"We found that the standard facelifting techniques are good, but with an atonic, heavy face, nothing lasts," he said at the American Academy of Cosmetic Surgery annual meeting here. "No matter what you do, nothing lasts. In two or three years, these patients will be back in the operating room for another invasive procedure."
Dr. Schwarcz, along with Robert A. Goldberg, M.D., F.A.C.S., and Norman Shorr, M.D., F.A.C.S., focused on a variety of minimally invasive techniques that addressed each facial area with the expectation that the patient will require a subsequent operation. This paradigm favors methods that are less aggressive and require less recovery time. To date, the team has used this paradigm of minimally invasive rehabilitation on many patients over the past five years.Paradigm for paralysis Facial paralysis carries a host of functional and cosmetic concerns including disfigurement, speech problems, difficulty chewing, inability to close the eye, and collapse of the nasal valve. So the paradigm addresses the upper-, mid-face, and lower face, and the upper and lower eyelid, to alleviate these issues and reestablish some degree of symmetry.
The patients' brows are usually — though not always — paralytic, Dr. Schwarcz says, who is affiliated with the Jules Stein Eye Institute — Division of Orbito-Facial Plastic and Reconstructive Surgery. His team has found an endoscopic brow lift on the paralyzed side to be most suitable for correcting asymmetric brows. He says the periosteum must be cut vertically to lift only the one side. Once the brow is positioned, he uses an external 2-0 nylon suture posterior to the endoscopic entry sites. But he advises caution in lifting the brow because it can aggravate lagophthalmos, the upper eyelid's inability to close.
Lagophthalmos is probably one of the more dire issues in facial paralysis, because it leaves the cornea unprotected and vulnerable to ulcers and other vision-threatening problems. In these cases, a 1 gram to 2 gram gold weight is implanted in the upper lid. The weight is just heavy enough to help the lid to close when the patient initiates the movement of eyelid closure.
The lower lid is also typically loose and the obicularis muscle doesn't function well.
Dr. Schwarcz says, "You can't really strengthen the eye muscle any more, or provide new innervation to that area, so what we do is raise the lower lid, usually with a mid-facelift, done endoscopically or under direct visualization with a trans-conjunctival approach."
He also implements the Coleman technique, injecting fat into the lower lid to correct any fat atrophy and contour defects and provide vertical support.
Improving symmetry The mid-facelift raises the lower lid to help protect the eye, and aims to improve facial symmetry. Cable lifts have been popular mainly for cosmetic purposes, but Dr. Schwarcz says the technique is also a particularly useful approach to both the mid- and lower face asymmetry in the atonic patient. A Gortex suture is loaded onto a 6 inch Keith needle and threaded into the nasolabial fold, exiting from the temporalis region. He makes a loop out of it, raising and supporting the cheek and mid-face with multiple layered superotemporal or superolateral vectors and securing it in the deep temporalis fascia.
The cable lift, he says, can often be performed in the office under local anesthesia, with care taken to maintain sterile surgical conditions. Anesthesia is accomplished using injections of tumescent solution of .1 percent lidocaine and 1:1,000,000 epinephrine in the cheek, which keeps the bleeding to a minimum.
As for the cable lift's staying power, Dr. Schwarcz says, "It doesn't last five years, but we've been getting a good two years out of it."