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Correction of the Nasal Base in the Flaccidly Paralyzed Face: An Orphaned Problem in Facial Paralysis

2010; Lippincott Williams & Wilkins; Volume: 126; Issue: 4 Linguagem: Inglês

10.1097/prs.0b013e3181ea923c

1529-4242

Robin W. Lindsay, Christopher Smitson, C. Edwards, Mack L. Cheney, Tessa A. Hadlock,

Reconstructive Facial Surgery Techniques

Sir: Nasal obstruction is an often overlooked but disturbing sequela of facial paralysis. Midfacial flaccidity causes atonicity of the lateral nasal wall and midface musculature, with subsequent lateral nasal wall collapse on inspiration, and inferomedial displacement of the alar base (Figs. 1 and 2), requiring superolateral displacement of the ala to improve nasal function.1 Our objective was threefold: to review the outcomes of fascia lata sling reconstruction, to quantify the improvement using anatomical measurements, and to highlight the importance of this zone in the management plan for flaccid facial paralysis.Fig. 1.: Frontal view of the paralyzed face shows the typical inferomedial displacement of the ala on the paralyzed side. Also note the displacement of the subnasale and the philtrum to the nonparalyzed side.Fig. 2.: Basal view of the paralyzed face shows the characteristic blunting of the nasal sill (arrow).A retrospective chart review was performed on 30 patients treated for nasal obstruction with fascia lata sling reconstruction at our facial nerve center. Preoperatively patients reported nasal obstruction on the paralyzed side that improved with superolateral displacement of the alar base. The preoperative and postoperative nasal basal views were evaluated by calculating the angles of the external nasal valves, defined as the angle between a line from the subnasale to the nasal tip, and a line from the midpoint of the nasal tip to the alar facial angle. Interestingly, there was no difference between the preoperative paralyzed and nonparalyzed angles of the external nasal valves (p > 0.05, paired t test), and both angles of the external nasal valves were narrower than in the controls (p < 0.05, two-tailed t test). Fascia lata sling reconstruction widened the paralyzed angles of the external nasal valves (p < 0.005, paired t test), which approached that of control subjects (Fig. 3).Fig. 3.: Typical preoperative and postoperative nasal base views, showing lateralization of the ala on the affected side.Nasal valve collapse in patients without facial paralysis is ordinarily the result of a narrowed internal nasal valve and/or collapse of the upper lateral cartilage and/or ala on inspiration,2 and can be effectively corrected using grafts that improve the structural integrity of the nasal framework.3 However, these procedures do not adequately address inferomedial alar displacement in facial paralysis patients. Placement of a fascia lata sling from the accessory cartilages of the ala to the temporalis fascia provides the superolateral displacement of the ala required for effective restoration of the nasal base by significantly increasing the angle of the external nasal valves on the reconstructed side. It also avoids the use of synthetic graft materials, which can stretch and become infected.4,5 Without midfacial tone and movement, the nonparalyzed side becomes dominant, leading to severe deviation of the philtrum and subnasale toward the nonparalyzed side, causing narrowing of the angle of the external nasal valves on both sides. Our patients did not complain of nasal obstruction on the nonparalyzed side despite their significantly narrower angle of the external nasal valves compared with the angle in controls, most likely secondary to the normal function of their midfacial musculature preventing lateral nasal wall collapse on inspiration. Facial paralysis–associated nasal obstruction is a commonly overlooked feature in flaccid facial paralysis and must be specifically addressed. Treatment of the alar base with fascia lata sling reconstruction is a straightforward, safe, and highly effective procedure for restoring nasal airflow, and thus improves the quality of life in facial paralysis patients. It primarily improves the geometry of the nasal base, unlike the more frequently used nasal valve techniques performed in nonparalyzed patients. Moreover, alar lateralization can be quantified through calculation of the angle of the external nasal valves. This technique should be considered in patients with midfacial flaccidity who respond to superolateral displacement of their alar base. ACKNOWLEDGMENTS Dr. Robin W. Lindsay and Dr. Tessa A. Hadlock had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. DISCLOSURE None of the authors has any commercial associations or financial disclosures to report in relation to the content of this article. Robin W. Lindsay, M.D. Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear Infirmary and Harvard Medical School Boston, Mass., and Department of Surgery Uniformed Services University of the Health Sciences Bethesda, Md. Christopher Smitson, B.S. Colin Edwards, B.A. Mack L. Cheney, M.D. Tessa A. Hadlock, M.D. Department of Otolaryngology–Head and Neck Surgery Massachusetts Eye and Ear Infirmary and Harvard Medical School Boston, Mass.