3. long-standing peripheral monolateral facial
paralysis in adults to
neurologists and plastic surgeons for centuries.
However, the ultimate goal of normality of the
paralyzed hemi-face with symmetry at rest, and the
achievement of a spontaneous symmetrical smile
with corneal protection,
4. A major step was taken in the second half of the
1970s, with the introduction of micro-neurovascular
muscle transfer in facial reanimation, which often
combined in two steps with
and
has become the most popular option for the
comprehensive treatment of long-standing facial
paralysis
5. In spite of these more complex, technically demanding,
time consuming procedures,
the results are partial, as with any other corrective
method,
and even at the end of a long
learning curve.
6. o In the second half of the 1990’s in France the authors proposed a
regional muscle transfer technique with the definite advantages of
being one-step,
dynamic procedure,
technically easier ,
and relatively fast,
o namely lengthening acquired
popularity among surgeons treating facial paralysis
o The temporalis muscle is elongated and the released coronoid
tendon of the muscle is transferred to the mouth angel.
7. Preoperative Evaluation
is mandatory for the determination of smile classification
They suggest the classification who have identified
the nasolabial fold as the keystone of the smiling mechanism.
8. of the mouth are pulled up and
outward followed by levators of
upper lip to show the upper teeth
.
9. , the
superioris are dominant
they contract first , exposing the
canine teeth ,the corners of the
mouth contract secondarily.
.
10. represents the
contraction of the periocular
musculature to support
maximum upper-lip elevation
along with contraction of the
depressors of the lower lip.
12. If the patient has a “ ” type smile, the temporalis
tendon will be preferably fixed on the mobile part of the
zygomaticus major muscle in the labial commissure area.
If the patient has a “ ” type of smile, the temporalis
tendon will be preferably fixed on the upper lip levator and
the posterior part of the nasal alae
If the patient has a “ ” smile, fixation will be
preferably made, as far as possible, on the zygomatic major
muscle, on the upper lip levator muscles.
14. A total of patients with facial paralysis were treated in
between 1997 and 2005 by a single surgeon who developed
2 variants of the technique (V1, V2), each with its
advantages and disadvantages,
But both based on the anatomo-functional
background and aim, which is transfer of the temporalis
muscle tendon on the coronoid process to the lips.
15. Classic coronal
approach
the coronal approach are done in the
classic manner, then
Subperiosteal dissection is carried out
on the zygomatic arch till it clearly
exposed and can be sectioned, using a
saw, and shifted inferiorly.
The zygomatic arch should be
far anteriorly to obtain the best access
to the coronoid process
First Approach (V1)
16. The entire temporalis muscle is dissected off
the bone by an elevator
The dissection is carried out in the temporal
fossa, on the lateral orbital rim, down to the
infratemporal crest
This
Classic coronal approach
First Approach (V1)
17. Nasolabial incision
A 4-cm incision is made in the nasolabial
crease
The cheek is tunnelized by scissors in the
plane of the corpus adiposum buccae
synsarcosis(buccal fat pad ) , medial to
the masseter muscle.
the temporalis tendon is detached from
its coronoid bone attachments, spread 3
to 4 cm wide, and sutured to the perioral
muscles
18. the plane of this tunnel follows the temporal
extension of the corpus adiposum buccae (buccal fat pad )
in the masticatory synsarcosis.
19. The temporalis muscle
body is then stretched and
sutured to the aponeurotic
strip
left on the anterior portion
of the crest.
20. Classic coronal approach
The zygomatic arch is fixed, closing and dressing of the
coronal approach are done in the classic manner like
21. Modified hemicoronal approach (V2)
The surgical approach is: (not coronal as in V1) and in the
nasolabial fold.
The undermining of scalp in subgaleal plane is
limited to the of muscle to respect
the perforator arteries from the contralateral
superficial temporal artery.
The dissection is carried out from the
temporal fossa to the infratemporal fossa
until reaching the infratemporal crest
(without direct vision).
The remaining steps are as in the V1
approach.
22. Modified hemicoronal
approach (V2)
So the major modification from version 1 (V1) consistsin
1. superficial
undermining of the part
of the temporal muscle
23. Modified hemicoronal
approach (V2)
So the major modification from version 1 (V1)
consistsin
2. performing of the
coronoid process with
avoiding the osteotomy of the
zygoma
24. Correction of lagophthalmos
For a comprehensive treatment of the paralysis, the
eyelids are usually managed by Paul Tessier's technique to
lengthen the levator muscle of the upper eyelid by
aponeurosis interposition,
combined with external blepharorrhaphy
26. Modified hemicoronal approach (V2)
: The surgery is quicker and less invasive in the second
approach, and usually the postoperative hospital stay is shorter.
: However, with the second approach, the main pedicles
are damaged. Additionally, as in some steps ,exposure of the structures is
less comfortable and some maneuvers are almost blind (as the final part ofthe
dissection of the deep surface of the muscle towards the infratemporal crest), and requires a
higher degree of confidence with the regional anatomy
The authors suggested to practice the , at least on
cadavers, before performing a lengthening temporalis myoplasty with
the second approach.
27. In general, the results with a 1-stage combination of
lengthening temporalis myoplasty and static
correction of the lagophthalmos appear
with the major series in the literature
using free microneurovascular transfers combined
with cross-facial nerve grafts for long- standing
peripheral monolateral facial paralysis
28. The obvious of temporalis
elongation myoplasty consist in its
• technical ease,
• a single step,
• low incidence of complications and
• markedly reduced operating time.
30. ). (Above, left) Complete left
facial paralysis nearly 3 years
after resection of a
medulloblastoma.
Preoperative markings and
asymmetric smile are shown.
(Above, right) Postoperative
appearance at 7 months after
lengthening temporalis
myoplasty.
(Below) Oblique view of
postoperative smile activation.
31. (Above) Complete right facial
paralysis over 2 years after resection
of a medulloblastoma. Shown
preoperatively at rest and with a full-
tooth smile.
(Below) Post-operative appearance at
2 months after revision of the tendon
insertion site. She did demonstrate
moderate right temporal hollowing
after the initial operation
a Review article BY D labbe Maxillofacial and plastic surgery department, Caen University Hospital, in France;
It was published in THE Italian Oto-rhino-laryngol ogi journal , in two thousand and twelve,
Official Journal of the Italian Society of Otorhinolaryngology
-- institute of otorhi-nolaryngology,Catholic University, Rome, Rome, Italy
One hundred eleven-19 -97-
The operative steps will be discussed in details in the next video presentation but highlighting the following points will be done:-
Synsarcosis:An anatomical term referring to a union between parts of the skeleton through muscles alone.
coming from the Ancient Greek :flesh
the junction of two or more bones by means of attached muscles (such as the hyoid with the mandible and sternum)
Its cheek extensions are inconsistent or disappear with age. However, its outline remains characteristic.
The CAB is always found under the SMAS plane which keeps it apart from superficial fat.
Synsarcosis:An anatomical term referring to a union between parts of the skeleton through muscles alone.
coming from the Ancient Greek :flesh- rather than a conventional joint
(such as the connection of the hyoid with the mandible and sternum)
buccal fat pad is a tubular-shaped collection of adipose tissue
the corpus adiposum buccae, or buccal fat pad (of Bichat)
It has numerous presumed functions including suckling, contributing to mastication, protection and cushioning of neurovascular bundles, separating the muscles of mastication from one another
In the infant, the buccal fat pad prevents the indrawing of the cheeks during sucking, while it enhances intermuscular motion
Its cheek extensions are inconsistent or disappear with age. However, its outline remains characteristic.
The CAB is always found under the SMAS plane which keeps it apart from superficial fat.
Horses do not have clavicles; their thoracic limb is attached to the trunk via a synsarcosis, i.e. there is only muscle attachment with no bony articulation- a joint without bone to bone contact, e.g., between scapula and thorax in quadrupeds. Called also fleshy joint, synsarcosis.-
So The temporalis muscle is lengthened at the expense of the posterior third
