Tendon Transfer Shows Promise in Correcting Facial Paralysis

BALTIMORE, July 16 -- Temporalis tendon transfer offers a safe, effective, and simple reconstructive procedure when reinnervation of facial muscles is not an option, Johns Hopkins surgeons said.

Seven consecutive patients treated with the technique rated their satisfaction with the surgical outcome as 8.5 on a scale of 10, according to a report in Archives of Facial and Plastic Surgery.

Every patient had postsurgical movement, which averaged 4.2 mm at the oral commissure, reported Patrick Byrne, M.D., and colleagues. The only notable complication was a case of postoperative salivary fluid collection that required drainage.

"This technique results in improved form and function, may often be performed in a minimally invasive manner, and eliminates the facial asymmetry typically produced by temporalis transfer," the investigators concluded.

The best results occur when the procedure is performed in conjunction with intensive physical therapy, they added.

Options for facial reanimation vary according to the duration and cause of facial paralysis. Most authorities agree that reinnervation of native facial musculature leads to the best possible results, the authors said, but reinnervation is not always possible. Moreover, it becomes ineffective after motor end plate fibrosis and muscle atrophy occur.

Dynamic muscle transfer offers an excellent option for facial reanimation when reinnervation is not possible, the authors stated. The principal technique is temporalis muscle transfer. However, the classic technique often leaves telltale signs of surgery, particularly facial asymmetry.

In the procedure described in the study, both the temporalis muscle and tendon are used. The tendon is spread horizontally for 3 to 4 cm and sutured to the perioral musculature and some deep dermis. The end result is orthodromic transfer of the insertion of the muscle as opposed to transfer of the origin of the muscle over the arch.

"We believe that this technique is measurably improved by performing the transfer in an orthodromic manner," Dr. Byrne and colleagues wrote. "Temporalis tendon transfer provides for improved function and elimination of the telltale signs . . . produced by the classic technique."

The reinsertion site for the temporalis tendon was determined on the basis of the dominant musculature in a patient's smile: more horizontal zygomaticus major versus more vertical levator labii superioris alaeque nasi.

Before surgery patients underwent comprehensive physical therapy that focused on helping each patient understand how to coordinate individual muscle contraction to produce facial expressions, particularly the smile. The physical therapy resumed after removal of sutures, usually about seven days after surgery.

A minimum of four months after surgery, each patient completed a questionnaire to assess satisfaction with the results. The patients' ratings averaged 8.4 for appearance, 8.1 for feeding, 8.7 for speech, and 7.1 for smile function.

Specialists in otolaryngology-head and neck surgery evaluated surgical outcomes on the basis of photographs of the patients. The physicians rated overall outcome as excellent to superb for four patients and good for the other three.

Dr. Byrne and colleagues emphasized that physical therapy for "facial retraining is essential to optimize results in most patients undergoing facial reanimation. Although the benefit of facial retraining is not proven, several studies have suggested a positive effect on outcomes."