Transoral orthodromic temporalis muscle transfer technique for dynamic reanimation of the paralysed face

In 1934, Sir Harold Gillies described his experience of the temporalis muscle sling to rehabilitate facial paralysis.1 Via preauricular and nasolabial incisions, the procedure involved rotating a band of temporalis muscle over the zygoma where the muscle sling was augmented with strips of fascia lata. This technique was later modified by McLaughlin without inversion of the temporal muscle but in an orthodromic manner.2 This modification avoided the soft tissue fullness over the zygomatic arch area and depression of the donor site. Proponents of the latter technique argued that the vector of the transferred muscle is similar to that of the original temporalis muscle direction and produces a more natural, aesthetically pleasing appearance.3 This article describes a modification of the orthodromic technique undertaken via a transoral approach, without any incisions on the face. The advantages of this technique are the lack of facial scarring, minimal postoperative discomfort and rapid healing of the buccal mucosa. In contrast to the external approach, facial soft tissue swelling and bruising is minimal. We have not encountered problems with chewing or diminutions of temporalis muscle function, suggesting that utilising a wide strip of muscle results in minimal long-term morbidity. Indeed, the main comment from patients about benefit is improved chewing as food no longer sits in the crevasse of the buccal cavity. This is probably as chewing activates the temporalis and dynamically moves the food to the centre of the oral cavity. In common with other temporalis muscle transfers, the patient can make a faux smile by clenching the jaw. The smile is not normal, but there can be a learnt dynamic mid-face movement as well as the positional change at rest due to the hitched up nasolabial fold. There is an inevitable decline in the position of the mouth and nasolabial fold with time. This is due to the continued effects of gravity and ageing. Overcorrection with considerable bulking up of the tissues will compensate for this although it is possible to revise the procedure. The procedure is mainly used in complete facial palsy following tumour resection and is often part of other procedures such as tarsal surgery and nerve grafting. There seems to be no drawback to doing the procedure at the same time as a nerve graft as the time taken for the nerve regrowth is similar to the main effects of the procedure to wear off. Indeed, the patients who have had this procedure at the same time as a decompression of their facial nerve have had symmetrical faces despite this having been done on one side. Nerve grafts, whether cable grafts, cross-facial grafts or facial hypoglossal do not give better results than House–Brackmann grade III, which is far from normal.4 The advantage in muscle tone, position or movement provided by this procedure is thus useful. We are grateful to Philip Ferguson Jones MMAA RMIP, Medical Illustrator (www.medicalartwork.co.uk), for providing the illustrations. None. None.