Temporalis muscle Transfers

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local muscle transfer

Local muscle transfers can be utilized to support the corner of the mouth and to re-establish some degree of active smiling. They are indicated for treating individuals whose facial paralysis is associated with damage or irreversible atrophy of the facial muscles. Segments of the chewing muscles on the side of the facial nerve paralysis can be rerouted and attached to the corner of the mouth. 


Clenching ones teeth together activates these muscle segments elevating the corner of the mouth. The procedure works because the innervation to the chewing muscles is different from the muscles of facial expression. 

temporalis muscle

temporalis illustration

temporalis transfer

temporalis illustration

 

The temporalis muscle is often chosen because its vector or angle of pull produces an upwardly oriented smile. The masseter muscle transfer creates a more horizontal movement at the corner of the mouth. Utilizing the temporalis and masseter transfers in combination has the potential to produce a multidirectional smile.

Muscle transfer procedures are often reserved for individuals whose age, general medical condition or previous surgeries prohibit more complex microsurgical procedures.  These procedures can also be utilized to augment facial motion in individuals who have made a partial recovery after facial nerve paralysis.

There are three principle ways of transferring the temporalis muscle:

  • Segmental muscle turn-over
  • Orthodromic muscle flap with fascia lata graft.
  • Lengthening myoplasty

The exact technique selected is guided by a complex series of variables including the degree of facial weakness.

Technique
Segmental muscle turn-over
The temporalis muscle transfer is performed through a face lift style incision that is created in front of the ear and extends into the temple. The central segment of the temporalis muscle is released on three sides leaving its base attached. 

The dense leathery tissue encasing the muscle (fascia) is unfurled to extend its reach. The temporalis muscle segment is then tunneled beneath the skin of the cheek and secured to the upper lip. The temporal void created by borrowing the muscle segment can be filled by rearranging local tissues or utilizing a number of biological or synthetic implants.

Orthodromic Temporalis Muscle Flap with Fascia Lata Graft

An incision is created in the hair bearing region of the temple and extended for a limited distance in front of the ear.  The tendinous portion of the temporalis muscle is now freed from its attachment to the jaw.  A graft of leathery tissue (fascia lata) obtained from the thigh is utilized to bridge the free end of the muscle to the lips and corner of the mouth.  When the teeth are clenched the fascial graft transfers the force of the temporalis muscle to the corner of the mouth creating a voluntary smile.  With diligent practice motivated individuals can develop a smile that is reflexive and biting is no longer required.


Lengthening Temporalis Myoplasty
A scalp incision is created in a zig-zag fashion similar to a cosmetic brow lift.   The temporalis muscle is mobilized from its attachments to the underlying cranial bone and its tendious insertion onto the jaw is released.  Intermittently, the cheek bone (zygomatic arch) may be temporarily released to facilitate the procedure and is restored to its native position at the completion of the surgery.  A limited incision is now created in the natural fold that extends from the base of the nose to the corner of the mouth (nasolabial fold).

Through this aperture the mobilized temporalis flap can be sutured to the corner of the mouth.  The proximal muscle is re-anchored in the scalp region.  With clenching of the teeth the force of the muscle is re-directed to the corner of the mouth creating a voluntary smile.  Again, with diligent practice many individuals through the process of neural plasticity with learn to create a smile that is independent of jaw clenching.

local muscle image 2

Before

local muscle transfer image 1

After

local muscle image 4

Before

local muscle image 3

After

local muscle image 6

Before

local muscle image 5

After

Recovery

The period of hospitalization with the temporalis-masseter muscle transfer typically ranges from 24 to 72 hours.  Patients are required to eat a soft diet for 4 weeks after surgery and avoid pressure on the operated side of the face.  Exercise and heavy lifting are also limited.

The corner of the mouth is intentionally over suspended at the time of surgery. The operated side of the face gradually relaxes and better symmetry is usually present by the third postoperative week. A physical therapy program is started early in the post operative period. 
  
Practice is essential to achieving a natural efficient smile.  Over time, highly motivated individuals may even learn to smile without biting down. 

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