Minimal Nasolabial Incision Technique for Nasolabial Fold Modification in Patients With Facial Paralysis

This case series compares the preoperative and postoperative facial function of patients who underwent a nasolabial fold creation procedure using the minimal nasolabial incision technique.

Key Points

Question

Can surgeons reliably create a nasolabial fold with a minimal nasolabial incision technique in flaccid facial paralysis?

Findings

In this case series involving 21 patients with peripheral facial paralysis who underwent nasolabial fold modification that used the minimal nasolabial incision technique, significant improvements were seen postoperatively in all facial function outcome measures, including the Facial Clinimetric Evaluation Scale (FaCE), clinician-graded electronic facial paralysis assessment (eFACE), expert-clinician scar assessment, and layperson aesthetic assessment.

Meaning

This minimal nasolabial incision technique is effective in rehabilitating the nasolabial fold in facial paralysis without the aesthetic penalty of a long linear scar to the central midface.

Abstract

Importance

Creation of symmetrical nasolabial folds (NLFs) is important in the management of the paralyzed face. Established techniques use a linear incision in the NLF, and technical refinements now allow the linear incision to be omitted.

Design, Setting, and Participants

This retrospective case series was conducted in a tertiary care setting from February 2, 2017, to June 7, 2017. Participants were all patients (N = 21) with peripheral facial paralysis who underwent NLF modification that used the minimal nasolabial incision technique at the Massachusetts Eye and Ear Infirmary Facial Nerve Center from February 1, 2015, through August 31, 2016.

Main Outcomes and Measures

Patient-reported outcome measures using the validated, quality-of-life Facial Clinimetric Evaluation (FaCE) Scale; clinician-reported facial function outcomes using a validated electronic clinician-graded facial paralysis assessment (eFACE); layperson assessment of the overall aesthetic outcome of the NLF; and expert-clinician scar assessment of the NLF.

Results

Of the 21 patients who underwent NLF modification that used the minimal nasolabial incision technique, 9 patients (43%) were female and 12 (57%) were male. The mean age was 41 (range, 9-90) years; 17 patients (81%) were adults (≥18 years) and 4 (19%) were children (<18 years). Overall, significant improvements were observed after NLF modification in all outcome measures as graded by both clinicians and patients. The mean (SD) scores for total eFACE were 60.7 (14.9) before the operation and 77.2 (8.9) after the operation (mean difference, 16.5 [95% CI, 8.5-24.2]; P < .001). The mean (SD) static eFACE scores were 61.4 (20.6) before the operation and 82.7 (12.4) after the operation (mean difference, 21.3 [95% CI, 10.7-31.9]; P < .001). The mean (SD) FaCE quality-of-life scores were 51.3 (20.1) before the operation and 70.3 (12.6) after the operation (mean difference, 19.0 [95% CI, 6.5-31.6]; P  =  .001). The layperson self-assessment of the overall aesthetic outcome of the NLF modification was higher among the group who had the minimal nasolabial incision than it was for the group who had a historical nasolabial incision (mean [SD], 68.17 [13.59] vs 56.28 [13.60]; mean difference, 11.89 [95% CI, 3.81-19.97]; P < .001). Similarly, the expert-clinician scar assessment of the NLF modification was higher for the group who had the minimal nasolabial incision than it was for the group who had a historical nasolabial incision (3.78 [0.91] vs 2.98 [0.81]; mean difference, 0.80 [95% CI, 0.29-1.32]; P  =  .007).

Conclusions and Relevance

The minimal nasolabial incision technique for NLF modification is effective in rehabilitating the NLF in facial paralysis without adding a long linear scar to the central midface.

Level of Evidence

4.

Introduction

Flaccidity in facial paralysis results in soft-tissue ptosis of the hemiface through loss of resting muscular tone and affects all the facial aesthetic landmarks in the hemiface. The nasolabial fold (NLF) is an important central facial landmark and is the linchpin of the smiling mechanism.¹ Loss or effacement of the NLF has been shown to contribute the most to facial landmark disfigurement in facial paralysis.²

The NLF is created by the insertion of upper lip elevators into the dermis. The NLF is formed by the muscular projections of the upper lip elevators and the fibrous tissue that connect the smiling mechanism to the dermis of the skin in the fold.¹ Numerous methods have been described to reduce the NLF, which characteristically deepens with age, or to recreate it when it is typically effaced in patients with facial paralysis. Bhama et al³ described a technique to reconstruct the NLF in the setting of facial paralysis. This technique has been used in the Massachusetts Eye and Ear Infirmary Facial Nerve Center since 2010, but we have further refined it into a minimal NLF incision approach over the past 16 months.

This study describes the new NLF modification technique and reports the quality-of-life, patient-reported, and clinician-reported outcome measures as well as the layperson and expert-clinician assessments of our initial series.

Methods

All patients who underwent NLF modification with the minimal nasolabial incision technique at the Massachusetts Eye and Ear Infirmary Facial Nerve Center from February 1, 2015, to August 31, 2016, were included in this review. This study was conducted from February 2, 2017, to June 7, 2017. Institutional review board approval was obtained from the Massachusetts Eye and Ear Infirmary Human Studies Committee, which also waived the need for patient informed consent.

Demographic characteristics, including sex and age, were recorded. The cause and type of facial paralysis (flaccid or hypertonic), duration of facial paralysis prior to surgical intervention, age at the time of NLF modification, and chief complaints of the patient were also recorded.

Outcome measures included patient-reported outcomes using the validated, quality-of-life Facial Clinimetric Evaluation (FaCE) scale⁴; clinician-reported facial function outcomes using the previously validated, clinician-graded electronic facial paralysis assessment (eFACE).^5,6,7

Blinded, randomized layperson assessment of the overall aesthetic outcome of NLF modification on the midface from 2 techniques (minimal nasolabial incision vs historical nasolabial incision) was performed using a visual analog scale of 0 (indicating a very poor aesthetic outcome) to 100 (indicating an excellent aesthetic outcome). Blinded, randomized expert-clinician assessment of the NLF modification scar on the hemi-midface from both techniques was also performed using a 5-point Likert scale (5 indicating an excellent scar; 4, good scar; 3, average scar; 2, poor scar; and 1, very poor scar).

Surgical Technique

Fascia Lata Harvest

The skin incision is made with a No. 15 blade and is followed by monopolar dissection to divide subcutaneous tissues to reach the fascia lata (FL). Blunt finger dissection is performed over the FL until the required amount of fascia is dissected. Typically, a 7 × 15-cm section of fascia is sufficient for a 3-ribbon suspension. Parallel longitudinal incisions are made into the fascia with bipolar scissors.

Transverse incisions are then made in the FL connecting to the ends of each of the parallel, longitudinal fascial incisions. Blunt finger dissection to the FL is performed. The fascia is retrieved from one of the transverse incisions, and any remaining fascial attachments are divided.

Hemostasis is achieved with a lit retractor and bipolar forceps. Incisions are closed in layers, and a size 10, closed-loop suction drain is placed.

Facial Dissection and FL Inset

The NLF on the unaffected side is marked prior to the induction of general anesthesia in the holding bay. Adding digital pressure in the philthrum toward the paralyzed side greatly aids in marking the ideal location of the NLF on the affected side.

It is important to preserve the nasofacial isthmus, an important facial landmark, to optimize the aesthetic outcome. A second curved incision is drawn on the alar facial sulcus.

Stab incisions to create the anchor points are placed 2 mm medial to the desired location of the new NLF and are marked and numbered at 5-mm intervals from the commissure to the cephalic portion of the nasofacial isthmus. Approximately 10 nasolabial anchor points are required in adult patients. Stab incisions into the dermis are then made at each marked point with a No. 11 blade.

The alar facial sulcus is incised to gain access medially to the accessory cartilages of the ala, and the sub–superficial musculoaponeurotic system plane of the face is approached laterally through a face-lift incision and extends from the temporal hair tuft to the lobule. During lateral to medial dissection, care is taken to avoid disrupting the orbital retaining ligament and the orbital contents, the inferior orbital nerve, and any native facial nerve branches. The ribbons of the FL are placed in the following order: nasal alar, oral commissure, and NLF. In dynamic rehabilitation, the gracilis muscle free flap eliminates the need for the oral commissure FL. The 2 ribbons (external nasal valve [ENV] and NLF) are placed first, and the inset of the gracilis muscle is performed last to avoid any potential disruption of the neurorrhaphy or microvascular anastomosis due to FL placement.

External Nasal Valve Correction

The accessory cartilages of the ala are secured to a 1.5-cm-wide FL strip with 3 size 3-0 polypropylene mattress sutures (Prolene; Ethicon US LLC). Then, the FL is secured to the deep temporal fascia (DTF) with 2 size 0 polypropylene mattress sutures (Prolene) and 1 size 0 polyglactin 910 suture (Vicryl; Ethicon US LLC). A slight overcorrection is executed.

Oral Commissure Correction

The second 1.5-cm-wide FL strip is placed from the DTF to the oral commissure. Size 3-0 polypropylene mattress sutures are used to attach the fascia to the oral commissure, and then the fascia is secured to the DTF with 2 size 0 polypropylene sutures and 1 size 0 polyglactin 910 suture. No overcorrection is executed. In dynamic rehabilitation, a gracilis muscle free flap, instead of a third ribbon of FL, is secured to the oral commissure.

Nasolabial Fold Creation

The third and final FL strip is placed from the DTF to the new NLF. The fascia is then trimmed to the curvature of the desired fold and marked at points corresponding to the 10 nasolabial anchor points.

Parachute Technique for Minimal Incision Placement of the Nasolabial FL

Double-armed, straight, size 3-0 polypropylene sutures are placed transcutaneously from outside—that is, they go in through the 10 nasolabial anchor points with horizontal mattress suturing, pass through the face-lift incision, and then continue passing through the fascia band at the corresponding markings. This procedure is as follows (Figure 1).

Figure 1. Transcutaneous Placement of Buried, Permanent Dermal Mattress Sutures.

A, First needle (of double-armed suture) is placed transcutaneously. B, The needle is then retrieved from under the facial flap and placed in the fascia. C, Second needle (of double-armed suture) is then passed through the dermis from one stab incision to the adjacent stab incision to create an anchor point. D, Second needle is then passed out through the facial flap (not shown) and placed into the adjacent mark on the fascia.

• Suture 1, needle 1: in through the punch incision 1 and pass under the facial flap to fascia marking 1.

• Suture 1, needle 2: in through the punch incision 1, pass through the dermis to exit punch incision 2, and then pass again through punch incision 2 under the facial flap to fascia marking 2.

The procedure repeats as above until completed. When all sutures are placed, the FL can be parachuted into place and secured (Figure 2 and Video).

Figure 2. Parachute Technique.

A, Facial flap. The needle of suture is retrieved from under the facial flap prior to placement in fascia. B, Completed anchor sutures in fascia. This is the situation after all the anchor sutures have been placed into the fascia. C, Parachute technique. The parachute technique allows the fascia to slide along the sutures into the operative field, until it lines up with the undersurface of the punch incisions.

Video. Nasolabial Fold Modification Technique.

Download video file ^{(452.7MB, mp4)}

The lateral aspect of the FL is secured to the DTF with 3 size 0 polypropylene sutures and 2 size 0 polyglactin 910 sutures. The wound is irrigated with antibiotic solution and checked for hemostasis. A closed suction drain is placed. The nasolabial incision is closed using a size 5-0 nylon suture in a simple interrupted fashion, and the nasofacial incision is closed in the same manner using a size 6-0 nylon suture. A standard face-lift dressing is applied (face-lift dressing is omitted in gracilis muscle free flap cases). Dressing and drains are removed on postoperative day 1.

Statistical Analysis

Data were analyzed for normality using the Shapiro-Wilk test. Differences between preoperative and postoperative eFACE scores and patient-reported quality-of-life scores (FaCE) were assessed using the independent samples Wilcoxon signed rank test for nonparametric data (2-tailed). Blinded, randomized layperson aesthetic outcome assessment of the NLF and expert-clinician scar assessment of the hemi-midface were compared using the independent samples Mann-Whitney test. Statistical tests were performed using SPSS Statistics (version 23; IBM Corp) with significance level (α) set at .05 (2-sided).

Results

A total of 21 control patients underwent NLF modification that used the minimal nasolabial incision technique. Of these patients, 9 (43%) were female and 12 (57%) were male. The mean age was 41 (range, 9-90) years; 17 patients (81%) were adults (≥18 years) and 4 (19%) were children (<18 years). Twelve patients (57%) had 3-ribbon FL modification, and 9 patients (43%) underwent 2-ribbon modification combined with muscle transfer to the commissure; 6 patients (29%) had NLF modification combined with nerve cable grafting or nerve transfer. The aim of these procedures was to create an NLF at rest and during a smile.

For 15 of the 21 patients (71%), preoperative FaCE scores were available; postoperative FaCE scores were available for 17 patients (81%). All patients had suitable preoperative and postoperative photographs to allow ratings by clinicians with experience in facial reanimation surgery (Figure 3).

Figure 3. Preoperative and Postoperative Nasolabial Fold Modification in Flaccid Facial Paralysis.

A, Preoperative flaccid left facial paralysis. B, Postoperative result following correction of left facial paralysis with minimal incision nasolabial fold (NLF) modification technique. C, Preoperative flaccid right facial paralysis. D, Postoperative result following correction of right facial paralysis with minimal incision NLF modification technique. Note the absence of a scar in the NLF.

Overall, significant improvements were observed in all facial function outcome measures: total, static, dynamic, and midface eFACE scores and FaCE quality-of-life scores were higher after the surgical procedure compared with before the operation (Table 1). Specifically, the mean (SD) scores for total eFACE were 60.7 (14.9) before the operation and 77.2 (8.9) after the operation (mean difference, 16.5 [95% CI, 8.5-24.2]; P < .001). The mean (SD) static eFACE scores were 61.4 (20.6) before the operation and 82.7 (12.4) after the operation (mean difference, 21.3 [95% CI, 10.7-31.9]; P < .001). The mean (SD) FaCE quality-of-life scores were 51.3 (20.1) before the operation and 70.3 (12.6) after the operation (mean difference, 19.0 [95% CI, 6.5-31.6]; P  =  .001). No patients experienced exposure of the polypropylene sutures from the nasolabial stab incision sites.

Table 1. Clinician-Graded and Patient-Reported Outcomes Before and After NLF Modification.

Outcome Measure	Mean (SD) Score		P Valuea	Mean Difference (95% CI)
	Before NLF Modification (n = 21)	After NLF Modification (n = 21)
Total eFACEb	60.7 (14.9)	77.2 (8.9)	<.001	16.5 (8.5-24.2)
Static eFACE	61. 4 (20.6)	82.7 (12.4)	<.001	21.3 (10.7-31.9)
Dynamic eFACE	38.0 (23.7)	61.6 (16.2)	<.001	23.6 (10.9-36.2)
Midface eFACE	37.0 (18.4)	67.1 (10.3)	<.001	30.1 (20.8-39.4)
FaCE (QOL) scalec	51.3 (20.1)	70.3 (12.6)	.001	19.0 (6.5-31.6)

Abbreviations: eFACE, clinician-graded electronic facial paralysis assessment; FaCE, Facial Clinimetric Evaluation scale; NLF, nasolabial fold; QOL, quality of life.

^aDetermined with the independent samples, 2-tailed Wilcoxon signed rank test for nonparametric data.

^beFACE: the highest score indicates better facial function as graded by each outcome measurement score.

^cFaCE: the highest score indicates better facial function as graded by each outcome measurement score.

Twenty-one patients who underwent NLF modification that used the minimal nasolabial incision technique were compared with 21 patients who received the historical nasolabial incision technique. Blinded, randomized assessment of the overall aesthetic outcome of the NLF was conducted by laypersons. This assessment showed that there were significant improvements for the minimal NLF incision technique group over the historical NLF incision technique group (mean (SD), 68.17 [13.59] vs 56.28 [13.60]; mean difference, 11.89 [95% CI, 3.81-19.97]; P < .001; Table 2). Similarly, the mean scores of the blinded, randomized, expert-clinician scar assessment of the hemi-midface were significantly higher for the group who received the minimal nasolabial incision than for the group who had a historical nasolabial incision (3.78 [0.91] vs 2.98 [0.81]; mean difference, 0.80 [95% CI, 0.29-1.32]; P  =  .007; Table 2).

Table 2. Combined Layperson Aesthetic Assessment and Expert-Clinician Scar Assessment.

Assessment	Mean (SD)		Difference, Mean (95% CI)	P Valuea
	Group With Historical Incision (n = 21)	Group With Minimal Incision (n = 21)
Layperson aesthetic outcome assessment	56.28 (13.60)	68.17 (13.59)	11.89 (3.81-19.97)	.001
Expert-clinician scar assessmentb	2.98 (0.81)	3.78 (0.91)	0.80 (0.29-1.32)	.007

^aDetermined with the independent samples Mann-Whitney test; both comparisons were significant at α = .05.

^bGraded on a 5-point Likert scale ranging from 1 (very poor scar) to 5 (very good scar).

Discussion

Fascia lata suspension is widely accepted as a static rehabilitation method in patients with facial paralysis.^8,9,10 In earlier descriptions of FL suspension in facial paralysis,³ we used a technique adapted from Clodius¹¹: placement of the FL through an NLF incision and attachment to a de-epithelialized dermal tag segment of the lateral upper lip subunit. The simplicity of the technique, combined with favorable outcomes, led to the expansion of its indications to its use as an adjunct to smile rehabilitation with free gracilis muscle transfers to refine the NLF.³

A limitation of our original technique³ was the introduction of a new scar to the central face. The presence of a defined NLF on the unaffected side was helpful to effectively camouflage this scar. The original technique³ was therefore relatively contraindicated in the pediatric population and younger patients who lacked a defined NLF. In the minimal nasolabial incision technique, the FL is secured to the NLF by multiple 1-mm stab incisions to aid the placement of transcutaneous, buried, permanent mattress sutures. This new technique enables the long NLF incision from the original technique to be omitted. Placement of the medial anchoring, buried mattress sutures through transcutaneous stab incisions allows precise control of the suture location, dermal depth, and spacing between subsequent sutures. A stab incision approach to NLF modification has been described previously,¹² and it differs substantially in that an alloplastic implant of a ribbon of polytetrafluoroethylene is used to anchor the suspension at the NLF. The minimal nasolabial incision technique, on the other hand, relies on deep dermal sutures. In addition, we favor suspension with a wide band of FL to distribute the force equally across the entire NLF, avoiding the sole use of polypropylene suture suspension.

Patient selection for the NLF modification using the minimal nasolabial incision technique broadly parallels that for our original technique.³ Static reanimation of flaccid paralysis requires the placement of 3 ribbons of FL, ENV, NLF, and oral commissure. In candidates for dynamic reanimation, only 2 ribbons of FL are placed at the ENV and NLF, with the oral commissure rehabilitated by a free muscle transfer. Hence, most patients can be grouped into 3 main indications: candidates for static reanimation (3-ribbon placement), candidates for reinnervation undergoing cable graft and nerve transposition (3-ribbon placement), and patients undergoing dynamic muscle rehabilitation (2-ribbon placement at the ENV and NLF combined with dynamic muscle at the oral commissure). No hypertonic patients were treated in the present series because they generally are not candidates for this procedure. The hypertonic midface commonly leads to a deeper NLF compared with the unaffected side, which obviates the need for NLF creation techniques.

Lack of an NLF in patients with facial paralysis produces a high aesthetic penalty for the patient.² Therefore, NLF modification in the global rehabilitation of these patients should be prioritized. The minimal nasolabial incision is a relatively quick and reproducible technique for rehabilitating the NLF in facial paralysis. We found significant improvements in all clinician-reported outcome measures. Total, static, dynamic, and midface eFACE scores showed statistically significant improvements. These ratings demonstrate that static NLF modification increased scores in both the repose and animation of these patients. Quality of life as measured by the validated FaCE scale also showed a statistically significant improvement. These results were achieved without the addition of a long linear scar to the central midface and led to improvements in layperson assessment of the overall aesthetic outcome of the NLF modification on the midface as well as better results on expert-clinician scar assessment of the NLF procedure.

At the Facial Nerve Center, the historical nasolabial incision technique is still considered for patients who have a preexisting deep NLF. If correctly performed, the technique can camouflage the resulting scar in a deep NLF.³ Therefore, the incisionless technique may not be warranted in all instances because of the additional complexity it brings.

Limitations

A limitation of the study is its retrospective design. Prospective studies are needed to fully characterize candidacy for this procedure.

Conclusions

The minimal nasolabial incision technique effectively rehabilitates the NLF in patients with facial paralysis without the aesthetic penalty of a long linear scar to the central midface. However, this technique is more technically complex than the historical nasolabial incision technique. Personalized decision making and patient preference should be exercised during patient selection for the minimal nasolabial incision technique.