Functional Reconstruction of Forehead and Midface Deficits Using the Endoscopic Technique and Bio-Absorbable Implants

Abstract

Objectives:

Functional deficits of the forehead and midface can pose significant problems for patients varying from mild asymmetry to various degrees of functional impairment including total paralysis. Our objectives were to analyse the use of bio-absorbable implants to reconstruct forehead and midface deficits, all of which were for functional (noncosmetic) reasons.

Methods:

This study was a retrospective case series between 2008 and 2018. Institutional review board approval was obtained from the Beaumont Health Human Investigation Committee. Surgeries were performed at a tertiary care centre. We evaluated 50 patients who underwent correction of functional deficits of forehead, eyebrow, and midface using the endoscopic technique and bio-absorbable implants. Patient demographics and indicated etiologies and characterization of minor and major complications and their occurrence rates were characterized.

Results:

Fifty patients were included in the study from 2008 to 2018, with 68% female and 32% male. Combined blepharoplasty and brow lift was the most commonly performed procedure, followed by midface lift and browplasty. The mean follow-up time was 372 days. No major operative complications including stroke, permanent nerve paralysis, or mortality occurred. There was a 4% rate of temporary nerve paresthesia that resolved, 2% rate of infection, and 6% rate of implant migration requiring revision surgery.

Conclusion:

The endoscopic approach and use of bio-absorbable implants to reconstruct functional deficits of the forehead and midface are safe and effective. There were zero major complications and most of the minor complications were temporary. There was a significant association between non-age-related functional impairment and risk of complication.

Introduction

Minimally invasive surgical approaches have gained considerable popularity over the past 2 decades.^1-3 The invention of angled endoscopes partnered with high-definition cameras and monitors have allowed surgeons to gain access to otherwise hard-to-reach areas of the head and neck while minimizing surgical morbidity.^4,5 Endoscopic approaches employ smaller camouflaged incisions that usually heal well and remain inconspicuous. Advances in material science and biomechanical engineering have dramatically improved the quality and safety of biologic implants. Both permanent and dissolvable implants are used in several head and neck surgical scenarios.^6-9 The development and implementation of biodegradable implants is very popular among cosmetic surgeons, allowing repositioning and adequate suspension of the forehead, midface, and neck soft tissues.^9,10 Plastic surgeons have earned a long track record of safety and efficacy of bio-absorbable implants to correct aesthetic eyebrow and midface deformity.¹¹

Absorbable multipoint fixation devices such as Endotine or Endotine ST (Microaire Corporation, Charlottesville, Virginia) have been used for 15 years to correct cosmetic deformities of the eyebrow and midface.^12-16 However, there are clinical situations that require functional (noncosmetic) repositioning of the forehead, eyebrow, and midface. Examples include obscured visual fields from a mechanical eyebrow ptosis, midface descent or paralysis contributing to lower eyelid retraction, and impairment of upper lip or oral commissure dysfunction. Etiologies include tumour ablation, facial and skull base trauma, Bell’s palsy, iatrogenic injury, or impaired visual fields secondary to age-related mechanical eyebrow ptosis. These pose significant difficulty for the patient from a functional and emotional standpoint.¹⁷

Paralysis of the forehead, eyebrow, and midface can evoke a substantial functional deficit for the patient who can be appropriately addressed with static or dynamic rehabilitation. In addition, the aging process and loss of connective tissue results in increased laxity of the facial retaining ligaments and loss of facial bone density.¹⁸ Consequently, patients may complain of upper eyelid heaviness and difficulty with peripheral vision, seeing things up high over the forehead, or having to manually elevate the eyelid and eyebrow complex to permit optimal vision.^14,19,20 Moreover, due to prolonged frontalis muscle contraction, patients may complain of tension headaches that are often exacerbated by reading or prolonged computer use.²¹

To our knowledge, there are no previous studies investigating the use of bio-absorbable implants in the treatment of functional deficits of the forehead, eyebrow, or midface. The following is a report on the use of the bio-absorbable implants by a single surgeon from a single department to correct functional deficits of the forehead, eyebrow, and midface over the past decade.

Methods

This study was a retrospective analysis of 50 patients who underwent correction of functional deficits of the forehead, eyebrow, and midface from 2008 to 2018. Institutional review board (IRB) approval was obtained from Beaumont Hospital Health System (IRB#: 2018-133). Records were examined from patients who required functional correction secondary to age-related ptosis (accompanied by documented visual field deficits indicating necessity for correction to optimize vision) or varying degrees of midface functional impairment secondary to partial or total paralysis. Inclusion criteria included males and females aged 18 years and older with functional deficits of the forehead, eyebrow, midface or lower face, and age-related ptosis with visual field obstruction documented by ophthalmology. The insurance carrier considered the proposed operation as “medically necessary.” Exclusion criteria included anyone younger than 18 years, pregnancy, medical comorbidities that would preclude anesthesia, patients with cosmetic or aesthetic concern only, and conditions not considered “medically necessary” by the patient’s insurance carrier.

Patients were followed for an average of 372 days following surgery. Factors such as patient demographics, comorbidities, and surgical complexity were collected and analysed. In addition, surgical outcomes including success, revision, and complication rates including infection, migration, nerve injury, stroke, and death were also evaluated.

Independent sample t test was used to assess for significant differences between American Society of Anesthesiologists (ASA) Score, blood loss, anesthetic type, and follow-up times in patients with postoperative complications versus those without postoperative complications. The t test is a commonly used method to test for significant variations between numerical data in normal distributions. Linear regression model was also utilized to determine whether any preoperative conditions were significant risk factors for postoperative complications. Linear regression can correlate a predictive model to an observed data set of values of the response variables, which in our case were complications. Statistical significance threshold was set at P < .05.

Results

Fifty patients were included in the study from 2008 to 2018, 68% were female and 32% were male, with an average age of 60 years. Combined blepharoplasty and brow lift was the most commonly performed procedure at 49.0%, followed by midface lift and browplasty at 23.5% and 25.5%, respectively. General anesthesia was most commonly used at 78%, followed by intravenous sedation at 29%. Mean blood loss from the procedures was 36 mL. There was significant improvement in midface elevation and brow position (Figures 1 and 2).

Figure 1.

A, A 57-year-old female with upper eyelid dermatochalasis and eyebrow ptosis due to aging, causing loss of peripheral vision. B, One-year postendoscopic brow lift with bio-absorbable implants and upper eyelid blepharoplasty with improved peripheral vision.

Figure 2.

A, A 79-year-old female with radical parotidectomy with facial nerve sacrifice and adjuvant radiation having oral incompetence and eyebrow/midface ptosis who underwent oral commissuroplasty endoscopic brow and midface lift; 10 months postoperation, she reacquired midface descend requiring revision surgery. B, One-year postrevision surgery with improved oral competence and midface and brow positioning.

Majority of patients were Caucasian at 76.0%, followed by Middle Eastern at 14.0% and African American at 8.0%. Patients were followed for an average of 372 days. No major complications including intraoperative stroke, nerve paralysis, or death occurred. Minor complications included temporary paresthesia at 4%, infection at 2%, and migration of implant requiring revision surgery at 6%. We did not have any incidence of delayed resorption or delayed hematoma/seroma in our patient cohort. The infection/abscess reported in our study developed within the first 2 weeks after surgery. Average ASA score was 2.27 for the entire patient population and 2.33 for those patients who had a postoperative complication. The ASA scores and surgical complexity were not significant risk factors for postoperative complications (P > .05). The top 3 etiologies included aging, posttumour resection, and Bell’s palsy (Figure 3). However, specific etiologies of ptosis, including stroke and cancer, had a significant correlation with postoperative complications (P < .01).

Figure 3.

Etiologies of facial dysfunction.

Discussion

Functional facial deficits are relatively common clinical presentations in otolaryngology and facial plastic surgery. Facial function is critical for optimal interpersonal communication, emotional expression, and mastication. Patients can have anywhere from exposure keratitis to difficulty with oral diet, depending on the severity of the symptoms. Significant psychological consequences, including anxiety and depression, have been reported among patients having facial dysfunction.²² In an increasingly social world, the ability to use facial expressions to display emotion is key to engaging in normal social interactions and can frequently impact quality of life.²³ As a result, patients seek out options to restore normal facial form and function. There are a number of surgical and nonsurgical options available to address deformities caused by upper and midface ptosis. Brow lifts, static slings, gold weights, nerve grafts and transfers, Botulinum toxin injections, and muscle transfers are all techniques that can be utilized in these patients.²⁴ The choice of surgical correction depends on several factors including the extent of ptosis, degree of functional impairment, patient expectation, other comorbidities, and surgeon preference or comfort level.

The advent of Endotine implants, bio-absorbable implants made of poly-l-lactic acid, has provided enhanced and long-lasting outcomes with minimal complications. These implants have been shown to be both safe and highly efficacious.²⁵ A key factor in achieving a prolonged and stable lift is the extent to which effective fixation is maintained. The various available short-term techniques (bolsters, posts, percutaneous screws, pins and tacks, K-wires, tissue adhesives, fibrin glue) do not provide throughout the critical early healing period. The Endotine implant has been show to provide effective fixation during healing.⁶ They promote re-adherence of the periosteum to the skull at the newly elevated area within 2 weeks following placement.²⁶ The unique structure of the device also promotes multiple points of contact with the elevated tissue, thus providing a more reliable and longer lasting fixation compared to sutures.^26,27 The Endotine implants allow avoidance of external wires, pins, metal screws, or sutures, which can protrude through the scalp and lead to irritation and alopecia. As a result, they have been used extensively in cosmetic procedures, particularly for endoscopic brow lifts.

However, the relative efficacy and safety of Endotine implants have not been extensively evaluated in patients having functional upper and midface ptosis. This patient cohort is more likely to present with nerve paralysis, multiple cardiopulmonary comorbidities, prior chemoradiation therapy, and older age. As a result, they can pose significantly different complications and outcomes compared to the cosmetic patient cohort.

Fifty patients were identified who met the inclusion criteria in our study. The results indicate that this is a safe operation with no major complications such as heart attack, stroke, death, or permanent nerve injury. There were 7 (14%) minor complications, 2 with temporary parasthesia of the dissection zone, 1 (2%) with a temporary partial facial palsy that corrected to baseline after 1.5 months, 1 (2%) with a postoperative infection/abscess that required wound drainage and implant removal, and 3 (6%) that required revision surgery. The first patient requiring revision surgery had a history of heavy cigarette smoking during the first procedure, requiring a unilateral revision accomplished in office. The second patient had an acquired midface paralysis secondary to forceps birth trauma and underwent revision 4 years later due to implant migration. The third patient had a radical parotid resection with facial nerve sacrifice and radiation therapy. She underwent a secondary procedure 10 months after the initial operation due to migration of the midface implant. During her initial surgery, the tissues were extremely fibrotic and elevation in the zones of dissection were difficult. These areas were further released during the secondary operation, allowing for optimal tissue repositioning with ideal results.

Although age-related etiology and surgical complexity had no significant role in predicting postoperative complications, 6 of the 7 patients with complications had non-age-related etiology including stroke, Bell’s palsy, birth trauma, and extensive obliterative cancer surgery followed by radiation therapy. These patients had significantly altered anatomy, fibrosis and scarring, compromised tissue, and muscle atrophy. There was a significant correlation between postoperative complications and etiology (P < .01). Most etiologies, other than aging, have an inherent facial nerve dysfunction and prior trauma that can increase surgical complexity and result in suboptimal outcomes requiring revision surgery. In addition, previously radiated soft tissue can have significant fibrosis and decreased blood supply that can also negatively impact final surgical outcomes and increase complication rates. Similar studies have reported complication rates anywhere from 0% to 13%.^11,25,28,29 Alopecia, paresthesia, and palpation of the implant following placement are some of the most commonly reported complications. Our study had an overall complication rate of 14%, which was comparable to a similar study that also utilized bio-absorbable implants endoscopically for functional facial deficits.²⁹ Higher complication rates can also be due to our longer mean follow-up time of 12 months or greater. Nonetheless, the significantly higher complications rate in patients with non-age-related ptosis makes it prudent for physicians to discuss this increased risk in this patient cohort.

Although we hope these findings will facilitate appropriate decision-making, enhance physician–patient communication, and even serve as an important evidence-based justification supporting the use of these modalities in interactions with various payors, there are several limitations inherent to our study design. These include small sample size, experiences from a single institute and surgeon, and retrospective nature of our data collection. Large multicentre randomized controlled trials would certainly further elucidate the correlation between etiology and complication risk. Although our average follow-up time was greater than 1 year, extending follow-up times can help identify additional long-term complications. Furthermore, with an increasing focus on health-care cost and the effectiveness on patient quality of life, additional investigations examining patient satisfaction and measuring the improvement in functionality would be important. Nonetheless, this study reports a unique patient cohort that has not been extensively studied and can assist with future surgical planning, patient care, and expected outcomes.

Conclusion

This is to date the largest series of patients with the longest average follow-up time analysing the correction of noncosmetic functional deficits of the forehead, eyebrow, and midface using the endoscopic technique with bio-absorbable Endotine implants. Overall, the technique is very safe and effective, with the majority of complications being rather minor and self-limited. The only statistically significant factor was the correlation of non-age-related functional deficit (deficits due to trauma, oncologic surgery, stroke, or Bell’s palsy) with an increased risk of postoperative complications. On several levels, noncosmetic facial deficits can prove debilitating for patients and the endoscopic approach and use of bio-absorbable Endotine implants is an excellent option to help alleviate the patient’s situation.