Dynamic Reconstruction of Eye Closure by Muscle Transposition or Functional Muscle Transplantation in Facial Palsy

Abstract

For patients with facial palsy, lagophthalmus is often a more serious problem than the inability to smile. Dynamic reconstruction of eye closure by muscle transposition or by free functional muscle transplantation offers a good solution for regaining near-normal eye protection without the need for implants. This is the first quantitative study of three-dimensional preoperative and postoperative lid movements in patients treated for facial paralysis. Between February of 1998 and April of 2002, 44 patients were treated for facial palsy, including reconstruction of eye closure. Temporalis muscle transposition to the eye was used in 34 cases, and a regionally differentiated part of a free gracilis muscle transplant after double cross-face nerve grafting was used in 10 cases. Patients' facial movements were documented by a three-dimensional video analysis system preoperatively and 6, 12, 18, and 24 months postoperatively. For this comparative study, only the data of patients with preoperative and 12-month postoperative measurements were included. In the 27 patients with a final result after temporalis muscle transposition for eye closure, the distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced from 10.33 +/- 2.43 mm (mean +/- SD) preoperatively to 5.84 +/- 4.34 mm postoperatively on the paralyzed side, compared with 0.0 +/- 0.0 mm preoperatively and postoperatively on the contralateral healthy side. In the resting position, preoperative values for the paralyzed side changed from 15.11 +/- 1.92 mm preoperatively to 13.46 +/- 1.94 mm postoperatively, compared with 12.17 +/- 2.02 mm preoperatively and 12.05 +/- 1.95 mm postoperatively on the healthy side. In the nine patients with a final result after surgery using a part of the free gracilis muscle transplant reinnervated by a zygomatic branch of the contralateral healthy side through a cross-face nerve graft, eyelid closure changed from 10.21 +/- 2.72 mm to 1.68 +/- 1.35 mm, compared with 13.70 +/- 1.56 mm to 6.63 +/- 1.51 mm preoperatively. The average closure for the healthy side was from 11.20 +/- 3.11 mm to 0.0 +/- 0.0 mm preoperatively and from 12.70 +/- 1.95 mm to 0.0 +/- 0.0 mm postoperatively. In three cases, the resting tonus of the part of the gracilis muscle transplant around the eye had increased to an extent that muscle weakening became necessary. Temporalis muscle transposition and free functional muscle transplantation for reanimation of the eye and mouth at the same time are reliable methods for reconstructing eye closure, with clinically adequate results. Detailed analysis of the resulting facial movements led to an important improvement of the authors' operative techniques within the last few years. Thus, the number of secondary operative corrections could be significantly reduced. These qualitative and quantitative studies of the reconstructed lid movements by three-dimensional video analysis support the authors' clinical concept of temporalis muscle transposition being the first-choice method in adult pat...

Facial reanimations: part II—long-standing paralyses

“…21 The most commonly used type is the double-belly temporalis flap. The cranial part of the flap lowers the upper eyelid when the temporalis muscle is voluntarily activated by opposition of the teeth.…”

The Combination of Muscle Transpositions and Static Procedures for Reconstruction in the Paralyzed Face of the Patient with Limited Life Expectancy or Who Is Not a Candidate for Free Muscle Transfer

“…8,9 Since then, the technique has been used and modified by several authors. 10 -14 Further modifications have been suggested by Frey et al 3 In 1949, McLaughlin described the use of the whole temporalis muscle after sectioning the coronoid process through an intraoral approach and using a strip of fascia lata 15 for reconstruction of the smile. Inspired by this approach, Labbé and Huault 16 described in 2000 the lengthening temporalis myoplasty for lip reanimation.…”

“…Frey et al stated that free muscle transplantation for reconstruction of the eye proves more efficient than the transposition of the temporal muscle both in clinical results and in the measured excursions of the movement of eye closure. 3 The temporal muscle flap provides voluntary dynamic motion of the eyelids but, because the muscle maintains in its newly acquired position its own innervation from a branch of the trigeminal nerve, a spontaneous blinking with protection and lubrication of the cornea cannot be restored. Therefore, the patient has to practice the mechanism of eyelid reanimation to ascertain with time and motivation a certain degree of spontaneous movement.…”

“…No previous operations for reconstruction of eye closure or the smile had been performed. 3. No further reconstructive measurements beyond the temporalis muscle transposition had been applied in the same operative procedure as the temporalis muscle transposition.…”

“…For partial transposition of the temporalis muscle, the technique described by Gillies 2 with some modifications as described by Frey et al 3 is applied.…”