|| FIG. 22-07. In this older patient, a facelift incision is elevated on the paralyzed side in preparation for temporalis muscle-fascial slips to upper and lower lids and a face lift. The sural nerve is then brought over to the pretragal area and marked with a large hemoclip and sutured securely in place.
FIG. 22-08. The temporalis muscle-fascial sling for the eye is turned down and will be tunneled to the upper and lower lids. The McLaughlin temporalis transfer to the mouth is also performed through an intraoral an extraoral approach.
FIG. 22-09. Early postoperative follow-up after crossfacial nerve grafting, facelift, and dynamic temporalis fascial slings to the eye, and corner of the mouth. Lid closure is poor and had to be readjusted with a lower tarsorraphy.
FIG. 22-10. The second stage is performed with the ipsilateral serratus muscle isolated on chest wall. The pedicle enters the superficial surface of the lowest three slips of serratus muscle posteriorly, allowing splitting of the anterior slip insertion without compromising the neurovascular supply.
FIG. 22-11. The lower three slips spread out over the paralyzed side, turned over so that the ninth slip goes to the eye and the eighth and seventh to the mouth. The vascular pedicle is now deep to the muscle. This facilitates later debulking, if necessary. The slips are inserted to the lids overlying the previous temporalis fascial slips, into the nasolabial fold, upper lip and commissure. We no longer put a slip into the lower lip.
FIG. 22-12. Postoperative follow-up at 16 months. Facial symmetry has been improved; the mouth is level at rest.
FIG. 22-13. Mild contraction of muscle. There is edema in the infraorbital area which has persisted.
FIG. 22-14. Independent contraction of the left muscle transplant. This disappears if the crossfacial nerve is blocked with local anesthetic.
FIG. 22-15. Left lateral at rest.
FIG. 22-16. Elevation of the commissure and nasolabial fold on smiling.
A 42-year-old woman underwent acoustic neuroma resection. (From Whitney, T.M., Buncke, H.J., Alpert, B.S., Buncke, G.M., and Lineaweaver, W.C.: The serratus anterior free muscle flap; experience with 100 consecutive cases. Plast. Reconstr. Surg. In press, 1990.)
FIG. 22-17. The right facial palsy failed to improve 2 years postoperatively.