Keywords
facial palsy - endoscopic - reanimation
Introduction
Inveterate facial palsy can be addressed with different surgical techniques aiming
at rehabilitating one or more facial units. The treatment must be individualized and
cannot be easily standardized since clinical presentation and patient condition are
different. There are patients that refuse microsurgical muscle transfer or patient
that for comorbidities or elderly are not eligible for complex and long surgery.[1]
[2] In such cases, procedures with limited invasiveness become a valuable tool to correct
the deformity. The endoscopically assisted multiple muscle transposition and lifts
(EMTL) procedure consists in a comprehensive endoscopic surgical treatment of facial
palsy.
Over a 3-year period (2015–2018), 14 patients with inveterate unilateral facial paralysis
had reanimation by EMTL procedure in our center.
Surgical Technique
EMTL is an association of multiple procedures in a single operation using several
endoscopic portals. Three different portals ([Fig. 1]) are used to treat the upper, medium, and lower face plus four stab incisions. The
procedure starts treating the orbital region with an endoscopic eyebrow lift and temporal
sling myoplasty of the eye and goes on with portals preparation for modified Labbè
myoplasty[3]
[4] and digastric muscles transposition with platismoplasty through the same access.
A strip of fascia temporalis is used to reinforce and lift the alae nasi. The temporalis
muscle with its fascia is used to reanimate and to support the lower lid with a partial
temporal sling.
Fig. 1 Scheme of the portals and the dissection area. Portal 1: eyebrow lift, temporalis
fascia graft, temporalis sling fabrication; Portal 2: modified Labbè myoplasty, ala
nasi support with temporalis fascia graft; Portal 3: digastric transposition and platismoplasty.
Red lines: accessory stab incision.
In-Depth Description of Treatment Site I: Parieto-Temporal Area
A 3-cm parieto-temporal skin incision at the hair bearing line is used to manage a
triple procedure: the eyebrow lifting, the temporalis fascia graft harvesting, and
the creation of a temporalis muscle sling for the eye.
Brow Lift
Lateral temporal approach to brow lift as described by Nahai and Saltz: through the
incision over the temporalis muscle the lateral orbital attachments, adhesions, and
septa are released and the parieto-temporal fascia is elevated and anchored to the
deep temporal fascia with lateral brown elevation.[5]
Temporalis Fascia Graft
A 1 × 3 cm strip of deep temporal fascia is harvested and grafted to support and lift
the ala nasi.
Temporalis Sling ([Fig. 2])
Fig. 2 Temporalis sling. (A) Harvesting. (B) Downwards rotation.
The temporalis muscle is harvested in its 2-cm central portion keeping intact the
cranial attachment to the parietal fascia and pedicled on the caudal area; it is then
flipped downwards and tunneled with the fascia extension separated in two 2-mm slips
which are afterwards conducted through the upper and lower lid by a needle-cannula
and secured at the medial canthal region by a stab incision.[6] When the temporal muscle contract it acts like a dynamic sphincter partially mimicking
the blink mechanism.
In-Depth Description of Treatment Site II: Nasolabial Fold
The technique is similar to the one described by Boahene et al[7] but the skin incision has been reduced through the use of endoscopy and a dedicated
instrumentation.
At the nasolabial fold is created a key point portal dedicated to the modified Labbè
myoplasty. A 1.5-cm skin incision is dissected down to the zygomatic area and blunt
dissection is used to expose the Bichat bubble and the parotid duct ([Fig. 3]). The dedicated instrumentation has been chosen to assist the dissection. It consists
of a long nasal speculum, blunt scissors, 2-mm 30-degree endoscope with a soft tissue
supporting valve, and a diathermy forceps ([Fig. 4]). When the safety of the duct is assured, the dissection proceeds endoscopically
and under magnification all around the temporalis tendon muscle, and the coronoid
process begins. The apex of coronoid process is dissected free in the subperiosteal
plane keeping in continuity the temporalis tendon to the medial insertion on the mandible.
A 2-mm chisel is used to perform the apex osteotomy and the tendon is detached medially
and derotated to gain length. The tendon is divided and secured to the orbicularis
oris and zygomaticus muscle insertion is performed in the region of the modiolus with
3–0 polydioxanone sutures. The position of the tendon insertion is determined by the
preoperative smile pattern. To establish the appropriate tension on the transposed
tendon, the temporalis muscle is stimulated through surface electrodes while varying
traction tension on the tendon is applied.
Fig. 3 Endoscopic Labbè myoplasty. (A) Preparation of the zygomatic area. (B) Isolation and preservation on Stenone duct. (C) Isolation of temporalis tendon. (D) Detachment of temporalis tendon from coronoid process.
Fig. 4 Dedicated instruments for modified Labbè procedure. (A) Optical endoscopic portal, bipolar electrocautery scissors, and blunt dissector.
(B) Nasal speculum. (C, D) Anterior and lateral view of the position of nasal speculum down to the zygomatic
area.
At the end the portal is also used to support the alar base of the nose with the temporal
fascia graft.
In-Depth Description of Treatment Site III: Mental Area
A 1- to 2-cm submental incision allows preparation and transfer of digastric muscle
and platismoplasty. The anterior digastric muscle is isolated maintaining the innervations
from the fifth cranial nerve and rotated to restore the function of the depressor
labii inferioris muscle. The median tendon is driven subcutaneously to the lower
lip and secured with a tiny stab incision. Conley et al[8] stressed the importance of including all of the subdigastric tendon because it provides
half the length of the transposed segment and permits strategic insertion into the
lower lip. This was performed by splitting the end of the digastric tendon and using
these two strips to suture to the orbicularis oris muscle at its middle or inferior
border. Instead of submandibular approach previously described, we use a single middle
submental incision and the dissection is assisted by the endoscope ([Fig. 5]). At this stage if platysma contracture is present it is treated through the same
portal with delivery and section of contracted fibers.
Fig. 5 Diagram of digastric transfer.
Accessory Stab Incisions
-
Incision centered in the midline in the hair bearing region: using a dedicate o-degree
endoscope, the forehead is elevated in the subperiosteal plane. The supraorbital nerve
and the supratrochlear nerve are identified, preserved, and released. The contralateral
corrugators attachments are released to improve symmetry.
-
(medial) and 3. (lateral). Two periorbital incisions helping the tunneling of the
temporal sling.
-
Incision located at the base of the alae nasi for temporal fascia graft positioning.
Postoperative Treatments
All patients were operated under general anesthesia and discharged the day after the
procedure. Intravenous administration of antibiotics was stopped at the time of discharge.
No drains were used during surgery. Face taping was applied and kept for 20 days.
Patients were advised to eat cold and soft meals for 10 days and to use protective
glasses and eye drops for few days. After taping removal, a tailored physical therapy
was started with muscle re-education and relaxation exercises, scar tissue massage
aiming to reduce adhesions, and to improve power of the rotated muscle.
Case Series
After institutional review board approval, we queried the facial palsy plastic surgery
database at out hospital to identify all patients who underwent facial reanimation
procedures between 2015 and 2018. Patients who had complete facial palsy for more
than 3 years and not eligible for microsurgical restoration were considered for the
EMTL procedure. We evaluated all patients who underwent operative EMTL treatment performed
by the first author from September 2015 to May 2018. The patients were analyzed retrospectively,
with more than 1 years of follow-up, and were evaluated in terms of functional-aesthetic
results and postoperative complications. Fourteen patients were enrolled in the study.
Several facial nerve scoring methods have been introduced over the years to document
facial nerve recovery. We use as standard in facial plastic clinic the Sunnybrook
Facial Grading System.[9]
[10]
We registered sex, age, original issue, evolution, and complications in all cases.
Physical examination, photographs, video, satisfaction questionnaires, and spontaneous
movement were carefully recorded and discussed at 1, 3, 6, and 12 months.
Informed consent was obtained, including permissions for images publication, from
all patients and the study was approved by the institutional review committee and
was performed in accordance with the ethical standards of the Declaration of Helsinki.
Mean age at the time of treatment was 60 years (range 51–72 years). There were 10
men and 4 women. They were all inveterate palsies with minimum 4 years from the initial
injury. Acoustic neuroma surgery was the predominant cause of the disability. Four
patients suffered from parotid surgery and one was a posttraumatic case. Two patients
had some form of restorative surgery without significant improvement. Three patients
wore gold lid implant with incipient extrusion. Five patients suffered from recurrent
corneal ulcerations with mild consequences. The preoperative Sunnybrook score ranged
from 0 to 5 and the postoperative score ranged from 30 to 65. Spontaneous smile achievement
was obtained in 10 patients and only mild restoration in one patient ([Figs. 6]
[7]). Two patients developed a postoperative cheek seroma with no adherence to the physiatrical
regimen and consequently poor outcome. There was a case of intraoral extrusion of
polydioxanone suture used to anchor the temporal tendon to the modiolo. The support
was partially lost in this patient. The scar and static correction were satisfactory
in all patients ([Fig. 8]). Eye protection was improved in all cases with some form of active blinking in
6 cases.
Fig. 6 Case series. (A, B) Evaluation preoperation (Sunnybrook composite score 8) and postoperation static
at 6 months with very good symmetry.
Fig. 7 Case series. (A, B) Dynamic evaluation at 3 months’ follow-up with Sunnybrook composite score 75.
Fig. 8 Case series. (A, B) Static evaluation with closed eyes pre- (composite Sunnybrook score 20) and postoperation
(composite Sunnybrook score 60). (C, D) Postoperative scar appearance at 1-year follow-up in frontal and mid lateral view.
Discussion
Gold standard treatment for inveterated facial palsy is functional muscle transfer
with staged cross-facial nerve grafting. To date, results with the one-stage reconstruction
with masseteric nerve as donor have been promising. We believe that one-stage method
offers potential advantages in terms of safety, patient preferences, shorter total
recovery time, and fewer resource implications. However, we support the concept described
by Hontanilla et al,[11] that is, “to recommend a free tissue transfer without offering the patient a chance
of rehabilitation with simpler techniques may seem somewhat aggressive.”
We present a case series study with in-depth description of three critical surgical
sites of intervention to approach all major components of the deformity and of the
functional deficit of complete facial palsy. Several well-established different corrective
techniques were conglobated in a single operation with minimal donor site morbidity
and tiny residual scarring. Endoscopic assistance was imperative to minimize the “portals”
for intervention and to reduce the complication rate. Conventional temporalis lengthening
myoplasty described by Labbè et al[12] has some drawbacks since it is quite invasive, as it requires a large temporal surgical
site, osteotomy of the zygomatic arch, and a long incision in the nasolabial fold
([Fig. 9]). Nevertheless, new improvements of the Labbè technique have been already described
showing the capacity to maintain benefits while reducing drawbacks. We started from
this newer variation of the original technique pushing forward the reduction of the
residual scar. Another consistent advantage in leaving temporalis muscle and its fascia
undisturbed in temporal fossa is that it allows to use a narrow strip of the muscle
separately for blink restoration.
Fig. 9 Conventional Labbè approach.
Despite the central temporal muscle being used for reanimating the eyelids and the
inferior tendon attachment to reanimate the lips, we have noticed only a mild synkinetic
action, since the power of muscle contraction activates the lower tendon at a higher
level. Nevertheless, it seems to be a drawback that is not perceived by the patient.
Conclusion
We present a reliable and reproducible surgical technique using a comprehensive endoscopic
procedure with minimal donor-site morbidity to treat complete inveterate unilateral
facial palsy. We have limited the description of this technique to inveterate facial
palsy as alternative to microsurgical reconstruction. For other cases many options
must be considered with particular attention to masseteric nerve transfer and cross-facial
grafting.
This study showed that facial palsy correction with EMTL procedure offers a promising
treatment alternative for patients with facial palsy not suitable for microsurgical
muscle transposition. The EMTL procedure is a one-stage procedure with a wide therapeutic
window since the rate of complications is low and the smile spontaneity can be restored
in the majority of patients.
