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A technique for reanimation of the face after paralysis of the seventh nerve
A T E C H N I Q U E F O R REANIMATION OF T H E FACE A F T E R PARALYSIS OF T H E SEVENTH NERVE By R. J. V. BATTLE,M.B.E., M.Chir., F.R.C.S. PIONEER work on the treatment of facial paralysis was Ferformed in America by Blair (I93O) and in Europe by Gillies (1934). These surgeons supplied intrinsic support for the muscles on the paralysed side by means of strips of fascia lata carried obliquely upwards from the mouth to fixed points in the parotid, zygomatic, and temporal regions. Gillies went further and harnessed the temporal muscle as a motor force to elevate the corner of the mouth. The technique he described was that of swinging down a muscle flap over the zygomatic arch, leaving intact the tendinous insertion to the coronoid process, and the attachment of this muscle flap to the fascial sling. He reported good movement in a number of patients. Barrett Brown (1939, 1948) has published impressive results from the simple expedient of threading his fascial strips into the temporal muscle at the lowest point available above the zygomatic arch where movement is likely to be the most pronounced and the motive force the strongest. He has mentioned that the separation of one section of the muscle and its attachment to the strips may well endanger the nerve supply of that section. During a visit to St Louis in 1948 the author saw two patients treated by him with this technique, each of whom had a most promising degree of movement. During a meeting of the British Association of Plastic Surgeons at East Grinstead in 1949, McLaughlin demonstrated several patients with fixed support of the corner of the mouth, the fascia being threaded through a small hole drilled in the zygoma. During the discussion that ensued, no voice was raised in favour of muscle attachments to produce reanimation. Grundt in 195o stated : " It is known . . . that the fascia tends to attach itself to the surrounding tissue and that a muscle flap may degenerate, so that the result will be a ' fixed smile.' " He suggested instead that the palmaris longus tendon with its paratenon should be grafted into the cheek and attached to a muscle flap from the temporal muscle above to the corner of the mouth below. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS The temporal muscle is innervated by the deep temporal nerves, small branches of the mandibular nerve. To q u o t e " Gray's Anatomy," these" are two in number, anterior and posterior. They pass above the upper border of the pterygoideus externus and enter the deep surface of the temporalis . . . . A third or intermediate branch is Often present." In fact the nerve supply is such that a flap of the muscle can be fashioned and brought out from behind the zygomatic arch and yet can be expected to continue to contract with the rest of the muscle so long as a fair continuity is maintained with the main muscle belly. The writer's technique regarding the preparation of the muscle flap is very similar to that of Grundt and was tried out first in 1949. It was felt that the degree of movement obtainable at the coronoid attachment would be so much greater than elsewhere that the extra time spent at operation in bringing out the flap was 247
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BRITISH JOURNAL OF PLASTIC SURGERY
justified. Moreover, the employment of a flap allowed a direct pull between the corner of the mouth and the superior temporal muscle attachment ; and finally, the tendinous extremity of the muscle would give a firmer attachment to the fascial strips. THE OPERATION
Three long strips of fascia lata are taken from the outer side of the thigh by means of a fasciaI stripper specially designed for the purpose. These are set aside between layers Of gauze rung out in saline. Three small incisions are made round the mouth in the skin vermilion junction line. Two of these, one in the upper and another in the lower lip, are placed just across the midline from the paralysed side of the face. The third incision is at the corner of the mouth on the affected side. A long incision is then made running upwards just in front of the ear and forwards, when it reaches the hairline across the temple to a point about an inch above the midpoint of the zygomatic arch. From here a straight incision is carried vertically upwards through skin and temporal fascia, exposing the underlying muscle. A strap of muscle ~ in. wide is raised in full depth of the temporal muscle from a point just above the zygomatic arch, right down into the temporal fossa, where it is cut away from the coronoid process and brought out. A pack is inserted into the fossa to control oozing, and the region is covered over until the last stage in the operation. The skin of the cheek is raised as an advancement flap, taken very thinly as in the classical" face lift" operation, and h~emostasis is secured. In the zygomatic region the undermining must be carried well forward and downwards so that space is left for the temporal muscle flap when it is lying over the arch and directed towards the corner of the mouth. The fascia is inserted round the mouth, in what Gillies describes as a " figure of eight," by a technique employing Blair's introducer, so ably described elsewhere by Kilner (1937). A good hold is obtained in healthy muscle of both lips, and the paralysed half of the mouth is gripped firmly by tying the fascia into a knot which is sutured with fine silk down to deep tissue at the commissure (Fig. I). A second loop of fascia is passed from the cheek beneath "the fascia at the corner of the mouth and back again, to be threaded through the parotid fascia and firmly secured with over-correction of the deformity. A third loop is then inserted from the zygomatic region in a similar manner, passing beneath the fascia at the corner of the mouth up to the temporal muscle flap, into the tendinous portion of which it is woven and then tied (Fig. 2). There should be firm tension only on the flap. The incisions are then closed, the cheek incision being sutured after the cheek flap has been advanced and tiny skin overlap removed. A penicillin umbrella has been ~mployed in all cases. DISCUSSION OF RESULTS
M o v e m e n t . - - T o date, the operation has failed in two patients (Nos. 6 and 8). Is it a coincidence that in each of these there was infection after operation with disturbance of the fascial attachment at the corner of the mouth ? In both these
REANIMATION OF THE FACE AFTER PARALYSIS OF THE SEVENTH NERVE 249 patients m o v e m e n t m a y yet appear with treatment b y faradic stimulation o f the temporal muscle. N o r m a l l y m o v e m e n t can be perceptible clinically within a m o n t h
FIG.
I
( FtG. 2
Fig. I.~Showing arrangement of fascial sling round mouth, after Kilner (x937)- (Drawn by M. Smyth.) Fig. 2.~Showing two fascial loops in the cheek: one connects the mouth sling to the parotid fascia, the other is attached to a flap of the temporal muscle which by its contraction raises the corner of the mouth. (Drawn by M. Smyth.) ~)f operation. W i t h delay, as ilf patient Nol 5, a course o f faradism was required. I t is probable that the trauma to muscle and the development o f a h m m a t o m a in t h e d o n o r site o f the flap are responsible for a transient paralysis o f the entire t e m p o r a l muscle (Fig. 3).
250
BRITISH
JOURNAL
OF PLASTIC
SURGERY
I n f e c t i o n . - - T h e insertion of fascia close to the mouth carries a risk of infection. If, in addition, there is an open mastoid cavity or a discharging ear, the risk is doubled. This is a weakness of the technique.
FIG. 3
Patient No. 5. A, B, C, Left facial paralysis of sixteen years' standing, followinga Bell's palsy. D, E, F, SIX months after operation. D i s s o c i a t i o n o f M o v e m e n t . - - P a t i e n t s are taught to practise in a mirror after operation. Barrett Brown's dictum that the patients must learn to appear "glum" is a very wise and practical one. T h e fact remains that control of the 9movement is difficult. T h e capacity for dissociating the facial expression from the clenching of the teeth would appear to be related to the intelligence of the individual. G e n e r a l Facial E x p r e s s i o n . - - I t is regretted that this technique fails to produce the normal smile line on the affected side. Adherence of both the muscle flap and the fascia to the skin results in a smooth movement of the entire cheek in one sheet. However, it must be remembered that paralysis of the seven.th nerve
REANIMATION
OF T H E FACE
AFTER PARALYSIS
OF THE
sEVENTH
NERVE
25I
leads to a very hideous and depressing facial deformity. To give support alone to the cheek gives much increased comfort to the patient. Add even the primitive
A
B
C
D FI6. 4 Patient No. 3. A and B, Left facial paralysis following excision of a large parotid tumour. C and D, One year and four months after operation.
movement that can be obtained by means of a temporal muscle attachment and the transformation in appearance is remarkable. The gratitude of the patients concerned is perhaps the best index of success (Fig. 4 ) -
BRITISH JOURNAL
252
OF PLASTIC
SURGERY
Table of Results Case I I No. Age. [ Sex. [
Lesion.
Previous History.
Date of Operation.
Result.
I x.
21
F.
Partial paralysis (right)
1937. Fractured skull. Initially a bilateral paralysis
1.9.49
2.
25
M'.
Complete paralysis (left)
I931. Mastoidectomy
5.4.50
3.
48
M.
Complete paralysis (left)
1946. Removal of large parotid
20.7.50
turnout
4.
49
F.
Complete paralysis (right)
3~
M.
Complete paralysis (left)
1937. Bell's palsy. 2.2.49. Fascia inserted without muscle flap, followed by infection I934, Bell's palsy. 1938. Decompression of nerve 1941. Fascia lata sling inserted. Infection
Second operation 26.7.5 ~
17.11.5 ~
++
6.
59
M.
When seen 195o, no evidence of fascia. Complete paralysis 1947. Mastoid opera(left). Dischargt.ion ing ear
7.
27
M.
Complete paralysis (left)
8.
...
F.
Complete paralysis (right)
28.9.5I
I6".11.5I 1934. Mastoid operation 1949. Fascia lata sling to month and temporal muscle flap to eyelid. Eyelid everted on contraction 195I (Nov.). Removal February I952 of auditory nerve tu./no1.tr
Smooth healing. Good movement, but patient has to clench her teeth very deliberately to get it. Eating is more comfortable than before operation. Smooth healing. Excellent dissociated movement. Smooth healing. Movement seen very early but a bit clumsy and deliberate. Following insertion of strip to muscle flap at second operation developed good powerful movement. Smooth healing. Movement delayed but eventually excellent. Required course of faradism.
Infection with exposure of fascia at comer of mouth. Only slight movement 1.5.5 2 . Flap attachment transferred from eyelid to mouth. Immediate and satisfactory degree of movement.
Infection with exposure of fascia at corner of m o u t h . N o movement 1.5.5 2,
REFERENCES BLAIR, V. P. (193o). Ann. Surg., 92, 694. BROWN, J. BARRETT(X939)- Ann. Surg., xo9, lO16. BROWN, J. BArneTT, McDowELL, F., and FRYZR, M. P. (1948). Ann. Surg., 127, 858. GILLIES, H. D. (1934). Proc. Roy. Soc. Med., 0-7, 1372. GRUI~T, B. (195o). Brit. ft. Plastic Surg., 3, 50. KILrCEa, T. P. (I937). In Malngot's "Post-graduate Surgery," vol. iii, p. 3745. London : Medical Publications Ltd. MCLAUGItLIN, C. R. (I949). Lancet, x, 255. 0950). Brit. J. Plastic Surg., 3, 87.
248
BRITISH JOURNAL OF PLASTIC SURGERY
justified. Moreover, the employment of a flap allowed a direct pull between the corner of the mouth and the superior temporal muscle attachment ; and finally, the tendinous extremity of the muscle would give a firmer attachment to the fascial strips. THE OPERATION
Three long strips of fascia lata are taken from the outer side of the thigh by means of a fasciaI stripper specially designed for the purpose. These are set aside between layers Of gauze rung out in saline. Three small incisions are made round the mouth in the skin vermilion junction line. Two of these, one in the upper and another in the lower lip, are placed just across the midline from the paralysed side of the face. The third incision is at the corner of the mouth on the affected side. A long incision is then made running upwards just in front of the ear and forwards, when it reaches the hairline across the temple to a point about an inch above the midpoint of the zygomatic arch. From here a straight incision is carried vertically upwards through skin and temporal fascia, exposing the underlying muscle. A strap of muscle ~ in. wide is raised in full depth of the temporal muscle from a point just above the zygomatic arch, right down into the temporal fossa, where it is cut away from the coronoid process and brought out. A pack is inserted into the fossa to control oozing, and the region is covered over until the last stage in the operation. The skin of the cheek is raised as an advancement flap, taken very thinly as in the classical" face lift" operation, and h~emostasis is secured. In the zygomatic region the undermining must be carried well forward and downwards so that space is left for the temporal muscle flap when it is lying over the arch and directed towards the corner of the mouth. The fascia is inserted round the mouth, in what Gillies describes as a " figure of eight," by a technique employing Blair's introducer, so ably described elsewhere by Kilner (1937). A good hold is obtained in healthy muscle of both lips, and the paralysed half of the mouth is gripped firmly by tying the fascia into a knot which is sutured with fine silk down to deep tissue at the commissure (Fig. I). A second loop of fascia is passed from the cheek beneath "the fascia at the corner of the mouth and back again, to be threaded through the parotid fascia and firmly secured with over-correction of the deformity. A third loop is then inserted from the zygomatic region in a similar manner, passing beneath the fascia at the corner of the mouth up to the temporal muscle flap, into the tendinous portion of which it is woven and then tied (Fig. 2). There should be firm tension only on the flap. The incisions are then closed, the cheek incision being sutured after the cheek flap has been advanced and tiny skin overlap removed. A penicillin umbrella has been ~mployed in all cases. DISCUSSION OF RESULTS
M o v e m e n t . - - T o date, the operation has failed in two patients (Nos. 6 and 8). Is it a coincidence that in each of these there was infection after operation with disturbance of the fascial attachment at the corner of the mouth ? In both these
REANIMATION OF THE FACE AFTER PARALYSIS OF THE SEVENTH NERVE 249 patients m o v e m e n t m a y yet appear with treatment b y faradic stimulation o f the temporal muscle. N o r m a l l y m o v e m e n t can be perceptible clinically within a m o n t h
FIG.
I
( FtG. 2
Fig. I.~Showing arrangement of fascial sling round mouth, after Kilner (x937)- (Drawn by M. Smyth.) Fig. 2.~Showing two fascial loops in the cheek: one connects the mouth sling to the parotid fascia, the other is attached to a flap of the temporal muscle which by its contraction raises the corner of the mouth. (Drawn by M. Smyth.) ~)f operation. W i t h delay, as ilf patient Nol 5, a course o f faradism was required. I t is probable that the trauma to muscle and the development o f a h m m a t o m a in t h e d o n o r site o f the flap are responsible for a transient paralysis o f the entire t e m p o r a l muscle (Fig. 3).
250
BRITISH
JOURNAL
OF PLASTIC
SURGERY
I n f e c t i o n . - - T h e insertion of fascia close to the mouth carries a risk of infection. If, in addition, there is an open mastoid cavity or a discharging ear, the risk is doubled. This is a weakness of the technique.
FIG. 3
Patient No. 5. A, B, C, Left facial paralysis of sixteen years' standing, followinga Bell's palsy. D, E, F, SIX months after operation. D i s s o c i a t i o n o f M o v e m e n t . - - P a t i e n t s are taught to practise in a mirror after operation. Barrett Brown's dictum that the patients must learn to appear "glum" is a very wise and practical one. T h e fact remains that control of the 9movement is difficult. T h e capacity for dissociating the facial expression from the clenching of the teeth would appear to be related to the intelligence of the individual. G e n e r a l Facial E x p r e s s i o n . - - I t is regretted that this technique fails to produce the normal smile line on the affected side. Adherence of both the muscle flap and the fascia to the skin results in a smooth movement of the entire cheek in one sheet. However, it must be remembered that paralysis of the seven.th nerve
REANIMATION
OF T H E FACE
AFTER PARALYSIS
OF THE
sEVENTH
NERVE
25I
leads to a very hideous and depressing facial deformity. To give support alone to the cheek gives much increased comfort to the patient. Add even the primitive
A
B
C
D FI6. 4 Patient No. 3. A and B, Left facial paralysis following excision of a large parotid tumour. C and D, One year and four months after operation.
movement that can be obtained by means of a temporal muscle attachment and the transformation in appearance is remarkable. The gratitude of the patients concerned is perhaps the best index of success (Fig. 4 ) -
BRITISH JOURNAL
252
OF PLASTIC
SURGERY
Table of Results Case I I No. Age. [ Sex. [
Lesion.
Previous History.
Date of Operation.
Result.
I x.
21
F.
Partial paralysis (right)
1937. Fractured skull. Initially a bilateral paralysis
1.9.49
2.
25
M'.
Complete paralysis (left)
I931. Mastoidectomy
5.4.50
3.
48
M.
Complete paralysis (left)
1946. Removal of large parotid
20.7.50
turnout
4.
49
F.
Complete paralysis (right)
3~
M.
Complete paralysis (left)
1937. Bell's palsy. 2.2.49. Fascia inserted without muscle flap, followed by infection I934, Bell's palsy. 1938. Decompression of nerve 1941. Fascia lata sling inserted. Infection
Second operation 26.7.5 ~
17.11.5 ~
++
6.
59
M.
When seen 195o, no evidence of fascia. Complete paralysis 1947. Mastoid opera(left). Dischargt.ion ing ear
7.
27
M.
Complete paralysis (left)
8.
...
F.
Complete paralysis (right)
28.9.5I
I6".11.5I 1934. Mastoid operation 1949. Fascia lata sling to month and temporal muscle flap to eyelid. Eyelid everted on contraction 195I (Nov.). Removal February I952 of auditory nerve tu./no1.tr
Smooth healing. Good movement, but patient has to clench her teeth very deliberately to get it. Eating is more comfortable than before operation. Smooth healing. Excellent dissociated movement. Smooth healing. Movement seen very early but a bit clumsy and deliberate. Following insertion of strip to muscle flap at second operation developed good powerful movement. Smooth healing. Movement delayed but eventually excellent. Required course of faradism.
Infection with exposure of fascia at comer of mouth. Only slight movement 1.5.5 2 . Flap attachment transferred from eyelid to mouth. Immediate and satisfactory degree of movement.
Infection with exposure of fascia at corner of m o u t h . N o movement 1.5.5 2,
REFERENCES BLAIR, V. P. (193o). Ann. Surg., 92, 694. BROWN, J. BARRETT(X939)- Ann. Surg., xo9, lO16. BROWN, J. BArneTT, McDowELL, F., and FRYZR, M. P. (1948). Ann. Surg., 127, 858. GILLIES, H. D. (1934). Proc. Roy. Soc. Med., 0-7, 1372. GRUI~T, B. (195o). Brit. ft. Plastic Surg., 3, 50. KILrCEa, T. P. (I937). In Malngot's "Post-graduate Surgery," vol. iii, p. 3745. London : Medical Publications Ltd. MCLAUGItLIN, C. R. (I949). Lancet, x, 255. 0950). Brit. J. Plastic Surg., 3, 87.