Complete Hemifacial Paralysis Post-facelift: Making Sense of a Plastic Surgeon's Worst Nightmare.

BACKGROUND: Postrhytidectomy hemifacial paralysis is a frightening clinical condition affecting the proximal facial nerve and most often associated with Bell's palsy. Associated symptoms are common and include auditory, salivary, vestibular, and gustatory complaints. OBJECTIVES: The aim of the study was to provide increased awareness of postrhytidectomy hemifacial paralysis secondary to Bell's palsy in the plastic surgery community. METHODS: Following a roundtable discussion with the senior author's (J.C.G.) plastic surgery colleagues located all over the world, 8 surgeons reported having had firsthand experience with hemifacial paralysis in patients following facelift. Descriptions of their cases, including preoperative, intraoperative, and postoperative courses were collected and reported. RESULTS: A total of 10 cases of postrhytidectomy hemifacial paralysis were analyzed based on results of a clinical questionnaire. Eight of the 10 cases involved all facial nerve branches, with 2 cases sparing the marginal mandibular branch. The vast majority of cases were referred to a neurologist and steroids initiated. Two patients were returned to the operating room for exploration. Associated symptoms reported included pain in the ear, hearing loss, ocular symptoms such as tearing or dryness, vestibular symptoms such as vertigo, changes in taste, and in 1 patient an electric-shock type sensation to the face. CONCLUSIONS: Hemifacial paralysis associated with Bell's palsy following rhytidectomy is a rare but known clinical entity that should be included in the preoperative informed consent process before facelift. Current management trends are neurology referral and steroid initiation.

Modified Lengthening Temporalis Myoplasty Using an Intraoral Approach.

BACKGROUND: Lengthening temporalis myoplasty (LTM) is a unique and definite facial reanimation procedure that involves inserting the whole temporal tendon directly into the nasolabial fold. However, the nasolabial fold incision remains one of the difficulties of this procedure, particularly in young or female patient. To avoid the need for this incision, the authors developed an intraoral approach to manipulate the temporal muscle tendon toward the nasolabial fold. in this study, we describe the details of this procedure. METHOD: The authors performed their intraoral approach procedure in 5 patients with established complete facial paralysis. instead of making an incision at the nasolabial fold to approach the coronoid process, the authors made the incision at the buccal mucosa. The results were evaluated both subjectively and objectively. RESULTS: The authors achieved facial reanimation without leaving any obvious scar on the face or neck and the effect of static reconstruction is obvious, even immediately after the surgery. All the patients obtained good facial movement within 4 months (2.5 months in average), and improved all evaluated parameters postoperatively. No infections or other major complications were reported following surgery; however, 1 patient developed a slight dimple that required revision. DISCUSSION: The authors could advance temporal tendon toward nasolabial fold firmly obtaining sufficient surgical field similar to that of nasolabial fold incision, and achieved fairly good results without an obvious scar on the face.Establishing LTM without nasolabial fold incision, we could expand the indication of LTM more widely, and it could be more familiar procedure for smile reanimation in all generation.

Cervico-Mental Angle Suspensory Ligament: The Keystone to Understand the Cervico-Mental Angle and the Ageing Process of the Neck.

The authors performed cadaveric dissections to investigate the existence of an anatomical structure creating and maintaining the cervical mental angle, aiming to understand the anatomical bases of the cervico-mental angle and its modifications over time. Six fresh cadaver dissections were performed; four were done in the Caen University anatomy laboratory one in Paris XV University and one in the Coventry University hospital, England. At the end of this investigation, the authors were able to demonstrate the existence of an anatomical structure in the neck, the cervico-mental angle suspensory ligament. This ligament that fixates the platysma and skin to deeper structures originated from the second branchial arch and seems to play a key role in the formation of the cervico-mental angle and in the anatomical alterations in the ageing process. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lengthening temporalis myoplasty: a surgical tool for dynamic labial commissure reanimation.

Lengthening temporalis myoplasty (LTM), first described by Labbé in 1997, ensures the transfers of the entire temporal muscle from the coronoid process to the upper half of the lip without interposition of aponeurotic tissue. The temporal muscle changes function because it is entirely mobilized toward another effector: the labial commissure. Thanks to brain plasticity, the muscle loses its chewing function, and after 6 months of speech rehabilitation it acquires its new smiling function. We describe technical points especially the coronoid process approaches both through an upper temporal fossa approach and a lower nasolabial fold approach. Rehabilitation starts 3 weeks after the surgery following a standardized protocol to move from a mandibular smile to a voluntary, then spontaneous, smile in three steps. The LTM is the main part of a one-stage global treatment of the paralyzed face. It constitutes a dynamic palliative treatment usually started at the sequelae stage, 18 month after the outcome of a peripheral facial paralysis. This one-stage procedure is a reproducible and relevant surgical technique in the difficult treatment of peripheral facial paralysis. It allows implementing an active muscle transfer to reanimate the labial commissure and re-create a mobile nasolabial fold.

Intralesional cryosurgery to treat keloid scars: results from a retrospective study.

BACKGROUND: A variety of treatment modalities have been proposed to treat keloid scars, but outcomes are often disappointing. Intralesional cryosurgery may significantly reduce these scars. OBJECTIVE: To evaluate the clinical safety and efficacy of intralesional cryosurgery to treat keloid scars. Feedback from patients on pain, pruritus and aesthetic discomfort was recorded before and after treatment. METHODS: A total of 10 patients with 14 keloid scars resistant to conventional treatments were enrolled in a retrospective study between October 2007 and October 2013. The efficacy of this treatment was evaluated by measuring the reduction in scar surface. RESULTS: Scar surface was reduced by an average of 58.5% after intralesional cryosurgery treatment for all scars (average pre-operative keloid scar surface: 874.6 ± 954.1 mm2; average post-operative keloid scar surface: 505.8 ± 1,024.7 mm2; p = 0.002). Pain and aesthetic discomfort were significantly decreased after treatment in all patients (p = 0.008 and p = 0.012, respectively). CONCLUSION: Our data suggest that intralesional cryosurgery is an effective treatment for keloids.

Submental area rejuvenation by digastric corset: anatomical study and clinical application in 20 cases.

UNLABELLED: Knowing the difficulties and limitations of surgery for rejuvenating the submental area during a cervicofacial rhytidectomy, we came up with the concept of the digastric corset, which is described in this article along with the surgical importance of the platysma, digastric and mylohyoid muscles based on anatomical dissections. A study of ten cadavers was conducted to describe precisely the limits of the submental area, the mandibular edge between the two Furnas ligaments, and the hyoid bone. Each anatomical item was dissected plane by plane: the skin, platysma, digastrics muscles, and mylohyoid muscle. The sliding of each muscle relative to the others was studied, photographed, and recorded. Feldman's corset technique was tested on two cadavers and a digastric corset was performed on eight cadavers. After suprahyoid fat lipectomy, we suture the digastric retaining ligaments to the mylohyoid muscles using a running suture, like a corset, then the platysma muscles are put aside on the median line followed by lateral platysma suspension. The different steps are presented and the results of 20 patients who underwent this procedure are presented after 1 year of follow-up. This study showed that the technique of a digastric corset anchored on the mylohyoid allows for one-step reconstruction of the floor of the mouth and a well-defined anterior cervical angle, a sign of a youthful-looking neck. This technique is indicated for difficult necks, when lateral repositioning of the platysma alone gives insufficient results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Out of water in the dark: Plasticity in visual structures and function in an amphibious fish.

Many fishes encounter periods of prolonged darkness within their lifetime, yet the consequences for the visual system are poorly understood. We used an amphibious fish (Kryptolebias marmoratus) that occupies dark terrestrial environments during seasonal droughts to test whether exposure to prolonged darkness diminishes visual performance owing to reduced optic tectum (OT) size and/or neurogenesis. We performed a 3-week acclimation with a 2 ×$\times $ 2 factorial design, in which fish were either acclimated to a 12 h:12 h or 0 h:24 h light:dark photoperiod in water or in air. We found that water-exposed fish had poorer visual acuity when acclimated to the dark, while air-acclimated fish had poorer visual acuity regardless of photoperiod. The ability of K. marmoratus to capture aerial prey from water followed a similar trend, suggesting that good vision is important for hunting effectively. Changes in visual acuity did not result from changes in OT size, but air-acclimated fish had 37% fewer proliferating cells in the OT than water-acclimated fish. As K. marmoratus are unable to eat on land, reducing cell proliferation in the OT may serve as a mechanism to reduce maintenance costs associated with the visual system. Overall, we suggest that prolonged darkness and air exposure can impair vision in K. marmoratus, and that changes in visual performance may be mediated, in part, by OT neurogenesis. More broadly, we show that plastic changes to the visual system of fishes can have potential consequences for organismal performance and fitness.

Radio-opaque ethylcellulose-ethanol is a safe and efficient sclerosing agent for venous malformations.

OBJECTIVE: To evaluate the efficacy and safety of gelified ethanol, a newly developed sclerosing agent for slow-flow vascular malformations. METHODS: Seventy-nine sclerotherapy procedures were performed on 44 patients with 37 venous malformations, 2 glomuvenous malformations, 2 lymphatic malformations, 2 lymphatico-venous malformations, and 1 Klippel-Trenaunay syndrome. The median injected volume was 1.00 mL/site of injection. Effects of sclerotherapy on pain, functional and cosmetic disturbance were statistically evaluated with a final result score. Local and systemic complications were recorded. RESULTS: The mean Visual Analogue Scores were 5.20 ± 2.81 before and 1.52 ± 1.25 after treatment (p < 0.001). Functional and aesthetic improvement was achieved in 31/35 patients (89%) and in 33/41 (80%), respectively. Minor local side effects included necrosis with or without issue of ethylcellulose, palpable residue, and hematoma. No systemic side-effects occurred. CONCLUSION: Per mL used, radio-opaque gelified ethanol is at least as effective as absolute ethanol. No systemic complication was observed, as only a low dose of ethanol was injected. Indications for sclerotherapy can be widened to areas with higher risk for local side effects (hands and periocular region), as ethanol is trapped in the lesion. Careful injection procedure is though necessary, because only a limited amount of ethylcellulose can be used per puncture. Key Points • Development of a new sclerosing agent for venous malformations. • Interesting novel way to deliver alcohol to slow-flow vascular malformations. • Alcohol-based with less local and systemic side-effects.

Paul Tessier's technique in the treatment of paralytic lagophthalmos by lengthening of the levator muscle: evaluation of 29 cases.

AIMS: Lagophthalmos is the major functional complication of facial paralysis because, in the absence of treatment, it can lead to corneal scarring and blindness. This disorder can be treated in a number of ways, including levator lengthening by aponeurosis interposition, a technique developed by Paul Tessier. We assessed the benefits of this technique, and compared the results to those with other techniques, in particular, the use of gold implants. MATERIALS AND METHODS: A total of 29 patients were operated by the same surgeon using levator lengthening by aponeurosis interposition as described by Paul Tessier. Aesthetic and functional results were assessed according to predefined criteria during patient consultation at 1 year and by the patients themselves (questionnaire). We reviewed other surgical techniques used to treat lagophthalmos and compared findings with previous international studies. DISCUSSION: The use of a gold plate implant remains the most widely used technique for the treatment of lagophthalmos. Although the functional results are good, the implant is always visible, leading to the disappearance of the superior palpebral fold and a risk of exposure and therefore of infection. Levator lengthening, a technique developed by Paul Tessier, allows identical functional results to be obtained, but conserves a natural appearance of the upper eyelid. It is a simple surgical procedure associated with a low morbidity rate. CONCLUSION: The lengthening of the levator by aponeurosis interposition is a simple, reliable, and easily reproducible technique allowing treatment of paralytic lagophthalmos with good results, in terms of both function and aesthetics.

Masseter muscle termination over the deep surface of the temporal fascia: look out the wrong path.

PURPOSE: The masticatory muscles have a common embryological origin. Despite numerous anatomical studies their close anatomical relationships are not always accurately described in anatomical treatises. An expansion of the masseter muscle inserted into the deep surface of the superficial temporal aponeurosis has been described. Despite the classical description of two transition bundles (Yoshikawa et al. in Kaibogaku Zasshi 37:206-217, 1962), the literature concerning these fibres has remained difficult to interpret. Given the clinical applications of the lengthening of the temporal muscle in myoplasty, it is important that we have accurate anatomical knowledge of it. METHODS: We dissected 14 embalmed or untreated anatomical cadaver heads with a sex ratio of 1 in order to analyse the aforementioned fibres and their variations. A radiologic study allowed us to understand the entanglement of the fibres. 10 craniofacial MRI were processed by 3D MPR reconstruction. RESULTS: The fibres were identified as an expansion of the posterior head of the masseter muscle and distinct from the two classically described transition bundles. These were present in all subjects of both sexes. We can systematically describe their origin, trajectory and termination. CONCLUSION: Fibres belonging to masseter muscle pass up to the zygomatic arch and terminate on the deep surface of the temporal fascia. Awareness of the nature and trajectory of these muscular fibres allows us to avoid taking "wrong path" when approaching the temporal muscle tendon on the coronoid process via the temporal fossa.

Sequelae of Facial Palsy: A Comprehensive Treatment.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the different types of facial paralysis sequelae and define the several medical and surgical techniques commonly available today. 2. Develop a surgical plan to restore symmetry of the face at rest and in dynamic expressions and manage the patient during smile rehabilitation after dynamic smile reanimation with regional or free muscle transfer. 3. Understand the different types of facial paralysis sequelae and know the several medical and surgical techniques commonly available today. 4. Establish a comprehensive treatment plan to restore symmetry of the face at rest and in dynamic expressions and support the patient during smile rehabilitation after dynamic smile reanimation with regional or free muscle transfer. SUMMARY: Sequelae of facial palsy have a negative impact on the cosmetic aspect and functions of the face. They bear severe consequences for patients with regard to their body image and social relationships. There are numerous medical and surgical treatments that should be proposed to patients to achieve comprehensive facial symmetry. The key to an adapted therapeutic choice, to achieve the best outcomes for patients, is to perform a comprehensive evaluation of the paralyzed face and have broad knowledge of the several techniques described over time in the literature. The patient should be informed of the different therapeutic alternatives, their implications, and their limits. With this article, readers will be able to accurately diagnose the different types of facial paralysis sequelae to develop a surgical plan adapted to each case to restore symmetry at rest and in motion.

Intralesional cryosurgery for the treatment of hypertrophic scars and keloids following aesthetic surgery: the results of a prospective observational study.

Hypertrophic scars and keloids following aesthetic surgery, which ignite patient dissatisfaction, are difficult to handle. Intralesional cryosurgery for the treatment of such scars has been introduced. This study was designed to evaluate the efficacy of this technology in the treatment of such scars and to assess the reduction of dissatisfaction. Eleven scars (on 11 patients) were treated by intralesional cryosurgery, following breast surgery, otoplasty, face-lifting, and brachioplasty. Each patient scored the concern from the scar and the scar deformity (scale from 1 to 5) prior and following treatment (higher score represents least satisfaction and a severe deformity). The follow-up period was between 3 months and 8 years. The results demonstrated a significant reduction in concern and deformity scores compared with before the cryotreatment (P = .001). The intralesional cryosurgery technique provides the plastic surgeon with an effective instrument to treat hypertrophic scars and keloids following aesthetic surgery, thus reducing the dissatisfaction of patients.

Facial Reanimation in the Seventh and Eighth Decades of Life.

BACKGROUND: Treatment of facial paralysis in the older population is often relegated to static rather than dynamic reanimation for fear of poor outcomes. This pervasive approach lacks physiologic foundation and is not evidence based. Thus, the authors present an extensive literature review demonstrating weak evidence supporting this misguided concept, followed by detailed outcomes from three centers of the largest reported series to date of patients older than 60 years after reanimation performed using three techniques-lengthening temporalis myoplasty, free functional muscle, and nerve transfers. METHODS: A PubMed search spanning over 40 years identified all reports on reanimation in patients older than 60 years. In addition, detailed demographics, surgical techniques, and outcomes of 30 patients older than 60 years were analyzed. RESULTS: Of 629 articles, only 45 patients were identified, described in case reports or small series, lacking details or consistent long-term follow-up. In the clinical series, average age, preoperative House-Brackmann score, and comorbidities were similar among the groups. Highest excursion was observed in the free functional muscle group, followed by nerve transfer and temporalis myoplasty, averaging 10.4, 6.8, and 3.1 mm, respectively. The most notable philtral deviation correction was in the lengthening temporalis myoplasty group, followed by the free muscle and nerve transfer groups, averaging 5.6, 2.2, and 1.13 mm, respectively. Complication rates were highest in the free functional muscle group. CONCLUSIONS: Facial palsy patients should not be denied dynamic restoration based on age alone. Although surgical technique may vary based on duration of palsy, surgeon experience, and preference, with each presenting advantages and disadvantages, dynamic restoration is feasible regardless of age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The developmental stage and cell type dependent phosphorylation of eNOS in murine enteric mucosa and myenteric plexus.

In order to clarify the developmental regulation of the eNOS activity in intestine by phosphorylation, we examined the immunohistochemical localizations of the eNOS phosphorylation sites at Ser(1177), Ser(116) and at Thr(495) in cells of the mouse enteric mucosa and myenteric plexus at E13.5, E14.5, E16.5, E18.5, E20.5 and P3. In addition, in cells of the E16.5 stage the protein levels of eNOS and the phosphorylation sites of eNOS at Ser(1177), Ser(116) and at Thr(495) were investigated by immunoblot. From E14.5 to P3, phosphorylation residues of eNOS at Ser(1177) and at Ser(116) were detected with different staining intensities in the enteric mucosa epithelium. In ganglion cells of the myenteric plexus Ser(116) was identified at E18.5 to P3. The absence of phosphorylated Thr(495) in cells of intestine during all developmental stages, was confirmed by immunoblot at E16.5. The immunoblot levels of eNOS and eNOS phosphorylated at Ser(1177) and at Ser(116) were comparable with the immunohistochemical results of E16.5 mouse intestine. It was concluded that development of epithelial cells of the enteric mucosa may be modulated by phosphorylation of eNOS at Ser(1177) and at Ser(116). The phosphorylation of eNOS in cells of the myenteric plexus is modulated at Ser(116). These data suggest that there is a developmental stage and cell type dependent phosphorylation of eNOS.

Hearing impairment, cochlear morphology, and peroxynitrite (ONOO(-)) formation in adult and aging NOS II knockout mice.

CONCLUSION: Nitric oxide synthase (NOS) II induction is a protective mechanism against age-related degeneration of the cochlea. OBJECTIVES: An induction of NOS II has been described in different inner ear pathologies. The objective was to examine the role of NOS II in age-related degeneration of the cochlea. METHODS: The hearing ability in adult and aging NOS II knockout mice (KO) and their wildtype (WT) littermates was explored via auditory brainstem response (ABR) measurements. Inner ear morphological differences were studied with scanning electron microscopy (SEM). Immunohistochemistry was used to examine the induction of NOS II in the inner ear of aging WT mice. Expression of nitrotyrosin, a marker protein for the reactive oxygen species peroxynitrite, was compared between KO and WT mice using immunohistochemistry. RESULTS: Adult KO mice exhibited a mild hearing impairment. WT mice showed an induction of NOS II after 6 months of age. Age-related hearing deterioration was accelerated in KO mice, which was accompanied by increased nitrotyrosin formation and outer hair cell loss.

Lengthening Temporalis Myoplasty: Virtual Animation-Assisted Technical Video.

Lengthening temporalis myoplasty is a well-established procedure for dynamic palliative reanimation of the lip in facial palsy sequelae. The particularity of this technique is that the entire temporal muscle is transferred from the coronoid process to the upper half of the lip without interposition of aponeurotic tissue. To date, no video describing the technique was available. This is the first video describing the entire procedure, from preoperative markings through postoperative rehabilitation. In the video presented herein, the authors craft virtual three-dimensional animations in addition to a live operation on a patient performed by Daniel Labbé, who first described this technique 20 years ago.

Computer-assisted planning of distraction osteogenesis for lower face reconstruction in gunshot traumas.

PURPOSE: Reconstruction of gunshot wounds of the lower face remains a challenge for the maxillofacial surgeon. We present our experience with the use of virtual surgery using Computer-Assisted Design (CAD)/Computer-Assisted Manufacturing (CAM) techniques to create a custom-made distraction device and prefabricated cutting guides (for both fibula and jaw osteotomies) and for device positioning. MATERIALS AND METHODS: We describe two cases of lower face reconstruction after gunshot wounds by osteogenic distraction osteogenesis (DO) and computer-assisted surgery (SurgiCase CMF 5.0® software, Materialise). Surgical osteotomies and placement of the custom-made distraction device were performed intraoperatively based on prefabricated guides. RESULTS: This fully digital preoperative planning improves the precision of osteotomies sites and distraction vectors. It largely reduces the operative time, with a greater operative safety. CONCLUSIONS: Reconstruction by DO allows the bone and soft tissues to be simultaneously regenerated. However, the control of three-dimensional reconstruction of the lower face with distraction is difficult in facial gunshot patients because of the difficulties in locating anatomical landmarks. Surgical osteotomies are pre-planned and rapidly performed using a cutting guide. Precise placement of the distraction device is achieved without the need for subjective assessment of the sole surgeon. In our experience, the surgery has resulted in outcomes similar to those predicted by the computer-assisted planning.

Activation of caspase-3 is associated with oxidative stress in the hydropic guinea pig cochlea.

The aim of this study was to investigate the involvement of oxidative stress and apoptosis in an animal model of Meniere's disease. Endolymphatic hydrops (ELH) is generally accepted as the decisive histological characteristic of Meniere's disease. Closure of the endolymphatic duct (Kimura's method) was used to induce endolymphatic hydrops in guinea pigs. Sham-operated animals served as controls. After 4 weeks the animals operated showed a significant elevation of the hearing thresholds as measured by audiometric brainstem responses (ABR) pre- and postoperatively. Immediately after the second ABR measurement, the animals were sacrificed for further immunohistological examinations of the inner ear with specific antibodies to active caspase-3 (cas-3) as a marker for apoptosis and antibodies to 8-isoprostane (8-iso) and nitrotyrosine (NT) as indicators of oxidative stress. Compared with the sham-operated controls, hydropic cochleae showed strong immunostaining for both oxidative stress markers in spiral ganglion cells, in the blood-vessels and fibrocytes of the lateral wall, as well as in supporting cells of the organ of Corti. Activation of cas-3 in spiral ganglion cells and the lateral wall was found exclusively in hydropic cochleae. Our findings suggest that oxidative stress is involved in the development of endolymphatic hydrops and may lead to cellular damage which induces apoptosis by activation of cas-3. Apoptotic cell death might contribute to the sensorineural hearing loss found in later stages of Meniere's disease.

Lengthening temporalis myoplasty for facial paralysis reanimation: an objective analysis of each surgical step.

IMPORTANCE: Lengthening temporalis myoplasty is a dynamic procedure used to reanimate the middle third of the paralyzed face. Since its original description, it has been progressively modified over the years, with a reduction in the number of surgical steps. However, these modifications can decrease lengthening needed for the tendon to reach the oral commissure and upper lip without tension or overcorrection. OBJECTIVES: To evaluate the maximal lengthening of the temporalis tendon that is possible with this technique and to assess the contribution of each surgical step to total lengthening. DESIGN, SETTING, AND PARTICIPANTS: Cadaveric dissection study from September 16 to 23, 2013, at a tertiary referral center using 10 cadaveric hemifaces. MAIN OUTCOMES AND MEASURES: Surgical exposure was obtained using coronal and melolabial incisions. The original surgical technique was broken down into 7 steps. Measurement of temporalis tendon lengthening relative to a fixed point was performed by a single surgeon after each surgical step using a millimeter ruler. RESULTS: Each surgical step resulted in progressive temporalis tendon lengthening for a median maximal total lengthening of 43.5 mm. The steps that contributed most to this lengthening were coronoidotomy and intraoral temporalis tendon dissection (median, 12.0 mm), incision of temporalis fascia insertion over the orbital rim (median, 6.5 mm), and zygomatic osteotomy with dissection of masseteric fibers (median, 11.5 mm), which represent the first and last 2 steps of the procedure, respectively. CONCLUSIONS AND RELEVANCE: Modifications of lengthening temporalis myoplasty must be considered with caution because the maximal lengthening potential can be obtained only when performing all 7 surgical steps. These modifications must be chosen appropriately based on the lengthening required for the temporalis tendon to reach the oral commissure and upper lip without tension or overcorrection. LEVEL OF EVIDENCE: NA.