Returning to the eye, the temporalis fascial slings to the upper and lower eyelids are then passed subcutaneously to the midtarsal area and attached to the tarsal plates of the upper and lower lids with 6.0 vicral sutures.

A large rectangle of temporalis fascia from the muscle origin on the skull down to the zygomatic arch is harvested to be used as a fascial extension for the McLaughlin temporalis transfer. The McLaughlin temporalis transfer is developed intraorally with an incision directly over the anterior edge of the coronoid process, transecting the coronoid process at the level of the notch well above the inferior alveolar nerve. The mobilized coronoid process with its temporal muscle attachment intact is then drilled with a 2 mm burr, creating an oval window 4 to 5 mm in length and 2 mm in height. A wire suture is then passed through this drill hole and fed through the cheek tissues with a large needle into the nasolabial fold incision area. The intraoral wound is closed and these instruments are set aside. Gown and gloves are changed and the external procedure continued. The coronoid process is brought into the nasolabial fold pocket with traction on the wire suture. Wire is used because sharp dissection may be necessary to mobilize the coronoid process from the tissues around it, and nonwire traction sutures may be cut. The free segment of temporalis fascia is then passed through the oval hole in the bone and used as a fascial extension to attach the transferred temporalis muscle into the corner of the mouth and the outer third of the upper lip. Subcutaneous and submucosal tunnels are created from the nasolabial fold to meet around the fibrotic orbicularis oris muscle fibers. The fascia is passed through these tunnels and knotted to itself at the hole in the coronoid process. This attachment is made tight, overexaggerating the elevation of the corner of the mouth and indentation of the nasolabial fold. It is commonly accepted that it is difficult to overcorrect at this stage because there is always loosening and sagging of these structures in the postoperative period. The nasolabial fold is then exaggerated by creating a 3 to 5 mm dermal flange of the entire length of the anterior edge of the nasolabial incision. One purposely attempts to create an inverted scar in this area. The fold should be carried all the way up to the base of the ala, duplicating the normal side.

In older individuals with redundant tissue, the incision is carried around behind the ear and a traditional facelift performed. In younger people, the facial incisions are closed after bringing the crossfacial nerve graft to the pretragal area where it is secured with heavy hemoclips and stabilizing sutures. It is important to attach this nerve end to the surrounding tissue to prevent migration if a hematoma develops postoperatively, and to help localize it for retrieval at the second stage.

SECOND OPERATION

Regeneration through the cross-facial nerve graft is monitored by the advancement of the Tinel's sign across the lower lip. Once it has reached the area of the nasolabial fold in 4 to 6 months, the second operation is scheduled.

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