| 1. Bell’s Palsy
This is a form of facial paralysis resulting from
damage to the 7th (facial) cranial nerve (see diagram a).
The transfer of the temporal muscle (innervated by the
5th cranial nerve –see diagram b) was discovered in 1934 along with
the GILLIES technique, consisting in folding a sampled flap attached to
bands of fascia (aponeurosis) over the zygomatic arch to reach the commissure
(diagram c). The results were disappointing: a deformation of the cheek
was visible when the temporal muscle was excessively contracted (but it
was necessary to control the flap). In 1952, McLaughlin released the tendon
of the temporal from the coronoid process (bottom of the lower jaw), so
that all the fibres could be contracted. But, he too, used a relay to
compensate for the insufficient length of the fibres, which also jeopardized
the results (diagram d).
Nowadays, GILLIES technique, perfected by the taking
of a larger flap (rear half of the temporal) is still carried out. Because
the muscle is running under the skin, and due to accretions, we still
observe a deformation of the cheek when it is contracted.
In 1994, Dr LABBE innovated with the lengthening
temporalis myoplasty. He lengthened the muscle by releasing it from the
temporal fossa (above the ear) and redistributing the fibres further ahead.
A relay is no longer needed: the tendon (lower extremity of the muscle),
released from the coronoid process (mandibular ramus) directly reaches
the commissure and the nasogenian sulcus (wrinkle running from the nostril
to the commissure) on which it is distributed. The temporal is no longer
under the skin, but far deeper, under the zygomatic arch and under the
masseter muscle, in a well-lubricated passage, preventing any subcutaneous
accretion and any deformation of the cheek during contraction of the transferred
muscle. Before the operation, doctors make sure the temporal is strong
enough as it is know to be atrophied in somes Mœbius palsies.
Before
the Operation, Relaxed and Smiling
The temporal muscle is a masticatory muscle running
under the zygomatic arch. It is inserted on the skull (in the shape
of a fan, upper insertion point) and on the lower jaw (lower insertion
point). Relaxed and smiling, the lips are down turned.
Contraction of the temporal muscle shortens the fibres and raises
the jaw, enabling clenching of the teeth.
|
Temporalis
muscle
 |
After the operation
The temporal muscle becomes a labial muscle (mainly
allocated to smiling and speech).
The temporal muscle upper insertion point is still on the skull, but shifted
to the front to be lengthened. At the bottom, it is now inserted on a
line running from the nostril to the corners of the lips.
| Relaxed,
the labial commissure is suspended; natural sulcus of the nose is
rebuilt at the commissure. |
|
Contraction
of temporal muscle shortens the fibres: commissure
is raised and gouges out the natural smile line. |
 |
I had the opportunity to be in charge of the first beneficiaries
of the lengthening temporalis myoplasty, which called for the conception
of specific check-up and speech therapy.
The reeducation of the areas that are not directly concerned
by the transfer of the temporal (the eyes, the forehead, the tongue, the
nose, the chin and the neck) remains the same as the usual reeducation
of facial palsies (see "Les Fonctions oro-faciales" - I. EYOUM,
F. MARTIN, G. COUTURE - Ortho-Edition). It involves gentle training in
order to avoid all the inherent complications to all FP: first of all
synkinesis (when a facial muscle is stimulated another one tenses up:
the nervous impulse – electricity – is oriented towards another
branch of the nerve and therefore towards another muscle).
First, the patient is interviewed and given a preoperative
orthopaedic check up. Special attention is given to his labial and jugal
muscular strength. Then he undergoes a functional examination of facial
expressions (mainly the smile), articulation (speech) and mastication.
The purpose of the interview is to inform the patient and make sure of
his motivation for an active participation in his postoperative reeducation.
The Postoperative Check Up
It is repeated during the reeducation. All the changes
are noted down:
- Cosmetic changes: suspension of the labial commissure,
rebuilt nasolabial fold, base of the ala of the nose which has been
raised.
- Muscular changes: the transferred temporal now enables contraction
of the cheek and raises the labial commissure when jaws are clenched
(clenching the teeth). It also enables retropulsion (pulling back lower
jaw), and lateral excursion of the operated side (shifting the jaw to
the operated side). Amplitude of the smile is measured, its direction
noted down.
- Functional changes: the transferred temporal is meant to improve smiling,
labial articulation, the initial step of deglutition (chewing), the
closing of inferior eyelid and nasal breathing.
Reeducation
It starts between the 15th and the
20th day after the operation (one session per week). The patient is asked
to train 4 times a day at home (s/he is given a leaflet describing the
various exercices).
Reeducation Focuses On:
1) The Relaxation of the Face: relaxation, orofacial
stimulations. The patient rediscovers the reanimated area and relearns
to control it.
2) The Softening of the Nasolabial Scar (in the
smile line): the patient learns to massage it (external circular smooth
compressions using the fingers; internal compressions using the tongue).
3) Muscular work (it must be done smoothly,
in order to prevent synkinesis):
- of the Lips: the raising of the commissure is achieved
thanks to the movements of the lower jaw corresponding to the original
function of the transferred temporal (clenching, retropulsion and lateral
excursion of the reinnervated side). The antagonist labial movements
of the commissural raising are also trained to develop the plasticity
of the temporal and the mobility of the lips. The labial closure has
to be improved in its new position.
- of the Cheek: the patient has to contract the
cheek against the teeth appealing to the transferred temporal.
4) Functional Work, including:
- the Smile: achieved by mobilizing the lower jaw, at
the beginning. After a few sessions, the patient tries to achieve this
by simple independent contraction of the temporal. It is then integrated
into exercises focussing on concrete and everyday situations getting
more and more natural and unpredictable, in order to achieve spontaneous
"temporal smile". At this part of the reeducation process
patients must have reconciled themselves with their new face and lost
their tendency to conceal it.
- Deglutition: exercises try to improve labial closure in order to prevent
dribbling, and temporal strength that enables the contraction of the
cheek and the evacuation of alimentary remains stagnant in the bottom
part of the cheeks (buccal vestibule).
- Articulation (speech): particular attention is paid to traction of
the labial commissure in pronouncing "stretched" phonemes
/i, eI/ ; labial closure in bilabial phonemes /p,b,m/ ; temporojugal
strength which has to oppose inflation of the flaccid cheek triggered
by articulation of bilabial and labiodental phonemes /p,b,m,f,v/.
- The Raising of the Inferior Eyelid: when smiling, the labial commissure
is raised, but the cheek too, and sometimes the inferior eyelid which
can therefore better fulfil its function of protecting the eye (efforts
are made to make sure that it is a passive raising of the inferior eyelid
and not a synkinesis).
- Nasal Breathing: temporal muscle exercises traction over the area
of the nostril. This traction prevents the joining of the ala of the
nose, observable during inspiration.
The Raising of the Labial Commissure Can Be Achieved
in Three Phases:
- Phase of the mandibular "smile":
commissural elevation can only be achieved if associated to a movement
of the lower jaw. This phase concerns all operated patients re-educated
or not.
- Phase of the voluntary temporal "smile":
the smile is realised without mobilizing the lower jaw, contraction
of the temporal remaining voluntary. The subject can modulate the amplitude
of the smile. All operated and re-educated patients manage to do it.
- Phase of the spontaneous temporal "smile":
almost all the patients reach, when smiling, articulating “stretched”
phonemes or when salivary glands empty, the phase of a spontaneous commissural
raising free from all mandibular movements (variable according to fatigue
and circumstances).
The transferred temporal relinquishes its original function
(masticatory muscle) to adopt the functions corresponding to commissural
movements toward the top and the back (it becomes a muscle of the smile,
of speech…). During such an evolution, the plasticity of the brain
plays an important part (especially if the new labial movements are practised
in real situations on a daily basis).
The surgery and the associated speech therapy cause the temporal to change
its function at the efferent level and at the cerebral level. This complete
therapy leads to the realisation of what I call the "temporal smile"
which can be described as follows: "a smile obtained by contraction
of the healthy temporal muscle transferred on the commissure and the paralysed
nasolabial sulcus, contraction of the re-educated temporal being now independent
of its original function (mandibular movements). The temporal smile voluntary
at first can become spontaneous. It is a smile in the literal sense of
the word and a full facial expression."
______
2. Information concerning Mœbius bilateral palsies:
The reeducation I propose appeals to nerve V. It is therefore
indicated after any surgical technique producing an active suspension
of the lips in the case of bilateral Mœbius. In fact, nerve VII being
inefficient on both sides, surgeons can only try to appeal to nerve V
(the one that innervates the temporal and the masseter, both masticatory
muscles).
Surgical technique involved in such reeducation (which
appeals to nerve V) are the following (I shall mention some of the features
to be taken into account):
- Lengthening Temporalis Myoplasty (LABBE): proximity
of the transferred muscle, right orientation of the fibres, nervous
suture not necessary.
- Temporalis Myoplasty (GILLIES): transfer of a flap
(large enough) of the muscle. More or less similar results, except a
weakened muscular strength and a deformation of the cheek, during contraction,
due to the subcutaneous position of the muscle.
- Masseter transfer technique: similar reeducation, but
deformation of the cheek due to accretions and, most important, too
horizontal smile due to the orientation of the fibres of the masseter
in the area of the commissure.
- Free flaps transfer technique (not much carried out
in France): a muscle is taken in a distant part of the body (the thigh
for example) and is transposed onto the face. This muscle needs to be
revascularised and re-innervated. It is connected to the branch of nerve
V allocated to the masseter muscle. The operation is carried out in
two phases, one side, then the other.
Lengthening Temporalis Myoplasty alone is particularly
interesting in my opinion, because it has a number of significant advantages:
- operation in a single time on both sides of the face.
No muscle or nerve is taken on another part of the body. Temporal muscle
does not need to be revascularised or re-innervated, because it is just
slightly shifted and not completely transposed,
- no deformation of the cheek,
- efficiency of the muscular strength of the temporal
due to complete activity of all the fibres,
- smile oriented to the top and the outside (same orientation
as a healthy smile).
For Mœbius palsies, activity of the triangularis muscle,
that sustains the smile, sometimes needs to be weakened.
It can be cured by:
- Conscious awareness of the phenomenon,
- Relaxation,
- Medicalised injection of botulic toxin into the relevant
muscles.
The results of the operation associated to the re-education
are quickly observable. They enable a significant smile and help the patients
feel better in themselves.
One of my young operated patients (8 years old,
Mœbius bilateral palsy) spontaneously told me, while playing Happy
Families (version of the game based on facial expressions we developed
together): "The family I imitate most easily is the one I like
the most, the smile-family".
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