Keywords
orthodromic transfer - eye closure - symmetry of mouth at repose - elevation of angle
of mouth
Introduction
The goal of facial reanimation is to restore symmetry in repose, and on animation
as much as possible. Reinnervation techniques are not possible in delayed cases, and
where proximal nerve end is not available. Hence, free functioning muscle transfer
(FFMT) becomes the ideal option, with a multistage cross-facial innervation. The delay
and multistage procedures are not acceptable to many and are also not feasible in
Hansen's.
The temporalis transfer has the advantages of providing symmetry at rest and controlled
movement of the angle of the mouth, with immediate results, and is especially good
for lagophthalmos where delay may cause loss of vision. Lateral tarsorrhaphy is a
temporary procedure with suboptimal aesthetic results. Of the static procedures available,
lid springs have unacceptable complications. Lid loading with gold weights have a
high extrusion rate.
Case Report
Transfer for Lagophthalmos
An incision is made just above the root of the helix curving upward and backward to
expose temporalis muscle. Posterior one-inch strip of temporalis muscle that is in
alignment with the horizontal axis of the eye is isolated, and the insertion is divided
just above the zygomatic arch ([Fig. 1]). The muscle is dissected upward for an inch. Fascia lata graft of ∼5–6 mm breadth
and 15 cm length is harvested, split into two except at one end. A 4–0 nylon suture
is used to transfix the undivided end. The nylon thread helps to position the two
slings of fascia as shown under the exposed canthal ligament ([Fig. 2]). Fascia is sutured to the medial canthal ligament. The fascial slings are tunneled
from medial to lateral under the skin of both eyelids close to the lid margins and
brought out through an incision made lateral to the orbit ([Fig. 3]). The sling is then tunneled to the temporal wound and fixed to the muscle at a
tension, removing all slackness and both lids opposing each other ([Fig. 4]).
Fig. 1 Posterior strip of muscle disinserted and attached to the medial canthus gives a
straight line of pull.
Fig. 2 Suture threads tunneled under medial canthus help pull the fascia lata graft in place.
Fig. 3 Distal end of graft transfixed to medial canthus. The tails are tunneled under the
skin of the eyelids close to the lid margins.
Fig. 4 The fascia lata grafts are fixed in a retrograde fashion to the temporalis tendon
with adequate tension just enough to close the eye.
Transfers for Face
The ideal vector of pull needed is upward and backward and hence mid portion of temporalis
muscle is chosen. Preoperatively, the patient is asked to say E and the horizontal,
vertical, and oblique movements needed are assessed ([Fig. 5]). For the face, a two-finger breadth of mid part of temporalis muscle is isolated,
divided, and dissected as before. A broad long strip of fascia lata is divided into
four strips with one end undivided. An incision is made in nasolabial groove, just
outside the angle, over the philtral column, midline of lower lip at labio-mental
groove and junction of ala with face. Fascial slings are tunneled from nasolabial
area to these sites and broader undivided end tunneled proximally to temporal area.
The fascial sling to the lower lip is sutured first across the midline into muscle;
then pulling at the undivided end and maintaining same tension, other slings are sutured
to angle, and upper lip, using 4–0 nylon and the incisions closed. Temporalis tendon
is pulled to remove slack from the muscle. A slit is made on the tendon and proximal
end of the graft pulled out through it. The undivided proximal fascia strip is pulled
upward and outward along the preoperatively measured vector and dimensions. It is
now sutured to the temporalis tendon using 3–0 nylon ([Video 1]).
Fig. 5 Preoperatively, the patient is asked to say E and the horizontal, vertical, and oblique
movements needed are assessed. The horizontal movement needed will be the difference
in distance between the medially displaced angle of the mouth and the mid-pupillary
line. The vertical movement needed is the difference in height between the deviated
angles of the mouth on the normal side from that on the affected side.
Video 1 Strips of fascia lata are first fixed to the lips and angle of mouth. They are then
pulled to preoperatively measured vertical and horizontal dimensions. Temporalis tendon
is stretched enough to remove slack and fascia lata strips are sutured at the determined
level.
A rough estimate of the muscle excursion was judged on the table. Performing the procedure under local anesthesia, an intramuscular
needle was inserted into the cut end of the chosen strip of muscle. The patient was
asked to bite and the movement of the needle was measured, which was found to be around
1 cm. After fixing the slings at the medial canthus and tunneling them to the temporal
wound, the amount of pull on the sling needed to bring eyelids together was measured.
It was also found to be around 1 cm. This helped in understanding the success of the
procedure.
Rehabilitation protocol: For the eye, looking at the mirror patient attempts eye closure, then bites, which
causes gentle complete eye closure. He then releases the bite and opens the eye. Over
time, with neural adaptation, he can close his affected eye along with the normal
one without biting. For the commissure, he first attempts to elevate angle of mouth
on the affected site, then bites, which causes elevation of angle of mouth followed
by releasing the bite and regaining resting position. Over time, he fine tunes the
strength of the bite and is able to elevate the angle by contracting temporalis muscle
imperceptibly. Anatomically, the fascia grafts from the eyelids are tunneled at different
planes as that to the mid and lower face where the two come close to each other at
the temporal area. Over time, with neuro adaptation the two movements get isolated.
This modified transfer performed by the senior author (S. K.) on 15 patients has given
comparable results.
Preoperative ([Video 2]) and postoperative videos ([Video 3]) clearly demonstrate the success of the procedure. Reducing the tension in the upper
eyelid sling corrects the narrowing of the aperture that is seen in [Video 3].
Video 2 Preoperative video showing the asymmetry of the angle of the mouth when the patient
says E. Lagophthalmos on gentle closing of the eyes, which gets obliterated only on
tight closure of the eyes, is demonstrated. Drooping of the paralyzed side angle of
the mouth on repose can be observed.
Video 3 Postoperative video of the patient. Temporalis transfer to the right side of the
face has been performed. Good symmetry of the face and angle of the mouth at repose
are seen. Adequate gentle excursion of the paralyzed side angle of the mouth on attempted
smile is demonstrated. Isolated gentle, smooth eye closure has been achieved with
practice.
Discussion
Sir Harold Gillies published his technique of temporalis transfer in the Proceedings of Royal Society of Medicine around the year 1930.[1] A fascia lata sling is looped as a double loop from the angle of the mouth encircling
the upper and lower lips on the paralyzed side, getting a purchase from the nonparalyzed
side. Temporalis muscle is turned down. Fascia lata is attached to the turned down
raw area of the muscle and attached to previously prepared fascial sling encircling
the lips. The tension is adjusted to give a straight mouth and nose at rest and a
simulation of expression when the muscle is contracted. Sir Gillies turned down a
flap of muscle further forward and split the deep temporal fascia into two slips,
tunneled them to meet each other at the medial canthus, and attached them to the periosteum.
When the muscle contracts, the eyelids were squeezed close.
Later on, as a modification, the temporal fascia was extended with the attached pericranium
and split into many tails.
Several modifications of the procedure are in vogue.[2] McLaughlin[3] in 1952 attached temporalis muscle tendon to the lips with fascial grafts after
detaching at the coronoid process. Labbé[4] in 1997 in addition performed an osteotomy of the zygomatic arch, and repositioned/lengthened
the temporalis by detaching the posterior third of the muscle resulting in a “temporalis
slide.”
Breidahl et al[5] divided the zygomatic arch and cut the temporalis tendon just before its insertion.
The advantages of our technique include: (1) easy to fix to canthus as it is in lax
position (suturing under tension is difficult, may over- or under-correct, and readjustment
will damage the canthal ligament); (2) retrograde tension adjustment can be revised
as many times as required; (3) no bulge over the zygomatic area; (4) no hollowness
in the temporal fossa; and (5) direction of muscle fiber is in the line of pull.
The limitation of the modification in our experience is that there is a learning curve
to get the tension adjustment right. We are yet to publish a case series to substantiate
our results. We have not done any comparative study with other techniques for lagophthalmos
Excursion of the angle of the mouth following temporalis tendon transfer and gracilis
free muscle transfer have been compared by Oyer et al.[6] Commissure symmetry during smile improved significantly for the temporalis transfer
patients in the vertical and angular dimensions, while the gracilis FFMT group had
significant improvement in the vertical and horizontal dimensions. Commissure excursion
significantly improved in both groups following surgery, with a larger improvement
seen in the gracilis FFMT group.
Ahn et al[7] suggest steps to correct the resultant ptosis—the fascia sling in the upper lid
could be terminated just short of medial canthus to reduce tension and weight. Lid
loading to correct lagophthalmos[8] has resulted with a 25% need for removal due to complications. The advantage is
ability to close eyes without conscious effort. The technique was developed in a leprosy
center and patients here could not afford gold weights.
Conclusion
Refinements to the technique of temporalis transfer as described by us for correction
of lagophthalmos results in smooth eye closure with adequate tendon excursion. Further
fine tuning of the technique to minimize the resultant mild ptosis is being explored.
Reanimation of nose and lips as addressed by us is simple and easy to perform.
