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Contiguous Temporalis and Masseter Muscle Transfer for Reanimation of the Smile in Facial Paralysis
Roger L. Simpson, MD, MBA, Jonathon Landon, MD, Janet Misuraca, R.N..
Long Island Plastic Surgical Group, Garden City, NY, USA.
PURPOSE: Reanimation of the paralyzed face using contiguous muscle transfer is a reproducible procedure with predictable long-standing dynamic results.
The medical records and photographs of 305 patients undergoing dynamic contiguous muscle facial reanimation (complete and partial) between 1957 and 2011 were reviewed. Only patients with complete medical data, surgical reports, pre-and postoperative photographs, and follow-up information were entered into a database, eliminating 93 patients. Fifty-nine patients underwent local shortening of the ipsilateral levator superioris labii and the zygomaticus major muscles. One hundred fifty-three patients underwent contiguous Temporalis muscle or Temporalis and Masseter muscle transfers. Length of follow-up ranged from 1 year to 40 years following the reanimation procedure. The cohort consisted of 69% females and 31% male. The median age at surgery was 46.3 years. The etiology of the paralysis was acoustic neuroma in 47%, Bell's palsy and viral origin in 24%, tumor involving the facial nerve in 19%, trauma 5%, and congenital 5%.
An objective assessment of the post surgical reanimation was based on either clinical pre and post operative examination or photographic review. The reconstructed dynamic smile was divided into 5 categories including symmetry of maxillary teeth show, excursion and balance of the commissure, symmetry of the nasal labial fold, relaxation of the upper lip at rest, and depression of the lower lip. Grades of excellent, good, fair, or poor were assigned on total points, formulating the final smile grade.
Of the 153 patients undergoing contiguous muscle transfer, 124 underwent reanimation using both Temporalis and Masseter muscles, 29 underwent transfer of the Temporalis only. Criteria for exclusion of the Masseter transfer included congenital paralysis (partial residual lower lip function) and partial facial paralysis where fibrosis of the recovered lower lip musculature provided a restraint to the strong upward Temporalis pull. Overall assessment of the reconstructed dynamic smiles based on the above criteria was 57% excellent, 24% good, 14% fair, and 5% poor.
Secondary shortening of the Temporalis transfer for improved balance was required in 34 patients (22%). Loss of downward pull of the Masseter transfer was noted to be significant in 8%, all patients then undergoing a V type resection of the lateral lower lip medial to the commissure. Botox was used in the normal side of the lower lip in 16 patients (13%) to improve symmetry.
CONCLUSION: Contiguous muscle transfer using an individualized combination of ipsilateral Temporalis and Masseter muscles is a reliable and reproducible method of long-lasting dynamic reanimation in facial paralysis. Rapid onset of motion of the muscle transfers begins at 3 days. Secondary revision rate is acceptably low. A high degree of patient satisfaction is present.
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