org

FAQ

In this type of operation, we have always used strips of fascia lata or PTFE. We have never used traditional threads because they cut through the tissues. Taking autologous fascia lata is a traumatic procedure. On the other hand, strips of PTFE harden over time and may ulcerate. Moreover, none of these strips is elastic. What are the advantages of this elastic thread?

The elastic thread does not cut into the tissues and has the same consistency as the subcutaneous tissue. The two-tipped needle enables the cheeks and neck to be lifted without dissection; in the case described, dissection is minimal and the procedure is carried out in an ambulatory setting.  In elastic lifting of the malar region, the first thread is implanted before subperiosteal dissection. As the malar region is dissected from the bony plane, it is gradually lifted by the elasticity of the thread. Clearly, then, it is very easy to achieve symmetry.

Is subperiosteal dissection difficult?

Not only is it not difficult, it has never caused us any problems.

How can the patient’s appearance be further improved?

These procedures are usually completed by means of Adipofilling®, which fills the space left by the removal of the parotid gland, thereby enhancing facial symmetry.

POST-PUBLICATION REVIEW

Video publication (7) shows how to carry out stable, static correction of paralysis of the facial nerve. A valid complement to this technique is Adipofilling, which corrects facial volumes and improves the symmetry of the face.
An interesting and extremely simple technique can be used to treat “scleral show”. Two elastic threads anchored to the temporal fascia through two 5 mm skin incisions lift the malar region upwards at their maximum elastic tension. Subsequently, through a small incision in the gingival fornix, the operator dissects the malar region below the periosteum. Once the malar region has been completely freed, it is suddenly lifted by the elastic traction of the threads. (30/07/15)