Lip Wedge Resection with Orbicularis Oris Plication for Facial Paralysis: A Novel Technique

Abstract

Introduction: Oral incompetence (OI) following facial nerve injury or sacrifice remains a frustrating problem for patients and clinicians alike. Dynamic procedures for facial paralysis often do not fully address OI and static surgeries are frequently needed. Current static options frequently involved multiple facial incisions. Methods: We describe a novel technique to address OI due to lower division facial nerve paralysis and report outcomes in an initial series of patients. Results: OI symptoms improved in 94% of patients following a single-stage surgery. Revision was required in one patient with subsequent resolution of symptoms. Major complications (19%) included persistent OI, wound dehiscence, and bothersome lip “bulk”. Conclusion: Lip wedge resection with orbicular oris plication resolves OI in facial paralysis patients with the added benefit of only a single incision on the face.

Introduction

Facial nerve paralysis is a potentially devastating condition that can be caused by malignancies, trauma, surgical complications, and idiopathic causes. Particularly devastating is weakness of the lower division of the facial nerve which can lead to oral incompetence (OI).^1,2 OI is often manifested by symptoms including drooling, dribbling with drinking, difficulty managing food boluses, dysarthrias, and lower facial asymmetry and is highly bothersome to patients.^1,3–6

While dynamic procedures have found favor in the treatment of facial nerve paralysis, lower division weakness often still leads to OI due to atrophy of the perioral musculature, especially with long-standing facial paralysis.^1–5 Traditional static lower lip interventions include a full-thickness wedge resection of the lower lip +/− resuspension of the contralateral orbicularis oris using a sling with multiple facial incisions.^1–6

We describe a technique that incorporates both partial thickness wedge resection of atrophic tissue with plication of the orbicularis oris muscle to the modiolus area using only one incision, with the primary goal of resolving symptoms of OI. The involved facial musculature is shown in Figure 1. The main candidates for this procedure are patients with preexisting lower division or total facial nerve paralysis who present with complaints related to OI. It may also be considered for patients with persistent symptoms of OI following dynamic reanimation. A case presentation representative of the characteristic presentation and course are provided.

Figure 1.

The relevant muscular anatomy of the oral commissure area including the adjacent modiolus area. (A) Orbicularis oris. (B) Risorius. (C) Mentalis. (D) Depressor labii inferioris. (E) Depressor anguli oris. (F) Platysma.

Case Presentation

An 80-year-old male presented to our clinic 1.5 years after wide local excision of a right buccal mucosal squamous cell carcinoma with concurrent neck dissection and reconstruction with an anterolateral thigh free flap followed by adjuvant radiation therapy. Approximately 6 months postoperatively, he began to have bothersome drooling from the right oral commissure with difficulty maintaining oral competence when drinking thin liquids. After discussion of options with the patient, he elected for wedge excision of the lower lip. Surgery was performed as described below and the patient followed up at 1 week postoperatively and subsequently 1, 3, and 6 months. His drooling and difficulty swallowing thin liquids was resolved completely with no recurrence at the last follow-up.

Methods

After the patient has been either placed under general anesthesia or properly positioned in the clinic, the face is prepped and draped in a standard sterile fashion. Incisions are then planned out prior to any local anesthetic infiltration to prevent distortion from the injection. First, the mentolabial sulcus is outlined with a marking pen. Next, attention is turned to the red lip to determine the width of excision. For preexisting facial nerve paralysis and perioral atrophy, all of the atrophic tissue should be included in the excision up to 30% to 50% of the lower lip length as needed. The lateral edge of the planned excision should be at least 5 mm from the oral commissure. After the width is planned, the incision should be continued in a vertical line of the same width to the mentolabial sulcus and tapered along the sulcus to prevent a standing cutaneous cone with closure. The incision is also tapered onto the wet lip; however, this should only involve approximately 1 cm of mucosa. Cutaneous triangles are marked along either limb with the inferior limb of the lateral triangle terminating at the level of the origination of the superior limb of the medial cutaneous triangle. This is done to create a nonlinear scar as the planned incision crosses the white lip perpendicular to the lines of relaxed skin tension. The triangles are offset in a superior to inferior direction to facilitate pulling the lip superiorly with the lateral plication and reattachment. A sample of the proposed incision pattern can be seen in Figure 2A and B.

Figure 2.

(A and B) Incision planning leaving at least 5 mm adjacent to the commissure intact. (C and D) Depth of dissection taken to the level of the muscular layer. (E and F) Final layered closure appearance.

Injection with 1% lidocaine with 1:100,000 epinephrine is then utilized for local anesthesia in the awake patient as well as for maintenance of a bloodless field in the anesthetized patient. After adequate time has passed, a #15 blade scalpel is used to incise the skin and subcutaneous tissues down to the level of the orbicularis oris. Dissection of the incised tissue is then performed using either electrocautery, scissors, or scalpel. Care should be taken that this not be a full-thickness resection: both the muscle layer and the underlying mucosa should remain intact (Figure 2C and 2D). Hemostasis is achieved using electrocautery. Muscular plication of the orbicularis oris is then performed using 3-0 Vicryl suture: the muscular layer is suspended from the wound bed toward the oral commissure and modiolus to create a muscular dam of tissue at the oral commissure. A large bite is taken through the exposed orbicularis oris muscle on one side and then a bite is taken through the wound bed burying the needle deep into the tissue at the modiolus on the side of the excision nearest the oral commissure. This suture is tied tightly to suspend the redundant atrophied muscle towards the commissure, creating needed bulk in this area. The incision is then closed in a layered fashion, taking care to realign the vermillion border and evert the skin edges (Figure 2E and F).

Postoperative care includes instructions to not smile, open the mouth widely, or talk for prolonged periods of time. Incisions are to be covered in the antibiotic ointment for at least 5 days to assist with wound healing. All patients are then followed up in the clinic postoperatively where they are assessed for subjective patient satisfaction of oral as well as clinician observation of both speech and ability to tolerate thin liquids. Nonabsorbable sutures are removed during the first postoperative visit. Figures 3(A-B) and 4(A-C) show preoperative, immediate postoperative, and 6-month postoperative views of a patient who underwent this procedure technique.

Figure 3.

(A) Preoperative photo of a patient with right-sided facial paralysis. Note the clear atrophy of the lower lip musculature. (B) Immediate postoperative view after completion of wedge resection.

Figure 4.

Six-month postoperative photos. (A) Mouth opening. (B) At rest. (C) Pursed lips.

Approval for this study was issued by the Loma Linda University Institutional Review Board (HS5160116).

Results

A total of 16 patients were retrospectively reviewed. The mean age of these patients was 76 (range: 61-88 years) and 10 were male. A total of 15 patients exhibited one or more signs of OI prior to undergoing wedge resection while one patient received a wedge resection at the time of the initial oncologic resection and reconstruction.

All patients but one, noted satisfactory improvement in subjective symptoms of OI following the wedge resection and all of these demonstrated oral competences with thin liquids on first postoperative follow-up. The sole patient with persistent OI was treated with revision wedge resection with complete resolution of symptoms.

Six patients experienced complications postoperatively: 3 complications requiring another procedure and 3 complications treated conservatively. The 3 major complications involved one persistent OI, which required revision wedge surgery with further excision and tightening of the lip, one wound dehiscence, and one complaint of internal lip “bulkiness” which was treated with in-office excision of the intraoral red lip. The 3 minor complications involved 2 superficial infections, both treated with antibiotics, and one superficial 1 cm white lip dehiscence, which was treated with local wound care.

Discussion

Rehabilitation of the lower lip in facial nerve paralysis patients has proven to be challenging both from a cosmetic as well as a functional standpoint. ⁷ While Botox injections and anterior belly of the digastric transfer have been shown to provide excellent cosmetic outcomes,^8,9 neither addresses the functional deficits inherent in lower lip paralysis. Botox also has the downside of being temporary, requiring patients to repeat the injections every 3 to 4 months. ⁹ Our described technique has the benefit of restoring symmetry to the lower face as well as tightening the oral sphincter to relieve the functional problems related to OI. It also offers the unique benefit of creating a static dam out of the paralyzed, atrophic muscle, as opposed to discarding this tissue as in a traditional full-thickness wedge resection. At the same time, we advance the dynamic lower lip musculature from the functional side to the nonfunctional side creating a more dynamic lower lip overall. Our patients have had good results with this technique with 94% finding at least satisfactory, if not complete, improvement in their subjective symptoms after a single surgery, which is similar to previous reports of 77% to 100% of patients having improvement in symptoms of OI.^10–12 Notably, postoperative assessment of oral competence is commonly driven by subjective patient reports of improvement and is often reported in the literature with vague descriptors such as “marked improvement,” ¹² “good control of drooling,” ¹¹ or “improvement” ¹⁰ —a shortcoming from which our own data is not immune.

Serious complication rates in our series are also similar to those reported in the literature. While we do report an overall complication rate of 38% following this procedure, this is in part due to the wide inclusion of all patient complaints regarding the surgical site as well as the small cohort of patients having this procedure. Our revision rate—6%—is slightly lower than the 8% incidence seen in previous studies and the 12% infection rate in our cohort is in line with the 9% to 12% rate reported in other studies.^11–14 While the incidence of patient concern regarding excessive lip bulk is markedly lower in our series—6%—compared to the 16% incidence seen in some series, previous results have similarly been skewed by low cohort numbers. ¹²

While similar techniques have been described in the literature, none utilize all 3 of the benefits of our technique. Bloch et al. describe a similar technique, however, this group utilizes a full-thickness excision of the lower lip, discarding the tissue that we use to create our static dam. ¹⁰ We found in our practice that the static dam provides more bulk at the commissure which provides better oral competence and helps to relieve drooling. Yavuzer and Jackson describe a technique with wedge excision of the atrophic tissue and then plication of the functional orbicularis oris to the modiolus through a separate nasolabial incision. ¹¹ The downsides of this technique are the extensive dissection of the face to create a subcutaneous tunnel as well as a second incision on the face. While this incision has the benefit of allowing the placement of a sling for additional static suspension of the oral commissure, additional facial incisions should be avoided whenever possible. With our technique, we manage to achieve lateral pull on the orbicularis sufficient to achieve oral competence with only one incision and a much less invasive technique. This technique, however, is not without its own drawbacks. Notably, plication of the atrophic orbicularis muscle without resection has the potential to create bothersome and cosmetically unfavorable bulk of the lower lip on the paralyzed side, as was noted by one patient in this series. Additionally, the scar created in the procedure is inherently unfavorable as it crosses the entire lower lip subunit perpendicular to the lines of relaxed skin tension. While we have found the scar to hide well by breaking it up with a cutaneous triangle, an optimal technique would use a more favorably oriented incision.

While our cohort of patients were not candidates for reanimation procedures, this technique could potentially be utilized in patients who have had dynamic procedures that are still experiencing problems with lower lip symmetry, atrophy, and OI. It offers the benefits of being a quick outpatient procedure with good results, minimal facial dissection, and only one incision that is well camouflaged when properly cared for with sun avoidance and ointment use in the healing phase.