Tension adjusted multivectorial static suspension with plantaris tendon in facial paralysis.

Facial paralysis in the midface causes loss of cheek tonus, asymmetry at rest, and inability to smile. Static suspension is generally performed in patients who cannot tolerate time-consuming dynamic reanimation. Current methods for static slings are overly simplistic. A sling, which is generally fascia lata or palmaris tendon, is placed between the modiolus and the zygomatic arch or the temporalis fascia, with further extension to the midline of the upper end lower lips in 1 vector. Recently, sutures are placed in a multivectorial approach, but suture failure via breakage is the main problem. In this study, the long, thin, and powerful plantaris tendon was used and divided into 3 slips. Placement of these slips and their tension adjustment were revised to provide strong and long-lasting upper lip and the modiolus pull, along with creation of a well-defined nasolabial fold, and to create sufficient cheek tonus. The first slip was positioned at 35 to 45 degrees to the horizontal plane between the modiolus and the upper preauricular area, second slip at 55 to 60 degrees between the upper lip and the deep temporal fascia, and the third slip at 0 to 10 degrees between the lower lip and lower preauricular area with gradually decreasing tension from above to below in 9 patients. Upper 2 slings were also sutured to the dermis of the nasolabial fold to define it optimally. Results were assessed both objectively and subjectively. Symmetry at rest, sufficient cheek tightness to prevent drooling, and a well-defined fold were obtained.

A double-layered, stepped spreader graft for the deviated nose.

BACKGROUND: In deviated noses, a beveled hump resection is recommended to preserve the shorter nasal wall. Even with this precaution, in some patients, the shorter wall does not reach the planned dorsal level when the lateral wall is transposed toward the midline after the lateral osteotomy. METHOD: A double-layered, stepped spreader graft was used on the shorter wall side to construct symmetrical lateral nasal walls. The composite graft was constructed by fixing a smaller cartilage graft to the side of the dorsal border of a slightly larger than normal standard spreader graft. The smaller graft component adds height to the shorter lateral wall while the larger one functions as a usual spreader graft. RESULTS: Stepped spreader grafts were used in 4 primary and 2 secondary rhinoplasty cases. All compound grafts were harvested from the septal cartilage except for one of the secondary cases, in which auricular cartilage was used. Two patients received a usual spreader graft on the contralateral side. Postoperatively, none of the patients exhibited significant recurrent deviation, and acceptable symmetrical dorsal esthetic lines were obtained in all patients. CONCLUSION: This technique should be considered whenever the height of the lateral wall is shorter than desired after centralization of a deviated nose. Reconstruction of the shorter wall by adding height with a stepped spreader graft results in a more stable dorsum that resists relapse. Dorsal esthetic lines can also be reconstructed at the same time.