Dynamic Facial Reanimation With Orthodromic Temporalis Tendon Transfer in Children

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1 Research Case Report/Case Series Dynamic Facial Reanimation With Orthodromic Temporalis Tendon Transfer in Children Rajanya S. Petersson, MD; Daniel E. Sampson, MD; James D. Sidman, MD IMPORTNCE To our knowledge, orthodromic temporalis tendon transfer (OTTT) for dynamic facial reanimation has not been described for use in children. OBSERVTIONS Three pediatric patients with permanent facial paralysis underwent OTTT using our modified technique between ugust 30, 2010, and January 23, Outcomes were assessed by the surgeons, patients, and patient families, with the longest follow-up period being 13 months after surgery. Two patients were 4 years old at the time of surgery, and the third patient was 17 years old. ll underwent upper eyelid gold weight placement and OTTT. The hospital length of stay was 1 to 2 nights. By the first postoperative visit, all patients exhibited improved symmetry at rest, creation of a melolabial crease, and voluntary movement of the oral commissure and smile production without physical therapy. CONCLUSIONS ND RELEVNCE The OTTT for dynamic facial reanimation in children seems to be safe and effective. To our knowledge, this is the first report of the use of this procedure in pediatric patients. This procedure has an advantage over free muscle transfer procedures in achieving immediate dynamic reanimation in a single-stage surgical procedure, without significant additional donor site morbidity. This is an important procedure in our armamentarium for treating pediatric facial paralysis. LEVEL OF EVIDENCE 4. JM Facial Plast Surg. 2014;16(6): doi: /jamafacial Published online September 25, Video and uthor udio Interview at jamafacialplasticsurgery.com uthor ffiliations: Department of Surgery, Virginia Commonwealth University, Richmond (Petersson); currently in private practice in St nthony, Minnesota (Sampson); Children s ENT and Facial Plastic Surgery, Children s Hospitals and Clinics of Minnesota, Minneapolis (Sidman); Department of Surgery, University of Minnesota, Minneapolis (Sidman). Corresponding uthor: Rajanya S. Petersson, MD, Department of Surgery, Virginia Commonwealth University, 1200 E Broad St, 12th Floor, Ste 313, PO Box , Richmond, V Facial nerve paralysis in the pediatric population is fraught with challenges for patients, their families, and the reconstructive surgeons. The inability to smile is a noticeable deficit in the paralyzed face. These patients can also be affected functionally in regard to oral competence and speech. The goal of facial reanimation procedures is to restore normal facial function in an aesthetically pleasing manner. No ideal procedure accomplishes this goal, especially if it is impossible to reestablish neural input to the facial musculature. If primary nerve repair, nerve grafting, and nerve transfer are not possible, 2 options exist for dynamic facial reanimation of the lower face, namely, free tissue transfer (most commonly with gracilis muscle) and orthodromic temporalis tendon transfer (OTTT). Interest has grown in the orthodromic transfer of the temporalis tendon to the oral commissure, and it has been well described in the literature for its use in adults, with excellent immediate results that persist in the long term. 1-3 Free gracilis transfer has been described for use in the pediatric population, with acceptable success rates and improved quality of life. 4-6 However, it may take several months to a year before results are noted, and it often requires a 2-stage procedure, with the first stage involving cross-facial nerve grafting. Even if performed in one stage using branches of cranial nerve 5, dynamic results are not immediate. In addition, free muscle transfer requires the availability of a microvascular surgeon, is associated with a longer hospital length of stay, and carries a higher risk of complications. To our knowledge, the OTTT has not been previously described in children. Herein, we present our modifications and application of the procedure in 3 pediatric patients. Methods Study Design Because this was a retrospective medical record review, no institutional review board approval was necessary. Three pediatric patients with facial paralysis underwent OTTT and upper eyelid gold weight placement between ugust 30, 2010, and January 23, Follow-up periods ranged from 9 to 13 months after surgery. Preoperative and postoperative photographs and video were obtained to allow for comparison in this case series. Results are descriptively summarized. No perioperative or postoperative complications were encountered in all 3 patients. 432 JM Facial Plastic Surgery November/December 2014 Volume 16, Number 6 jamafacialplasticsurgery.com

2 Case Report/Case Series Research Figure 1. Surgical Technique Lip incision markings Intraoral incision Exposure of ramus and coronoid process Tunnel connecting upper lip incision with intraoral incision B C D Osteotomy performed with reciprocating saw ttaching fascia lata graft to temporalis tendon Tunnel connecting upper and lower lip incisions Fascia lata passed through tunnel to upper lip incision E F G H Dividing fascia lata Testing with Peña muscle stimulator (EM901; BGE Médica) Incisions closed I J K Surgical Technique The procedure described below is a modification of that originally reported in 2007 by Byrne et al 1 and in 2011 by Boahene et al. 2 Modifications to the original description of the procedure include an intraoral incision to access the temporalis tendon, a fascia lata extension graft between the temporalis tendon and the area of the modiolus, and small external skin incisions near the oral commissure for suturing the graft to the orbicularis oris muscle. melolabial crease incision is avoided because children do not have a well-defined crease, and an incision there would be aesthetically unadvisable. In our experience, the pediatric temporalis muscle has insufficient laxity to allow for tendon transfer without a fascia lata extension graft. strip of fascia lata measuring approximately cm is harvested in the standard manner and set aside. Skin incisions are marked along the upper and lower lateral lips near the oral commissure, each measuring approximately 7.5 mm (Figure 1). Care is taken not to place these incisions right at the vermillion-cutaneous junction or within the light scroll; these are placed at the junction of the light scroll and the cutaneous lip. Incisions are made through skin and subcutaneous tissues. The orbicularis oris muscle is identified. tunnel is started toward the coronoid process using a curved hemostat. ttention is then turned toward the intraoral approach to the coronoid. The ramus is palpated intraorally, and an incision is made directly over it with electrocautery and carried down onto the bone (Figure 1B). Subperiosteal dissection is performed on the lateral and medial aspects of the ramus until the coronoid process and temporalis tendon are identified (Figure 1C). With the temporalis tendon still attached to the coronoid, a 2-0 polypropylene suture is placed through the temporalis tendon in horizontal mattress fashion, just superior to the bone, and the needle is left on with the suture left long, allowing for control of the tendon once the coronoidectomy is performed and the muscle retracts. The tunnel is completed from the upper lip incision to the intraoral incision (Figure 1D). Penrose drain is passed through the tunnel to allow for identification. The sigmoid notch is identified laterally. nerve hook is placed through the notch laterally and then visualized medially, allowing for full visualization of the coronoid process. The inferior extent of the coronoid is marked. The angle of the osteotomy is anterior-inferior to posterior-superior. jamafacialplasticsurgery.com JM Facial Plastic Surgery November/December 2014 Volume 16, Number 6 433

3 Research Case Report/Case Series Figure 2. Case 1 Preoperative smile Smile 4 wk after surgery t rest 3 mo after surgery C E Preoperative teeth clenching Smile with teeth clenching 4 wk after surgery Smile with teeth clenching 3 mo after surgery B D F, Preoperative asymmetry with smiling. B, Preoperative asymmetry with teeth clenching. C, Four weeks after surgery, less asymmetrical smile. D, Four weeks after surgery, good symmetry with teeth-clenching attempt at smiling. E, Three months after surgery, improved symmetry at rest. F, Three months after surgery, improved appearance of smile with teeth clenching. Protecting the soft tissues medially, a reciprocating saw or side-cutting burr is used to perform the osteotomy (Figure 1E). Just before the coronoidectomy is fully completed, a Kocher forceps is placed on the coronoid process. The osteotomy is then completed with the saw, burr, or osteotome. The detached coronoid process can be manipulated with the Kocher forceps to free it from the surrounding soft tissues. The temporalis tendon is then carefully dissected free from the bone, preserving as much of the tendon as possible. The fascia lata extension graft is attached to the temporalis tendon with the previously placed 2-0 polypropylene suture with 2 horizontal mattress sutures (Figure 1F). The suture tails are left long and tagged with a curved hemostat. tunnel joining the 2 lip incisions is created (Figure 1G). The extension graft is then passed through the previous tunnel to the upper lip incision (Figure 1H). The graft is divided in the midline, with a limb for the lower and upper lip incisions (Figure 1I). The graft to the lower lip incision is tunneled through. The temporalis muscle is then stimulated percutaneously using a Peña muscle stimulator (EM901; BGE Médica) to test contraction (Figure 1J and Video 1). This allows us to confirm the correct vector of pull when the temporalis tendon is transferred. The upper lip graft is sutured to the orbicularis oris once the appropriate tension and vector of pull are determined, with some overcorrection. Once sutured appropriately with 4-0 polypropylene in a horizontal mattress fashion, the graft is trimmed of excess length. The lower limb is then similarly secured. The muscle is stimulated again to check the vector of pull. The intraoral and skin incisions are closed (Figure 1K). The patient is admitted for 1 to 2 nights and discharged when oral intake is adequate and pain is well controlled. Report of Cases Case 1 The first patient was a 4-year-old boy with congenital absence of cranial nerves 7 and 8 on the right, as well as absent right cochlea and semicircular canals. Genetics evaluation revealed no unifying diagnosis. He underwent right OTTT as described above, upper eyelid gold weight placement, and boneanchored hearing aid abutment placement. t 3 weeks after surgery, the overcorrection had relaxed to give good symmetry with a suitable melolabial crease, and he had some motion at the right oral commissure. t 2½ months after surgery and after some physical therapy, he had good motion at the right oral commissure with teeth clenching. lthough some asymmetry was still present (the equivalent appearance of a House-Brackmann score of 3 out of 6), it was a great improvement from his preoperative state (House-Brackmann score of 6 out of 6). t his last documented visit at 9 months after surgery, he was noted to have stable motion (Figure 2). Case 2 The second patient was a 4-year-old girl with Möbius syndrome, with paralysis of cranial nerves 6, 7, and 12 on the left and paralysis of cranial nerve 6 on the right. She underwent left OTTT and upper eyelid gold weight placement. One week after surgery, she exhibited some motion at the left oral commissure with teeth clenching. Therapy was then initiated with her speech therapist. t approximately 6 weeks after surgery, she was moving her face almost symmetrically, without requiring much concentration. t her last documented follow-up visit at 13 months after surgery, she had good symmetry and motion at the left oral commissure (equivalent to a House-Brackmann score of 2 out of 6) (Figure 3, Video 1,andVideo 2). 434 JM Facial Plastic Surgery November/December 2014 Volume 16, Number 6 jamafacialplasticsurgery.com

4 Case Report/Case Series Research Figure 3. Case 2 Preoperative at rest t rest 6 wk after surgery t rest 13 mo after surgery C E Preoperative attempt at smiling Smile 6 wk after surgery Smile 13 mo after surgery B D F, Preoperative at rest. B, Preoperative attempt at smiling with no movement of the left oral commissure. C, t rest 6 weeks after surgery, with some overcorrection present on the left. D, Six weeks after surgery, smile with movement of the left oral commissure. E, Thirteen months after surgery, at rest with symmetry. F, Smile at 13 months after surgery. Case 3 The third patient was a 17-year-old girl who had undergone resection of a large left facial nerve schwannoma, which had caused left facial paralysis (House-Brackmann score of 6 out of 6) before resection. t the time of resection, a sural nerve graft was performed, but at 2½ years after surgery she still did not have facial movement. She underwent left OTTT and upper eyelid gold weight placement. One week after surgery, she appeared overcorrected and had some motion. t 2½ months after surgery, she appeared undercorrected but had better motion at the left oral commissure, especially when shown how to clench her teeth. She was instructed to continue biofeedback techniques, watching herself in the mirror when working on creating motion with teeth clenching. t her last postoperative visit at 13 months after surgery, she had some motion at the left oral commissure but still lacked adequate symmetry (equivalent to a House-Brackmann score of 3 out of 6). Nevertheless, she was much improved from the preoperative state and was satisfied with the result (Figure 4). Discussion We believe that a minimally invasive, single-stage procedure can be used to reanimate the paralyzed face in children. In addition, this is the first report, to our knowledge, of the use of OTTT in the pediatric population. This procedure has the potential to provide immediate results in terms of symmetry and dynamic motion of the oral commissure. It has been described in adults that this procedure can be performed without the need for fascia lata extension grafts, enabling performance without additional donor site morbidity. 1,2 However, in our experience with pediatric cases, we found insufficient muscle laxity to perform the tendon transfer without an extension graft. It is possible that the temporalis muscle in adults has greater laxity, allowing it to stretch to the oral commissure. Because of the need to use fascia lata, a donor site incision is required. Fortunately, the incision is small, and the morbidity at this site is minimal. The OTTT has several advantages over free muscle transfer. Most notably, OTTT provides immediate results that are more predictable, with minimal lag time from surgery to actual movement by the patients. Free muscle transfer procedures require a period of reinnervation that needs several months to a year to achieve movement, with less predictablity. 1 The temporalis flap is easily accessed, harvested, and transferred through minimal incisions. Free muscle transfer procedures require a longer preauricular incision and more extensive dissection for flap inset, as well as greater donor site morbidity. The vector of pull for the temporalis muscle when used in this manner is ideal to provide symmetry to the oral commis- jamafacialplasticsurgery.com JM Facial Plastic Surgery November/December 2014 Volume 16, Number 6 435

5 Research Case Report/Case Series Figure 4. Case 3 Preoperative smile B Postoperative smile ture and activity. 2,7 Lambert-Prou 8 describes the approach to acquiring a temporal smile with the assistance of speech therapists. Boahene et al 2 state that directed physical therapy is crucial for achieving optimal results with OTTT. dherence to therapy may be difficult in young children, especially in the presence of cognitive issues or developmental delay. However, it is encouraging that our 2 younger patients seemed to gain movement of the oral commissure with minimal training. Enrollment of our teenage patient in a more intensive therapy program may be helpful. It will be important to continue long-term follow-up care in these patients to determine whether they become proficient in acquiring the temporal smile. sure on the paralyzed side of the face. Free muscle transfer itself can cause facial asymmetry by adding bulk to the face, and it can potentially be oriented incorrectly. 7 In addition, free muscle transfer procedures have potentially high revision rates and the possibility that reinnervation does not occur in some patients. 2 The hospital length of stay and operating time associated with OTTT are significantly less than those for free muscle transfer procedures. To optimize results from either procedure, patients must have the capacity to learn to smile using different muscula- Conclusions The OTTT is a simple, minimally invasive, single-stage procedure that provides immediate dynamic facial reanimation to the lower face with symmetry. s our experience grows, improvements should be seen in terms of symmetry. Long-term follow-up care will be important for assessing crucial elements to achieving success in terms of a spontaneous smile in young children. RTICLE INFORMTION ccepted for Publication: May 28, Published Online: September 25, doi: /jamafacial uthor Contributions: Drs Petersson and Sidman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: ll authors. cquisition, analysis, or interpretation of data: Petersson. Drafting of the manuscript: Petersson, Sidman. Critical revision of the manuscript for important intellectual content: ll authors. Statistical analysis: Petersson. Obtained funding: Petersson. dministrative, technical, or material support: Sidman. Study supervision: Sampson, Sidman. Conflict of Interest Disclosures: None reported. Previous Presentation: This study was presented at the 116th nnual Meeting of the Triological Society at the Combined Otolaryngological Spring Meetings; pril 12, 2013; Orlando, Florida. Correction: This article was corrected on September 29, 2014, to include another citation of Video 1. REFERENCES 1. Byrne PJ, Kim M, Boahene K, Millar J, Moe K. Temporalis tendon transfer as part of a comprehensive approach to facial reanimation. rch Facial Plast Surg. 2007;9(4): Boahene KD, Farrag TY, Ishii L, Byrne PJ. Minimally invasive temporalis tendon transposition. rch Facial Plast Surg. 2011;13(1): Sidle DM, Fishman J. Modification of the orthodromic temporalis tendon transfer technique for reanimation of the paralyzed face. Otolaryngol Head Neck Surg. 2011;145(1): Hadlock T, Malo JS, Cheney ML, Henstrom DK. Free gracilis transfer for smile in children: the Massachusetts Eye and Ear Infirmary experience in excursion and quality-of-life changes. rch Facial Plast Surg. 2011;13(3): Terzis JK, Olivares FS. Long-term outcomes of free muscle transfer for smile restoration in children. Plast Reconstr Surg. 2009;123(2): Bianchi B, Copelli C, Ferrari S, Ferri, Sesenna E. Facial animation in children with Moebius and Moebius-like syndromes. J Pediatr Surg. 2009;44 (11): Bae YC, Zuker RM, Manktelow RT, Wade S. comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve. Plast Reconstr Surg. 2006;117(7): Lambert-Prou MP. The temporal smile: speech therapy for facial palsy patients after temporal lengthening myoplasty [in French]. Rev Stomatol Chir Maxillofac. 2003;104(5): JM Facial Plastic Surgery November/December 2014 Volume 16, Number 6 jamafacialplasticsurgery.com