Background: Left untreated, paralytic lagophthalmos may result in corneal dryness, ulcerations, and subsequent blindness. The most common nondynamic surgical solution is upper eyelid weight placement in a superficial, pretarsal pocket, carrying the risk of visibility, extrusion, and entropion. The authors present a technique useful in patients presenting with either primary symptoms of corneal exposure or complications of previous implants that is equally efficacious, with a potentially decreased risk of complications, in which the weight is inserted into a deeper, postseptal position but requires use of a heavier weight. Methods: Nineteen patients, 15 primary and four secondary, treated between the years 2008 and 2012 with the postseptal approach, were evaluated for demographics, cause, resolution of primary symptoms, and complications. The average weight difference between that measured in the clinic versus weight used in surgery in the primary group and the average weight difference between that inserted in previous surgery versus weight placed in corrective surgery were calculated. Results: The average weight difference was 0.213 g (range, 0 to 0.4 g) in the primary group and 0.2 g (range, 0 to 0.4 g) in the revision group. Symptoms resolved in all but one patient, neither revisions nor complications were noted, and the longest follow-up was 4 years. Conclusions: The retroseptal technique has proven to be safe, reproducible, and very useful in both primary and secondary upper eyelid surgery for paralytic lagophthalmos. It successfully addresses several common problems encountered with more superficial weight placement, including visibility, exposure, and entropion, but often necessitates use of a heavier weight. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background: Synkinetic patients often fail to produce a satisfactory smile because of antagonistic action of a hypertonic depressor anguli oris muscle and concomitantly weak depressor labii inferioris muscle. This study investigated their neurovascular anatomy to partially explain this paradoxical depressor anguli oris hypertonicity and depressor labii inferioris hypotonicity and delineated consistent anatomical landmarks to assist in depressor anguli oris muscle injection and myectomy. Methods: Ten hemifaces from five fresh human cadavers were dissected to delineate the neurovascular supply of the depressor anguli oris and depressor labii inferioris muscles in addition to the depressor anguli oris muscle relation to consistent anatomical landmarks. Results: The depressor anguli oris muscle received innervation from both lower buccal and marginal mandibular facial nerve branches, whereas the depressor labii inferioris muscle was solely innervated by marginal mandibular branches. The mandibular depressor anguli oris origin was on average 39 mm wide, and its medial and lateral borders were located 17 mm from the symphysis and 41 mm from the mandibular angle, respectively. The depressor anguli oris fibers consistently passed anterior to the first mandibular molar toward their insertion into the modiolus, which was located 10 mm lateral and 10 mm caudal to the oral commissure. Conclusions: Depressor anguli oris muscle dual innervation versus depressor labii inferioris single innervation may explain why depressor anguli oris hypertonicity and depressor labii inferioris weakness are commonly observed concomitantly in synkinetic patients. Based on treatment goals, diagnostic percutaneous injection with lidocaine can be performed on the depressor anguli oris muscle along a cutaneous line from the modiolus to the mandibular first molar border, and an intraoral depressor anguli oris myectomy can be performed along that same transmucosal line.

Midface reanimation in patients with chronic facial paralysis is not always possible with an ipsilateral or contralateral facial nerve innervating a free neuromuscular tissue transfer. Alternate use of nonfacial nerves is occasionally indicated but may potentially result in inadvertent motions. The goal of this study was to objectively review videos of patients who underwent one-stage reanimation with a gracilis muscle transfer innervated by the masseteric nerve for (1) inadvertent motion during eating, (2) characterization of masticatory patterns, and (3) social hindrance perceived by the patients during meals. Between the years 2009 and 2012, 18 patients underwent midfacial reanimation with partial gracilis muscle transfer coapted to the masseter nerve for treatment of midfacial paralysis. Sixteen patients were videotaped in detail while eating. Involuntary midface movement on the reconstructed side and mastication patterns were assessed. In addition, 16 patients were surveyed as to whether involuntary motion constituted a problem in their daily lives. All 16 patients videotaped during mastication demonstrated involuntary motion on the reconstructed side while eating. Several unique masticatory patterns were noted as well. Only one of the 16 patients reported involuntary motion as a minor disturbance in daily life during meals. All patients with chronic facial paralysis who plan to undergo midface reanimation with a free tissue transfer innervated by the ipsilateral masseter nerve should be told that they would universally have involuntary animation during mastication. Most patients do not consider this a major drawback in their daily lives. Therapeutic, IV.

This article presents the philosophy, technique, and personal and team approach for treating children with unilateral cleft lip-nose deformities based on the senior author's 36 years of experience. The treatment of unilateral cleft lip almost without exception must involve correction of the nasal deformity. To obtain excellent results, the surgeon must integrate technique, teamwork, and timing based on multidisciplinary protocols developed over the years. Technique must involve broad dissection of the nasal and lip elements off the abnormal skeletal base and delicate but wide dissection of the nasal cartilage to achieve contour and tip projection. The team must include and assimilate surgical, orthodontic, speech, and when necessary orthognathic viewpoints to achieve the optimal result. The final goal is to bring the child to normal facial appearance at conversational distance. It is important to realize that the treatment of the unilateral cleft is rarely one procedure at one time but rather a culmination of several interventions precisely timed in the growing phase of the child from infancy to adulthood.