Five Things Oculoplastic Surgeons Should Know About Facial Plastic Surgery

David A. Sherris, M.D.,* and Craig S. Murakami, M.D.

*Division of Facial Plastic Surgery, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota; andDivision of Facial Plastic Surgery, Department of Otolaryngology Head & Neck Surgery, Virginia Mason
Medical Center, Seattle, Washington, U.S.A.

Otolaryngologists in general and facial plastic surgeons in particular have many opportunities to collaborate with colleagues in ophthalmology, especially oculoplastic surgeons. In our experience, such collaborations have always been fruitful and productive for both the patients and the physicians involved. Because of the separate routes of training, each specialist brings a different but overlap-ping fund of knowledge and experience to the table. The greatest benefit of the collaboration is the combination of this enlarged fund of knowledge and experience to serve patients better. With this in mind, we describe five points of mutual interest to facial plastic surgeons and oculoplastic surgeons.

FACIAL NERVE PARALYSIS

Patients often are referred to the ophthalmologist with problems from paralytic lagophthalmos. Al-though a diagnosis of the cause of the facial nerve paralysis may very well be in hand, it is imperative to solicit a full history and perform a thorough ex­amination to help determine the underlying disor­der. Immediate-onset, complete facial paralysis is more indicative of infectious causes or Bell's palsy, whereas single-branch or slowly progressive facial paralysis usually indicates a graver cause, such as parotid gland malignancy or facial nerve tumor. All patients with a new onset of facial nerve paralysis need a complete evaluation, including a full head and neck examination and appropriate laboratory and imaging studies, before surgical interventions are undertaken to correct the facial nerve paralysis and its sequelae.

NASAL AND SINUS PROBLEMS

In patients with indications for dacryocystorhi­nostomy or orbital decompression for Gravesdisease, or in patients with orbital tumors, one must always consider the neighboring nasal anatomy (1,2). Depending on the presenting disorder, sinus disease, septal deformity, allergic rhinitis, primary tumors of the nasal cavity or sinuses, and similar conditions should be considered in the differential diagnosis of the orbital problem. These disorders can exacerbate the orbital condition, contribute to its severity, or make surgical or medical therapy more difficult. Anterior rhinoscopy and appropriate radiologic imaging studies are indicated in many of these patients. This allows optimal preoperative planning and possible simultaneous treatment of a comorbid condition by a colleague.

ENDOSCOPIC BROWLIFT

The advent of endoscopic browlifting and com­bined endoscopic brow and midfacelifting has ex­panded the patient population appropriate for forehead procedures in conjunction with or instead of blepharoplasty (3). More subtle anomalies can be approached relatively noninvasively, especially in the younger patient. Postoperative sequelae that were common with coronal browlifting, like scar alopecia, scalp anesthesia, and significant blood loss, have been virtually eliminated. Endoscopic browlift can be performed to treat glabellar frown lines alone, or in conjunction with surgery for brow ptosis and lateral hooding. The endoscopic midfacelift is directed at relieving deep nasolabial creases and malar fat pad descent. This descent can make a normal lower lid appear abnormal. Both proce­dures should be considered in conjunction with or instead of blepharoplasty, as the entire periorbital region is important in the restoration of normal anatomy in the area.

DEEP PLANE FACELIFT

FIG. 1. The zygomaticus major muscle (arrow) is visualized during a deep plane cervicofacial rhytidectomy. Care is taken to continue the midface dissection superficial to this landmark.

Traditional skin-only and skin plus superficial musculoaponeurotic system rhytidectomy have little or no effect on the lower eyelids and malar fat pad. Both the deep plane and the composite rhyti­dectomy elevate the malar fat pad and help improve the lower lid and the malar region (4,5) (Fig. 1). Lower lid blepharoplasty may be avoided in some patients with descent of the malar fat pad, which causes relative deficiency in the malar region and apparent abnormality of the lower lid. Patients with significant aging of the face along with lower lid abnormalities should be considered for deep plane rhytidectomy before or in concert with lower lid surgery (Fig. 2). Deep plane rhytidectomy, how-ever, places the facial nerve at a greater risk of injury. Surgeons using this technique should be trained in deep facial anatomy and treatment of fa­cial nerve injury (see Figs. 1 and 2).

REGIONAL FLAPS

The surgeon should not forget regional flaps like the forehead flap and temporalis muscle flap for periocular reconstruction (6). Even major orbital exenteration with large soft tissue loss can some-times be addressed with these flaps or other regional flaps to avoid the need for microvascular free flap reconstruction. With proper training, these regional flaps are easily obtained and are robust, and the procedure can usually be done using local anesthesia with sedation. If the surgery is done cor­rectly, flap failure is extremely uncommon, and morbidity is much lower than in microvascular re-construction.

FIG. 2. A. Preoperative appearance of a patient with lateral hooding, a dorsal nasal deformity, prominent nasolabial creases, jowling, microgenia, and cervicomental fat with skin laxity. B. The same patient after endoscopic browlift, lower blepharoplasty, septorhinoplasty, deep plane cervicofacial rhytidectomy, and chin implant. Notice especially the improvement in the lateral hooding, nasolabial creases, malar fat pad position, and cervicomental angle.

Collegial collaboration across overlapping dis­ciplines improves the skills of all physicians in­volved, advances innovation, and works for the greater good of the patient. Sinus tumors that in­vade the orbit, orbital tumors that invade the sinus, reconstruction of major periocular defects, brow-lifts that need frontal bone contouring, and malar complex problems that involve the lids are several examples where collaboration and the team ap­proach may improve patient satisfaction and overall care.

REFERENCES

• Metson R, Woog JJ, Puliafito CA. Endoscopic laser dac­ryocystorhinostomy. Laryngoscope 1994;104:269-74.
• Metson R, Dallow RL, Shore JW. Endoscopic orbital de-compression. Laryngoscope 1994:104:950-7.
• Freeman MS, Graham HD. Endoscopic surgery of the forehead and midface. Facial Plast Surg Clin 1997;5:1 13-32.
• Hamra ST. Composite rhytidectomy. Plus' Reconstr Surg 1992;90:1-13.
• Sherris DA, Otley CC, Bartley GB. Comprehensive treat­ment of the aging face - cutaneous and structural rejuvenation . Mayo Clin Proc 1998;73:139-146.
• Larrabee WF, Sherris DA. Principles of Facial Reconstruc­tion. Philadelphia : Lippincott-Raven Press, 1995.