Endoscopic Approach for Lengthening the Temporalis Muscle

Transcription

1 Ideas and Innovations Endoscopic Approach for Lengthening the Temporalis Muscle Rubén Contreras-García, M.D., Pedro D. Martins, M.D., and Jefferson Braga-Silva, M.D., Ph.D. Porto Alegre, Brazil The temporalis muscle has been used for the treatment of facial paralysis since 1934, when Gillies described the rotation of the temporalis muscle over the zygomatic arch with the use of a sling of fascia lata to reach the nasolabial fold. 1,2 In 1949, McLaughlin described temporalis rotation with coronoid process section with the use of the fascia lata to reach the nasolabial crease. 1,2 In 1997, Labbé, 3,4 inspired by McLaughlin s technique, proposed temporalis lengthening without the fascia lata, with partial release of the temporalis line of fusion and transfer of its tendon from the coronoid process to the nasolabial crease. This procedure required an open approach by coronal and nasolabial crease incisions and osteotomy of the zygomatic arch. The objective of this report is to describe an endoscopic approach for lengthening of the temporalis muscle without zygomatic fracture. METHODS Endoscopic rotation and lengthening of the temporalis muscle was performed in 10 fresh cadavers to develop and improve technical skills. Two patients with total unilateral facial paralysis (House-Brackmann grade VI 5 ) were operated on. Both patients had had facial palsy for more than 2 years; one was an 18-year-old man who had had three previous surgeries for left cholesteatoma, and the other was a 36-yearold woman who had had resection of a right facial nerve schwannoma. Surgical Technique Using a 4-mm, 30-degree-angled scope, three incisions were made: oblique temporal, 4 cm from the hairline; paramedian frontal, 4 cm behind the hairline; and 6 cm in the superior gingivobuccal sulcus, extending distally from the first premolar. Part of the technique for endoforehead lifts 6 8 was followed. Dissection began with endoscopic visualization of the temporal area (zone 1) (Fig. 1) beneath the superficial temporal fascia, with sacrifice of the sentinel vessel. 9 Zones 2 and 3 could be dissected without the endoscope in the subperiosteal plane. At this point, an endoforehead lift can be performed if needed. The inner wall of the zygomatic arch was dissected using an elevator. It is necessary to feel the elevator against the bone throughout the dissection of the arch (Fig. 1). With the aid of the endoscope, the muscle was freed from the bone. Dissection continued to the area where the anteroposterior deep temporal nerves emerged. The optical cavity decreased in the posterior aspect of the temporal fossa, making visualization difficult. However, it was critical to free up the muscle here to allow inferior advancement (Fig. 2). The muscle was cut from its origin with endoscopic aid, leaving a 2-cm-long muscle-aponeurotic strip parallel to the temporalis line of fusion. Once the temporalis muscle was liberated from its cephalic origin, dissection of the coronoid process was performed through a superior gingivobuccal sulcus approach. The masseter muscle was held laterally with an Aufricht retractor. Bichat s fat pad may also be retracted. The coronoid process was palpated while moving the mandible and was fractured with the tendon still attached to the bone. The From the Department of Plastic and Reconstructive Surgery, Hospital São Lucas, Pontificia Universidade Católica do Rio Grande do Sul. Received for publication December 21, 2001; revised March 25, Presented at the XXXVIII Congresso Brasileiro de Cirurgia Plástica, in São Paulo, Brazil, on November 15, DOI: /01.PRS

2 Vol. 112, No. 1 / TEMPORALIS MYOPLASTY 193 tendon was then advanced to the nasolabial crease (Fig. 3). The position of fixation of the temporalis tendon to the nasolabial crease depends on the position and shape of the patient s smile (Rubin classification 1 ). All cadaver dissections had the tendon attached to the distal insertions of the zygomaticus major and minor muscles. A subcutaneous tunnel through the endo-oral approach was made to insert the tendon at the desired level and was secured two or three times with 2-0 nylon, without removing the coronoid process (Fig. 4). Once it was fixed at the nasolabial fold, the muscle was stretched and sutured (anteroposteriorly) to the aponeurotic strip left on the temporalis line of fusion. This fixation progressively gave tension to the muscle, elevating the corner of the mouth, and was continued until the gum above the canine incisor could be seen. Measurements were performed before and after the muscle was stretched (Fig. 5). No contralateral myotomies were performed. Closed suction drains at the temporal area were placed, and standard dressings were used. Physiotherapy was started on the seventh postoperative day. The patients could eat a regular diet after 2 weeks. FIG. 1. Diagram of the incisions. In zone I, dissection proceeded over the deep temporal fascia toward the zygomatic arch. In zones II and III, subperiosteal dissections were performed. The inner wall of the zygomatic arch was dissected using an elevator. RESULTS In both cadavers and live patients the objectives were accomplished: the temporalis myoplasty was lengthened by endoscopic approach without zygomatic fracture. Intraoperative and postoperative measurements were performed. In the cadavers, a mean lengthening of 4.7 cm was achieved after rotation and complete release. After reattachment of the temporalis muscle to the anterior two thirds of the temporal line, a mean lengthening of 3 cm was achieved. In our two patients, a mean lengthening of 4.0 cm was achieved after rotation and complete release. After reattachment of the temporalis muscle to the anterior two thirds of the temporal line, a mean lengthening of 2.7 cm was achieved. The differences between the groups could have been due to muscle tone. With regard to mobility, movement was observed 24 hours after surgery. Both patients had House-Brackmann grade VI facial paralysis. 5 Currently, the 18-year-old man has mild facial paralysis (House-Brackmann grade III) (Fig. 6), and the 36-year-old woman has moderate facial paralysis (House-Brackmann grade IV) (Fig. 7). 5 The patients had few problems with postoperative analgesia, but they had moderate facial swelling for up to 3 weeks. No depressed donor-site defect was detected. Movement of the myoplasty while eating and chewing were noted, but with physiotherapy involving mirror exercises the patients learned to control these movements and reduce their amplitude. To smile, the patients needed to close the mandible firmly, a maneuver that was learned without difficulty. DISCUSSION Currently, the endoscope is widely used in several surgical specialties. Adant 10 in 1998 and Wong et al. 11 in 1999 described the use of the endoscope for the static suspension of the paralyzed face. This report presents its use in the dynamic treatment of facial paralysis. The use of the endoscope for dissection of the temporal area has been described for endo face lifts by many researchers. Use of the endoscope in the treatment of condylar fractures has also been described This technique describes temporalis muscle release and lengthening with endoscopic aid. The endo-

3 194 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2003 FIG. 2.(Above, left) An incision was made in the deep temporal fascia, and the muscle was released to create an optical cavity to dissect the muscle from the bone. (Below, left) Dissection reached the deep temporal pedicles. (Right) Endoscopic views of the temporal bone (T), the deep temporal vessels (DTV), and the nerves (DTN). FIG. 3.(Left) Coronoid process fracture. (Right) Endoscopic view of the coronoid process (CP), Bichat s fat pad (BFP), masseter muscle (MM), and the buccinator muscle (BM).

4 Vol. 112, No. 1 / TEMPORALIS MYOPLASTY 195 FIG. 4. Fixation of the temporalis tendon to the nasolabial crease. FIG. 5. Measurement of the lengthening to be performed. scope allows magnified visualization of the nerve and vessels, making the procedure safer. It allows the surgeon to maintain the integrity of the structures and planes. The 4-mm endoscope allows dissection in the temporal fossa to the emergence of the pedicles. This eliminates the need for the zygomatic arch fracture described in the original technique 3,4 and its associated morbidity, probably reducing pain, cost, and hos-

5 196 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2003 FIG. 6. Preoperative (above) and postoperative (below) photographs of an 18-year-old male patient 3 weeks after the procedure. pital stay. The endo-oral approach permits the coronoid fracture and temporalis tendon fixation to the nasolabial crease, avoiding external incisions. We found it unnecessary to remove the coronoid process; its presence did not create a problem, its removal is timeconsuming, and its preservation may be useful for radiographic control. The use of the temporal muscle in facial paralysis is a good alternative to restore facial tone, symmetry, and movement, and it does not interfere with neural integrity. Use of the temporal muscle has been described for early cases of total facial paralysis in which the facial nerve is intact but recovery is estimated to exceed 1 year, or when recovery will not be complete. 15 The method described here seems to be a good alternative for these patients, mainly because it has low morbidity, less pain, fast recovery, and no donor-site defect. With systematic training in endoscopic procedures, it is possible to accomplish this surgery in less time than with the open approach

6 Vol. 112, No. 1 / TEMPORALIS MYOPLASTY 197 FIG. 7. Preoperative (above) and postoperative (below) photographs of a 36-year-old female patient 3 weeks after the procedure. because of the time it saves in osteotomies and osteosynthesis. The endoscope can also be used to suspend the forehead, eyebrow, lateral canthus, and cheek as necessary, and to restore symmetry to the upper half of the face. All of the steps may be performed through small, hidden incisions. Further research is necessary to compare open versus endoscopic temporalis lengthening in terms of morbidity, patient satisfaction, and cost-effectiveness. SUMMARY This report described a new surgical procedure of temporalis myoplasty for the treatment of facial paralysis, based on Labbé s technique. The new method consists of muscle rotation and lengthening, partial release of the muscle at the temporal line of fusion, and endoscopic transfer of the muscle tendon attached to the coronoid process to the corner of the mouth. With this approach, osteotomy of the zygo-

7 198 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2003 matic arch is unnecessary. Ten cadaver dissections were performed to develop surgical skills and measure progression of the technique. Results in two patients were reported. The technique requires familiarity with the endoscope, and it permits excellent visualization of the neurovascular structures. This approach seems to be less painful and less likely to result in neurovascular injury, and it can be performed through smaller incisions Rubén Contreras-García, M.D. Serviço de Cirurgia Plástica Hospital São Lucas - PUCRS Av. Ipiranga 6690, Porto Alegre, R.S., Brazil rubecong@hotmail.com REFERENCES 1. Baker, D. Paralisis facial. In J. McCarthy (Ed.), Cirugía Plástica, La Cara II. Buenos Aires: Edit. Méd. Panamericana, Pp Baker, D. Reconstruction of the face. In Grabb and Smith s Plastic Surgery, 5th Ed. Philadelphia: Lippincott- Raven, Pp Labbé, D. Myoplastie d allongement du temporal et réanimation des lèvres: Note technique. Ann. Chir. Plast. Esthét. 42: 44, Labbé, D., and Huault, M. Lengthening temporalis myoplasty and lip reanimation. Plast. Reconstr. Surg. 105: 1289, House, J. W., and Brackmann, D. E. Facial nerve grading system. Otolaryngol. Head Neck Surg. 93: 146, Ramirez, O. M. Endoscopic subperiosteal brow lift and facelift. Clin. Plast. Surg. 22: 639, Ramirez, O. M. Endoscopic forehead and face-lift: Step by step. Oper. Tech. Plast. Reconstr. Surg. 2: 129, Ramirez, O. M. Subperiosteal endoscopic techniques. In B. Guyuron (Ed.), Facial Rejuvenation in Plastic Surgery: Indications, Operations, and Outcomes, Vol. 5. St. Louis: Mosby, Pp Moss, C. J., Mendelson, B. C., and Taylor, G. I. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast. Reconstr. Surg. 105: 1475, Adant, J. P. Endoscopically assisted suspension in facial palsy. Plast. Reconstr. Surg. 102: 178, Wong, G. B., Stokes, R. B., Stevenson T. R., et al. Endoscopically assisted facial suspension for treatment of facial palsy. Plast. Reconstr. Surg. 103: 970, Sandler, N. A., Andreasen, K. H., and Johns, F. R. The use of endoscopy in the management of subcondylar fractures of the mandible: A cadaver study. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 88: 529, Lauer, G., and Schmelzeisen, R. Endoscope-assisted fixation of mandibular condylar process fractures. J. Oral Maxillofac. Surg. 57: 36, Chen, C. T., Lai, J. P., Tung, T. C., and Chen, Y. R. Endoscopically assisted mandibular subcondylar fracture repair. Plast. Reconstr. Surg. 103: 60, Cheney, M. L., McKenna, M. J., Megerian, C. A., and Ojemann, R. G. Early temporalis muscle transposition for the management of facial paralysis. Laryngoscope 105: 993, 1995.