Orthodromic Temporalis Tendon Transfer Research Articles

Functional Outcome of single-stage facial reanimation surgery with radical parotidectomy.

Facial nerve sacrifice during radical parotidectomy impairs quality of life. This study assessed the effectiveness of simultaneous single-stage facial reanimation surgery with radical parotidectomy in restoring facial function. A retrospective analysis was conducted on patients who underwent single-stage facial reanimation with radical parotidectomy. Techniques included selective reinnervation and orthodromic temporalis tendon transfer. Outcomes were measured using modified House-Brackmann and Terzis grades, Emotrics facial assessment, and the Facial Disability Index (FDI). Among thirteen patients (median age 54, 69% male), ten received selective reinnervation. Nine of these patients showed improved results of House-Brackmann grade III and Terzis grade 4-5. The remaining three underwent tendon transfer, achieving moderate functional outcomes. Emotrics analysis indicated balanced facial symmetry in the selective reinnervation group. FDI scores reflected satisfactory physical and social/well-being functions. Single-stage facial reanimation effectively restores facial function in patients undergoing radical parotidectomy. This approach offers significant benefits in early facial function recovery.

Smile Outcomes of an Externally Scarless, Intraoral Orthodromic Temporalis Tendon Transfer.

Background: Temporalis tendon transfer (TTT) often relies on external incisions in the nasolabial fold, temporal region, or both. Herein, we studied smile outcomes of a TTT technique via a single intraoral incision without external skin incisions. Objective: To measure the difference in static perioral positions before and after intraoral TTT. Methods: Five patients underwent an externally scarless TTT technique via an intraoral approach. Iris measurements were used to estimate pixel-to-millimeter conversion for facial analysis of vertical and horizontal oral commissure excursion vectors using the JAVA-based program Facegram version 1.0 (Massachusetts Eye & Ear Infirmary). Results: After surgery, mean vertical height on the affected side significantly increased from 3.4 mm to a postoperative value of 20.6 mm, p = 0.016. There was no difference in horizontal smile excursion after surgery (35.7 mm vs. 32.2 mm, p = 0.37). Smile angle difference between affected and healthy smile (Δα) reduced from 27.0° preoperative to 3.5°, representing a decrease in facial asymmetry (p = 0.002). Conclusion: Intraoral, externally scarless TTT is an effective option for dynamic facial reanimation, obviating external incisions in select patients.

Facial nerve management in patients with malignant skull base tumors.

The course of the facial nerve through the cerebellopontine angle, temporal bone, and parotid gland puts the nerve at risk in cases of malignancy. In contrast to Bell's palsy, which presents with acute facial paralysis, malignancies cause gradual or fluctuating weakness. We review malignancies affecting the facial nerve, including those involving the temporal bone, parotid gland, and cerebellopontine angle, in addition to metastatic disease. Intraoperative management of the facial nerve and long term management of facial palsy are reviewed. Intraoperative management of the facial nerve in cases of skull base malignancy may involve extensive exposure, mobilization, or rerouting of the nerve. In cases of nerve sacrifice, primary neurorrhaphy or interposition grafting may be used. Cranial nerve substitution, gracilis free functional muscle transfer, and orthodromic temporalis tendon transfer are management options for long term facial paralysis. Temporal bone, parotid gland, and cerebellopontine angle malignancies pose a tremendous risk to the facial nerve. When possible, the facial nerve is preserved. If the facial nerve is sacrificed, static and dynamic reanimation strategies are used to enhance facial function.

Facial Reanimation by Modified Intraoral Temporalis Tendon Transfer With Ancillary Procedures.

Facial nerve palsy is an exceedingly debilitating condition, incapacitating functional and aesthetic facets of the face. Orthodromic transfer of temporalis muscle is an easy and predictable technique which offers early animation of oral commissure and lower face. A retrospective chart review of 6 patients of facial palsy treated with orthodromic temporalis tendon transfer for facial reanimation is presented. The technique consisted of intra-oral coronoidectomy followed by attachment of fascia lata grafts from the coronoid to the commissure, the upper and lower lips via small cutaneous incisions. Contraction of the temporalis, pulls the fascia lata extensions thereby reanimating the lower face. 4 male and 2 female patients with an age range of 25 to 49 years were treated. Simultaneous fat grafting (2 patients), depressor labi inferioris muscle resection (2 patients) and wedge excision of nasolabial fold (2 patients) was done as ancillary procedures. Post-operative smile evaluation was carried out using the Terzis and Noah facial grading system. Patients were asked to smile with and without biting, and photographs and video were taken. The results were graded from 1 to 5 based on a 5-point scale (ie, poor, fair, moderate, good, and excellent) by an independent observer. The results were excellent in 1 patient (Terzis grading 5/5) and good in the remaining 5 patients (Terzis grading 4/5). Excursion of the oral commissure ranged from 6 to 10 mm. Our experience indicates that temporalis tendon transfer for facial reanimation has a short learning curve and provides early predictable outcome without significant complications. This single-stage, day-care procedure can be easily incorporated by maxillofacial surgeons to expand their surgical spectrum.

Complex treatment of locally advanced squamous cell carcinoma of the parotid gland and secondary primary melanoma

Primary squamous cell carcinoma of the parotid gland accounts for 0.35% up to 9.8% of all parotid malignancies. In advanced stages, the gold standard is wide excision, lymphadenectomy and postoperative radiotherapy. Furthermore, head and neck cancers have an increased risk of secondary primary tumors development. Case report: A 82-year-old male underwent subtotal parotidectomy with facial nerve preservation for right parotid squamous cell carcinoma, in another department. Due to incomplete resection, 4 months later he presented with locoregional recurrence and cutaneous invasion. The patient underwent total parotidectomy en bloc with facial nerve, part of the external auditory meatus, posterior belly of digastric and part of sternocleidomastoid muscle with modified radical neck dissection, levels I-V. The defect was closed with ipsilateral pectoralis major myocutaneous flap, followed by a temporary lateral tarsorrhaphy after two months. The patient underwent adjuvant radiotherapy. One year after surgery, functional and aesthetic impairment of the facial nerve palsy were corrected: the lower face deficit by an orthodromic temporalis tendon transfer; lagophthalmos by lid loading with gold-weight. Postoperative outcome was satisfactory for the patient, with 3 years of postoperative evolution with no recurrence or metastasis. Concomitantly, the patient developed pT1a secondary primary melanoma on the skin island of the flap, which was excised. Conclusion: Patients with locoregional advanced parotid squamous cell carcinoma can benefit from wide excision with neck dissection and postoperative radiotherapy. When the facial nerve cannot be preserved, facial asymmetry can be improved through reanimation procedures. Secondary primary malignancies require proper treatment concomitantly with index tumor follow-up.

Comprehensive approach to reestablishing form and function after radical parotidectomy

IntroductionThe reconstructive goals following radical parotidectomy include restoration of symmetry, reanimation of the face, and reestablishment of oral competence. We present our experience utilizing the anterolateral thigh (ALT) free flap, orthodromic temporalis tendon transfer (OTTT), and facial nerve cable grafting to reestablish form and function. Material and methodsFrom 2010 to 2016, 17 patients underwent radical parotidectomy followed by immediate reconstruction. An ALT was harvested to accommodate the volume and skin defect. Additional fascia lata and motor nerve to vastus lateralis (MNVL) were obtained. Anastomosis of the ALT to recipient vessels was performed, most commonly using the facial artery and internal jugular vein. OTTT was performed by securing the medial tendon of the temporalis to orbicularis oris through a nasolabial incision. Fascia lata was tunneled through the lower lip, then secured laterally to the temporalis tendon. The MNVL was cable grafted from either the proximal facial nerve or masseteric nerve to the distal facial nerve branches. ALT fascia was suspended to the superficial muscular aponeurotic system. ResultsAverage follow up was 19 months. Only one patient failed to achieve symmetry attributed to dehiscence of OTTT. All patients achieved oral competence and dynamic smile with OTTT activation. Facial nerve recovery was seen in 8 patients. 5 reached a House Brackman Score of 3. Two donor site seromas and two wound infections occurred. ConclusionSimultaneous ALT, OTTT, and facial nerve cable grafting provides early reestablishment of facial symmetry, facial reanimation, and oral competence with minimal morbidity.

Lower facial reanimation techniques following cancer resection and free flap reconstruction.

Evaluate outcomes of the standard static sling and orthodromic temporalis tendon transfer reanimation for facial nerve paralysis. Retrospective case series at a tertiary care hospital of head and neck cancer patients with facial nerve palsy secondary to malignancy or resection. From 2004 to 2014, patients undergoing resection of malignancy that involved facial nerve palsy requiring facial reanimation were identified. All procedures were performed by the senior author (e.l.r.). Demographics, methods, revision rates, combination with other procedures, and complications were evaluated. A total of 77 patients underwent 92 procedures, with two patients requiring more than one revision, for a total of 20 revisions. Average time to revision was 9 months. Age, sex, race, side of repair, paralysis prior to procedure, sling type or method, timing of procedure, and radiation therapy were not significantly different between those requiring revision and those who did not. There was no difference in complications between patients who received radiation and those who did not (P = .5), nor between static versus orthodromic temporalis muscle transfer (P = .5). Complication rate was low at 5.4%. Sling procedures can be successfully performed in patients with facial nerve palsy secondary to cancer resection with radiation therapy, with a low revision rate and few complications. 4 Laryngoscope, 126:1990-1994, 2016.

Facial reanimation: evolving from static procedures to free tissue transfer in head and neck surgery.

The purpose of this article is to review and evaluate the surgical options for treating patients with facial paralysis, covering primary neurorrhaphy to facial reanimation, with microvascular free tissue transfer. In recent years, free tissue transfer has been increasingly common for rehabilitating the paralyzed face, providing a more dynamic and aesthetic outcome, than has been possible prior to microvascular surgery in facial plastic and head and neck surgery. Although primary facial nerve repair attains the best results, nerve grafting with the sural nerve and commercially available motor nerve allografts can be used alone, or in combination with masseteric nerve grafts to attain facial tone and protect eyelid function. The workhorse for reanimation is the gracilis free tissue transfer innervated by the masseteric nerve or contralateral facial nerve using a cross-face nerve graft. The orthodromic temporalis tendon transfer has minimal donor site morbidity and acceptable reported outcomes. Static procedures continue to be used alone and in combination with other paradigms for facial nerve reanimation.

Management of Facial Paralysis due to Extracranial Tumors.

Treatment of advanced parotid or cutaneous malignancies often requires sacrifice of the facial nerve as well as resection of the parotid gland and surrounding structures. In addition to considerations regarding reinnervation and dynamic reanimation, reconstruction in this setting must take into account unique factors such as soft tissue volume deficits and the high likelihood of adjunctive radiation therapy. Furthermore, considerations of patient comorbidities including advanced age and poor long-term prognosis often influence reconstructive modality. The optimal reconstructive technique would provide potential for restoration of facial tone and voluntary movement as well as immediate restoration of facial support and function. Beyond considerations of facial movement and rest position, restoration of lost soft tissue volume is critical to obtain facial symmetry. To control long-term volume in the setting of adjunctive radiation therapy, vascularized tissue is required. In this chapter, we describe a comprehensive approach to the management of radical parotidectomy and similar facial defects that addresses these concerns and also describes management strategies over time. Specific techniques employed include anterolateral thigh free flaps, nerve grafting utilizing motor nerves to the vastus lateralis muscle, and orthodromic temporalis tendon transfer. Further considerations relative to the eye, forehead, and long-term facial refinement are also discussed.

Facial Reanimation Technique for Facial Nerve Paralysis following Cancer Resection

Objectives: Analyze outcomes after static sling suspension and orthodromic temporalis tendon transfer reanimation for facial nerve paralysis after definitive cancer resection with flap reconstruction. Methods: Prospectively collected case series in which patient data were collected prospectively from 2004 to 2013 for patients undergoing reconstruction and facial reanimation after resection of malignancy which involved facial nerve sacrifice. Thirty patients were selected for 2 cohorts: static sling suspension (n = 18) and orthodromic temporalis tendon transfer (n = 12). Revision rates, length of stay, complications, time to follow-up, and postoperative symmetry were compared between the 2 groups. Results: Of the 30 patients, 18 underwent static suspension and 12 underwent temporalis tendon transfer. In the static sling group, 6 patients (33%) were advised to undergo revision compared with 2 in the temporalis tendon group (17%; P = .31). Only 4 patients underwent revision, 3 from the static group and 1 from the temporalis transfer group. Suture size, average number of sutures used to suspend the face, timing of procedure, radiation history, and flap reconstruction played no significant role between patients requiring revision surgery and those that did not. Of the patients requiring revision in the static sling group, 33% had undergone preoperative radiotherapy compared with 0% in the temporalis tendon transfer group ( P = .35). The remaining patients either underwent adjuvant therapy or were observed. Conclusions: There was no significant difference between the reconstruction methods. Static sling was performed more commonly at time of flap reconstruction.

Orthodromic temporalis tendon transfer

Chronic facial paralysis is a challenging clinical entity. One of the primary goals is re-establishment of a dynamic smile, which is so important to everyday social interaction. When the facial muscles are denervated for longer than approximately 2 years, they atrophy and fibrose making nerve transfer procedures ineffective. In these cases, regional or free muscle transfer is necessary to achieve dynamic facial movement. Over the past decade, orthodromic temporalis tendon transfer has become a favored facial reanimative procedure. The surgical technique, and important pre- and postoperative factors, are discussed.

Simultaneous Anterolateral Thigh Flap and Temporalis Tendon Transfer to Optimize Facial Form and Function After Radical Parotidectomy

Background Extirpation of aggressive parotid or cutaneous facial tumors often involves facial nerve sacrifice and the creation of a large soft-tissue defect. We describe a method for single-stage reconstruction during radical parotidectomy to restore facial form and function without additional morbidity. Methods We conducted a review of immediate reconstruction/reanimation of radical parotidectomy defects with the use of anterolateral thigh (ALT) fat and fascia flaps for facial contouring, orthodromic temporalis tendon transfer (OTTT), cable grafting of the facial nerve, and fascia lata lower lip suspension. Results Five patients (mean age, 67.4 years) underwent extirpation of malignant tumors with facial nerve sacrifice resulting in large soft-tissue deficits. All patients had ALT free tissue transfer to correct facial contour defects and OTTT to restore facial form and function. Four patients underwent cable grafting of facial nerve branches. Branches of the motor nerve to the vastus lateralis harvested from the ALT surgical site were used for cable nerve grafting in 3 patients. Fascia lata from the same ALT harvest site was used for lower lip suspension to the OTTT in 4 patients. There were no donor site complications. All patients achieved midfacial symmetry at rest, oral competence with dynamic corner-of-mouth movement, and full eye closure. Conclusions Tumor clearance, symmetric facial appearance, as well as dynamic facial rehabilitation were accomplished in a single-stage procedure using the method described herein. The ALT free flap provides versatile options for soft-tissue defects as well as access to motor nerves optimal for grafting without additional morbidity. Patients undergoing extirpation of malignant tumors requiring facial nerve sacrifice can undergo immediate free tissue contour reconstruction and facial reanimation procedures with no additional morbidity.

Orthodromic Temporalis Tendon Transfer

Objectives To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials...

Highlights of Archives of Facial Plastic Surgery

Archives of Facial Plastic SurgeryVol. 14, No. 1 Free AccessHighlights of Archives of Facial Plastic SurgeryPublished Online:2 Jan 2012AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Auricular Keloids: Combined Therapy With a New Pressure DeviceGregor M. Bran, MD, and colleagues describe the use of a custom-made pressure device used as adjuvant therapy following treatment of auricular keloids by surgical excision and corticosteroid injection. The authors applied this device to 7 patients postoperatively and did not observe any keloid recurrences over a mean follow-up period of 24 months.See page 20Orthodromic Temporalis Tendon Transfer: Anatomical ConsiderationsNoah P. Parker, MD, and colleagues present the results of an anatomical study of the orthodromic temporalis tendon transfer, a surgical technique used for the dynamic reanimation of the paralyzed face. The authors performed cadaveric dissections on 20 hemifaces to define the locations of relevant at-risk structures in the field of surgical dissection and to define the reach of the mobilized temporalis tendon during this reconstructive procedure.See page 39Nasal Batten Grafts: Are Patients Satisfied?A hmed Sufyan, MD, and colleagues performed a prospective study on the use of porous polyethylene alar batten grafts for the treatment of nasal valve collapse. The procedure was performed on 18 patients with nasal airway obstruction, most of whom underwent concurrent septoplasty and inferior turbinate surgery. The results were analyzed to determine the impact of surgery on patient perceptions of both nasal airway patency and cosmetic appearance of the nose.See page 14Zygomaticomaxillary Complex FracturesDanny Meslemani, MD, and Robert M. Kellman, MD, performed a review of zygomaticomaxillary complex fractures. The authors highlight the classification, presentation, diagnosis, and management of this commonly encountered facial fracture pattern.See page 62The Four Seasons: Winter, by François Boucher (1703-1770).See page page 76This issue's Highlights were written by Richard Wright, MD.FiguresReferencesRelatedDetails Volume 14Issue 1Jan 2012 InformationCopyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Highlights of Archives of Facial Plastic Surgery.Archives of Facial Plastic Surgery.Jan 2012.7-7.http://doi.org/10.1001/archfaci.2011.1480Published in Volume: 14 Issue 1: January 2, 2012PDF download

Orthodromic Temporalis Tendon Transfer

To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials. Ten fresh cadavers provided 20 hemifaces for dissection. Measurements and photographic documentation were used to examine the parotid duct, masseteric artery, inferior alveolar nerve, internal maxillary artery, and mobilized tendon relative to adjacent landmarks. The parotid duct was found in a reproducible region posterior to the melolabial crease and inferior to a parotid duct reference line. The masseteric artery was found posterior to the posterior-most attachment of the tendon at its exit from the sigmoid notch (mean, 14.5 mm). The inferior alveolar nerve was found posterior to the anterior edge of the ascending ramus (mean, 18.3 mm). The internal maxillary artery coursed superiorly from posterior to anterior along the medial mandible near the coronoidectomy site. The tendon reached beyond the melolabial crease in 17 of 20 hemifaces (85%). The parotid duct reference line and the melolabial crease allow estimation of the parotid duct location. Anatomical relationships between the tendon, parotid duct, neurovasculature, and anatomical landmarks underscore the importance of deliberate soft-tissue retraction and subperiostial elevation to minimize injury. The tendon alone usually provides adequate length for orthodromic suspension.

Orthodromic Temporalis Tendon Transfer: An Anatomic Study

Objective: 1) Understand the relationship of anatomic structures at risk for injury during the transfacial orthodromic temporalis tendon transfer procedure (OTTT) for facial reanimation. 2) Define the anatomic limitations of the OTTT without temporal releasing incisions of the muscle origin or perioral lengthening materials. Method: Ten fresh cadavers were used to perform 20 hemi-face dissections. Detailed measurements and photographic documentation examined the parotid duct (PD), masseteric artery (MA), inferior alveolar nerve (IAN), and internal maxillary artery (IMA) relative to surgical landmarks. The perioral reach of the mobilized temporalis tendon was measured and photographically documented. Results: Measurements revealed a consistent relationship between the PD and a reproducible reference line. The PD was located within the superior dissection field in all dissections. The IAN was consistently located over a centimeter from the TT insertion on the medial mandible and from the anterior ascending ramus. The MA consistently coursed within millimeters of the most inferior portion of the sigmoid notch within the substance of the masseter muscle. The IMA consistently coursed superiorly from posterior to anterior just medial to the mandible. All tendons (100%) reached beyond the melolabial crease to the perioral musculature for orthodromic resuspension. Conclusion: Reproducible PD-reference line measurements allow for pre-incision PD localization. Consistent relationships between the tendon, PD, neurovascular structures, and bony landmarks underscore that deliberate soft tissue retraction and subperiostial elevation minimizes injury risk. The mobilized tendon appears to achieve adequate length for resuspension without temporal releasing incisions or perioral lengthening materials.

Management of Facial Paralysis in the 21st Century

Facial paralysis is a clinical entity associated with significant morbidity, which has a treatment paradigm that is continually evolving. Surgical management of the paralyzed face poses significant challenges to achieve the goal of returning patients to their premorbid states. Here we attempt to review the advances in facial reanimation, in particular with regards to chronic facial paralysis. These include recent developments in static and dynamic rehabilitation including advances like artificial muscles for eyelid reconstruction, dynamic muscle transfer for the eye, and orthodromic temporalis tendon transfer.

Modification of the Orthodromic Temporalis Tendon Transfer Technique for Reanimation of the Paralyzed Face

To report a modification of the temporalis tendon transfer technique used in facial paralysis where dynamic adjacent muscle transfer is determined to be the best treatment option. Case series with chart review. Tertiary care teaching hospital. Review of 10 consecutive patients who underwent orthodromic transfer of the temporalis tendon and the attached coronoid process for the treatment of longstanding facial paralysis. Outcomes measured included patient satisfaction, measurements of oral commissure elevation with smiling, and grading of preoperative and postoperative patient photographs by objective physician observers. Reporting of complications. Patient satisfaction was high, with a mean score of 7.0 (possible score of 10). Four patients were graded by the observer as excellent to superb. The other 6 patients were rated as having fair to good postoperative results. Movement was identified in every patient and ranged from 2.1 to 9.3 mm, with mean movement of the oral commissure of 5.12 mm. One patient developed a seroma at the site of harvest of the fascia that was drained without further complication. This facial reanimation procedure is a novel modification of the temporalis tendon transfer technique in which the coronoid process is transferred in conjunction with the tendon. This technique is minimally invasive and may result in less variability of the postoperative aesthetic result. The procedure allows orthodromic action of the temporalis muscle, is relatively easy to perform, and eliminates the facial asymmetry typically produced by transfer of the origin of the temporalis muscle.

Facial paralysis rehabilitation: state of the art

Surgical management of facial paralysis continues to undergo evolution. Advances made in management reflect the challenging nature of facial paralysis and the drive to ever improve outcomes. Recent advances have been made in neuronal transfers using the masseteric nerve, minimally invasive static procedures, and dynamic transfer of the temporalis tendon. Continued evolution of techniques for the management of facial paralysis is reflected in the current literature. Broader application of neuronal transfers, minimally invasive static procedures, and orthodromic temporalis tendon transfer, among other techniques, indicates a vibrant field of surgeons who pursue ever better results for patients with facial paralysis.