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Multiple muscle substitution for correction of facial paralysis
MULTIPLE
MUSCLE SUBSTITUTION OF FACIAL WM.
FOR CORRECTION
PARALYSIS
MILTON
ADAMS, M.D.
LMemphis, Tennessee
F
ACIAL paralysis presents not onIy a disabling and disfiguring deformity, but a most diffrcuh problem from the standpoint of satisfactory correction. One should not be content mereIy to give support to the affected muscIes; it is aIso necessary to restore as much motion as possible to the entire paralyzed side of the face. This may tax to the Iimit the ability of the most highly skiIIed surgeon. In paraIysis incident to simple severance of the facial nerve, regeneration may follow suture of the two ends. In the event the ends of the nerve have probabIy been bruised, permanent suture is best deIayed unti1 the eighteenth to the twenty-first day foIlowing injury, since one can then determine the exact extent of the damage to the nerve beyond the point of severance. In the presence of a smaI1 gap in the nerve, a free graft may often be utilized for repair. A defect in that part which lies within the facial bony cana lends itseIf well to the nerve graft procedure described by Bunnell in 1927. If neither of these methods is feasibIe, a satisfactory resuIt may occasionally be obtained by an anastomosis of the dista1 end of the facia1 nerve to one of the other crania1 nerves, usuahy the eleventh. For extensive injury of the nerve or permanent paraIysis, either fascia1 strips or muscIe pedicle grafts may be utilized. By far the most popuIar technic has been the use of fascia1 strips attached to the temporaIis fascia or muscle, or both, the strips being carried down to give support to the most noticeably sagging areas of the face. There are two reasons for the popularity of this procedure: the technic is simpIe and the improvement is immediate. No motion is obtained, however, or at least only a negIigibIe amount. NeaI Owens has utilized the masseter muscIe in preference to the temporalis, attaching the fascia1 strips to the Iips and corner of the mouth and Iooping them through the body of the masseter muscle. He has found that this not onIy provides support, but the results are definitely better with respect
to motion about the corner of the mouth than foIIowing the use of the temporalis muscle. MuscIe transpIantation provides support equal to that of fascia1 strips and, in addition, permits voluntary motion. In some cases, moreover, fascia1 strips tend to relax, with a consequent return of the sagging of the muscIes, whereas following the transplantation of muscles, the tone improves as reeducation of the transplants is continued. The principle of muscle substitution seems to have been first employed by Lexer in 1867, who transplanted a pedicle of the masseter muscle to the corner of the mouth, to give motion in this region of the face. A number of other surgeons have since transpIanted the masseter muscIe by one technic or another for the same purpose. Gillies and Sheehan have each empIoyed the temp’oralis aIone for restoring motion to the entire side of the face. The muscIe is detached at its origin above, divided into strips and brought down; one strip is attached in the upper eyelid, one in the Iower lid,, one in the supra-orbital region and one or more around the angIe of the mouth. When the temporalis muscle is transpIanted to the region of the mouth, however, its puI1 is Iargely upward and only sIightIy backward. This muscle is most suitable for restoring motion and giving support to the eyeIids, providing, as it does, a sIightIy upward puI1. In paraIysis of the facia1 nerve, there is a IOSS of function of eleven major and nine minor muscIes of expression. One cannot, therefore, expect one muscIe to carry out the work of the entire group. Obviously, the larger the number of different muscles which can be brought into play, the better the function one wiI1 be abIe to restore to the paraIyzed area. By substituting muscles from different locations, muscIe puI1 in various directions may be provided, thus insuring a more nearly normal direction of motion. The masseter muscIe, because of its Iocation, is most suitable for reanimating the corner of the mouth and the Iower part of the paralyzed
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FIG. I. TranspIantation of the masseter muscle to the region about the angle of the mouth. i I j Freeing the mtlsseter muscle from its insertion along the lower border of the mandible through an incision in the buccal mucosa. (2) The masseter muscle Hal, divided at its distal end and swung a.nteriorIy to the region about the mouth. (3) The muscle ffap being threaded through the formed tunnet beneath the mucous membrane of the mouth into the body of the obicuIaris oris musck of the upper and Iower lip. The ends of the flaps are sutured as near the midline of the lips as possible. A third sutun is placed at the latera border of the obicularis oris muscle where it conjoins with thv risorius to bring out the nasokrbial expression line. (See footnote p. 664)
face. By transplanting the end of the insertion of the muscle at the lower border of the mandible, one is Iess likely to disturb the nerve supply, the puIl is in the desired direction, being slightly up*-ard and backwzard, function is thus mote active and the effect is mote natural than if the temporalis muscle \\-ete utilized. The operation is best performed under focal anesthesia, in that it is desirabIe to have the patient’s assistance in contracting the muscle from time to time during the operation. Unless the masseter muscIe is unusualIy small or is attached posteriorI>, on the bodv of the mandiNe, the intra-oral approach Is used. By having the patient clinch the teeth, the body of’ the muscle is brought forward against the buccal mucosa. On incising the mucosa along the anterior margin of the muscle, one
immediately encounters the muscle and ma\; readily deliver it through the incision. (Fig. I :‘) If the muscIe is attached more posteriorly on the mandible, an extra-oral approach along the Iowet border of the man&Me is preferable. The pedicle is dissected up from the Iower margin of the mandible and the fibers are separated iongitudinally by gentIe finger dissection. The muscIe should be divided only for g sufficient distance to form a flap of proper length, as the higher the dissection is carried, the greater the danger of impairing the nerve is next made in the supply. A small incision VISCOUSmembrane of both the upper and lower lips, just Iateral to the midline at or near the vermilion border. Through each of these incisions a tunnel is formed through the body of the orhicularis oris muscle, the tunne1.s meeting at the corner of the mouth. The
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FIG. 2. Transplantation of a flap of the temporalis muscle to the eyelids. (I) The Iocation and amount of temporalis muscle used to form a ffap; (2) the freed temporalis muscle flap with overIying fascia intact; (3) the overIying fascia reflected down from the body of the mu&e to give needed length to reach the inner canthal region and divided to give a strip for both the upper and Iower eyeIid; (4) the flaps threaded through the eyelids and the ends sutured in the inner canthal region.
tunne1 is then continued backward from this point to the masseter region. The distal end of the pedicIe is now spIit in half for 45 to x inch, and the upper and lower haIves are delivered through the tunnels of the upper and lower lips, respectively, and attached to the muscle. A third suture is placed in the fork of the pedicIe, which is just IateraI to the corner of the mouth; this aids in forming the nasolabial expression line when the patient contracts the muscle. Within two months after the operation, the patient is able, by cIinching the teeth, to deveIop fairly satisfactory contro1 of the pedicIe, with motion in the corner of the mouth and surrounding region. Further improvement may be expected for an indefinite period, as Iong as the patient persists in daiIy exercise of the muscIe. The temporalis muscIe is utiIized in a similar manner to restore support and function to the paralyzed upper and Iower eyerids. Again, the end of the insertion of the muscle is trans-
planted. A vertica1 incision I $5 inches in Iength is made inside the hairline and just above the zygomatic arch, usuaIIy anterior to the temporal artery. (Fig. 2.) The muscle flap, which shouId be about 35 inch wide, is dissected up from the anterior portion of the coronoid process of the mandible. To sever the attachment from the coronoid process, Iong slender scissors with an acute angulation at the ends of the bIades are used. The overlying fascia of the temporahs muscIe is Ieft attached to the flap and, in order to lengthen the flap sufficiently to reach the inner canthal region, the fasica is reflected downward. .Here, also, in forming the pedicIe, the fibers are separated IongitudinaIly with gentle blunt dissection to interfere as little as possible with the nerve suPPlY* A tunne1 is created through the subcutaneous tissues from the tempora1 incision to the outer canthal region, thence through both eyelids to the inner canthal region. The distat end of the flap is split for a distance of I to 146 inches,
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FIG. 3. The transplantation of the frontalis Aap to the opposite eyebrow region. (1) and (2) show two smaI1 incisions at the inner border of the eyebrow just below the hairlinc and the area of skin of the central portion of the forehead undermined at the donor site of the frontalis flap. (3) and (4) show the flap being swung over to its new Iocntion and the point of fixation of the distal end.
and one-half is threaded through each of these tunnels, brought together and attached to the inner canthal ligamentous tissue. A maIIeabIe dissecting probe is useful in dehvering the flap through the tunnel, a thread being tied around the ends of the flap and passed through the eye of the probe. One shoutd be careful with respect to the tension on the Aap; the tension should be sufficient to permit closure of the lid on relaxation of the levator, yet not enough to prevent raising of the lid on contracture of this muscle. The tension may be tested by having the patient open and close the lids before the transplant is permanentIy sutured in pIace. The immediate effect of this procedure is dramatic, in that the patient is abIe to open and cIose the Iids at wiII as soon as the muscle flap is attached to the inner canthaI ligament.
It is m,y impression that this is not a result of the contracture of the muscle pedicle; rather, the tension of the flaps automaticaIIy draws the lids together upon reIaxation of the Ievator palpehral and orbicularis muscles. The ability to open and close the lids by contracture of the transplanted muscle is not acquired until two or three months later. Some patients with facia1 paralysis have extremely active muscles of the brow and forehead, the brows being constan& raised and Iowered. An active forehead on one side, in contrast to the blank immobility and drooping lid and brow of the paralyzed side, presents a conspicuous disfigurement. By transferring a muscle fIap of the active frontalis to the muscIe bed of the paralyzed eyebrow, attaching it just beyond the midline of the fore-
American
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Case I. Preoperative picture showing patient attempting to close eyes, muscles of erpression &axed; B, patient smiling showing asymmetry of the face.
FIG.
4.
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head, one cannot only support and eIevate the drooping brow, but can aIso restore some degree of upward motion in this area. The frontalis muscle is transplanted through . . . two mcisrons 35 inch in length at the inner border of each eyebrow, just beIow the hairline. (Fig. 3.) Through these incisions, the skin overIying the middIe third of the forehead is compIeteIy undermined. An incision is made beneath the skin down to the periosteum in the midIine of the forehead from the hairIine to the gIabelIa region. From this point, the media1 $i or 15 inch of the frontalis muscIe is severed at its Iowest attachment and divided high enough to permit the distal end to be shifted across the midline into the opposite eyebrow region. In peduncuIating the muscle, the fibers are separated verticaIIy by blunt dissection, The pedicle is sutured into the body of the orbicularis occuIi superciIia muscIe with No. oooo chromic catgut. AIthough the muscIe puIl is more or Iess obIiqueIy upward near the midbne of the forehead rather than vertical, the resuIt is a distinct improvement over the previous deformity. ApproximateIy three months is required for restoration of function to this transplant, in contrast to the two months required for the same purpose foIIowing transpIantation of the temporalis and masseter muscles to the eyelids
and mouth. The rate of improvement and the end results are in direct proportion to the amount of exercise given the involved muscles. FolIowing al1 these procedures, an elastic pressure bandage is applied, to be worn for one week as a precaution against postoperative hemorrhage and excessive swelling of the tissues. Motion shouId not be attempted for eighteen to twenty-one days after operation. The patient is then instructed in the necessary movements and is encouraged to carry out the exercises faithfuIly every day, preferably before a mirror. EIectric stimuIation for a few minutes daily is useful as an aid in reeducation of the muscles. In the transplantation of muscIe flaps, severa facts shouId be borne in mind, othewise the operation may be a failure. First, the ffaps should be of sufficient size to insure the necessary strength and support to the paralyzed region. Second, the tension on the flaps should be ampIe to insure support and motion; on the other hand, undue stretching may Iead to ischemia of the Haps. Likewise, too much angulation of the pedicIe might interfere with its circulation. Third, we cannot too strongly emphasize the importance of care in separating the muscle fibers to form the Hap in order not to disturb the nerve suppIy any more than necessary.
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Paralysis
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FIB;. 5. Case 1. Six months postoperative
pictures. A, showing patient with eye almost closed and face bilaterally symmetrical in relaxed position; IS, patient with eyes open, smiting slightly, showing the two sides of the face practically bih~terally symmetrical.
The resuks of these procedures, though far from perfect, are beIieved superior to those obtained by the usual supportive operations, either by fascia1 strips or the use of onIy one muscle. In each of the three tran.spIants, the point of insertion of the muscIe, rather than the Physiopoint or origin, is peduncuIated. logically and mechanicaIIy, this insures the least interference with its circuIation, nerve suppIy and direction of pul1. Function improves as the patient re-educates the muscle and its tone increases. By continued efforts along this line, I am confident that we can give these patients consistentI?: better resuIts, bearing in mind the fact that muscIe transpIantation offers most to those with a definitely permanent paralysis. CASE
REPORTS
CASE I. B. F. S., femaIe, aged twenty-one years, was observed in the Plastic Surgery Department of the U. S. Naval HospitaI, Oakland, California, having been referred by the Neurosurgical Department foIlowing removal of a neurofibroma from the left eighth nerve. The tumor had been located beside the brain stem and had extended from the left temporal notch to the region of the meduIIa. The seventh nerve throughout this region had been sacrificed in its removal. The patient’s convaIescence was uneventfu1, though the Ieft acoustic and faciaI nerves were permanently para-
lyzed. She wore a pIastic support hooked into the corner of the mouth and attached around the Irft car. (Figs. 4~ and B.) One morith after remova of the neurotibroma, the first stage of the repair was carried out. A muscIe flap about 94 inch in diameter and 255 inches in Iength was obtained from the anterior third of the temporalis muscIe by dissection from its insertion at the head of the coronoid process of the mandible. A tunneI was made beneath the skin over the maIar bone and across the upper and Iower eyeIids, and the flap was passed through the tunnel to the outer corner of the eye. At this point, the dista1 I inch of the pedicIe was spIit in half, and each end was sutured into the orbicuIaris occuIi of the upper and Iower lids near the mid-portion. Three weeks foIIowing operation, it was observed that the patient sIept with the eyelids cIosed. Between the fifth and sixth week, she was abIe partiaIIy to contro1 the lids by cIinching the teeth. Function graduaIIy increased, and by the end of three months she was abIe to cIose the Iids compIeteIy. This function was better when the patient was not fatigued. AIthough contro1 of the lids was not entireIy restored, the result was a materia1 improvement. It is believed the outcome wouId have been more successfu1 had the muscle flap been long enough to reach the inner cantha region. Function might stiI1 be improved by an cIongation of the fascia to the inner canthus or by a simple fascia1 impIant to support the lower lid. Three weeks after the foregoing procedure, an intraoral incision was made aIong the anterior
Adams-FaciaI
ParaIysis
FIG. 6. Case II. A, preoierative photograph showing asymmetry of face in LIaxed position. Drooping of wide Ieft palpebral fissure, drooping Ieft side of face and pulling of mouth to right. B, six months postoperative with face in norma reIaxed position.
A
B
FIG. 7. Case II. A, preoperative picture showing marked asymmetry of facia1 muscIes of expression with patient trying desperately to ctose left eye; B, six months postoperative picture showing patient able to comptetely close left eye and retract left corner of mouth. Nasolabial fold detiniteIy formed. muscle, and a pediclc graft bo brder of the massetcr W: 1s dissected from its attachment at the Iower The dista1 end of the bo lrder of the mandible. into the upper pe ,dicIe was split and transpIanted to the technic described. an Id lower Iips, according A Iight pressure bandage was applied and mainta ined over the area for one week. The patient was
able to contract the corner of the mouth after five weeks. To support and restore motion to the eyebro\z muscle on the right region, a flap of the frontalis side, $5 inch in diameter, was detached from its insertion, swung across to the paralyzed Ieft side and attached into the body of the orbicuIaris occuIi
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showing marked asymmetry with the patient attempting to whistle; B, six months postoperntive showing improvement with patient whistling. Alnrked improvement in asymmetry of entire face.
FIG. 8. Case II. A, preoperative
photographs
supercilia muscIe and the lower portion of the frontalis. The first movement of the media1 portion of the left eyebrow was observed two months Iater. Unquestionably, this was a case of complete, permanent paralysis, without any possibility of a return of function except by surgica1 treatment. Circumstances prevented the patient from receiving more than one eIectrica1 treatment each week for the first two months. The function obtained by the three muscte transplantations was not entirely satisfactory (Figs. 3~ and R), yet the improvement obtained must be accredited to the operations. At her last observation, the paraIysis was not obvious and, when relaxed, the two sides of the face were almost symmetrica1. CASE II. J. E. S., CorporaI, U. S. M. C. R., aged twenty-two years, had received a throughand-through gunshot wound of the head during active duty. The buIIet had entered just beIow the left eye, ranged through the Ieft side of the face, through the inferior portion of the malar bone and the facial canal, and emerged through the left mastoid region. The wound had been debrided and drained in a lieId hospita1. Roentgenograms had revealed a comminutrd fracture of the Ieft malar bone, the Ia’teraI waI1 of the left maxiIIa, the neck of the condyle of the mandible and the left mastoid process. There was no prrvious history of paralysis or sensory disturbance. The patient was admitted to the Neurological Service of the U. S. NavaI Hospital at Oakland, California, six weeks folIowing the injury. He had a healed scar at the entrance of the buIIet beIow the left eve, and another behind the Ieft ear. Neuro-
logic examination reveaIed a compIete left facia1 paraIysis. (Figs. 61\, 7~ and 8~.) The Ieft pupil was diIated and fixed, and a massive white area was present in the Iower outer quarter of the retina. Below the bulIet wound of the cheek, sensation was Iost over an area approximateIy 3 inches in diameter, and there was some weakness in the muscIes of mastication on the Ieft. Hearing in the left ear was totaIIy Iost. No other signs of nerve injury were elicited. The right side of the face was normal. For a period of four months, the patient wore a pIastic hook in the corner of the mouth and attached around the Ieft ear, to support the Ieft side of the mouth. Repeated neurologic examinations reveaIed no evidence of regeneration of the faciaI nerve during this period. The paratysis was therefore regarded as permanent and the patient was transferred to the Plastic Surgery Department for treatment. Under local anesthesia, a Ilap of the temporatis muscle, about $4 inch in diameter and 3 inches in Iength, was dissected from the head of the coronoid process through a vertical incision. The fascia of the muscIe Ilap was reIIected downward and spIit into two parts, one for each eyeIid. Profiting by our experience in the previous cast, wherein we had dcspended entireIy upon the temporalis muscle of the Ilap, which reached only to the mid-portion the lower lid eyeIid and thus failed to support sufficiently to permit full closure of the lids, the pedicle in the present case was made of proper Iength to reach the inner canthal region, in the hope of providing the necessary support. A tunnel was made heneath the skin over the maIar bone and
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across the upper and Iower Iids, the two haIves of the pedicIe were deIivered through these tunnels and the dista1 ends were sutured into the inner ,canthaI region. Through an intra-ora incision aIong the anterior border of the masseter muscle, the anterior haIf of the muscle was peduncuIated from its attachment at the Iower border of the mandible. This pedicIe was made at Ieast one-third Iarger than that used in the First case in the behef that the resuIts might thus be improved. The distal end of the pedicIe was spht and the hap was threaded through a tunne1 constructed beneath the bucca1 muscosa to the corner of the mouth. The two ends were then passed through the body of the orbicuIaris oris, one through the lower Iip, the other through the upper Irp, and sutured to the muscIe near the midline. To accentuate the nasoIabia1 foId, the ffap was sutured to the outer border of the orbicuIaris oris at its junction with the risorius muscIe. A Iight pressure bandage was appIied to the Ieft half of the face. To prevent sweIIing and intervention of the mucous membrane between the upper and Iower teeth, a thin moId of dental wax was inserted between the teeth and soft tissue of the cheek and Ieft in pIace for severa days. The pressure bandage was removed at the end of one week. The most noticeabIe disfigurement at this time was the paraIysis of the Ieft half of the forehead and eyebrow region. To correct this condition, a flap of the right frontaIis muscIe, ,2 1’ inch wide, was detached from its insertion, swung across to the paralyzed side, and fixed to the body of the obicularis occuli superciIia muscIe and the Iower portion of the paraIyzed frontaIis muscle. AIthough the patient had support of the Iower Iid immediateIy foIIowing operation and the Iids remained cIosed when he sIept, he was cautioned against exerting the muscIes of mastication for two weeks. After this period, he was instructed to begin reeducation of these muscles by clinching his teeth. By the end of the third week, he couId partiaIIy cIose the lids on tightIy chnching the teeth. The function of the Iids continued to improve, and after the Fifth week he was abIe to cIose the eyelids at wiI1. The patient had no controIIed contracture about the corner of the mouth for a period of four weeks. In order to re-educate the muscIe, he practiced at length before a mirror, and from the third week postoperatively, received daiIy electrical stimuIation of the muscIe. The first motion about the corner of the mouth was observed at the end of the fourth week. StrangeIy, he could move the cornei of the mouth onIy by clinching his teeth and moving his right ear at the same time. One week later, he was abIe to contract the corner of the mouth without moving his car, and thereafter contracture of this area progressiveIy improved,
ParaIysis Nine weeks eIapsed before any motion was apparent in the eyebrow region, and then only a sIight twitching of the inner haIf of the Ieft brow obIiqueIy upward and medially was preseqt. Four weeks later, the right eyebrow became extremeIy arched, producing a marked contrast in the two haIves of the forehead. With a No. I I Bard Parker knife bIade, a smaI1 incision was made in the skin of the forehead $5 inch above the middIe third of the right eyebrow, the greater portion of the frontaIis muscIe was incised horizontaIIy down to the periosteum and a pressure bandage was applied. This decreased to some extent the overcontracture of the frontalis muscIe. The contracture of the frontaIis pedicIe on the Ieft was not pronounced at the patient’s Iast observation, six months foIthough the eyebrows were lowing operation, symmetrica when at rest and motion was stiI1 improving. After the fourth month, motion of the eyeIids and about the corner of the mouth improved onIy sIightIy. At six months, the patient couId cIose the eyelids and contract the corner of the mouth onIy by cIinching the teeth. (Figs. 6~, 7~ and 8~.) With his mouth open, he couId retract the Ieft side of his face on hoIding the muscIes of mastication tense. EIectricaI stimuIation to the facia1 nerve had no apparent effect unti1 seven months foIIowing operation. At that time, a IittIe movement of the muscIes of expression of the Iower haIf of the face, indicating a slight regeneration of the nerve to this group of muscIes, was observed on stimulation of the nerve just anterior to the mastoid regeneration of the nerve will process. Whether continue is difficult to predict. In any event, correction of the paraIysis was satisfactory by the end of the second month foIIowing operation. REFERENCES
S. Suture of facial nerve within the temporaI bone. .%rg., Gynec. PYObst., 12: 712, 1927. OWENS, NEAL. Implantation of fascia1 strips through the masseter muscIe for surgical correction of facia1 paraIysis. Plastic @7Keconstr. Surg., 2: 25, 1947.
I. BGNNELI., 2.
DONALD M. GLOVEK (CIeveIand, Qhio): I can only express admiration for this beautifu1 contribution to repair of the very disfiguring effects of facia1 paraIysis. I cannot discuss it because I have not done the operation in this way. FrankIy, 1 have aIways been a bit skeptical about the future of muscle slip transplants from limited experimental observation, but the resuIts shown arc convincing and the method deserves wider use than it has had.
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Adams---Facial
I M-“&i like to ask a cou$c of questions uf the essayist, if 1 may: First, about the future of muscle slips, whether or not he has had any opportunity to observe them over long periods of time to determine how much fibrosis takes place in the musde dip and how much function remains permanently? in this particuIar case, with the beautiful resuIt which is unquestioned, I thought that at the outset the patient had a little facial muscle function before the operation and I was wondering if that was a compIete nerve Ioss or if there was any function at a11 in the nerve or any tendency to regenerate on the part of the facia1 nerve. It has been observed, I think, by atmost everyone who has done the fascia1 transplant operation for fascial paraIysis over a period of years, that the patients so treated, devetop apparent movement of a sbght degree in the side which is paraIyzed. This movement appears to be contributed by the tension on the unaffected muscles of the good side, These patients may thus have a IittIe sham movement on the paraIyzed side which gives the impression of function which is not actually there. EDWARD A. KITLO~SKI (BaItimore, Md.): This work by Dr. Adams again brings up a question which has puzzled us through the years: What function remains after a period of years in slips of muscle and how much fibrosis takes pIace? As Dr. GIover mentioned, we have evaIuated paralysis in many cases in this way: In a great many of the cases there is some regeneration of the nerve. Now, the flaccidity of the face stays because the muscles on the good side have overstretched the muscles on the weakened side, so that even though some nerve supply comes back, that muscIe is overstretched so that it cannot function in opposition directIy to the muscIes on the other side. With simpIe fascia transplants, you can heIp that muscIe to such an extent that I wil1 even go further than Dr. GIover and say that in some of these cases, we believed definitely that there was muscle function after a period of years. That muscle has had a chance to contract some, and will then exhibit its activity in conjunction with that contraction. In cases of BeII’s palsy, we have aIways thought it very important that early, very earIy, a hook attached to a head strap be put in the corner of the mouth to keep traction on the affected side. Quite frequently, if that is done conscientiously, the muscle wiI1 not be damaged during the period when that nerve is coming back and what Iooks Iike a very sad result wiI1 uItimateIy show a very satisfactory face. I managed to get some of the statistics from Dr. Lexer’s clinic, where they had done sixteen of these muscle transplants of the face. After experience with sixteen of them over a period of about six or eight years, Dr. Lexer decided that they were not
Paralysis worth the doing. Apparently there was SO much fibrosis that it simply acted as straps, and fascia transpIants would be just about as satisfactory. We believe, as in some of Dr. Owens’ work, that where a fascia strip is fastened to the masseter and is permitted to take on some of the function of contracting, you can get some permanent muscular effect, because you have not traumatized tht masseter muscle. As mentioned before, I do not have enough experience with these muscIe transplants to say how long they wit1 survive as such. I believe that a slip of muscle handIed in this way, particuIarIy where it is split down, as Dr. Adams explained, wiI1 unquestionabIy not survive and atrophy may be a SIOW process over a period of two or three years or even longer; but I stiI1 beIievc that in the end, he wiI1 again have the same thing as one gets with a strip of fascia. NEAL OWFNS (New Orleans, La.): No method for the correction of facial paratysis offering completely satisfactory support and animation has been developed. The improvement reflected from the use of muscIe transplants or fascia1 transpIants incorporated in functioning muscle has been sufficient to be of great comfort to patients with complete facial paralysis. Effort directed toward the development of a surgical procedure which will improve existing methods is worthwhile, if it does IittIe more than to stimulate renewed interest. Correction of facia1 paralysis, should entail more than actua1 support of sagging muscIes, because support without reanimation means Iittlc comfort to the patient. In answering some of the questions regarding the fibrosis of muscIe slips, I can say that I have observed one case repaired by muscle transpIants for about tweIve years. One of the first cases recorded was corrected over tweIve years ago and that case was corrected by means of muscIe sIips from the masseter muscle. Three slips were utilized, bringing one to the upper lip, one to the angle of the mouth and one to the Iower lip. Asatisfactory result has persisted through a period of over eIeven years. This patient has been examined regularly from year to year, I have seen him within the past three months and the resuIt is better today than it was two months foIIowing the operation. It has been found, on the basis of experience, that these cases wilt show definite improvement during one, two or three years. 1 do not mean to impIy that this is a reflection of more power from the muscIe but probabIy is a combination of increased muscIe power plus a degree of animation resuiting from increased coordination, which is developed as a result of exercises done before a mirror. This is a most important procedure to have patients follow. Unless the patient has the necessary desire to deveIop animation, which can be attained only through constant exercise and practice,
664
AmericanJournal of Surger.~
Adams-Facial
the result wiI1 be proportionateIy less. Patients are instructed routinely regarding the exercise of the masseter muscle. By comparing movements which they visualize in a mirror, they Iearn to develop a marked degree of reanimation. During a tweIve-year period, twelve cases have been corrected. Three or four of those were done by muscle slip transplants, the others were done by fascia transplants, incorporated in the masseter muscle. I was of the opinion that the fascia transpIant subjected the masseter muscle to Iess truma and for that reason discarded the muscIe transplant operation for that one utiIizing the transpIantation of fascia1 strips into the masseter. There are three things which one should consider if pI&ning to use a muscle transplant operation: (I) possible injury of the nerve and muscIe; (2) the inability of advancing muscIe transplants past the midline of the lip and (3) disturbing or appIying too much tension on Stensen’s duct. Patients corrected by means of fascia1 transpIants incorporated in the masseter muscIe have been just as satisfactory, in so far as I can evaIuate, as those corrected by utilization of muscIe transpIants. The use of fascia1 transpiants makes a much simpler operation and one that can be approached by the extra-ora route, avoiding the possibiIity of infection. PAUL W. GREELEY (Chicago, III.): There is one point which I do not beIieve has been’ stressed adequately, and one which has aIways been diffIcuIt for me to decide, that is, just what patients shouId be seIected for operation. I have not been abIe to find any test, either myself or from information given to me by others that wiI1 answer this question accurateIy. The surprising thing is that many patients who have been operated upon by simpIe support of fascia1 strips very soon thereafter appear to have some motion on that side of the face. I have come to beIieve that many of these individuaIs have aIready had a certain amount of spontaneous regeneration of nerve function, which has never been perceptabIe or compIete. Hence, when fascia strips have been inserted in the paralyzed side of the face so as to offset the overpuI1 of the normaI side, it is then possibIe to note a certain amount of motion in the muscIes on the affected side, even though it may be slight. ConsequentIy, I have come, as time has gone on, to operate on more and more individuals with facial paraIysis much earlier than I had in the past. I believe if an individua1 has gone arbitrariIy, say,
Paralysis from three to six months, and has not shown definite signs of a very marked and dramatic return of the function of the muscIes from the nerve injury on that side, that one is justified in recommending some type of fascia support operation. This wiI1 miminize considerabIe permanent atrophy from disuse, and at the same time wiI1 encourage the patient to utiIize what motion remains. I do wish to make it clear, however, that I am speaking of the patient who has a partial return of his nerve function, and not of the individua1 with a known, permanent, compIete paralysis as described by Dr. Adams. Whl. MILTON ADAMS (cIosing): Thank you, Dr. GIover, Dr. KitIowski, Dr. Owens and Dr. Greeley. In regard to the question of complete facial nerve paraIysis in the cases presented, it was the opinion of Captain Bill Livingston, of the Peripheral Nerve SurgicaI Department of the U. S. NavaI HospitaI at OakIand, that the paralysis was complete in both cases and the condition could be improved onIy by facial suspension or muscIe transpIantation. As to the future function of the FuscIe transplant, my experience has been that it continues to improve. Whether the transpIant wiI1 or wiI1 not function depends upon the nerve suppIy. Once the nerve supply is destroyed, the muscIe atrophies. This has been concIusiveIy proved by army and navy surgeons who have been using muscIe substitution in the extremities, particuIarIy the hand. Whether the effect of the operation wiI1 be lasting or fibrosis wiI1 deveIop two or three years Iater Iikewise depends entireIy upon whether or not the nerve suppIy to the transpIanted muscIe has been interrupted. Dr. Owens has pointed out the necessity for daily exercise of the transplant. Without supervised reeducation of the muscIes, preferabIy before a mirror, one cannot expect maximum function. We believe that the use of three muscIes gives the patient the best prospect of restoration of function, with a more norma direction of pull. Granted that the nerve suppIy is ample, the end result will depend upon the patient’s persistence in carrying out the prescribed exercises. * All the ilIustrations in this article are published through the courtesy of The Williams 81 Wilkins Company who published them originally in their journal, ADAMS, WILLIAM MILTON. The use of the masseter, temporahs, and frontalis musdes in the correction of facial paralysis. Plastic e+~Reconstr. Surg., I :2, September, 1946.
MUSCLE SUBSTITUTION OF FACIAL WM.
FOR CORRECTION
PARALYSIS
MILTON
ADAMS, M.D.
LMemphis, Tennessee
F
ACIAL paralysis presents not onIy a disabling and disfiguring deformity, but a most diffrcuh problem from the standpoint of satisfactory correction. One should not be content mereIy to give support to the affected muscIes; it is aIso necessary to restore as much motion as possible to the entire paralyzed side of the face. This may tax to the Iimit the ability of the most highly skiIIed surgeon. In paraIysis incident to simple severance of the facial nerve, regeneration may follow suture of the two ends. In the event the ends of the nerve have probabIy been bruised, permanent suture is best deIayed unti1 the eighteenth to the twenty-first day foIlowing injury, since one can then determine the exact extent of the damage to the nerve beyond the point of severance. In the presence of a smaI1 gap in the nerve, a free graft may often be utilized for repair. A defect in that part which lies within the facial bony cana lends itseIf well to the nerve graft procedure described by Bunnell in 1927. If neither of these methods is feasibIe, a satisfactory resuIt may occasionally be obtained by an anastomosis of the dista1 end of the facia1 nerve to one of the other crania1 nerves, usuahy the eleventh. For extensive injury of the nerve or permanent paraIysis, either fascia1 strips or muscIe pedicle grafts may be utilized. By far the most popuIar technic has been the use of fascia1 strips attached to the temporaIis fascia or muscle, or both, the strips being carried down to give support to the most noticeably sagging areas of the face. There are two reasons for the popularity of this procedure: the technic is simpIe and the improvement is immediate. No motion is obtained, however, or at least only a negIigibIe amount. NeaI Owens has utilized the masseter muscIe in preference to the temporalis, attaching the fascia1 strips to the Iips and corner of the mouth and Iooping them through the body of the masseter muscle. He has found that this not onIy provides support, but the results are definitely better with respect
to motion about the corner of the mouth than foIIowing the use of the temporalis muscle. MuscIe transpIantation provides support equal to that of fascia1 strips and, in addition, permits voluntary motion. In some cases, moreover, fascia1 strips tend to relax, with a consequent return of the sagging of the muscIes, whereas following the transplantation of muscles, the tone improves as reeducation of the transplants is continued. The principle of muscle substitution seems to have been first employed by Lexer in 1867, who transplanted a pedicle of the masseter muscle to the corner of the mouth, to give motion in this region of the face. A number of other surgeons have since transpIanted the masseter muscIe by one technic or another for the same purpose. Gillies and Sheehan have each empIoyed the temp’oralis aIone for restoring motion to the entire side of the face. The muscIe is detached at its origin above, divided into strips and brought down; one strip is attached in the upper eyelid, one in the Iower lid,, one in the supra-orbital region and one or more around the angIe of the mouth. When the temporalis muscle is transpIanted to the region of the mouth, however, its puI1 is Iargely upward and only sIightIy backward. This muscle is most suitable for restoring motion and giving support to the eyeIids, providing, as it does, a sIightIy upward puI1. In paraIysis of the facia1 nerve, there is a IOSS of function of eleven major and nine minor muscIes of expression. One cannot, therefore, expect one muscIe to carry out the work of the entire group. Obviously, the larger the number of different muscles which can be brought into play, the better the function one wiI1 be abIe to restore to the paraIyzed area. By substituting muscles from different locations, muscIe puI1 in various directions may be provided, thus insuring a more nearly normal direction of motion. The masseter muscIe, because of its Iocation, is most suitable for reanimating the corner of the mouth and the Iower part of the paralyzed
634
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Paralysis
FIG. I. TranspIantation of the masseter muscle to the region about the angle of the mouth. i I j Freeing the mtlsseter muscle from its insertion along the lower border of the mandible through an incision in the buccal mucosa. (2) The masseter muscle Hal, divided at its distal end and swung a.nteriorIy to the region about the mouth. (3) The muscle ffap being threaded through the formed tunnet beneath the mucous membrane of the mouth into the body of the obicuIaris oris musck of the upper and Iower lip. The ends of the flaps are sutured as near the midline of the lips as possible. A third sutun is placed at the latera border of the obicularis oris muscle where it conjoins with thv risorius to bring out the nasokrbial expression line. (See footnote p. 664)
face. By transplanting the end of the insertion of the muscle at the lower border of the mandible, one is Iess likely to disturb the nerve supply, the puIl is in the desired direction, being slightly up*-ard and backwzard, function is thus mote active and the effect is mote natural than if the temporalis muscle \\-ete utilized. The operation is best performed under focal anesthesia, in that it is desirabIe to have the patient’s assistance in contracting the muscle from time to time during the operation. Unless the masseter muscIe is unusualIy small or is attached posteriorI>, on the bodv of the mandiNe, the intra-oral approach Is used. By having the patient clinch the teeth, the body of’ the muscle is brought forward against the buccal mucosa. On incising the mucosa along the anterior margin of the muscle, one
immediately encounters the muscle and ma\; readily deliver it through the incision. (Fig. I :‘) If the muscIe is attached more posteriorly on the mandible, an extra-oral approach along the Iowet border of the man&Me is preferable. The pedicle is dissected up from the Iower margin of the mandible and the fibers are separated iongitudinally by gentIe finger dissection. The muscIe should be divided only for g sufficient distance to form a flap of proper length, as the higher the dissection is carried, the greater the danger of impairing the nerve is next made in the supply. A small incision VISCOUSmembrane of both the upper and lower lips, just Iateral to the midline at or near the vermilion border. Through each of these incisions a tunnel is formed through the body of the orhicularis oris muscle, the tunne1.s meeting at the corner of the mouth. The
656
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Adams-Facial
ParaIysis
FIG. 2. Transplantation of a flap of the temporalis muscle to the eyelids. (I) The Iocation and amount of temporalis muscle used to form a ffap; (2) the freed temporalis muscle flap with overIying fascia intact; (3) the overIying fascia reflected down from the body of the mu&e to give needed length to reach the inner canthal region and divided to give a strip for both the upper and Iower eyeIid; (4) the flaps threaded through the eyelids and the ends sutured in the inner canthal region.
tunne1 is then continued backward from this point to the masseter region. The distal end of the pedicIe is now spIit in half for 45 to x inch, and the upper and lower haIves are delivered through the tunnels of the upper and lower lips, respectively, and attached to the muscle. A third suture is placed in the fork of the pedicIe, which is just IateraI to the corner of the mouth; this aids in forming the nasolabial expression line when the patient contracts the muscle. Within two months after the operation, the patient is able, by cIinching the teeth, to deveIop fairly satisfactory contro1 of the pedicIe, with motion in the corner of the mouth and surrounding region. Further improvement may be expected for an indefinite period, as Iong as the patient persists in daiIy exercise of the muscIe. The temporalis muscIe is utiIized in a similar manner to restore support and function to the paralyzed upper and Iower eyerids. Again, the end of the insertion of the muscle is trans-
planted. A vertica1 incision I $5 inches in Iength is made inside the hairline and just above the zygomatic arch, usuaIIy anterior to the temporal artery. (Fig. 2.) The muscle flap, which shouId be about 35 inch wide, is dissected up from the anterior portion of the coronoid process of the mandible. To sever the attachment from the coronoid process, Iong slender scissors with an acute angulation at the ends of the bIades are used. The overlying fascia of the temporahs muscIe is Ieft attached to the flap and, in order to lengthen the flap sufficiently to reach the inner canthal region, the fasica is reflected downward. .Here, also, in forming the pedicIe, the fibers are separated IongitudinaIly with gentle blunt dissection to interfere as little as possible with the nerve suPPlY* A tunne1 is created through the subcutaneous tissues from the tempora1 incision to the outer canthal region, thence through both eyelids to the inner canthal region. The distat end of the flap is split for a distance of I to 146 inches,
Adams-Facial
ParaIysis
AmericanJournafofSurRery
657
FIG. 3. The transplantation of the frontalis Aap to the opposite eyebrow region. (1) and (2) show two smaI1 incisions at the inner border of the eyebrow just below the hairlinc and the area of skin of the central portion of the forehead undermined at the donor site of the frontalis flap. (3) and (4) show the flap being swung over to its new Iocntion and the point of fixation of the distal end.
and one-half is threaded through each of these tunnels, brought together and attached to the inner canthal ligamentous tissue. A maIIeabIe dissecting probe is useful in dehvering the flap through the tunnel, a thread being tied around the ends of the flap and passed through the eye of the probe. One shoutd be careful with respect to the tension on the Aap; the tension should be sufficient to permit closure of the lid on relaxation of the levator, yet not enough to prevent raising of the lid on contracture of this muscle. The tension may be tested by having the patient open and close the lids before the transplant is permanentIy sutured in pIace. The immediate effect of this procedure is dramatic, in that the patient is abIe to open and cIose the Iids at wiII as soon as the muscle flap is attached to the inner canthaI ligament.
It is m,y impression that this is not a result of the contracture of the muscle pedicle; rather, the tension of the flaps automaticaIIy draws the lids together upon reIaxation of the Ievator palpehral and orbicularis muscles. The ability to open and close the lids by contracture of the transplanted muscle is not acquired until two or three months later. Some patients with facia1 paralysis have extremely active muscles of the brow and forehead, the brows being constan& raised and Iowered. An active forehead on one side, in contrast to the blank immobility and drooping lid and brow of the paralyzed side, presents a conspicuous disfigurement. By transferring a muscle fIap of the active frontalis to the muscIe bed of the paralyzed eyebrow, attaching it just beyond the midline of the fore-
American
Journd
of Surgery
Adams-Facial
A
ParaIysis
I3
Case I. Preoperative picture showing patient attempting to close eyes, muscles of erpression &axed; B, patient smiling showing asymmetry of the face.
FIG.
4.
A,
head, one cannot only support and eIevate the drooping brow, but can aIso restore some degree of upward motion in this area. The frontalis muscle is transplanted through . . . two mcisrons 35 inch in length at the inner border of each eyebrow, just beIow the hairline. (Fig. 3.) Through these incisions, the skin overIying the middIe third of the forehead is compIeteIy undermined. An incision is made beneath the skin down to the periosteum in the midIine of the forehead from the hairIine to the gIabelIa region. From this point, the media1 $i or 15 inch of the frontalis muscIe is severed at its Iowest attachment and divided high enough to permit the distal end to be shifted across the midline into the opposite eyebrow region. In peduncuIating the muscle, the fibers are separated verticaIIy by blunt dissection, The pedicle is sutured into the body of the orbicularis occuIi superciIia muscIe with No. oooo chromic catgut. AIthough the muscIe puIl is more or Iess obIiqueIy upward near the midbne of the forehead rather than vertical, the resuIt is a distinct improvement over the previous deformity. ApproximateIy three months is required for restoration of function to this transplant, in contrast to the two months required for the same purpose foIIowing transpIantation of the temporalis and masseter muscles to the eyelids
and mouth. The rate of improvement and the end results are in direct proportion to the amount of exercise given the involved muscles. FolIowing al1 these procedures, an elastic pressure bandage is applied, to be worn for one week as a precaution against postoperative hemorrhage and excessive swelling of the tissues. Motion shouId not be attempted for eighteen to twenty-one days after operation. The patient is then instructed in the necessary movements and is encouraged to carry out the exercises faithfuIly every day, preferably before a mirror. EIectric stimuIation for a few minutes daily is useful as an aid in reeducation of the muscles. In the transplantation of muscIe flaps, severa facts shouId be borne in mind, othewise the operation may be a failure. First, the ffaps should be of sufficient size to insure the necessary strength and support to the paralyzed region. Second, the tension on the flaps should be ampIe to insure support and motion; on the other hand, undue stretching may Iead to ischemia of the Haps. Likewise, too much angulation of the pedicIe might interfere with its circulation. Third, we cannot too strongly emphasize the importance of care in separating the muscle fibers to form the Hap in order not to disturb the nerve suppIy any more than necessary.
\‘<,I..
Adams-Facial
1.XXIV. NIL $
A
Paralysis
B
FIB;. 5. Case 1. Six months postoperative
pictures. A, showing patient with eye almost closed and face bilaterally symmetrical in relaxed position; IS, patient with eyes open, smiting slightly, showing the two sides of the face practically bih~terally symmetrical.
The resuks of these procedures, though far from perfect, are beIieved superior to those obtained by the usual supportive operations, either by fascia1 strips or the use of onIy one muscle. In each of the three tran.spIants, the point of insertion of the muscIe, rather than the Physiopoint or origin, is peduncuIated. logically and mechanicaIIy, this insures the least interference with its circuIation, nerve suppIy and direction of pul1. Function improves as the patient re-educates the muscle and its tone increases. By continued efforts along this line, I am confident that we can give these patients consistentI?: better resuIts, bearing in mind the fact that muscIe transpIantation offers most to those with a definitely permanent paralysis. CASE
REPORTS
CASE I. B. F. S., femaIe, aged twenty-one years, was observed in the Plastic Surgery Department of the U. S. Naval HospitaI, Oakland, California, having been referred by the Neurosurgical Department foIlowing removal of a neurofibroma from the left eighth nerve. The tumor had been located beside the brain stem and had extended from the left temporal notch to the region of the meduIIa. The seventh nerve throughout this region had been sacrificed in its removal. The patient’s convaIescence was uneventfu1, though the Ieft acoustic and faciaI nerves were permanently para-
lyzed. She wore a pIastic support hooked into the corner of the mouth and attached around the Irft car. (Figs. 4~ and B.) One morith after remova of the neurotibroma, the first stage of the repair was carried out. A muscIe flap about 94 inch in diameter and 255 inches in Iength was obtained from the anterior third of the temporalis muscIe by dissection from its insertion at the head of the coronoid process of the mandible. A tunneI was made beneath the skin over the maIar bone and across the upper and Iower eyeIids, and the flap was passed through the tunnel to the outer corner of the eye. At this point, the dista1 I inch of the pedicIe was spIit in half, and each end was sutured into the orbicuIaris occuIi of the upper and Iower lids near the mid-portion. Three weeks foIIowing operation, it was observed that the patient sIept with the eyelids cIosed. Between the fifth and sixth week, she was abIe partiaIIy to contro1 the lids by cIinching the teeth. Function graduaIIy increased, and by the end of three months she was abIe to cIose the Iids compIeteIy. This function was better when the patient was not fatigued. AIthough contro1 of the lids was not entireIy restored, the result was a materia1 improvement. It is believed the outcome wouId have been more successfu1 had the muscle flap been long enough to reach the inner cantha region. Function might stiI1 be improved by an cIongation of the fascia to the inner canthus or by a simple fascia1 impIant to support the lower lid. Three weeks after the foregoing procedure, an intraoral incision was made aIong the anterior
Adams-FaciaI
ParaIysis
FIG. 6. Case II. A, preoierative photograph showing asymmetry of face in LIaxed position. Drooping of wide Ieft palpebral fissure, drooping Ieft side of face and pulling of mouth to right. B, six months postoperative with face in norma reIaxed position.
A
B
FIG. 7. Case II. A, preoperative picture showing marked asymmetry of facia1 muscIes of expression with patient trying desperately to ctose left eye; B, six months postoperative picture showing patient able to comptetely close left eye and retract left corner of mouth. Nasolabial fold detiniteIy formed. muscle, and a pediclc graft bo brder of the massetcr W: 1s dissected from its attachment at the Iower The dista1 end of the bo lrder of the mandible. into the upper pe ,dicIe was split and transpIanted to the technic described. an Id lower Iips, according A Iight pressure bandage was applied and mainta ined over the area for one week. The patient was
able to contract the corner of the mouth after five weeks. To support and restore motion to the eyebro\z muscle on the right region, a flap of the frontalis side, $5 inch in diameter, was detached from its insertion, swung across to the paralyzed Ieft side and attached into the body of the orbicuIaris occuIi
Vo..
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5
A
Paralysis
I3
showing marked asymmetry with the patient attempting to whistle; B, six months postoperntive showing improvement with patient whistling. Alnrked improvement in asymmetry of entire face.
FIG. 8. Case II. A, preoperative
photographs
supercilia muscIe and the lower portion of the frontalis. The first movement of the media1 portion of the left eyebrow was observed two months Iater. Unquestionably, this was a case of complete, permanent paralysis, without any possibility of a return of function except by surgica1 treatment. Circumstances prevented the patient from receiving more than one eIectrica1 treatment each week for the first two months. The function obtained by the three muscte transplantations was not entirely satisfactory (Figs. 3~ and R), yet the improvement obtained must be accredited to the operations. At her last observation, the paraIysis was not obvious and, when relaxed, the two sides of the face were almost symmetrica1. CASE II. J. E. S., CorporaI, U. S. M. C. R., aged twenty-two years, had received a throughand-through gunshot wound of the head during active duty. The buIIet had entered just beIow the left eye, ranged through the Ieft side of the face, through the inferior portion of the malar bone and the facial canal, and emerged through the left mastoid region. The wound had been debrided and drained in a lieId hospita1. Roentgenograms had revealed a comminutrd fracture of the Ieft malar bone, the Ia’teraI waI1 of the left maxiIIa, the neck of the condyle of the mandible and the left mastoid process. There was no prrvious history of paralysis or sensory disturbance. The patient was admitted to the Neurological Service of the U. S. NavaI Hospital at Oakland, California, six weeks folIowing the injury. He had a healed scar at the entrance of the buIIet beIow the left eve, and another behind the Ieft ear. Neuro-
logic examination reveaIed a compIete left facia1 paraIysis. (Figs. 61\, 7~ and 8~.) The Ieft pupil was diIated and fixed, and a massive white area was present in the Iower outer quarter of the retina. Below the bulIet wound of the cheek, sensation was Iost over an area approximateIy 3 inches in diameter, and there was some weakness in the muscIes of mastication on the Ieft. Hearing in the left ear was totaIIy Iost. No other signs of nerve injury were elicited. The right side of the face was normal. For a period of four months, the patient wore a pIastic hook in the corner of the mouth and attached around the Ieft ear, to support the Ieft side of the mouth. Repeated neurologic examinations reveaIed no evidence of regeneration of the faciaI nerve during this period. The paratysis was therefore regarded as permanent and the patient was transferred to the Plastic Surgery Department for treatment. Under local anesthesia, a Ilap of the temporatis muscle, about $4 inch in diameter and 3 inches in Iength, was dissected from the head of the coronoid process through a vertical incision. The fascia of the muscIe Ilap was reIIected downward and spIit into two parts, one for each eyeIid. Profiting by our experience in the previous cast, wherein we had dcspended entireIy upon the temporalis muscle of the Ilap, which reached only to the mid-portion the lower lid eyeIid and thus failed to support sufficiently to permit full closure of the lids, the pedicle in the present case was made of proper Iength to reach the inner canthal region, in the hope of providing the necessary support. A tunnel was made heneath the skin over the maIar bone and
662
American
Journal of Surgery
Adams-Facial
across the upper and Iower Iids, the two haIves of the pedicIe were deIivered through these tunnels and the dista1 ends were sutured into the inner ,canthaI region. Through an intra-ora incision aIong the anterior border of the masseter muscle, the anterior haIf of the muscle was peduncuIated from its attachment at the Iower border of the mandible. This pedicIe was made at Ieast one-third Iarger than that used in the First case in the behef that the resuIts might thus be improved. The distal end of the pedicIe was spht and the hap was threaded through a tunne1 constructed beneath the bucca1 muscosa to the corner of the mouth. The two ends were then passed through the body of the orbicuIaris oris, one through the lower Iip, the other through the upper Irp, and sutured to the muscIe near the midline. To accentuate the nasoIabia1 foId, the ffap was sutured to the outer border of the orbicuIaris oris at its junction with the risorius muscIe. A Iight pressure bandage was appIied to the Ieft half of the face. To prevent sweIIing and intervention of the mucous membrane between the upper and Iower teeth, a thin moId of dental wax was inserted between the teeth and soft tissue of the cheek and Ieft in pIace for severa days. The pressure bandage was removed at the end of one week. The most noticeabIe disfigurement at this time was the paraIysis of the Ieft half of the forehead and eyebrow region. To correct this condition, a flap of the right frontaIis muscIe, ,2 1’ inch wide, was detached from its insertion, swung across to the paralyzed side, and fixed to the body of the obicularis occuli superciIia muscIe and the Iower portion of the paraIyzed frontaIis muscle. AIthough the patient had support of the Iower Iid immediateIy foIIowing operation and the Iids remained cIosed when he sIept, he was cautioned against exerting the muscIes of mastication for two weeks. After this period, he was instructed to begin reeducation of these muscles by clinching his teeth. By the end of the third week, he couId partiaIIy cIose the lids on tightIy chnching the teeth. The function of the Iids continued to improve, and after the Fifth week he was abIe to cIose the eyelids at wiI1. The patient had no controIIed contracture about the corner of the mouth for a period of four weeks. In order to re-educate the muscIe, he practiced at length before a mirror, and from the third week postoperatively, received daiIy electrical stimuIation of the muscIe. The first motion about the corner of the mouth was observed at the end of the fourth week. StrangeIy, he could move the cornei of the mouth onIy by clinching his teeth and moving his right ear at the same time. One week later, he was abIe to contract the corner of the mouth without moving his car, and thereafter contracture of this area progressiveIy improved,
ParaIysis Nine weeks eIapsed before any motion was apparent in the eyebrow region, and then only a sIight twitching of the inner haIf of the Ieft brow obIiqueIy upward and medially was preseqt. Four weeks later, the right eyebrow became extremeIy arched, producing a marked contrast in the two haIves of the forehead. With a No. I I Bard Parker knife bIade, a smaI1 incision was made in the skin of the forehead $5 inch above the middIe third of the right eyebrow, the greater portion of the frontaIis muscIe was incised horizontaIIy down to the periosteum and a pressure bandage was applied. This decreased to some extent the overcontracture of the frontalis muscIe. The contracture of the frontaIis pedicIe on the Ieft was not pronounced at the patient’s Iast observation, six months foIthough the eyebrows were lowing operation, symmetrica when at rest and motion was stiI1 improving. After the fourth month, motion of the eyeIids and about the corner of the mouth improved onIy sIightIy. At six months, the patient couId cIose the eyelids and contract the corner of the mouth onIy by cIinching the teeth. (Figs. 6~, 7~ and 8~.) With his mouth open, he couId retract the Ieft side of his face on hoIding the muscIes of mastication tense. EIectricaI stimuIation to the facia1 nerve had no apparent effect unti1 seven months foIIowing operation. At that time, a IittIe movement of the muscIes of expression of the Iower haIf of the face, indicating a slight regeneration of the nerve to this group of muscIes, was observed on stimulation of the nerve just anterior to the mastoid regeneration of the nerve will process. Whether continue is difficult to predict. In any event, correction of the paraIysis was satisfactory by the end of the second month foIIowing operation. REFERENCES
S. Suture of facial nerve within the temporaI bone. .%rg., Gynec. PYObst., 12: 712, 1927. OWENS, NEAL. Implantation of fascia1 strips through the masseter muscIe for surgical correction of facia1 paraIysis. Plastic @7Keconstr. Surg., 2: 25, 1947.
I. BGNNELI., 2.
DONALD M. GLOVEK (CIeveIand, Qhio): I can only express admiration for this beautifu1 contribution to repair of the very disfiguring effects of facia1 paraIysis. I cannot discuss it because I have not done the operation in this way. FrankIy, 1 have aIways been a bit skeptical about the future of muscle slip transplants from limited experimental observation, but the resuIts shown arc convincing and the method deserves wider use than it has had.
\‘<>I..
1_xSIV, No. 5
Adams---Facial
I M-“&i like to ask a cou$c of questions uf the essayist, if 1 may: First, about the future of muscle slips, whether or not he has had any opportunity to observe them over long periods of time to determine how much fibrosis takes place in the musde dip and how much function remains permanently? in this particuIar case, with the beautiful resuIt which is unquestioned, I thought that at the outset the patient had a little facial muscle function before the operation and I was wondering if that was a compIete nerve Ioss or if there was any function at a11 in the nerve or any tendency to regenerate on the part of the facia1 nerve. It has been observed, I think, by atmost everyone who has done the fascia1 transplant operation for fascial paraIysis over a period of years, that the patients so treated, devetop apparent movement of a sbght degree in the side which is paraIyzed. This movement appears to be contributed by the tension on the unaffected muscles of the good side, These patients may thus have a IittIe sham movement on the paraIyzed side which gives the impression of function which is not actually there. EDWARD A. KITLO~SKI (BaItimore, Md.): This work by Dr. Adams again brings up a question which has puzzled us through the years: What function remains after a period of years in slips of muscle and how much fibrosis takes pIace? As Dr. GIover mentioned, we have evaIuated paralysis in many cases in this way: In a great many of the cases there is some regeneration of the nerve. Now, the flaccidity of the face stays because the muscles on the good side have overstretched the muscles on the weakened side, so that even though some nerve supply comes back, that muscIe is overstretched so that it cannot function in opposition directIy to the muscIes on the other side. With simpIe fascia transplants, you can heIp that muscIe to such an extent that I wil1 even go further than Dr. GIover and say that in some of these cases, we believed definitely that there was muscle function after a period of years. That muscle has had a chance to contract some, and will then exhibit its activity in conjunction with that contraction. In cases of BeII’s palsy, we have aIways thought it very important that early, very earIy, a hook attached to a head strap be put in the corner of the mouth to keep traction on the affected side. Quite frequently, if that is done conscientiously, the muscle wiI1 not be damaged during the period when that nerve is coming back and what Iooks Iike a very sad result wiI1 uItimateIy show a very satisfactory face. I managed to get some of the statistics from Dr. Lexer’s clinic, where they had done sixteen of these muscle transplants of the face. After experience with sixteen of them over a period of about six or eight years, Dr. Lexer decided that they were not
Paralysis worth the doing. Apparently there was SO much fibrosis that it simply acted as straps, and fascia transpIants would be just about as satisfactory. We believe, as in some of Dr. Owens’ work, that where a fascia strip is fastened to the masseter and is permitted to take on some of the function of contracting, you can get some permanent muscular effect, because you have not traumatized tht masseter muscle. As mentioned before, I do not have enough experience with these muscIe transplants to say how long they wit1 survive as such. I believe that a slip of muscle handIed in this way, particuIarIy where it is split down, as Dr. Adams explained, wiI1 unquestionabIy not survive and atrophy may be a SIOW process over a period of two or three years or even longer; but I stiI1 beIievc that in the end, he wiI1 again have the same thing as one gets with a strip of fascia. NEAL OWFNS (New Orleans, La.): No method for the correction of facial paratysis offering completely satisfactory support and animation has been developed. The improvement reflected from the use of muscIe transplants or fascia1 transpIants incorporated in functioning muscle has been sufficient to be of great comfort to patients with complete facial paralysis. Effort directed toward the development of a surgical procedure which will improve existing methods is worthwhile, if it does IittIe more than to stimulate renewed interest. Correction of facia1 paralysis, should entail more than actua1 support of sagging muscIes, because support without reanimation means Iittlc comfort to the patient. In answering some of the questions regarding the fibrosis of muscIe slips, I can say that I have observed one case repaired by muscle transpIants for about tweIve years. One of the first cases recorded was corrected over tweIve years ago and that case was corrected by means of muscIe sIips from the masseter muscle. Three slips were utilized, bringing one to the upper lip, one to the angle of the mouth and one to the Iower lip. Asatisfactory result has persisted through a period of over eIeven years. This patient has been examined regularly from year to year, I have seen him within the past three months and the resuIt is better today than it was two months foIIowing the operation. It has been found, on the basis of experience, that these cases wilt show definite improvement during one, two or three years. 1 do not mean to impIy that this is a reflection of more power from the muscIe but probabIy is a combination of increased muscIe power plus a degree of animation resuiting from increased coordination, which is developed as a result of exercises done before a mirror. This is a most important procedure to have patients follow. Unless the patient has the necessary desire to deveIop animation, which can be attained only through constant exercise and practice,
664
AmericanJournal of Surger.~
Adams-Facial
the result wiI1 be proportionateIy less. Patients are instructed routinely regarding the exercise of the masseter muscle. By comparing movements which they visualize in a mirror, they Iearn to develop a marked degree of reanimation. During a tweIve-year period, twelve cases have been corrected. Three or four of those were done by muscle slip transplants, the others were done by fascia transplants, incorporated in the masseter muscle. I was of the opinion that the fascia transpIant subjected the masseter muscle to Iess truma and for that reason discarded the muscIe transplant operation for that one utiIizing the transpIantation of fascia1 strips into the masseter. There are three things which one should consider if pI&ning to use a muscle transplant operation: (I) possible injury of the nerve and muscIe; (2) the inability of advancing muscIe transplants past the midline of the lip and (3) disturbing or appIying too much tension on Stensen’s duct. Patients corrected by means of fascia1 transpIants incorporated in the masseter muscIe have been just as satisfactory, in so far as I can evaIuate, as those corrected by utilization of muscIe transpIants. The use of fascia1 transpiants makes a much simpler operation and one that can be approached by the extra-ora route, avoiding the possibiIity of infection. PAUL W. GREELEY (Chicago, III.): There is one point which I do not beIieve has been’ stressed adequately, and one which has aIways been diffIcuIt for me to decide, that is, just what patients shouId be seIected for operation. I have not been abIe to find any test, either myself or from information given to me by others that wiI1 answer this question accurateIy. The surprising thing is that many patients who have been operated upon by simpIe support of fascia1 strips very soon thereafter appear to have some motion on that side of the face. I have come to beIieve that many of these individuaIs have aIready had a certain amount of spontaneous regeneration of nerve function, which has never been perceptabIe or compIete. Hence, when fascia strips have been inserted in the paralyzed side of the face so as to offset the overpuI1 of the normaI side, it is then possibIe to note a certain amount of motion in the muscIes on the affected side, even though it may be slight. ConsequentIy, I have come, as time has gone on, to operate on more and more individuals with facial paraIysis much earlier than I had in the past. I believe if an individua1 has gone arbitrariIy, say,
Paralysis from three to six months, and has not shown definite signs of a very marked and dramatic return of the function of the muscIes from the nerve injury on that side, that one is justified in recommending some type of fascia support operation. This wiI1 miminize considerabIe permanent atrophy from disuse, and at the same time wiI1 encourage the patient to utiIize what motion remains. I do wish to make it clear, however, that I am speaking of the patient who has a partial return of his nerve function, and not of the individua1 with a known, permanent, compIete paralysis as described by Dr. Adams. Whl. MILTON ADAMS (cIosing): Thank you, Dr. GIover, Dr. KitIowski, Dr. Owens and Dr. Greeley. In regard to the question of complete facial nerve paraIysis in the cases presented, it was the opinion of Captain Bill Livingston, of the Peripheral Nerve SurgicaI Department of the U. S. NavaI HospitaI at OakIand, that the paralysis was complete in both cases and the condition could be improved onIy by facial suspension or muscIe transpIantation. As to the future function of the FuscIe transplant, my experience has been that it continues to improve. Whether the transpIant wiI1 or wiI1 not function depends upon the nerve suppIy. Once the nerve supply is destroyed, the muscIe atrophies. This has been concIusiveIy proved by army and navy surgeons who have been using muscIe substitution in the extremities, particuIarIy the hand. Whether the effect of the operation wiI1 be lasting or fibrosis wiI1 deveIop two or three years Iater Iikewise depends entireIy upon whether or not the nerve suppIy to the transpIanted muscIe has been interrupted. Dr. Owens has pointed out the necessity for daily exercise of the transplant. Without supervised reeducation of the muscIes, preferabIy before a mirror, one cannot expect maximum function. We believe that the use of three muscIes gives the patient the best prospect of restoration of function, with a more norma direction of pull. Granted that the nerve suppIy is ample, the end result will depend upon the patient’s persistence in carrying out the prescribed exercises. * All the ilIustrations in this article are published through the courtesy of The Williams 81 Wilkins Company who published them originally in their journal, ADAMS, WILLIAM MILTON. The use of the masseter, temporahs, and frontalis musdes in the correction of facial paralysis. Plastic e+~Reconstr. Surg., I :2, September, 1946.