BRINGING BACK
THE SMILE

Orthodromic Temporalis Muscle Transfer:
Single Stage Facial Reanimation

A 49-year-old male patient was brought to BLK Centre for Plastic Surgery & Cosmetic Surgery with a left side incomplete facial nerve palsy (Bell’s palsy). He was concerned about the asymmetry of his face and the deviation of the angle of his mouth while smiling and excessive watering from the left eye.
The patient underwent orthodromic temporalis muscle transfer in order to restore the symmetry of his face. Preoperative markings of zygomatic arch, temporomandibular joint, coronoid process, modiolus and nasolabial crease were done on the left side. After infiltration, preauricular incision extending to the temporal region was given and flap was raised in subgaleal plane. Temporalis muscle was identified and its attachment with the coronoid process under zygomatic arch was divided preserving the neurovascular pedicle. About 14 x 2.5 cm fascia lata graft was harvested from the right thigh.

After identifying the modiolus, risorius and zygomaticus major muscles, a tunnel was dissected under the zygomatic arch through the buccal space. Fascia lata strip was attached to the modiolus, risorius and zygomaticus major muscle in order to achieve a full face smile post-operatively. After adjusting adequate tension, the other end of the fascia lata graft was secured to the tendinous portion of the temporalis muscle. SMAS plication was also performed to correct the sagging of the left side of the face. In order to treat excessive watering of the left eye, a strip of fascia lata graft was used as a lower eyelid static sling.

The patient was advised a soft diet for 2 weeks post-operatively and after 3 weeks the patient was asked to start physical therapy where he had to stand

in front of the mirror and clench his teeth to initiate smile.

Post-operatively the symmetry of the face significantly improved in resting state and on facial animation during conversation and smiling. After 3 months the patient was able to smile spontaneously without conscious effort. The patient was extremely satisfied after the restoration of his smile and there was a significant improvement in his self-esteem.

Orthodromic temporalis muscle transfer is a single stage procedure for incomplete facial nerve palsy which gives satisfying and prompt results without any bulge over zygomatic arch. SMAS plication during operation gives additional benefit in improving facial symmetry. Over a period of time due to plasticity of the brain most patients are able to obtain spontaneous and emotional expressions over the face. Combining additional procedures like static support to the lower lid (as was done in the present case), gold weight implant to the upper lid and eyebrow elevation procedures as on required basis can further give additional improvements in cases of facial nerve palsy for holistic management of a very difficult and complex problem.