ORIGINAL ARTICLE Minimally Invasive Temporalis Tendon ...

ORIGINAL ARTICLE

Minimally Invasive Temporalis TendonTranspositionKofi D. Boahene, MD; Tarik Y. Farrag, MD; Lisa Ishii, MD; Patrick J. Byrne, MD

Objective: To describe a minimally invasive approachof the temporalis tendon transposition technique for dy-namic reanimation in patients with long-standing facialparalysis.

Methods:Wereportacaseseriesof17consecutivepatientswithfacialparalysiswhounderwentminimallyinvasivetem-poralis tendon transposition surgery for dynamic facial re-animationbetweenJanuary1,2006,andDecember31,2008.The minimally invasive technique is described. Preopera-tiveandpostoperativerecords,photographs,andvideoswerereviewedforfeasibilityofthetechnique,symmetry,oralcom-petence, and dynamic oral commissure movement.

Results: All the patients tolerated the procedure well,and none developed procedure-related complications. All

the patients achieved improved symmetry at rest and vol-untary motion of the oral commissure. In all the pa-tients, the temporalis tendon was transposed to the mo-diolus without the need for fascial extension orlengthening myoplasty.

Conclusions: The temporalis tendon can be trans-posed for immediate dynamic reanimation of the para-lyzed lower face using a minimally invasive approach. Thisprocedure involves a single small incision and minimaldissection, with no major osteotomies. Acquisition of de-sired facial movement requires intensive physiotherapyand a motivated patient.

Arch Facial Plast Surg. 2011;13(1):8-13

T HE PRIMARY GOAL OF ALL FA-cial reanimation protocolsis to restore facial move-ment that is controlled,symmetrical, and sponta-

neous. This is best achieved when neuralinput to the paralyzed facial muscles is re-established by direct facial nerve repair.Successful reinnervation of the paralyzedface requires the presence of viable facialmuscle fibers, functional motor end plates,and unfibrosed facial nerve conduitsthrough which axonal regeneration can oc-cur. When viable nerves or muscular unitsare unavailable for reinnervation, func-tionally innervated and vascularized re-gional muscles may be transferred to re-produce desired facial movements.

Rubin1 and Baker and Conley2 popu-larized use of the temporalis muscle turn-down flap in reanimation of the para-lyzed lower face in the early 1970s. Theclassic technique of temporalis muscletransfer described by Rubin and othershas the disadvantages of donor site de-

pression and midfacial widening. In ad-dition, it depends on a nonanatomic con-traction of the transposed muscle segment.This temporalis sling procedure has un-dergone several refinements to improvefunctionality and aesthetic appearance.McLaughlin3 first described the transoraltechnique for transferring the coronoidprocess with the attached temporalis ten-don to the corner of the mouth. This pro-cedure avoids the fullness over the zygo-matic arch area and the temporal donorsite depression that is produced by theturned-down temporalis muscle flap. Sev-eral authors have highlighted the advan-tages of the transfer of the temporalistendon in an orthodromic manner to re-animate the lower face.4-7 We previouslydescribed our experience with transfer ofthe temporalis tendon for dynamic facialreanimation.8 In this previous descrip-tion, we used a technique that required atemporal incision and segmental re-moval of the zygomatic arch for expo-sure of the coronoid process and mobili-zation of the temporalis tendon. It wasoccasionally necessary to mobilize the tem-poralis muscle origin to reach the oral com-missure. We subsequently found that thistemporal dissection is unnecessary, and we

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Author Affiliations: Division ofFacial Plastic andReconstructive Surgery,Department ofOtolaryngology–Head and NeckSurgery, The Johns HopkinsUniversity School of Medicine,Baltimore, Maryland.

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have limited the technique to a single incision, and weapproached the tendon from the nasolabial fold or transor-ally via a buccal sulcus incision. In this study, we de-scribe our technique, minimally invasive temporalis ten-don transposition (MIT3), for dynamic reanimation ofthe paralyzed lower face.

METHODS

PREOPERATIVE PREPARATION

The MIT3 technique is most commonly used for patients withlong-standing facial paralysis in whom reinnervation tech-niques are impossible. Success critically depends on the func-tional capabilities of the temporalis muscle. This is best as-sessed by simple palpation of the patient’s muscle belly withcontraction.

The goal of facial paralysis treatment is to improve symme-try. This is of the utmost importance. Thus, the newly pro-vided dynamic movement will be successful only if it is fairlysymmetrical with the nonparalyzed side. Because the tempo-ralis tendon transfer can elevate the oral commissure in only 1dimension, it is important that the contralateral smile patternis trained to mimic this. A “Mona Lisa” smile, in which the oralcommissure is elevated by the zygomaticus musculature butno upper or lower lip elevation occurs to show the dentition,is the goal of facial retraining. This smile pattern is “prac-ticed,” linking the simple smile pattern of the contralateral sideto a temporalis contraction on the involved side. The acquisi-tion of a “temporal smile” is then the next goal, postopera-tively. This is briefly described in the “Comment” section.

SURGICAL TECHNIQUE

Surgical Anatomy

The temporalis muscle is a fan-shaped muscle that originatesfrom the temporal fossa and inserts onto the coronoid processof the mandible. The tendon starts high within the muscle inthe form of a broad tendinous lamina that gradually thickens

and converges on the coronoid process. The muscle passesdeep to the zygomatic arch with a glide plane between themuscle and the bone. The temporalis tendon wraps aroundthe medial and anterior surfaces of the coronoid, extendingdown onto the anterior mandibular ramus. A small portion isseen on the lateral surface of the coronoid. Then, the tendoninserts on the medial and lateral surfaces of the coronoid pro-cess of the mandible. Most of the tendon is found on the me-dial aspect and extends inferiorly toward the buccinator line.The coronoid process can be directly approached through thebuccal space. This approach requires a good understanding ofthe buccal space anatomy. The buccal space is bordered later-ally by the superficial muscular aponeurotic system and facialmimetic muscles, medially by the buccinator muscle and buc-cal mucosa, and posteriorly by the masseter muscle and man-dible. The buccal space is occupied mainly by the buccal fatpad, which has ligamentous projections to the buccinators,temporalis tendon, maxilla, and zygomatic arch. Except forthe branch to the buccinator muscle, the facial nerve brancheslie superficial to the buccal fat. Blunt dissection deep to thebuccal fat, dividing the ligamentous projections to the bucci-nator and temporalis tendon, will lead to exposure of thecoronoid process.

Marking the Patient

Preoperatively, the patient’s smile pattern is determined, and amimicking incision is planned by marking in the melolabial creaseon the involved side (Figure 1). The desired vector of pull isthen determined for attachment of the temporalis tendon.

INCISION ANDBUCCAL SPACE DISSECTION

Through the melolabial crease, an approximately 2-cm inci-sion is made. Through this incision, dissection is bluntly per-formed in the buccal space, and deep retractors are placed toretain the buccal fat. The ligamentous projections between theintermediate and posterior buccal fat lobes are bluntly di-vided, taking care not to violate the buccinator muscle and buc-cal mucosa. This way, oral contamination is avoided. By pal-pation and by manually opening and closing the jaw, the anterioredge of the ascending mandibular ramus is identified (Figure2).

Figure 1. A 2-cm incision is planned in the melolabial crease based on thesmile pattern and vector of pull on the unaffected side. A melolabial incisionis chosen in patients with a deep contralateral crease. In patients without amelolabial crease, a transoral incision or approach is chosen.

Figure 2. Transbuccal dissection provides direct access to the mandibularramus and coronoid process.




Using an angled clamp, the mandibular notch is identified, andthe coronoid process is exposed. In patients with an indistinctmelolabial crease, a buccal sulcus incision directly below theplanned line of tendon insertion is used to gain access to thebuccal space.

Isolation of the Temporalis Tendonand Coronoidectomy

Dissection is performed bluntly to expose the anterior edgeof the ascending mandibular ramus. Using electrocautery, theperiosteum is incised, and the temporalis tendon is elevated fromthe medial and lateral aspects of the ascending ramus(Figure 3). The tendon is kept attached to the coronoid pro-cess. Care is taken to isolate the temporalis tendon as medialas possible and down to the buccinator to obtain adequate ten-don length. A reciprocating saw is used to divide the coronoid

process in an oblique manner, thus leaving as much of the ten-don attached to the coronoid as possible. Before detaching thecoronoid, a Kocher clamp is placed to prevent retraction. Thetemporalis tendon is detached as inferior as possible and isgrasped with Allis forceps and retracted toward the melolabialincision (Figure 4 and Figure 5).

Transposition and Insertionof the Temporalis Tendon

The temporalis tendon is transposed through the buccal spaceand is secured to the orbicularis oris and zygomaticus muscleinsertion in the region of the modiolus. The tendon is then su-tured into place in a horizontal mattress manner (Figure 6).The position of the tendon insertion is determined by the pre-operative smile pattern. The tendon may be unfurled to attainwidth for suturing across a broader plane. To aid in establish-ing the appropriate tension on the transposed tendon that maxi-mizes muscle excursion, the temporalis muscle may be stimu-lated through surface electrodes using a muscle stimulator whilevarying traction tension on the tendon. With a Kocher clampplaced on the tendon and traction tension varied, the tempo-ralis muscle is stimulated and the degree of excursion of theKocher clamp is observed. Once the ideal tension is deter-mined, the tendon is sutured in place at that muscle length.Muscle excursion is lost when excessive traction tension is re-quired to reach the modiolus, and in such cases, a tendon ex-tender graft should be considered. This gross method of estab-lishing the appropriate muscle length and tension for insertingthe transposed temporalis muscle is feasible only when long-acting paralytic agents are avoided at the beginning of the case.

Fascia Lata Extension

In some patients, the lips are pulled to the contralateral sideowing to compensatory contraction. In these patients, we of-ten place a fascia lata extension to allow fixation to the lips acrossthe midpoint to the contralateral side. The fascia lata exten-sion is secured to the temporalis tendon and is tunneled intothe upper and lower lips. The fascia lata extension is securedto the middle of the upper and lower lips to pull the philtrumand the lower lip toward the midline (Figure 7).

Skin Closure

The melolabial incision is closed in a layered manner to mimicthe contour of the contralateral crease. In a patient with a deep

Temporalistendon

Parotidgland

Zygomaticarch Buccinator

muscle

Cut

Cut

Massetermuscle

2

1

Figure 4. Osteotomy, performed at the neck of the coronoid process, allowsmobilization of the temporalis tendon. 1 indicates incision in periostem;2, bone cut.

Tip ofcoronoidprocess

Temporalistendon

Temporalistendon attached

to orbicularisoris muscle

Figure 5. The temporalis tendon is transposed through the buccal space andis fixated at the modiolus based on the predetermined vector of smile.

Temporalistendon

Coronoidprocess

Figure 3. The temporalis tendon wraps around the coronoid process but hasan extension along the mandibular ramus down to the buccinator ridge. Togain adequate tendon length, subperiosteal tendon dissection should beperformed toward the buccinator ridge.




melolabial crease, the incision is closed in an overriding man-ner to recreate a deep crease. If the contralateral melolabial creaseis shallow, the skin edges are approximated in an end-to-endmanner.

PATIENTS

Seventeen consecutive patients who underwent the MIT3 pro-cedure between January 1, 2006, and December 31, 2008, werestudied. We analyzed these cases to determine the ease of ac-cess for coronoidectomy through the minimal melolabial in-cision and transbuccal approach, the ability to mobilize andtranspose the temporalis tendon to the modiolus without fas-cia lata extension, the preservation of neuromuscular func-tion by muscle stimulation, symmetry at rest, lip continence,and acquisition of oral commissure excursion.

RESULTS

Of the 17 patients, 7 experienced their facial paralysisafter the excision of parotid gland malignant tumors in-volving the facial nerve, 1 after a motor vehicle crash, 4after cerebellopontine angle tumor excision with post-operative facial paralysis (Figure 8), 1 related to pro-gressive multiple cranial nerve palsies, 1 related to con-genital facial nerve paralysis 1 related to a glomus jugularetumor, 1 related to hemangioma of the temporal bone,and 1 related to herpes zoster infection. All the patientstolerated the procedure, and none developed procedure-related complications. The modiolus was reached for di-rect tendon suturing in all the patients without the needfor fascia lata extensions. All the patients achieved sym-metry at rest, oral commissure movement, lip conti-nence, and subjective improvement in articulation. In 3patients, intraoperative temporalis muscle stimulation wasperformed after the MIT3 procedure, and dynamic re-animation was recorded (a video is available at http://www.archfacial.com). The postoperative dynamic rangeof oral commissure movement differed from patient topatient.

COMMENT

We found that the MIT3 technique is an effective andreliable method of dynamic facial reanimation. Thetransbuccal route to the coronoid process offers directaccess to the temporalis tendon without the need for ex-tensive incisions, dissection, and osteotomies. It alsoensures preservation of a glide plane between the zy-goma and the temporalis tendon for untethered muscleexcursion. Inadequate length of the temporalis tendonhas been cited as a limitation of the temporalis tendontransposition procedure. Previous descriptions of thetemporalis tendon transfer procedure by McLaughlin3

and Croxson et al5 have included the use of fascia lataextenders to reach the targeted insertion site. We foundthis unnecessary to reach the oral commissure. To at-tain adequate length, other surgeons advocated disin-serting the temporalis muscle origin from the temporalfossa, thus allowing inferior transposition of the entiremuscle and tendon. With the MIT3 procedure, ad-equate tendon length is achievable without disturbingthe muscle origin. To do so, the temporalis tendonshould be elevated off the medial surface of the man-dibular ramus down to the buccinator line. An ob-liquely oriented osteotomy of the coronoid process en-sures that most of the tendon is kept attached to the

Figure 7. Intraoperative view.

A B

Figure 8. Preoperative (A) and postoperative (B) views of a 49-year-oldwoman who developed facial paralysis after surgical resection ofcerebellopontine angle tumor resection.

Divided fascia latastrip

Figure 6. Fascia lata extension from the inserted tendon to the middle ofthe lip.




coronoid. Benateau et al6 performed a nice anatomicdissection to demonstrate the anatomic features of thetemporalis tendon and its attachment to the coronoidprocess and mandibular ramus. We attained adequatelength to reach the oral commissure in all the patients.In select cases, fascia lata extension was included toreach and correct a displaced phitrial column, as de-scribed by Sherris.9

Beyond the described technical aspects of the MIT3procedure, directed physical therapy is essential to achievean optimal outcome. The visible movement gained fromdynamic muscle transposition does not translate into aspontaneous controlled smile without intensive neuro-muscular retraining. A physiotherapist should performa comprehensive evaluation, ideally before surgery, to ob-tain baseline data. In patients who have undergone tem-poralis tendon transposition, physical therapy focuses onacquisition of a temporal smile. Lambert-Prou10 de-scribed a stepwise approach to achieving a spontaneoustemporal smile. The first phase in the acquisition of a man-dibular smile involves mobilization of the mandible bycontracting the transposed temporalis muscle and by in-ducing an elevation of the oral commissure. The secondphase focuses on learning a voluntary temporal smile bycontraction of the temporalis muscle independent of man-dibular movement, which remains under voluntary con-trol. The last phase is designed to achieve a spontane-ous smile independent of mandibular movement. Coulsonet al11 demonstrated the efficacy of combining video self-

modeling and implementation intentions to improve thespontaneity of a learned smile.

The MIT3 is an effective procedure for the manage-ment of long-standing facial paralysis (Figure 9). It isuseful for all such patients, even those with profoundfacial ptosis. In these cases, we typically combine theMIT3 with adjunctive procedures, such as rhytidec-tomy, browlifting, and so on (Figure 10). The MIT3offers several distinct advantages over free tissue trans-fer and the classic temporalis sling. These 2 alternativeprocedures, by their very nature, create facial asymme-try. The gracilis free flap, although an excellent optionin many patients, adds bulk to the face. Revision ratesare high, reinnervation is delayed up to a year, andsome patients do not reinnervate. The classic tempora-lis sling adds bulkiness over the zygomatic arch and adepression in the temple. We have found that even verythin patients with very short hair experience none ofthese contour changes with the MIT3 (Figure 11). Re-habilitation is accelerated, with good results and move-ment seen in 2 to 3 weeks, which is much quicker thanwith other techniques (Figure 12).

Dynamic reanimation after facial paralysis remainschallenging but can be achieved in selected patients usingthe MIT3. The MIT3 technique offers an option for im-mediate dynamic facial movement with a single proce-dure without the need for staged nerve grafting, as withfree muscle transfer procedures. Although the tech-

A B

Figure 9. Preoperative (A) and postoperative (B) views of a patient withlong-standing paralysis.

A B

Figure 10. Preoperative (A) and postoperative (B) views of severe soft-tissuedescent in a patient with long-standing paralysis.

A B

Figure 11. Preoperative (A) and postoperative (B) views of a very thin patientwith short hair. Notice the lack of temporal depression or any protrusionover the zygoma.

A B

Figure 12. Preoperative (A) and postoperative (B) views. Three weekspostoperatively, this patient shows the ability to smile.




nique is straightforward and dynamic movement can bedemonstrated with intraoperative muscle stimulation, ac-quisition of desired facial movement requires intensivephysiotherapy and a motivated patient.

Accepted for Publication: February 22, 2010.Correspondence: Patrick J. Byrne, MD, Division of Fa-cial Plastic and Reconstructive Surgery, Department ofOtolaryngology–Head and Neck Surgery, The Johns Hop-kins University School of Medicine, 601 N Caroline St,Sixth Floor, Baltimore, MD 21287-0910.Author Contributions: Study concept and design: Boa-hene, Farrag, and Byrne. Acquisition of data: Boahene, Far-rag, and Byrne. Analysis and interpretation of data: Boa-hene, Farrag, Ishii, and Byrne. Drafting of the manuscript:Boahene, Farrag, and Byrne. Critical revision of the manu-script for important intellectual content: Boahene, Farrag,Ishii, and Byrne. Statistical analysis: Farrag and Ishii. Ad-ministrative, technical, and material support: Boahene andFarrag. Study supervision: Boahene and Byrne.Financial Disclosure: None reported.Online-Only Material: A video is available at http://www.archfacial.com.

REFERENCES

1. Rubin LR, ed. Reanimation of the Paralyzed Face. St Louis, MO: CV Mosby; 1977.2. Baker DC, Conley J. Regional muscle transposition for rehabilitation of the para-

lyzed face. Clin Plast Surg. 1979;6(3):317-331.3. McLaughlin CR. Permanent facial paralysis: the role of surgical support. Lancet.

1952;2(6736):647-651.4. Labbe D. Lengthening of temporalis myoplasty and reanimation of lips: techni-

cal notes [in French]. Ann Chir Plast Esthet. 1997;42:44-47.5. Croxson GR, Quinn MJ, Coulson SE. Temporalis muscle transfer for facial pa-

ralysis: a further refinement. Facial Plast Surg. 2000;16(4):351-356.6. Benateau H, Alix T, Labbe D, Elissalde JM, Salame E. Anatomic study of the ten-

dinous insertion lamina of the temporalis muscle. Surg Radiol Anat. 2004;26(4):281-284.

7. Breidahl AF, Morrison WA, Donato RR, Riccio M, Theile DR. A modified surgicaltechnique for temporalis transfer. Br J Plast Surg. 1996;49(1):46-51.

8. Byrne PJ, Kim M, Boahene K, Millar J, Moe K. Temporalis tendon transfer aspart of a comprehensive approach to facial reanimation. Arch Facial Plast Surg.2007;9(4):234-241.

9. Sherris DA. Refinement in reanimation of the lower face. Arch Facial Plast Surg.2004;6(1):49-53.

10. Lambert-Prou MP. The Temporal Smile: speech therapy for facial palsy patientsafter temporal lengthening myoplasty [in French]. Rev Stomatol Chir Maxillofac.2003;104(5):274-280.

11. Coulson SE, Adams RD, O’Dwyer NJ, Croxson GR. Physiotherapy rehabilitationof the smile after long-term facial nerve palsy using video self-modeling and imple-mentation intentions. Otolaryngol Head Neck Surg. 2006;134(1):48-55.

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