Muscle Transposition for Facial Reanimation Rubinl popularized the technique of temporalis muscle transposition to reanimate the face, although it was first advanced at the turn of the century by Lexer and Eden.2 Rubin has modified the muscle swing and stressed the importance of analyzing the facial expression on the normal side to create the mirror image on the uninvolved side. He lengthened the temporalis muscle to reach the vermilion of the lips and the medial canthal tendon of the eyelids by suturing the stripped fascia of the temporalis to the leading edge of the muscle. Between August 1974 and 1986, 138 temporalis muscle procedures were performed by me (Table I), using first Rubin's technique and then incorporating my modifications to his technique. This report reviews my surgical technique,J and analyzes and updates the results of this procedure. INDICATIONS FOR THE PROCEDURE The causes of the facial nerve lesions requiring reanimation are listed in Table 2. The lesion was most often due to trauma resulting from acoustic surgery. General Indications There were four general indications for performing muscle transposition for facial reanimation: (1) inadequacy of the peripheral facial neuromuscular system; (2) lack of availability of the central stump of the facial nerve for grafting, when the patient refused to
have the hypoglossal nerve sacrificed; (3) contraindications to performing a hypoglossal-facial nerve anastomosis, as in a patient with von Recklinghausen disease or a tenth cranial nerve deficit; and (4) unsatisfactory degree of improvement in patients who had undergone nerve repair, grafting, hypoglossal-facial nerve anastomosis, or cross-face grafting. Specific lndications The specific indications for muscle transposition surgery to reanimate the face include: (1) developmental facial paralysis in a patient of consenting age (defined as one who understands the risks, potential complications, and benefits of this procedure); (2) long-standing facial paralysis (4 years or longer); (3) desire for facial reanimation following massive cerebellopontine angle surgery when the proximal stump of the facial nerve is unidentifiable or is unsuitable for facial nerve grafting, and when the patient refuses to have the hypoglossal nerve sacrificed; (4) massive soft tissue loss as a result of traumatic facial injury; (5) poor prognosis for long-term survival following total resection of the parotid or partial or total temporal bone resection for cancer; (6) the presence of tenth cranial nerve deficit, which is a contraindication to hypoglossal-facial anastomosis because it could result in crippling of the swallowing mechanism; (7) von Recklinghausen disease, because there is a likelihood that other cranial nerves may be involved; and (8) rare situations in which the cause of
Director, Facial Paralysis Center, Shadyside Hospital, Pittsburgh, PA. Clinical Professor, Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA Reprint requests: Mark May, M.D.., EA.C.S., 510 S. Aiken Avenue, Suite 206, Pittsburgh, PA 15232 Copyright 01992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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Mark Mavf M.D., EA.C.S.
FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
The area of the incision in the scalp is prepared by shampooing the entire scalp, face, and neck with a Eyelid spring implants 167 povidone-iodine solution. The hair is then parted in Gold weights (eyelid) 122 the area of the incision and a small area prepared on Temporalis muscle transposition to the mouth 138 Miscellaneous 357 either side of the area of the planned incision by trimming the hair with a scissors (Fig. 1A). The 784 Total center portion of the temporalis muscle with its overlying temporalis fascia is elevated from the underlying skull. Two parallel incisions, 4 cm apart, are extended to the zygomatic arch with the use of the Table 2 Causesof Paralysis in Faces That Were Reanimated cutting cautery (Fig. 1A-D). In the event that the Trauma 190 Tumor 75 patient has some facial function and the integrity of Bell's palsy 42 the facial nerve is to be spared, a tunnel is made just Developmental 26 deep to the subcutaneous tissue and just lateral to Herpes zoster 22 Inflammatory 4 the superficial musculoaponeurotic system. This is Melkersson Rosenthal syndrome 2 accomplished with scissors (Fig. 1E).The facial nerve Other 6 branches are protected by this layer of fascia, and if Total 367 the surgeon stays lateral to this plane the underlying facial nerve branches will be spared. This tunnel is extended all the way to the vermillion, as illustrated the facial paralysis is not found and there is still a in Figure IF-G. The tunnel is enlarged to accommopossibility of spontaneous recovery; in such in- date two fingers (Fig. 1H). By creating this wide stances it is undesirable to interrupt the peripheral pocket the muscle that will be transposed into this pocket will lie flat, which helps to reduce the bulge facial nerve course by grafting. created by the temporalis muscle folded over the zygomatic arch. Once the tunnel has been prepared, the muscle is SURGICAL TECHNIQUE bisected. Then a 2-0 nylon monofilament figure-ofThe details of the temporalis muscle transposition eight locking suture is placed in each side of the operation, as modified by May, are illustrated in muscle by passing the suture material from the fascia on the lateral surface of the muscle through the musFigure 1A-N. Facial Reanimation Procedures Performed August 1974-1 986
C D Figure 1. A-N: Step-by-steptechnique for temporalis muscle transposition, as modified by May. (Reprintedfrom May M (ed): The Facial Nerve. New York, Thieme-Stratton, 1986, pp 714-717.)
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Table 1.
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FACIAL REANIMATION-May
K Figure 1, cont.
cle and out the periosteum on the deep surface of the muscle. These two connective tissue layers with the muscle sandwiched between them hold the suture and prevent it from slipping (Fig. 11). Next, Kelly clamps are passed through the tunnel, from the vermilion to the scalp incision, and a suture is
grasped by each. The Kelly clamps are then withdrawn in such a way that the muscle is not twisted and the ends remain properly oriented (Fig. 1J-K). These sutures are used to fix the muscle to the cheeklip line in the submucosa on the deep side (Fig. 1L) and to the subdermis on the lateral aspect (Fig. 1M).
FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
M
N
Figure 1, cont.
RESULTS The results of muscle transposition for mouth reanimation were considered: (1) superb if the patient demonstrated a synchronous smile and was able to show his or her teeth on the previously paralyzed side; (2) excellent if the patient could voluntarily smile and show his or her teeth; (3) good when the patient could produce a slight smile, as evidenced by lifting and lateral movement of the lateral corner of the mouth; (4) fair if facial symmetry was achieved; and (5) poor if there was no change from the preoperative status. Table 3 summarizes the results of performing this procedure in 138 patients; 92% of patients had some degree of improvement. The patient pictured in Figure 2A-D is one of three patients who had a superb result. Following the procedure there was a considerable amount of swelling and ecchymosis, particularly around the eye region. This persisted for 5 to 10 days but resolved by the third week. The 116 patients
Table 3.
Results of Tem~oralisMuscle Trans~osition
Recovery Grade
No.
Superb Excellent Good Fair Poor Total
3 11 102 14 8 138
Percent
2 8 74 10
6
Definition
Synchronous smile (show teeth) Smile with showing teeth Smile Symmetry Drooping mouth
100
(84%) who were able to demonstrate a smile began to show dramatic improvement in the movement of the mouth by the sixth week, when the results of the procedure could be appreciated. Six weeks after the surgery, the patients are instructed to begin to exercise the temporalis muscle by chewing on a piece of plastic placed between the teeth. If the function of the temporalis muscle activating the mouth was not overcorrected at the time of the surgery, then the final results of surgery were inadequate, as some of the lift was lost during the recovery period. Mouth movement continues to improve for a year.
DISCUSSION Reasons for unsatisfactory final results of mouth region reanimation surgery have included: (1) inadequate fixation of the muscle to the submucosa and subdermis in the lip cheek crease region, (2) infection that led to sloughing (three instances), (3) late granulomas with sloughing and extrusion of sutures in the lip cheek crease, (4) extrusion or point tenderness over the Silastic implant, (5) persistent overcorrection or lack of sufficient correction, and (6) a persistent bulge over the zygoma. Failure to secure the muscle may have been due to technique in some instances, but more likely was due to the variability in healing properties of different patients. There were cases in which the muscle was quite short and under a great deal of tension. Perhaps in those cases a fascia1 extension as de-
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Note that the corner of the mouth is overcorrected at the completion of the procedure (Fig. IN). The vermilion incision is then closed in layers, with an elastic drain inserted, and a Jackson-Prattdrain is placed in the scalp through a stab incision to drain the undermined tunnel and scalp defect. A soft Silastic implant is placed in the defect left by transposing the muscle, and the scalp wound is closed with 3-0 chromic suture and then skin staples. Following the procedure, the hair is shampooed, a pressure dressing is applied and the elastic drain is connected to wall vacuum drainage for 48 hours. Prior to discharge on the third to the fifth postoperative day, the patient is visited by a beautician and the hair is washed, combed, and set. Female patients appreciate not having their scalp shaved, placement of incisions in areas that are not visible, and especially the provision of professional hair care prior to discharge.
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FACIAL REANIMATION-May
Figure 2. Patient with total facial paralysis present for 18 years before referral for facial reanimation. Computed tomography scan and surgical exploration revealed a meningioma involving the facial nerve at the geniculate ganglion as the cause of the facial paralysis. A: Patient in repose; B: patient attempting to smile prior to treatment. C: Patient in repose; D: patient demonstrating a synchronous smile 6 weeks after reanimation surgery.
119
FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992 Prevention of implant extrusion or point tenderness has been accomplished by making the implant much smaller than the defect and by using very soft material. The bulge created by the muscle transposed over the zygomatic arch tends to become less of a problem with time, and in 6 months to a year after surgery very few patients complain about it. Because it can be camouflaged with eyeglasses and hair style, we have not attempted to reduce the bulk of the muscle in the few cases where it did seem to be prominent.
COMMENTS The most rewarding aspect of temporalis muscle transposition surgery has been the patient's ability to smile. This result is achieved in 6 weeks by an operation that takes a little over an hour. We use the muscle to reanimate the mouth only, and other techniques to reanimate the eye region, to permit eye movement to be separate from mouth movement. However, although this is a significant improvement over using the temporalis muscle for both eye and mouth reanimation, it still does not satisfy the ultimate goals of the facial reanimation surgeon-the ideal is to restore synchronized mimetic facial language. Many advances have been made in reanimating the paralyzed face, but restoring spontaneous facial language at the moment is beyond the grasp of the most imaginative and skilled reanimation surgeon.
REFERENCES 1. Rubin L: Reanimation of the Paralyzed Face. St. Louis: CV Mosby, 1977 2. Lexer E, Eden R: Uber die chirurgische Behandlung der peripheren Facialislahmung. Beitr Klin Chir 73:116, 1911 3. May M: Muscle transposition for facial reanimation: indications and results. Arch Otolaryngol 110:184-189, 1984
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scribed by Rubin might have overcome this problem. However, when meticulous surgical notes were reviewed in the light of postoperative results, there was little correlation between short muscle and poor results of the procedure; in fact, some of the best results were in patients who had shorter muscles. In addition, in six patients the muscle had been injured by previous surgery, and two of these patients experienced useful return of function after reanimation surgery: in one the result was good and in the other fair. Therefore, even though patients have had middle cranial fossa surgery, the temporalis muscle has been used in an attempt to reanimate the face, it may still be helpful to try reanimation surgery. However, when patients have undergone skull base procedures and the temporalis muscle or fifth nerve innervation to the muscle has been significantly damaged or lost, then the temporalis muscle technique is not a consideration. All of the infections that have occurred, with one exception, involved the area just under the dissection between the lip cheek crease and the vermilion. This was in spite of routine use of preoperative intravenous therapeutic doses of cephalosporin. However, placing an elastic drain and leaving it in the vermilion incision for 48 hours has resulted in no recurrence of this problem. One other caution regarding prevention of infection should be obvious, but yet was not immediately recognized in one patient in this series. In this patient the deep suture through the submucosa actually passed through the mucosa into the mouth, and acted as a wick for bacteria from the oral cavity to soil the wound bed. This was recognized when a permanent monofilament suture was found to be exposed in the oral cavity. Once the suture was removed the infection promptly came under control. Sloughing of sutures and suture granulomas have been controlled by not using permanent sutures in the subdermis: we now use absorbable sutures to fix the muscle to the subdermis.
have the hypoglossal nerve sacrificed; (3) contraindications to performing a hypoglossal-facial nerve anastomosis, as in a patient with von Recklinghausen disease or a tenth cranial nerve deficit; and (4) unsatisfactory degree of improvement in patients who had undergone nerve repair, grafting, hypoglossal-facial nerve anastomosis, or cross-face grafting. Specific lndications The specific indications for muscle transposition surgery to reanimate the face include: (1) developmental facial paralysis in a patient of consenting age (defined as one who understands the risks, potential complications, and benefits of this procedure); (2) long-standing facial paralysis (4 years or longer); (3) desire for facial reanimation following massive cerebellopontine angle surgery when the proximal stump of the facial nerve is unidentifiable or is unsuitable for facial nerve grafting, and when the patient refuses to have the hypoglossal nerve sacrificed; (4) massive soft tissue loss as a result of traumatic facial injury; (5) poor prognosis for long-term survival following total resection of the parotid or partial or total temporal bone resection for cancer; (6) the presence of tenth cranial nerve deficit, which is a contraindication to hypoglossal-facial anastomosis because it could result in crippling of the swallowing mechanism; (7) von Recklinghausen disease, because there is a likelihood that other cranial nerves may be involved; and (8) rare situations in which the cause of
Director, Facial Paralysis Center, Shadyside Hospital, Pittsburgh, PA. Clinical Professor, Department of Otolaryngology Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA Reprint requests: Mark May, M.D.., EA.C.S., 510 S. Aiken Avenue, Suite 206, Pittsburgh, PA 15232 Copyright 01992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: NYU. Copyrighted material.
Mark Mavf M.D., EA.C.S.
FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
The area of the incision in the scalp is prepared by shampooing the entire scalp, face, and neck with a Eyelid spring implants 167 povidone-iodine solution. The hair is then parted in Gold weights (eyelid) 122 the area of the incision and a small area prepared on Temporalis muscle transposition to the mouth 138 Miscellaneous 357 either side of the area of the planned incision by trimming the hair with a scissors (Fig. 1A). The 784 Total center portion of the temporalis muscle with its overlying temporalis fascia is elevated from the underlying skull. Two parallel incisions, 4 cm apart, are extended to the zygomatic arch with the use of the Table 2 Causesof Paralysis in Faces That Were Reanimated cutting cautery (Fig. 1A-D). In the event that the Trauma 190 Tumor 75 patient has some facial function and the integrity of Bell's palsy 42 the facial nerve is to be spared, a tunnel is made just Developmental 26 deep to the subcutaneous tissue and just lateral to Herpes zoster 22 Inflammatory 4 the superficial musculoaponeurotic system. This is Melkersson Rosenthal syndrome 2 accomplished with scissors (Fig. 1E).The facial nerve Other 6 branches are protected by this layer of fascia, and if Total 367 the surgeon stays lateral to this plane the underlying facial nerve branches will be spared. This tunnel is extended all the way to the vermillion, as illustrated the facial paralysis is not found and there is still a in Figure IF-G. The tunnel is enlarged to accommopossibility of spontaneous recovery; in such in- date two fingers (Fig. 1H). By creating this wide stances it is undesirable to interrupt the peripheral pocket the muscle that will be transposed into this pocket will lie flat, which helps to reduce the bulge facial nerve course by grafting. created by the temporalis muscle folded over the zygomatic arch. Once the tunnel has been prepared, the muscle is SURGICAL TECHNIQUE bisected. Then a 2-0 nylon monofilament figure-ofThe details of the temporalis muscle transposition eight locking suture is placed in each side of the operation, as modified by May, are illustrated in muscle by passing the suture material from the fascia on the lateral surface of the muscle through the musFigure 1A-N. Facial Reanimation Procedures Performed August 1974-1 986
C D Figure 1. A-N: Step-by-steptechnique for temporalis muscle transposition, as modified by May. (Reprintedfrom May M (ed): The Facial Nerve. New York, Thieme-Stratton, 1986, pp 714-717.)
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Table 1.
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FACIAL REANIMATION-May
K Figure 1, cont.
cle and out the periosteum on the deep surface of the muscle. These two connective tissue layers with the muscle sandwiched between them hold the suture and prevent it from slipping (Fig. 11). Next, Kelly clamps are passed through the tunnel, from the vermilion to the scalp incision, and a suture is
grasped by each. The Kelly clamps are then withdrawn in such a way that the muscle is not twisted and the ends remain properly oriented (Fig. 1J-K). These sutures are used to fix the muscle to the cheeklip line in the submucosa on the deep side (Fig. 1L) and to the subdermis on the lateral aspect (Fig. 1M).
FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
M
N
Figure 1, cont.
RESULTS The results of muscle transposition for mouth reanimation were considered: (1) superb if the patient demonstrated a synchronous smile and was able to show his or her teeth on the previously paralyzed side; (2) excellent if the patient could voluntarily smile and show his or her teeth; (3) good when the patient could produce a slight smile, as evidenced by lifting and lateral movement of the lateral corner of the mouth; (4) fair if facial symmetry was achieved; and (5) poor if there was no change from the preoperative status. Table 3 summarizes the results of performing this procedure in 138 patients; 92% of patients had some degree of improvement. The patient pictured in Figure 2A-D is one of three patients who had a superb result. Following the procedure there was a considerable amount of swelling and ecchymosis, particularly around the eye region. This persisted for 5 to 10 days but resolved by the third week. The 116 patients
Table 3.
Results of Tem~oralisMuscle Trans~osition
Recovery Grade
No.
Superb Excellent Good Fair Poor Total
3 11 102 14 8 138
Percent
2 8 74 10
6
Definition
Synchronous smile (show teeth) Smile with showing teeth Smile Symmetry Drooping mouth
100
(84%) who were able to demonstrate a smile began to show dramatic improvement in the movement of the mouth by the sixth week, when the results of the procedure could be appreciated. Six weeks after the surgery, the patients are instructed to begin to exercise the temporalis muscle by chewing on a piece of plastic placed between the teeth. If the function of the temporalis muscle activating the mouth was not overcorrected at the time of the surgery, then the final results of surgery were inadequate, as some of the lift was lost during the recovery period. Mouth movement continues to improve for a year.
DISCUSSION Reasons for unsatisfactory final results of mouth region reanimation surgery have included: (1) inadequate fixation of the muscle to the submucosa and subdermis in the lip cheek crease region, (2) infection that led to sloughing (three instances), (3) late granulomas with sloughing and extrusion of sutures in the lip cheek crease, (4) extrusion or point tenderness over the Silastic implant, (5) persistent overcorrection or lack of sufficient correction, and (6) a persistent bulge over the zygoma. Failure to secure the muscle may have been due to technique in some instances, but more likely was due to the variability in healing properties of different patients. There were cases in which the muscle was quite short and under a great deal of tension. Perhaps in those cases a fascia1 extension as de-
Downloaded by: NYU. Copyrighted material.
Note that the corner of the mouth is overcorrected at the completion of the procedure (Fig. IN). The vermilion incision is then closed in layers, with an elastic drain inserted, and a Jackson-Prattdrain is placed in the scalp through a stab incision to drain the undermined tunnel and scalp defect. A soft Silastic implant is placed in the defect left by transposing the muscle, and the scalp wound is closed with 3-0 chromic suture and then skin staples. Following the procedure, the hair is shampooed, a pressure dressing is applied and the elastic drain is connected to wall vacuum drainage for 48 hours. Prior to discharge on the third to the fifth postoperative day, the patient is visited by a beautician and the hair is washed, combed, and set. Female patients appreciate not having their scalp shaved, placement of incisions in areas that are not visible, and especially the provision of professional hair care prior to discharge.
Downloaded by: NYU. Copyrighted material.
FACIAL REANIMATION-May
Figure 2. Patient with total facial paralysis present for 18 years before referral for facial reanimation. Computed tomography scan and surgical exploration revealed a meningioma involving the facial nerve at the geniculate ganglion as the cause of the facial paralysis. A: Patient in repose; B: patient attempting to smile prior to treatment. C: Patient in repose; D: patient demonstrating a synchronous smile 6 weeks after reanimation surgery.
119
FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992 Prevention of implant extrusion or point tenderness has been accomplished by making the implant much smaller than the defect and by using very soft material. The bulge created by the muscle transposed over the zygomatic arch tends to become less of a problem with time, and in 6 months to a year after surgery very few patients complain about it. Because it can be camouflaged with eyeglasses and hair style, we have not attempted to reduce the bulk of the muscle in the few cases where it did seem to be prominent.
COMMENTS The most rewarding aspect of temporalis muscle transposition surgery has been the patient's ability to smile. This result is achieved in 6 weeks by an operation that takes a little over an hour. We use the muscle to reanimate the mouth only, and other techniques to reanimate the eye region, to permit eye movement to be separate from mouth movement. However, although this is a significant improvement over using the temporalis muscle for both eye and mouth reanimation, it still does not satisfy the ultimate goals of the facial reanimation surgeon-the ideal is to restore synchronized mimetic facial language. Many advances have been made in reanimating the paralyzed face, but restoring spontaneous facial language at the moment is beyond the grasp of the most imaginative and skilled reanimation surgeon.
REFERENCES 1. Rubin L: Reanimation of the Paralyzed Face. St. Louis: CV Mosby, 1977 2. Lexer E, Eden R: Uber die chirurgische Behandlung der peripheren Facialislahmung. Beitr Klin Chir 73:116, 1911 3. May M: Muscle transposition for facial reanimation: indications and results. Arch Otolaryngol 110:184-189, 1984
Downloaded by: NYU. Copyrighted material.
scribed by Rubin might have overcome this problem. However, when meticulous surgical notes were reviewed in the light of postoperative results, there was little correlation between short muscle and poor results of the procedure; in fact, some of the best results were in patients who had shorter muscles. In addition, in six patients the muscle had been injured by previous surgery, and two of these patients experienced useful return of function after reanimation surgery: in one the result was good and in the other fair. Therefore, even though patients have had middle cranial fossa surgery, the temporalis muscle has been used in an attempt to reanimate the face, it may still be helpful to try reanimation surgery. However, when patients have undergone skull base procedures and the temporalis muscle or fifth nerve innervation to the muscle has been significantly damaged or lost, then the temporalis muscle technique is not a consideration. All of the infections that have occurred, with one exception, involved the area just under the dissection between the lip cheek crease and the vermilion. This was in spite of routine use of preoperative intravenous therapeutic doses of cephalosporin. However, placing an elastic drain and leaving it in the vermilion incision for 48 hours has resulted in no recurrence of this problem. One other caution regarding prevention of infection should be obvious, but yet was not immediately recognized in one patient in this series. In this patient the deep suture through the submucosa actually passed through the mucosa into the mouth, and acted as a wick for bacteria from the oral cavity to soil the wound bed. This was recognized when a permanent monofilament suture was found to be exposed in the oral cavity. Once the suture was removed the infection promptly came under control. Sloughing of sutures and suture granulomas have been controlled by not using permanent sutures in the subdermis: we now use absorbable sutures to fix the muscle to the subdermis.
