Polypropylene and poliglecaprone mesh implant for lifting muscles in facial paralysis
Implante de tela de polipropileno e poliglecaprone para elevação da musculatura na paralisia facial

INTRODUCTION

Facial paralysis has a wide range of etiologies and can result from injuries to the facial nerve and, depending on the level of this injury, changes occur in the muscles of facial mimicry. It is usually a reversible phenomenon spontaneously or through clinical or surgical treatment. Even so, about 20% of cases evolve with some sequel, ranging from a mild degree to complete paralysis of facial muscle movements¹,².

The treatment will depend on some variants, mainly the time, place and mechanism of injury. One can try to reanimate the mimic musculature for early injuries through neuroanastomoses or nerve repairs. For example, in late paralysis, one may try dynamic suspension with a muscle flap or static suspension when the mimic function is not recovered, only the aesthetics³.

In surgery, the polypropylene and poliglecaprone mesh, commercially called ULTRAPROTM (Figure 1), is partially absorbable, has interesting space, and is mainly required for abdominal hernia repair. It generates tissue fibrosis, providing support but simultaneously stimulating a flexible scar and promoting multidirectional elasticity, providing the abdominal wall with normal dynamics and physiology⁴.

Figure 1 - ULTRAPROTM mesh (composed of polypropylene and poliglecaprone).

Figure 1 - ULTRAPROTM mesh (composed of polypropylene and poliglecaprone).

OBJECTIVE

Thus, this work aims to present a case report at Hospital das Clínicas de Recife-PE, in which the polypropylene and poliglecaprone mesh was used to treat the aesthetic sequel of a patient with facial paralysis, with the function of raising the right hemifacial structures.

CASE REPORT

S.RS, female, 55 years old, presents with facial paralysis of unknown etiology for approximately 27 years, having already performed another surgery in an attempt to correct the paralysis in another center, but without satisfactory results. At the initial physical examination-June 2016 (Figure 2), she had an incompetent eyelid seal, scleral show, labial commissure deviation, and no right temporal musculature movements. After evaluation by the neurology service, it was decided to correct the asymmetry by employing a facelift with the elevation of the musculature and fixation of the entire hemiface structure with the ULTRAPRO® mesh due to its support characteristic associated with flexibility and elasticity.

Figure 2 - Patient in the initial physical examination with scleral show, deviation of the labial commissure and without movements of the right temporal musculature.

Figure 2 - Patient in the initial physical examination with scleral show, deviation of the labial commissure and without movements of the right temporal musculature.

During surgery - in May 2017, with the patient in dorsal decubitus and under general anesthesia, marking was performed with bright green using a compass, and then started with an incision below the sideburn, pre and retroauricular with a detachment of the skin flap on the entire right hemiface. After lifting the superficial musculoaponeurotic system (SMAS) and fixing it with mononylon threads (Figure 3), the ULTRAPRO® mesh was placed in the middle third of the right hemiface (Figure 4). The mesh was fixed with monocryl over the SMAS.

Figure 3 - SMAS lifted and fixed with mononylon threads.

Figure 3 - SMAS lifted and fixed with mononylon threads.

Figure 4 - ULTRAPRO® mesh placed in the third middle region of the right hemiface and fixed with monocryl over the SMAS.

Figure 4 - ULTRAPRO® mesh placed in the third middle region of the right hemiface and fixed with monocryl over the SMAS.

The canthotomy and lateral canthopexy of the right eyelid were performed as a complement. On the left hemiface, the same incision was made below the pre- and retroauricular sideburns over the previous marking with skin flap detachment and treatment of the SMAS. Suspension of the tail of the left eyebrow was performed according to the Castanares technique. After a review of hemostasis, suturing was performed in layers. Tubular drains were introduced in both hemifaces.

In the immediate postoperative period, the patient evolved without edema, retractions or bulges. One year and eight months after the surgery, she presents complete integration of the mesh, remaining with the fixation of the musculature in its new location, showing no fibrosis or recurrence of sagging (Figure 5).

Figure 5 - A: Patient in an initial consultation before the procedure; B: Patient at 1 year and 8 months postoperatively.

Figure 5 - A: Patient in an initial consultation before the procedure; B: Patient at 1 year and 8 months postoperatively.

DISCUSSION

Facial paralysis is a disorder that involves the nerves of the face region; the etiology is quite wide, with more than 75 causes described, such as congenital, idiopathic, traumatic and tumoral. However, the etiological diagnosis is often difficult to give, thus increasing the idiopathic casuistry known as Bell’s palsy⁵.

For surgical treatment, the advantages and disadvantages of each proposal must be informed, stating that it is not possible to restore sufficient voluntary movements to restore facial mimicry⁶.

The choice of treatment will also depend on the cause and duration of the injury⁷. Numerous techniques have already been described to improve the function and appearance resulting from facial nerve injuries, such as immediate reconstruction by direct or indirect sutures or by the interposition of nerve grafts⁸. In these cases, an attempt is made to restore nerve function through neurorrhaphy, as reported by Viterbo et al.⁹ in several cases.

Another, more recent way of trying to recover nerves is using stem cells, as has been studied for some time. These cells must act in nerve regeneration¹⁰.

In long-term paralysis, the static suspension is the simplest surgical treatment. In 1934, Gillies¹¹ described the use of temporal muscle transposition for facial resuscitation, which showed good results, but was impractical for the patient in question.

Some new static techniques for correcting long-term paralysis continue to be proposed, many with alloplastic materials, as presented by Alam¹², in which “Gore-tex strip” was used, with a good aesthetic response, especially when analyzing the nasolabial fold.

Following the use of new materials, the use of ULTRAPROTM mesh can be considered a viable technique, as it was in this case. The main characteristic of generating tissue fibrosis, providing support and, at the same time, an elastic, flexible scar, motivated the choice of this product, which made that the result of the suspension, by the traction of the SMAS, was maintained even after absorption of the mesh⁴.

Therefore, it can be concluded that using polypropylene and poliglecaprone mesh can correct the muscle flaccidity resulting from facial paralysis and maintain its surgical result without presenting skin deformities, even with the mesh placed in the subcutaneous tissue, not causing retraction.