patient’s blink is the most time-sensitive and important function in terms of
daily living.
■ Once the patient has been denervated for over 2 years and the orbicularis
oculi has atrophied beyond salvage, it becomes very challenging to recreate a
blink.
■ In contrast, a smile can be reliably restored years after irreversible
denervation with a free gracilis or temporalis transfer.
■ This is also the reason the author generally reserves temporalis transfer for
cases in which native facial musculature is unsalvageable, as the temporalis
generally does not restore eye closure.
■ Lower lip motion and depression complete a symmetric outcome.
■ If the patient presents within 2.5 years after the initial denervation, a needle
electromyography (EMG) is performed specifically to assess viability of the
orbicularis oculi, zygomaticus major, and depressor anguli oris.1
■ If there is muscle viability, nerve-to-masseter and minihypoglossal transfers
are typically performed; if there is no viable muscle, functioning muscle
transfer is required.
SURGICAL MANAGEMENT
■ The first choice in nerve reconstruction of a discreet segmental defect is
always primary nerve grafting. Only the facial nerve can provide spontaneous
facial motion.
■ The ideal patient is one that has a relatively short segmental defect, no tumor
in the proximal facial nerve trunk, and no prior radiation (FIG 2).
■ An anterolateral thigh free flap provides not only soft tissue replacement to
fill the defect but also donor nerve graft in the form of a motor branch to the
vastus lateralis muscle. The nerve can be left attached to the pedicle as a
vascularized nerve graft or, more commonly, harvested separately to allow
for greater freedom of inset.
FIG 2 • This patient has undergone parotidectomy for
adenoid cystic carcinoma with transection of the upper
division of the facial nerve. He will lack brow elevation,
blink, and smile. Additionally, he will be receiving
adjuvant radiotherapy and has a significant volume
deficit that can be disfiguring. This discreet defect with
no microscopic disease proximally is ideal for primary
nerve grafting.
■ Patients who do not have a reliable proximal facial nerve stump available can
have smile and at least lower eyelid motion restored with a nerve-to-masseter
transfer. This will provide volitional but not spontaneous and emotional motion
of the zygomaticus major and orbicularis oculi complex in 3 or 4 months.
■ While not ideal, nerve-to-masseter transfer is highly reliable, and some
patients may not require an upper eyelid weight and frequent eye drops once
reinnervation is complete.
■ In cases in which there is no proximal facial nerve trunk available, the author’s
practice has evolved to using dual nerve transfers so as to avoid a grotesque
mass facial motion from a single nerve transfer to all distal branches.
■ The patient is evaluated preoperatively to confirm normally functioning
masseteric and hypoglossal nerves. If there is a deficiency, these nerve donors
are avoided, and other donors such as the spinal accessory nerve can be
considered.
■ Cross-face nerve grafting provides the potential for spontaneous motion when
the ipsilateral facial nerve is unavailable.
■ One significant drawback of this technique is the variability in strength of the
outcome compared with nerve transfers that deliver reliable power but cannot
compete with cross-face nerve grafting in terms of spontaneity.
■ It is also most commonly performed in two stages, which may not be feasible
in cases of more advanced disease.
■ For patients in whom the ipsilateral nerve is unusable, however, this is the
only procedure that provides spontaneous motion.
T E C H N I Q U E S
■ Nerve Grafting and Direct Repair
Nerve Reconstruction
■ Following nerve harvest, the nerve is carefully prepared by removing the
adventitia (TECH FIG 1A).
■ In theory, this maximizes the likelihood for nerve graft take and survival in
the way a thinner skin graft has higher survivability than a thicker
composite graft (TECH FIG 1B).
■ The nerve is then brought to the field, and a neurorrhaphy is performed from
the inferior fascicles of the upper division of the facial nerve to the distal
zygomatic facial nerve branch for smile (TECH FIG 1C).
■ An epineurial repair is performed with 10-0 nylon suture.
■ Ideally, during the time of tumor ablation, the specific fascicular bundles
from the proximal facial nerve are stimulated and mapped to match the
distal remnant facial nerve branches targeting smile and blink.
■ Following proximal neurorrhaphy, the nerve graft is divided to allow
adequate length for tension-free nerve repair (TECH FIG 1D).
■ The distal end of the nerve graft is now repaired to the distal zygomatic
branch for smile, typically running alongside the transverse facial artery.
■ Either 10-0 or 11-0 nylon is used, depending on the caliber of the nerve at
this level. In this case, there is a single cable graft repaired in antegrade
fashion.
■ If sural nerve graft is used, the proximal sural nerve is repaired in
antegrade fashion, where there is not much branching from the sides.
■ Once the sural nerve is harvested distal to where the medial and lateral
sural nerves join, there is often significant branching, and a reverse
orientation of the nerve may be preferable to minimize loss of axons
through side branches in the nerve.
■ The remaining nerve graft has a Y orientation, and this is repaired
proximally to the more superior nerve fascicular bundles destined for blink.
■ The two ends of the Y are then repaired to distal facial nerve branches
targeted for blink (TECH FIG 1E).
TECH FIG 1 • A. Adventitia is removed from the nerve
graft that was harvested with the anterolateral thigh
flap using a branch of the motor nerve to the vastus
lateralis. B. Nerve graft completely cleaned of
adventitia. C. Epineurial nerve repair to the stump of
the upper division of the facial nerve. D. Measuring
the nerve graft required and precisely trimming to
length as needed. E. Primary nerve grafting
completed and repaired to distal facial nerve stumps
for blink and smile.
Free Flap Defect Repair
■ The facial nerve reconstruction is now complete, but a significant volume
defect remains. Without volume replacement, the skin will contract and
adhere to the masseter muscle, the ear may become sunken and tethered, and
secondary nerve surgery in this region could be potentially hazardous.
■ At this point, an adipofascial anterolateral thigh free flap is precisely shaped
and inset, typically using the facial artery or superior thyroid artery and
branch of the internal jugular vein as recipient vessels (TECH FIG 2).
■ In cases in which direct nerve repair is challenging, as in a significant caliber
mismatch or fascicular bundles that easily spread apart due to a flimsy
epineurium, a nerve conduit is very useful and may provide a better
outcome.2,3
■ There are a variety of choices available, including autologous vein as well
as manufactured options, such as the porcine submucosal nerve tube.
TECH FIG 2 • Adipofascial anterolateral the free flap
to cover the nerve repairs and to maintain normal
facial contour following radiotherapy.
■ Nerve-to-Masseter Transfer
■ The nerve transfer procedure begins with palpating the corner where the
inferior border of the zygomatic arch reaches the anterior border of the neck
of the mandible.
■ A horizontal incision at the inferior border of the zygoma is then made, and
the posterior third of the superficial head of the masseter muscle is divided.
■ A whitish musculotendinous layer is then encountered, marking the start of
the deep head of the masseter muscle.
■ The nerve lies within the deeper layers of this portion of the muscle.
■ Using a nerve stimulator and bipolar cautery, sequential division of the deep
head is performed layer by layer until the nerve to the masseter is identified.
■ It always runs with a vascular pedicle so if one encounters bleeding,
cautery should not be used in order to avoid occult injury to the nerve.
■ Gentle pressure is applied until bleeding is arrested, and the nerve is then
unroofed and mobilized distally (inferiorly) until it begins to arborize where
it is divided and transposed anteriorly for nerve repair.
■ This descending main trunk of the nerve to the masseter is generally used,
and the smaller transverse branch of the nerve coursing anteriorly can be
left intact to maintain some masseter function.
■ Complete sacrifice of all masseteric branches will result in atrophy of the
masseter muscle that may be particularly visible if no autologous tissue
transfer was used to cover the parotidectomy defect.
■ The nerve to the masseter can be repaired either directly with an epineurial
repair to the distal facial nerve target or using a porcine nerve tube (TECH
FIG 3).
■ The donor and recipient nerves are telescoped into the tube until they just
make contact.
TECH FIG 3 • Patient with sacrifice of the upper
division of the facial nerve following parotidectomy
with residual microscopic disease present in the
proximal stump. Both nerve graft and a supplemental
nerve-to-masseter transfer were used in the event the
microscopic disease renders the nerve graft
inadequate. A porcine nerve tube was used for
neurorrhaphy from the nerve to the masseter to the
zygomatic facial nerve branch for smile and lower
eyelid motion.
■ Two 9-0 nylon sutures are then placed at either end of the tube, 180
degrees apart, and sutured to the adventitia of the nerves to secure the tube.
■ A nerve conduit may be preferable in cases where a flawless primary repair
is not possible.
■ Nerve caliber mismatch and the lack of a cohesive group of fascicles are
situations where primary repair can be challenging.
■ The specific target for nerve transfer is at the surgeon’s discretion based on
intraoperative stimulation of the distal facial nerve branches if performed at
the time of ablation.
■ In the delayed setting, in which nerve branches cannot be stimulated, the
zygomatic branch running with the transverse facial artery is commonly a
target for nerve transfer.
■ Adjacent nerve branches can also be recruited and repaired in and end-to-
side fashion to small side branches off of the main masseteric nerve trunk
for more widespread reinnervation.
■ These reconstructions are typically covered with an anterolateral thigh
adipofascial free flap for contour restoration.
■ The patient is placed on a soft diet for 10 days to avoid aggressive
masseteric contraction, which could disrupt the nerve repairs.
■ Dual Minihypoglossal and Masseteric Nerve
Transfers (Dual Babysitter)
■ The nerve-to-masseter transfer is performed as described above to the upper
division of the facial nerve.
■ Additionally, a minihypoglossal nerve transfer is performed to the lower
division of the facial nerve to restore lower facial motion.
■ Once the hypoglossal nerve is identified beneath the digastric muscle just
superficial to the carotid artery, an epineurial window is created on its cranial
surface as previously described by Terzis.4,5
■ Up to 40% of the cross-sectional area of the cranial portion of the
hypoglossal nerve can be transected without significant harm to hypoglossal
function.
■ In the author’s practice, 30% of the nerve is incised, longitudinal to the
fibers using a diamond knife until the fascicles are bulging out of the
window.
■ The surgeon must be confident that axotomies have been incurred to ensure
axonal sprouting into the distal facial nerve target.
■ The distal facial nerve branches, typically the marginal mandibular branch
(TECH FIG 4) and oftentimes an additional buccal or cervical branch, are
then sewn end to side to the hypoglossal nerve using 10-0 nylon suture.
■ A short nerve graft may be necessary if the patient has a particularly long
neck or if the parotidectomy defect extends very anteriorly.
TECH FIG 4 • A patient with adenoid cystic carcinoma
of the parotid gland required radical parotidectomy
with partial temporal bone resection and no usable
proximal facial nerve stump. He underwent a nerve-to-
masseter transfer to two distal zygomatic facial nerve
branches (yellow arrows) and minihypoglossal nerve
transfer using end-to-side neurorrhaphy to the
marginal mandibular nerve (blue arrows). An
adipofascial anterolateral thigh free flap was placed
over the nerve transfers to mitigate cosmetic distortion
following radiation and provide cushion over the
delicate nerve repairs in case of future surgical
revision.
■ Cross-Face Nerve Grafts
Facial Nerve Exposure
■ The approach begins with the unaffected side, where a modified preauricular
facelift incision is made with an extension anteriorly below the mandibular
border to expose the entire facial nerve.
■ Lidocaine and paralytics are avoided to ensure nerves can be reliably
stimulated.
■ The SMAS is elevated off of the capsule of the parotid gland where facial
nerve branches can be seen at the anterior border of the parotid.
■ Using a micromosquito dissector, a major zygomatic or buccal branch is
identified by carefully spreading parallel to the direction of the fibers.
■ The nerve is then unroofed proximally until the upper division and then the
main trunk are encountered.
■ The entire nerve can then be exposed and mapped using a nerve stimulator.
Donor Nerve Selection
■ Two dominant variables in decision-making on the input side of the
reanimation are axonal load and nerve donor selection.
■ Axonal load has previously been shown to directly affect the power of
muscle excursion.6,7
■ The more the axons entering the graft, the more the power driving the
targeted muscle.
■ Nerve donor selection is equally critical because selecting the wrong nerve
will lead to a failed reinnervation and synkinesis.
■ Panfacial reanimation is the goal, with typically three cross-face nerve grafts
placed for blink, smile, and lower lip depression.
■ Crippling the normal side is avoided by ensuring that at least one nerve
branch providing blink, smile, and lower lip depression is left intact.
■ The facial nerve branch providing a pure blink with both superior and
inferior portions of the orbicularis oculi muscle firing on stimulation is the
nerve donor target.
■ The more proximal the donor nerve is transected, the greater the axonal
load. The nerve is taken as proximally as is feasible as long as an additional
nerve providing blink is left completely intact.
■ The same decisions are made for smile and lower lip depression using
careful intraoperative stimulation.
■ 0.5 milliamps is all that is required for stimulation, and the nerve should be
completely dry.
■ Inhalation agent is also turned off prior to facial nerve mapping as it may
interfere with nerve stimulation.
Tunnel Creation and Nerve Reconstruction
■ Once nerves are selected and transected, subcutaneous tunnels are created
and open up into the paralyzed side of the face, where a similar modified
facelift incision is made.
■ Two tunnels are made separately for smile and blink, one traveling just under
the nose and one traveling just above the upper lip.
■ One tunnel for two nerves can lead to unwanted synkinesis through cross-
innervation between adjacent nerve grafts.
■ The tunnel for lower lip motion is made below the mandible around the top
of the neck.
■ Bilateral sural nerves are harvested using a stair-step technique, with the
proximal two-thirds of each sural nerve used for blink and smile and the
distal thirds of the sural nerves sewn together for use in lip depression.
■ Alternatively, saphenous nerve can be used. Twenty-five centimeters of
nerve graft can reliably cross the entire face.
■ The nerve grafts are then carefully repaired to their respective nerve donors
on the normal side (TECH FIG 5A) and tunneled to the paralyzed side.
■ The nerves are then secured to the preauricular region with 4-0 Prolene
suture, and a photo is taken to mark the specific location of these nerves for
reference in the second stage (TECH FIG 5B).
■ The patient is followed with tapping the face along the length of the nerves,
hopefully eliciting a Tinel’s, which should progressively migrate across the
face.
Stage 2
■ The second stage is performed 9 to 12 months later, when the distal ends of
the nerves are identified and trimmed back at least 1 cm or more to healthy
tissue.
■ Frozen section biopsy of the nerve can confirm if there are viable-appearing
axons and fascicles.
■ If the patient had a babysitter or dual babysitter procedure and the muscle
excursion is powerful, at least 50% of the fascicles receiving innervation
from the babysitter are transected and plugged into the respective cross face
nerve graft.
TECH FIG 5 • A. Three cross-face nerve grafts placed
in the donor side for blink (green arrow), smile (yellow
arrow), and lower lip depression (blue arrow). B. The
same cross-face nerve grafts inset on the paralyzed
side for future use. Blink (green arrow), smile (yellow
arrow), and lower lip depression (blue arrow).
■ If, however, the babysitter procedure resulted in a moderate or weak
excursion, free functioning muscle in the form of a gracilis for smile is
typically used on top of the partly functioning native musculature.
■ If there is no muscle function, depending on the surgeon’s confidence in the
cross-face nerve graft, a dual-innervation approach can be performed using
the nerve to masseter and the cross-face nerve graft plugged into the
obturator nerve to the gracilis.
■ Functioning gracilis transfer is covered in another chapter of this text.
■ Regarding restoration of blink and lower lip depression, the platysma and
digastric muscles can be used, respectively, as previously described by
Terzis.8–10
PEARLS AND PITFALLS
Timing
■ Perform facial reanimation at the time of tumor ablation when possible.
Graft
choice
■ Ipsilateral nerve graft is the first choice when reliable.
Blink
■ Prioritize restoration of blink by neurotizing native orbicularis oculi if
viable.
Nerve
transfer
■ Use nerve transfers if proximal facial nerve stump is unreliable, if there is
disease in the proximal stump, or if there was prior radiation.
Flaps
■ Liberally use adipofascial free flaps for parotidectomy bed reconstruction
to mitigate the effects of radiation.
FIG 3 • A. Early postoperative result prior to nerve
reinnervation following radical parotidectomy, temporal
bone resection, dual babysitters, and adipofascial
anterolateral thigh free flap. B. One year postoperative
result following external beam radiotherapy with
satisfactory recovery of pan-facial motion. No eyelid
weight or eye drops were required.
OUTCOMES
■ The early postoperative results of the patient in TECH FIG 4 are shown in
FIG 3.
REFERENCES
1. Terzis JK, Rose EH, Manktelow R, Walton RL. Facial nerve injury: diagnosis
and repair. Aesthet Surg J. 2005;25:495-505.
2. Arslantunali D, Dursun T, Yucel D, et al. Peripheral nerve conduits:
technology update. Med Devices (Auckl). 2014;7:405-424.
3. Muheremu A, Ao Q. Past, present, and future of nerve conduits in the
treatment of peripheral nerve injury. Biomed Res Int. 2015; 2015:237507.
4. Terzis JK, Tzafetta K. “Babysitter” procedure with concomitant muscle
transfer in facial paralysis. Plast Reconstr Surg. 2009;124:1142-1156.
5. Terzis JK, Tzafetta K. The “babysitter” procedure: minihypoglossal to facial
nerve transfer and cross-facial nerve grafting. Plast Reconstr Surg.
2009;123:865-876.
6. Terzis JK, Wang W, Zhao Y. Effect of axonal load on the functional and
aesthetic outcomes of the cross-facial nerve graft procedure for facial
reanimation. Plast Reconstr Surg. 2009;124:1499-1512.
7. Hembd A, Nagarkar PA, Saba S, et al. Facial nerve axonal analysis and
anatomical localization in donor nerve: optimizing axonal load for cross-facial
nerve grafting in facial reanimation. Plast Reconstr Surg. 2017;139:177-183.
8. Terzis JK, Karypidis D. Blink restoration in adult facial paralysis. Plast
Reconstr Surg. 2010;126:126-139.
9. Terzis JK, Karypidis D. The outcomes of dynamic procedures for blink
restoration in pediatric facial paralysis. Plast Reconstr Surg. 2010;125:629-
644.
10. Terzis JK, Kalantarian B. Microsurgical strategies in 74 patients for
restoration of dynamic depressor muscle mechanism: a neglected target in
facial reanimation. Plast Reconstr Surg. 2000;105:1917-1931.
50
CHAPTER
Temporalis Flap and
Lengthening Temporalis
Myoplasty for Facial
Paralysis
Andre Panossian
DEFINITION
■ Facial paralysis is the result of facial nerve dysfunction (cranial nerve VII). It
can be congenital or acquired, bilateral or unilateral. Patients with facial
paralysis exhibit drooping of the lower face and loss of lip closure/elevation.
■ Muscle transfers are indicated in cases of long-term, or permanent, facial
paralysis (greater than 18 months).
■ Regional or free muscle transfer can restore unidirectional movement of the
lips and lower face by using branches of the contralateral facial nerve or
unaffected ipsilateral cranial nerves (eg, trigeminal nerve branches for
mastication [V3]).
■ The temporalis flap is a procedure for transferring the function of the
ipsilateral temporalis muscle in a retrograde, or “turnover,” fashion to the lips
and oral commissure for the purpose of reanimating the lower face. The
methods outlined herein include further refinements to the techniques
originally developed by Gillies.
■ The lengthening temporalis myoplasty is a procedure for reorganizing and
transferring the function of the ipsilateral temporalis muscle in an orthodromic
fashion to the lips and oral commissure for the purpose of reanimating the
lower face. The methods outlined herein include further refinements to the
techniques originally developed by McLaughlin1 and refined by Labbé.2,3
ANATOMY
■ The temporalis is one of four muscles of mastication (innervated by cranial
nerve V). It is a broad muscle that originates in the temporal fossa and inserts
onto the coronoid process of the mandible.
■ The temporalis consists primarily of two layers, deep and superficial, that
converge onto a single tendon (FIG 1A). The tendon is broad and wraps
around the coronoid process in a conical fashion, extending down onto the
ramus for several millimeters.
■ The muscle is dually innervated at the infratemporal crest by the deep
temporal nerves (from the mandibular division of the trigeminal nerve V3). It
also has dual circulation from the deep temporal arteries (branching from the
maxillary artery) (FIG 1B).
■ Muscle fibers from the masseter and the pterygoids attach to portions of the
temporalis tendon as it passes through the zygomatic, or infratemporal, fossa.
PATHOGENESIS
■ There are numerous causes of facial paralysis that are broadly classified as
congenital or acquired.
■ The most common form is acquired complete unilateral facial nerve palsy of
an inflammatory etiology (ie, Bell palsy). Although most cases will resolve
spontaneously, a small number of patients will continue to experience
persistent facial paralysis or weakness causing noticeable asymmetry of
function and appearance.
■ The cause of a patient’s paralysis must be investigated in order to direct
treatment and estimate prognosis for recovery.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Preoperative evaluation of patients with facial paralysis includes a detailed
history and assessment of the patient’s current facial nerve function and
secondary deformities.
■ History
■ Etiology (trauma, viral, tumor, syndromic, etc.). It is important to determine
whether the cause is congenital or acquired.
■ Associated symptoms (vertigo, tinnitus, vision changes, ataxia, apraxia,
symptoms related to other cranial nerve palsies, stroke, etc.)
■ Treatments administered to date (radiation, slings, canthoplasty, muscle flaps,
etc.)
■ Unilateral vs bilateral and complete vs partial facial paralysis
■ Time course
• Early: less than 12 months
• Intermediate: 12 to 18 months
• Late: greater than 18 months
■ Physical examination is used to determine the location and extent of facial
paralysis and resulting deformities. In addition, physical examination should
document function of other cranial nerves and assess potential causes of facial
paralysis (if possible).
■ For assessment of facial paralysis and its sequela, the face is divided into
thirds.
• Upper third: Paralysis of the upper face results in brow ptosis, lack of
forehead rhytides, and compensatory contralateral forehead elevation.
• Middle third: Middle third paralysis results in incomplete eyelid closure
with lower lid malposition (lagophthalmos and ectropion). The physical
examination should document Bell phenomenon (a defensive movement of
the eye that is present in most patients resulting in upward movement of the
eye with eye closure) and reliance on eye lubricants. In addition, symptoms
of epiphora and dry eyes should be elicited.
Zygomaticotemporal nerve branch of maxillary nerve V2) Zygomaticofacial nerve B Infratemporal crest Superficial layer of temporalis Deep layer of temporalis - Temporal fascia Temporalis muscle Deep temporal nerves - Superficial temporal artery •Middle temporal artery Deep temporal arteries Mandibular nerve (V3) Maxillary artery in intratemporal fossa External carotid artery
FIG 1 • A. The temporalis muscle consists primarily of
superficial and deep layers. B. Dual neurovascular
supply of the temporalis muscle. Deep temporal nerves
derive from the mandibular division of the cranial nerve
(V3), and deep temporal arteries branch from the
maxillary artery.
• Lower third: Lower third paralysis results in mouth droop, drooling, loss of
or asymmetric smile, pucker, articulation, and lower lip depression
■ Smile assessment
■ Loss of nasolabial fold: Patients with partial facial paralysis will have partial
loss or asymmetric nasolabial folds.
■ Contralateral deflection of the lips, accentuated with smiling (negative vector
of excursion)
■ Incomplete bilabial closure
■ Record vector direction and length of oral commissure excursion of
paralyzed and nonparalyzed sides (may be a negative number).
■ Examination and documentation of remaining cranial nerve function
particularly function of the fifth cranial nerve. This can be done simply by
assessing temporalis and masseter muscle function when biting down.
■ Diagnostic studies
■ Brain MRI is sometimes indicated to rule out tumor etiology or secondary
compression.
■ Although nerve conduction studies may be helpful in treatment planning for
facial paralysis patients in the intermediate term, they are of limited use in
patients experiencing permanent or long-standing facial nerve palsy.
IMAGING
■ Brain MRI or CT scans are occasionally needed when an intracranial mass or
vascular malformation is suspected.
■ In patients with long-standing (or, late) facial paralysis with proper early
workup, diagnostic studies are rarely indicated in order to proceed to surgery.
SURGICAL MANAGEMENT
■ Retrograde temporalis flap
■ Temporalis flap is a retrograde, or “turnover,” muscle transfer that passes
over the zygomatic arch, using the contraction produced by the temporalis.
■ There are several versions of the retrograde temporalis flap for facial
paralysis. We describe the traditional version with modifications herein.
■ Candidates for a traditional temporalis flap exhibit permanent facial paralysis
(greater than 18 months) with either no anticipated recovery or inadequate
recovery.
■ Unilateral or bilateral temporalis flaps may be performed simultaneously.
■ Risks include temporal hollowing, adhesions, loss of mobility, excessive
cheek bulk, unfavorable scarring, persistent asymmetry, and unusual facial
dimpling.
■ Lengthening temporalis myoplasty
■ Lengthening temporalis myoplasty is an orthograde, or orthodromic, muscle
transfer deep to the zygoma, using the natural direction of pull produced by
the temporalis (FIG 2).
■ Candidates for lengthening temporalis myoplasty exhibit permanent facial
paralysis (greater than 18 months) with either no anticipated recovery or
inadequate recovery.
■ Minimum age for procedure is approximately 5 years.
■ Unilateral or bilateral temporalis myoplasties may be performed
simultaneously.
■ Risks include neurovascular injury to the temporalis muscle being
transferred, avulsion of the tendon from the implantation site, temporal
hollowing, adhesions, loss of mobility, unfavorable scarring, persistent
asymmetry, and unusual facial dimpling.
■ Revision of the insertion site at the nasolabial fold may be required if there is
loss of motion postoperatively.
Preoperative Planning
■ Mark the location of the desired nasolabial fold (use unaffected side for
symmetry, if unilateral). Patient must be able to participate in order to identify
accurately the position of the nasolabial fold. In bilateral cases, the location is
determined by digital manipulation of the upper lip skin to simulate a smile,
thereby identifying the junction between cheek and lip (FIG 3A).
■ Mark the direction or vector of excursion of the smile at the oral commissure
and mid upper lip on the unaffected side and replicate for paralyzed side (FIG
3B).
Positioning
■ Place the patient in supine position with shoulder roll to gently extend the
neck.
■ A standard endotracheal or armored tube is sutured orally in the midline,
making sure there is no tension on the lips.
■ Prep the entire head and neck, including oral and nasal passages, with diluted
iodine or other prep solution.
■ Inject 1:500 000 to 1 000 000 dilution of epinephrine solution in tumescent
fashion over the temporalis muscle and midface. Avoid use of local anesthetic
solution to prevent paretic effect on the temporalis muscle.
Approach
■ Coronal and nasolabial fold incisions are outlined and confirmed. The
dissection of the temporalis muscle is the first step.
FIG 2 • Concept of lengthening temporalis myoplasty as
an orthodromic muscle transfer.
FIG 3 • A. Demonstration of the nasolabial fold
simulated with posteriorly directed pressure of the
upper lip skin. B. Preoperative facial markings of the
intended nasolabial fold and vector of excursion as
mirrored from the contralateral side.
T E C H N I Q U E S
■ Temporalis Flap
Dissection
■ Place a coronal anterior hairline incision from the ipsilateral parietal area,
converging to a preauricular (facelift-type) incision.
■ Alternatively, a coronal incision (without preauricular incision) may be
used in conjunction with a nasolabial fold counterincision. The nasolabial
fold is verified, and key points are tattooed with gentian violet and a 25-
gauge needle (TECH FIG 1A).
■ Make the marked incisions, and elevate the anterior and posterior skin flaps
in a deep subcutaneous plane. The plane must proceed along the superficial
layer of the deep temporal fascia, preserving an unnamed fat pad over the
anterior and inferior portion of the dissection.
■ The fat pad must be elevated with the skin flap to avoid devascularization
and subsequent temporal hollowing (TECH FIG 1B).
■ The dissection proceeds anteriorly onto the lateral orbital rim in a
subperiosteal plane. This continues onto the zygoma and zygomatic arch,
extending posteriorly to the location of the external acoustic meatus.
■ At this point, the entire superficial surface of the temporalis is visualized.
Flap Elevation
■ Different options exist for elevation of the temporalis origin. Typically, only
a strip of temporalis muscle of the middle third (approximately 4–5 cm wide)
is designated for elevation and transfer to minimize temporal hollowing
(TECH FIG 2A). This often involves a periosteal extension extending 1 to 3
cm into the parietal area.
■ Elevation of the flap occurs in a superior to inferior direction in the
subperiosteal plane.
■ As the dissection reaches the infratemporal crest, careful release of the
periosteum will increase the mobility of the muscle (TECH FIG 2B).
■ Care must be taken to avoid injury to vessels emanating from the cranial
base, which are difficult to visualize and control if ruptured.
■ The preauricular skin flap is dissected in the subcutaneous plane to several
millimeters anterior of the planned nasolabial fold (TECH FIG 2C).
■ Dye marks on the skin assist in placement of anchoring sutures. These
marks are made by tattooing the skin with gentian violet or equivalent dye.
■ Place three or four anchoring sutures (0 or 2-0 PDS or equivalent) along the
oral commissure and upper lip in a figure-of-8 fashion to simulate the desired
smile vector.
TECH FIG 1 • A. Redraw the anterior hairline incision
as necessary and extend into a preauricular incision.
Alternatively, only the coronal incision may be used
with a counterincision in the nasolabial fold. B. The
temporal fat pad located on the deep temporal fascia
(indicated by instrument) must be elevated with the
skin flap to avoid devascularization and temporal
hollowing.
TECH FIG 2 • A. A 4 to 5 cm strip of temporalis
muscle from the central section is elevated. The
anterior portion of the muscle should not be elevated
so as to avoid temporal hollowing. B. Dissection of the
temporalis muscle at the infratemporal crest.
Periosteal scoring may increase mobility, but care
must be taken not to injure the dual neurovascular
pedicle. C. Creation of a subcutaneous tunnel for
transmission of the temporalis muscle after it is turned
over the zygomatic arch. D. Transverse releasing
incision is placed in deep temporal fascia to increase
the lengthening of the temporalis muscle flap.
■ Sutures must be accurately placed to avoid eversion or inversion of the lip.
This corresponds to the level of the orbicularis oris muscle.
■ The temporalis muscle may now transfer over the zygomatic arch. An
incision in the deep temporal fascia is helpful in achieving additional
lengthening of the muscle when transferred (TECH FIG 2D).
■ If muscle length is not an issue, the muscle may be anchored with little to
no tension on the oral commissure and upper lip. Run a 5-0 nylon or
Prolene suture over the repair for strengthening purposes.
Interposition Graft
■ Frequently, muscle length is insufficient, even with a periosteal extension. In
this case, a tendon or fascia interposition graft is necessary. There are several
options.
■ Most commonly, a segment of fascia lata may be harvested from the lateral
thigh. There are several techniques to harvest this structure.
■ The author’s preferred technique involves two incisions over the lateral
thigh. A proximal transverse skin incision is placed over the lateral mid-
thigh area. The fascia lata is dissected over its superficial surface. A
transverse fascial incision is then placed, followed by parallel cuts directed
distally. A counterincision is placed at the distal extent of the harvest,
approximately 10 cm proximal to the lateral femoral condyle. A distal
transverse fascial incision is made followed by delivering the fascia lata. A
long clamp will facilitate transferring the fascia distally. A large 3- to 4-cm-
wide length of fascia lata may be harvested for use in the face.
■ Alternatively, a palmaris longus tendon graft may be harvested when
present. The disadvantage is that the palmaris longus tendon is narrow and
may not widely attach to the muscle and the perioral insertion site. A 1-cm
proximal wrist crease incision is placed over the PL tendon. The tendon is
identified and dissected bluntly as far proximally and distally as possible.
The distal insertion is then cut. A 1-cm mid forearm incision is then placed
over the musculotendinous portion. The tendon is once again maximally
dissected and transected proximally. The tendon is withdrawn and the
incisions closed in standard fashion.
Flap Inset and Completion
■ The distal portion of the temporalis flap is then prepared for implantation of
the intervening tendon or fascia graft.
■ Several 4-0 Vicryl U-stitches are placed to prevent a “cheesewire” effect
when anchored.
■ The graft is then secured to the distal portion of the temporalis flap with 2-
0 PDS sutures in figure-of-8 fashion (TECH FIG 3A).
■ A small amount of overcorrection at the oral commissure is expected.
■ The distal portion of the graft is then inset using the 2-0 PDS anchoring
sutures along the oral commissure and upper lip in figure-of-8 fashion. A
running 5-0 nylon suture is used to fortify the repair.
■ The reconstruction may now be tested using a muscle stimulator. Observe
movement at the oral commissure and upper lip with stimulation and adjust
sutures as necessary (TECH FIG 3B,C).
■ The resulting defect at the donor site may be filled by a local temporoparietal
fascial flap or by an implant.
■ A closed channel drain is placed in the temporalis fossa. If desired, an
indwelling local anesthetic delivery catheter may be inserted into the vicinity
of the neurovascular bundle to prevent spasm of the muscle postoperatively.
■ Close incisions in standard layered fashion.
■ Optional: injection of botulinum toxin into contralateral zygomaticus major
and minor muscles and risorius to prevent excessive countertension on the
repair
TECH FIG 3 • A. The temporalis muscle anchored at
the oral commissure and the upper lip just distal to the
nasolabial fold. An intervening fascia lata graft may be
required to make up for insufficient muscle length. B.
Percutaneous muscle stimulation prior to final closure
allows for adjustment of the origin or the insertion of
the temporalis as necessary.
■ Lengthening Temporalis Myoplasty
Flap Harvest
■ Place a coronal anterior hairline incision from the ipsilateral parietal area to
the root of the helix.
■ Alternatively, a traditional bicoronal zigzag incision may be used.
■ The nasolabial fold incision is verified, and key points are tattooed with
gentian violet and a 25-gauge needle (see TECH FIG 1A).
■ Begin with the coronal incision, and elevate the anterior and posterior skin
flaps in a deep subcutaneous plane.
■ The plane must proceed along the superficial layer of the deep temporal
fascia, preserving the fat pad over the anterior and inferior portion of the
dissection.
■ The fat pad must be elevated with the skin flap to avoid devascularization
and subsequent temporal hollowing (see TECH FIG 1B).
■ The dissection proceeds anteriorly onto the lateral orbital rim in a
subperiosteal plane.
■ This continues onto the zygoma and zygomatic arch, extending posteriorly
to the location of the external acoustic meatus.
■ The masseter insertions onto the zygoma are dissected only from the
superior and anterior surfaces of the arch to avoid complete disinsertion.
■ At this point, the entire superficial surface of the temporalis is visualized.
■ Identify the true temporalis tendon, which is located deep to muscle fiber
contributions from the masseter near the zygomatic arch (TECH FIG 4A,B).
■ Osteotomy of the zygomatic arch is performed to facilitate visualization and
dissection of the temporalis tendon in the infratemporal space.
■ Oblique osteotomies at the anterior and posterior borders are performed,
leaving the masseter attached to the osteotomized segment inferiorly
(TECH FIG 4C).
■ The loose segment will need to be repaired at the conclusion of the surgery
with either plate or wire fixation.
■ A broad Freer elevator is used to bluntly dissect away the masseter fibers
over the anterior surface of the temporalis tendon until its insertion on the
coronoid.
■ This is a blind dissection, unless a zygomatic arch osteotomy has been
performed.
■ Coronoidectomy can be performed at this stage via exposure through the
infratemporal space or later through the nasolabial fold incision (TECH FIG
4D).
TECH FIG 4 • Lateral (A) and bird’s eye (B) view
showing identification of the temporalis tendon deep to
masseter contributions near the zygomatic arch. C.
Zygomatic arch osteotomy can be performed with a
reciprocating saw or osteotome in an oblique fashion
to facilitate plate fixation at the conclusion of surgery.
D. Coronoidectomy is performed in an oblique fashion
posterosuperiorly to anteroinferiorly through the
sigmoid notch to maximize temporalis tendon
extension onto the mandibular ramus. The periosteum
is stripped only in the path of the osteotomy. E.
Coronoid process is grasped and gently retracted
superiorly. A Freer elevator is used to carefully release
muscle contributions from the masseter and
pterygoids. F. Incision of the deep temporal fascia,
maintaining a 1-cm cuff anteriorly and superiorly for
muscle anchoring.
■ The periosteum is stripped from the sigmoid notch and directed inferiorly
toward the anterior border of the mandibular ramus.
■ Do not strip off the temporalis tendon. Only expose the intended osteotomy
site.
■ A reciprocating saw is then used to perform the osteotomy.
■ The coronoid process is grasped with a clamp and gently retracted superiorly
as muscle fibers from the masseter and pterygoids are stripped away with a
broad Freer (TECH FIG 4E).
■ The temporalis fascia is incised circumferentially to begin the deep
dissection. A 1-cm cuff of fascia is preserved anteriorly for reanchoring the
muscle in its new position (TECH FIG 4F).
Elevating and Advancing the Temporalis Muscle
■ Elevate the temporalis muscle in its entirety from the temporalis fossa using
a periosteal elevator (see TECH FIG 2B).
■ As the dissection reaches the infratemporal crest, identify the dual
neurovascular supply with a nerve stimulator.
■ Careful release of the periosteum will allow for increased mobilization of
the muscle. Care must be taken to avoid injury to vessels emanating from
the cranial base, which are difficult to visualize and control if ruptured.
■ Additional muscle fiber contributions from the lateral pterygoid are now
bluntly separated from the temporalis tendon anteriorly.
■ Gentle superior and posterior traction on the temporalis may facilitate this
process.
■ Incise the nasolabial fold along the tattooed markings and dissect posteriorly
for 1.5 to 2 cm in a subcutaneous plane. Then bluntly enter the buccal space
and tunnel toward the infratemporal space and the coronoid process.
■ Create a wide tunnel to allow sufficient space for passage of the
musculotendinous segment of the temporalis.
■ Retract the subcutaneous tissues to sufficiently expose the coronoid process
and the superior portion of the anterior mandibular ramus.
■ If coronoidectomy was not performed at the prior step, it can be performed
at this stage through the nasolabial fold incision. Refer to the description
above.
■ Grasp the coronoid process with a clamp, and gently advance through the
buccal space tunnel while bluntly separating additional attachments from the
masseter and pterygoid muscles to the tendon circumferentially using a broad
Freer.
■ If there is insufficient advancement of the tendon, additional dissection in
the infratemporal fossa may be necessary (TECH FIG 5A).
■ Place three or four anchoring sutures (0 or 2-0 PDS or equivalent) along the
oral commissure and upper lip in a figure-of-8 fashion to simulate the desired
smile vector.
■ These sutures are more easily placed prior to transferring the temporalis
muscle to the nasolabial fold.
■ Sutures must be accurately placed to avoid eversion or inversion of the lip.
Ideally, this corresponds to the level of the orbicularis oris muscle.
■ Place an atraumatic vascular clamp along the tendon, proximal to the
coronoid process to prevent retraction into the tunnel. Strip the tendon
meticulously from the coronoid process using a scalpel and/or Freer elevator
(TECH FIG 5B).
■ The temporalis tendon may now be opened broadly from its original conical
configuration. Gently trim loose strands from the end (TECH FIG 5C).
■ Secure the tendon in its new location with the anchors placed previously.
Run a 5-0 nylon or Prolene suture over the repair for fortification of the
repair (TECH FIG 5D).
■ Tension and overcorrection at the oral commissure must be avoided. No
intervening tendon or fascia interposition graft is necessary.
■ The temporalis tendon advances distally by rotating the muscle anteriorly
and inferiorly in the temporalis fossa. This results in repositioning of the
posterior portion anteriorly, leaving an “empty space” posteriorly.
■ Reanchor the muscle origin to the cuff of the temporalis fascia using 0 or 2-0
PDS or Prolene sutures (TECH FIG 5E).
Completion
■ The reconstruction can now be tested using a muscle stimulator. Observe
movement at the oral commissure and upper lip with stimulation, and adjust
sutures as necessary (see TECH FIG 3B,C).
■ If the zygomatic arch was osteotomized, it must be fixed with plates or
wires.
■ A closed channel drain is placed in the temporalis fossa. An indwelling local
anesthetic delivery catheter is inserted into the vicinity of the neurovascular
bundle to prevent spasm of the muscle postoperatively.
■ Close incisions in standard layered fashion.
■ If wished, botulinum toxin can be injected into contralateral zygomaticus
major and minor muscles and risorius to prevent excessive countertension on
the repair.
TECH FIG 5 • A. Delivery of coronoid process with
attached temporalis tendon through the tunnel created
in the buccal space. It is then anchored with sutures
along the oral commissure and upper lip. B. The
temporalis tendon is stripped away from the coronoid
process. An atraumatic vascular clamp placed
proximal to this point prevents retraction of the tendon
into the buccal tunnel. C. The temporalis tendon is
gently stripped of loose attachments and spread to
create a broad surface for anchoring. D. The
temporalis tendon is secured in place with the
anchoring sutures. E. The origin of the temporalis is
rotated to advance the posterior half of the muscle into
the infratemporal fossa for lengthening at the distal
end. The muscle is reanchored with no tension
applied at the nasolabial fold. The zygomatic arch is
reduced and secured with plate fixation.
PEARLS AND PITFALLS
Anatomy
■ Proper release of the temporalis muscle is dependent on full release
of attachments from the masseter and pterygoid muscles.
■ A frequent mistake is the incorrect identification of the true
temporalis tendon. Failure to identify and excise the superior
extension of masseter fibers will result in their incorporation into the
advancing tendon and inability to easily pass through the
infratemporal tunnel.
Temporalis
flap
■ The most common problem encountered is insufficient length of
temporalis muscle, requiring an intervening graft. In order to
maximize lengthening, additional release of periosteum at the level
of the infratemporal crest is sometimes helpful.
■ Minimize the amount of intervening tendon or fascia graft by
maximizing mobility of the muscle.
■ In elevating the skin flap over the temporalis muscle, be sure to
identify the temporal fat pad as the dissection reaches the zygomatic
arch. The fat pad must be elevated with the skin flap to maintain
viability and to avoid postoperative temporal hollowing.
■ The risk of temporal hollowing is also minimized by leaving the
anterior third of the muscle intact.
Lengthening
temporalis
myoplasty
■ The most common problem encountered is insufficient release of
the temporalis muscle resulting in limited advancement. It is
important to carefully proceed with dissection of the masseter and
pterygoid contributions that can bind the muscle.
■ Also, if the infratemporal fossa is narrow despite adequate release
of extraneous muscle attachments, then it may be necessary to
excise a small amount of masseter muscle located posterior to the
zygomatic arch.
■ Osteotomy of the coronoid process should be oblique through the
sigmoid notch with sufficient inferior angulation to capture as much
temporalis tendon as possible without destabilizing the mandible.
■ In elevating the skin flap over the temporalis muscle, be sure to
identify the temporal fat pad as the dissection reaches the zygomatic
arch. The fat pad must be elevated with the skin flap to maintain
viability and to avoid postoperative temporal hollowing.
Therapy
■ Therapy must begin between 3 to 4 weeks following surgery to
allow for proper excursion of the muscle and to avoid adhesions.
POSTOPERATIVE CARE
■ Drains and anesthetic pump catheter are removed at 2 days postoperatively.
■ Avoid contact sports and hard foods for 6 weeks.
■ Begin therapy for facial muscle rehabilitation with a focus on muscle
retraining at 3 to 4 weeks. Work closely with the therapist to avoid excessive
massage at the insertion site and to encourage biofeedback techniques. Mirror
exercises (mime therapy) are the cornerstone of successful muscle retraining.
OUTCOMES
■ Movement of the lips may be seen soon after surgery.
■ Postoperatively, spasm of the temporalis muscle may occur, leading to tension
on the reconstruction and an overcorrected appearance that may last several
days to weeks. This is temporary and resolves spontaneously over 2 to 3
months. Continued improvements in muscle excursion occur over 1 to 3 years.
■ After flap creation, it is common to have noticeable bulk over the zygomatic
arch. Patients must be made aware of this during the preoperative consultation.
■ After a lengthening procedure, the full range of muscle excursion may not be
seen for several weeks to months. As muscle spasm improves, and the muscle
accommodates to its new position and resting length and increased control, and
excursion of the lips is seen.
COMPLICATIONS
■ Avulsion of the temporalis tendon insertion site may occur. This may be
related to the constant spasm and stimulation of the temporalis muscle due to
persistent innervation.
■ In addition, the contralateral functioning facial musculature may add to
tension on the reconstruction. Tendon avulsion may occur in the first 4 weeks
following surgery. Loss of nasolabial fold definition and mouth drooping,
coupled with lack of visible movement, may result.
■ Adhesions of the temporalis tendon in the subzygomatic space may occur,
limiting muscle excursion and visible movement.
■ If the complications listed above occur, revision surgery for adhesiolysis and
tendon reimplantation may proceed no sooner than 6 months postoperatively.
REFERENCES
1. McLaughlin CR. Surgical support in permanent facial paralysis. Plast
Reconstr Surg. 1953;11(4 suppl):302-314.
2. Labbé D, Huault M. Lengthening temporalis myoplasty and lip reanimation.
Plast Reconstr Surg. 2000;105(4 suppl):1289-1297.
3. Labbé D. Lengthening temporalis myoplasty V.2. and lip reanimation. Ann
Chir Plast Esthet. 2009;54(6 suppl):571-576.
51
CHAPTER
Labbé Procedure:
Lengthening Temporalis
Myoplasty
Daniel Labbé and Pierre Guerreschi
DEFINITION
■ Facial paralysis sequelae might lead to major physical and social consequences
that can drive patients to isolation, unemployment, and depression.
■ The facial asymmetry observed at rest is aggravated by facial motion.
ANATOMY
■ All facial muscles can be affected.
■ Muscles on the paralyzed side do not contract effectively and can even be the
object of erratic cocontractures.
■ After a few years, they can even spasm in an intermittent or permanent
manner, leading to facial twitch or hemifacial spasm.
■ Muscles on the opposite side tend to be overactive and thus aggravate the
facial asymmetry.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ We differentiate three different clinical pictures: complete facial paralysis,
facial paresis, and spams with secondary muscle overactivity. These different
clinical pictures can occur simultaneously successively over time.
■ Complete facial paralysis leads to both static and dynamic asymmetries.
■ At rest, the median line is offset to the healthy side. The forehead is relaxed,
smooth, and inexpressive.
■ The eyebrow is droopy especially toward the outside; we often note a ptosis
of the eyebrow’s outer corner aggravating an eventual dermatochalasis.
■ The lower eyelid is also impacted by the absence of muscle tone. It droops,
leading to an eversion of the eyelid with an ectropion that varies according to
the patient’s age.
■ The cheek is flaccid and distended.
■ The commissure droops.
■ Spontaneous facial animation unveils and aggravates the facial asymmetry.
■ Facial paresis mimics this clinical picture. When static, the facial symmetry
might be almost normal, yet facial animation will unveil the asymmetry.
■ During the course of the pathology, some muscles can spasm, sometimes
progressing to real contractures leading to hemifacial spasm.
■ This spasm can remain clonic and discreet or worsen and become a
contracture, with varying degree of pain severity. It is associated with
progressive motor impairment. It becomes more severe when the patient
becomes emotional or stressed.
■ Several muscle groups can therefore be affected by spasms: the depressor
labii inferior (DLI) muscles can be spastic, with at the forefront the depressor
anguli oris (DAO)/platysma complex. The spasm of this muscle group
prevents the elevation of the labial commissure.
■ On the healthy side, muscles often progress to overactivity.
■ The frontalis muscles mark forehead wrinkles and elevates the eyebrow on
the healthy side, even at rest.
■ The levator anguli oris muscles are also frequently affected by offsetting the
mouth toward the healthy side in an exaggerated manner.
■ The overactive DLI impairs elocution by everting the median labial line
toward the healthy side.
■ Finally, the platysma neck cords are a sign of platysma muscle overactivity.
IMAGING
■ Imaging studies are rarely needed in patients with chronic facial paralysis or
facial paresis.
■ In rare instances, brain MRI or CT scans may be necessary to rule out an
intracranial cause of facial paralysis.
NONOPERATIVE MANAGEMENT
■ Botulinum toxin is largely used for all stages of facial paralysis and concerns
all facial muscles.
■ It is particularly relevant because its action is very selective on the different
muscle groups, yet its effectiveness is temporary.1 It allows for a fine action
on the overactive muscles, especially the zygomaticus major and minor and
the DLI, where myectomy procedures are more complicated to perform.2
■ In facial paresis, botulinum toxin can treat spasms and cocontractures.
■ Interestingly, when regularly treated, muscles become atrophied, and the
therapeutic action of the botulinum toxin seems to last longer over time.
SURGICAL MANAGEMENT
■ Myoplasty techniques use the adjacent muscles with different innervations (V)
to reanimate the functions normally provided by the paralyzed facial muscles.3
The first myoplasty was performed by Lexer with the masseter muscle at the
beginning of the 20th century.
■ Some anatomic-pathologic data reinforce the choice of myoplasty surgery:
simultaneous action with the muscles responsible for facial mimics,
proximity, and presence of a trigeminofacial reflex.
■ The muscle mobilized during myoplasty must retain its own innervation and
vascularization. It is essential to harvest enough quantity of muscle taking into
account the location of its vascular and nerve pedicles.
■ Lengthening temporalis myoplasty first published in 19974 was inspired by the
use of the temporalis muscle previously described.
■ This technique is a synthesis and an achievement, even if its author considers
that the technique could still be improved (June 10, 2013). It consists of
mobilizing the entire temporalis muscle freed from its distal and proximal
insertions. Lowering the temporalis muscle through the buccal fat pad is
associated with a lengthening of the muscle to the detriment of its posterior
fibers.5
■ The insertion of the muscle transfer onto the lip is done according to the type
of smile. Studying the patient’s smile during the preoperative period is
essential to match as closely as possible the smile symmetry at rest and when
contracting.
Preoperative Planning
■ The refined preoperative study of the patient’s smile on the healthy side helps
determine the respective insertions of the zygomatic muscles and superficial
and deep elevator muscles of the upper lip and also help refine the type of
smile that needs to be achieved.
■ These anatomic landmarks identified on the healthy side will be transposed
onto the paralyzed side as a mirror image to locate precisely the anchor points
of the muscle flap.
■ The nasolabial fold and its exact shape, concave or straight, are also refined.
The impaired nasolabial fold on the paralyzed side is restored by passively
lifting up the lower lip and moving it backward.
■ This is performed when the patient is sitting down and then controlled again
with the patient lying down.
Positioning
■ The patient is positioned in the supine position, and orotracheal intubation is
performed.
■ The tube is fixed to the lower incisors via a wire thread.
■ The sterile draping completely frees the cephalic extremity up to the upper
clavicular notches.
Approach
■ Two surgical approaches are necessary to perform the procedure: a zigzag
Cairns approach and a nasogenial approach for smile reanimation.
T E C H N I Q U E S
■ Lengthening Temporalis Myoplasty
Exposure and Osteotomies
■ With the zigzag Cairns approach, a flap of scalp is detached in the subgaleal
plane to expose the entire temporalis muscle (TECH FIG 1A).
■ About 2 cm above the orbital rim, the periosteum is incised, and the
dissection continues in a subperiosteal plane along the external orbital
margin.
■ Passing through the two sheets of the superficial aponeurosis of the
temporalis muscle, the temporalis aponeurosis is resected at the level of the
superexternal angle of the orbit. The dissection goes through the two sheets
of the superficial aponeurosis that contains the fat pad and the median
temporal vascular pedicle (TECH FIG 1B).
■ We make sure to leave the fat contained in the two sheets of this
aponeurosis attached to the scalp flap to avoid an unsightly temporal notch
(Video 1).
Video p3-c051_01
■ The retrozygomatic dissection frees the superficial side of the muscle from
its insertions on the zygomatic arch.
■ The subperiosteal dissection on the deep side of the zygomatic arch is
performed with a “periosteal elevator.”
00:00 / 00:00
TECH FIG 1 • A. A zigzag Cairns approach allows to
expose the entire temporalis muscle. B. The
dissection goes through the two sheets of the
superficial aponeurosis of the temporal muscle. C.
Osteotomy of the zygomatic arch.
■ Osteotomy of the zygomatic arch (TECH FIG 1C):
■ The temporalis muscle is protected with the malleable retractor to perform
the osteotomy of the zygomatic arch in order to put it in valgus with the
subjacent scalp flap.
■ This gesture is completed by freeing the residual fibers of the masseter
muscle, inserted into the deeper of the two layers of the superficial
aponeurosis of the temporal muscle.
■ Osteotomy of the coronoid process: after the subperiosteal dissection of the
sigmoid notch, we place a malleable retractor on the internal side of the upper
branch of the mandible to perform the osteotomy of the coronoid process.
Myeloplasty
■ Incision of the aponeurosis of the temporalis muscle and deep dissection of
the muscle.
■ The incision of the aponeurosis of the temporalis muscle leaves a thin flap
of this aponeurosis inserted into the temporal crest to allow the reinsertion
of the muscle at the end of the procedure (TECH FIG 2A).
■ The temporalis muscle is freed from the temporal fossa using the
Obwegeser-type periosteal elevator (TECH FIG 2B).
■ The surgeon needs to perform the dissection with caution around the deep
temporal pedicles.
■ Via the nasolabial approach, the anchor points of the tendon of the upper lip
are positioned according to the preoperative drawing.
■ Commonly, three Prolene 4.0 thread sutures are tested during the procedure
to ensure the correct shape of the smile (Video 2).
Video p3-c051_02
■ The tendon is passed via the buccal fat pad of Bichat.
■ Via the nasolabial approach, a tunnel is created via the buccal fat pad. Then,
via the transjugal approach, the coronoid process is securely seized with
Kocher forceps (TECH FIG 2C).
■ The tendon of the temporalis muscle inserted in the coronoid processed is
lowered through the jaw toward the labial commissure that needs to be
reanimated.
■ To facilitate this lowering, one needs to pull back the masseter muscle
fibers with the Obwegeser-type periosteal elevator (Video 3).
00:00 / 00:00
Video p3-c051_03
■ The tendon is then resected from the coronoid process with a cold blade
while preserving a maximum of tendon fibers.
■ The tendon is then spread out using two Halsted forceps in a vascular clamp
(TECH FIG 2D).
■ We fix the prepared tendon to the anchor points, making sure not to wrinkle
the skin (TECH FIG 2E); then, we close with 3.0 barbed suture thread to
complete the insertion of the muscle on the entire lip.
■ The muscle is reinserted in the temporal area on the aponeurotic flap left in
place in the anterior part of the temporal crest to obtain a symmetric result
using separate Flexocrin 3.0 sutures (TECH FIG 2F).
■ The surgeon’s assistant monitors the absence of elevation of the labial
commissure during the fixation of the muscle on the temporal crest.
■ We perform a percutaneous electrostimulation during the surgery to validate
the shape of the reanimated smile by contracting the transferred temporalis
muscle (3–8) as well as validating the amplitude gained for the labial
commissure course (TECH FIG 2G) (Video 4).
00:00 / 00:00
Video p3-c051_04
■ Osteosynthesis of the zygomatic arch is performed with nonresorbable
thread.
■ It is essential to reinsert the fat pad from the split aponeurosis at the top of
the temporal crest with a U-shaped suture (TECH FIG 2H).
■ Surgical closure is performed over two silicon surgical drains, one in the
transjugal opening and the other in the temporal area.
■ Surgical closing of the scalp is done using staples or resorbable sutures,
especially in children.
00:00 / 00:00
TECH FIG 2 • A. The incision of the aponeurosis of
the temporalis muscle leaves a thin flap of this
aponeurosis inserted into the temporal crest to allow
the reinsertion of the muscle at the end of the
procedure. B. The temporalis muscle is freed from the
temporal fossa using the Obwegeser-type periosteal
elevator. C. The coronoid process is securely seized
with Kocher forceps. D. The tendon is then spread out
using two Halsted forceps. E. The tendon is fixed to
the anchor points making sure not to wrinkle the skin.
F. The muscle is reinserted in the temporal area on
the aponeurotic flap. G. A percutaneous
electrostimulation is performed during the surgery to
validate the shape of the reanimated smile by
contracting the transferred temporalis muscle. H.
Reinsertion of the fat pad from the split aponeurosis at
the top of the temporal crest.
PEARLS AND PITFALLS
Under- or
overcorrection
■ At the end of the surgery, the shape of the smile must be tested
via electrical stimulation of the muscle before waking up the
patient. One must ensure not to have major overcorrection that
would lead to a permanent retraction of the labial commissure.
Temporal notch
■ The fat pad located between the two sheets of the superficial
aponeurosis of the temporalis muscle must remain fixated to the
scalp flap and reinserted at the end of the procedure.
Retraction of
the labial
commissure
■ Each step of the dissection allows the complete freeing of the
temporalis muscle that remains attached to its deep pedicles. It is
important to free the numerous insertions with the masseter
muscle.
Perioperative
blood loss
■ The bitemporal approach is a hemorrhagic one. It is essential to
use Michel suture clips or fix the surgical drape on the two
margins of the scalp used for the surgical approach.
Horizontal
direction of the
labial
commissure
traction vector
■ The external fibers of the tendon correspond to the muscle fibers
of the posterior part of the temporalis muscle. Reinserted
preferably on the commissure, they help give a proper horizontal
direction to the labial commissure traction vector.
POSTOPERATIVE CARE
■ Rehabilitation can start 3 weeks after surgery. The speech therapist is in charge
of this rehabilitation.
■ The patient follows a three-step protocol to go from a mandibular smile to a
temporal smile to finally achieve a spontaneous smile.
■ During the first step, to obtain a symmetric smile, the patient must clench the
jaw in order to contract the transferred temporalis muscle. This is what we call
the mandibular smile.
■ During the second step, the patient can obtain an almost symmetrical smile
without clenching the jaw. This is called the voluntary temporal smile.
■ Finally, the last rehabilitation phase helps the patient obtain a spontaneous
smile attributed to brain plasticity.
■ It is essential to accompany the patient for at least 6 months of rehabilitation
and propose Botulinum toxin treatment for overactivity and cocontractures.
OUTCOMES
■ Lengthening temporalis myoplasty can and must offer the patient better
symmetry at rest and offer movement capacity of the labial commissure when
smiling, thus underlining the nasolabial fold.
■ This procedure can be proposed when the labial commissure contracture is
50% less important than the one on the healthy side, in spite of a well-
conducted rehabilitation program.
■ In case of partial paresis, lengthening temporalis myoplasty can, most times,
help the patient retrieve facial movements present before the procedure, as
there is no risk for the facial nerve.
■ The new movements allowed by the transferred temporalis muscle are then
complementary of the preoperative facial mimic.
COMPLICATIONS
■ Postoperative hematoma: managing hemostasis during the procedure requires
caution.
■ Achieving hemostasis as the end of the procedure is essential especially for
the bitemporal approach.
■ Two Redon drains are left in place for 3 days after surgery for vacuum
wound drainage: one in the subgaleal plane and the other one in the intrajugal
tunnel.
■ Local infection: The distal insertion into the labial commissure can become
infected because it is partially devascularized during the procedure, and the
nasolabial approach is close to the oral cavity.
■ It is important to use a vascular clamp to seize the temporalis muscle tendon
in a nontraumatic manner.