종설1 종설2 원저1
증례1 원저2
증례2 증례3 증례4 증례5
서울대학교 의과대학 성형외과학교실
박준호, 장 학
Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
Jun Ho Park, Hak Chang
불완전 안면마비의 대퇴근막 장근 슬링을 이용한 교정술
J Korean Skull Base Society 14권 2호 : 39~43, 2019
Facial paralysis affects the quality of life of patients by disrupting the innate connection between mimetic muscles and emotions, which results in a social interaction barrier. Various methods, including static and dynamic treatment have been introduced and free functional muscle transfer with dual innervation method has gained popularity in the last decade. However, for patients with incomplete facial paralysis, free functional muscle transfer is burdensome by its relatively unpredictable outcome and lengthy operation. Rather than aggressive free functional muscle transfer, tensor fascia lata sling remains to be one of the most valuable tool for reanimation in patient with incomplete facial paralysis.
Static treatment of incomplete facial paralysis with tensor fascia lata sling
논문 접수일 : 2019년 8월 10일 논문 완료일 : 2019년 8월 30일 주소 : Department of Plastic and
Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul 03080, Korea
Tel : +82-2-2072-2375 Fax : +82-2-3675-7792 E-mail : [email protected]
Hak Chang
교신저자
Fascia lata, Facial paralysis, Reconstructive surgical procedures Key Words
▒ INTRODUCTION
Facial paralysis affects the quality of life of patients by disrupting the innate connection between mimetic muscles and emotions, which results in a social interaction barrier.
Various methods, including static and dynamic treatment have been introduced and free functional muscle transfer with dual innervation method has gained popularity in the last decade.
However, for patients with incomplete facial paralysis, free functional muscle transfer is burdensome by its relatively unpredictable outcome and lengthy operation. In this article, we report a simple and effective technique using tensor fascia
lata (TFL) sling for incomplete facial paralysis patients.
▒ CASE REPORT
A 22-year-old male patient diagnosed as having left facial nerve paralysis visited an outpatient clinic expecting to improve his smile symmetry at rest and smile vector. He had fractured his left temporal bone in a traffic accident when he was 1-year old. His tympanic membrane was traumatically perforated, fracture line involved otic capsule, and facial nerve was destructed at geniculate ganglion portion. A week after the accident, subtotal petrosectomy and hypoglossal-facial
Fig. 1
Harvested tensor fascia lata (11×2 cm).
Fig. 2
Intraoperative photographic finding after tensor fascia lata inset.
nerve crossover were performed.
When the patient visited the clinic, House-Brackmann grade was identified as V. On focusing on patient’s mouth, resting asymmetry and only slight movement of lips was noticed.
Electro-diagnostic exam for facial nerve evaluation was done.
Severe partial axonotmesis indicating incomplete recovery was confirmed. First, we considered free latissimus dorsi muscle transfer with dual innervation technique, which is performed on most of facial paralysis patients in our department without co-morbidities. However, considering that the patient wanted (resting lip symmetry and improved smile vector), the operation plan was changed to sling technique using TFL.
The operation underwent with a two-team approach. After general anesthesia, 2 cm linear incision was made 10 cm above the lateral condyle of tibia. Subcutaneous dissection to reach TFL was performed and supra-TFL dissection was performed proximally for 11 cm. Additional 2 cm incision was made proximal to first incision line and 11 × 2 cm TFL was harvested (Fig. 1).
Two incisions were made on the left hemiface; the first incision line was along temporal hairline and the other incision line was on the estimated nasolabial fold considering the contralateral fold and planned smile vector. Dissection continued in the subcutaneous plane until the superficial
musculoaponeurotic system (SMAS) layer was exposed. After supra-SMAS layer (subcutaneous layer) tunneling with Mayo scissors between the two incisions, the harvested TFL sling was inset. At this point, cautious approach is essential to avoid dissecting beneath the zygomaticus muscle along the most superior portion of the SMAS as the SMAS is very thin in this area. Three-point fixation of TFL on the modiolus and 5-point fixation on the deep temporal fascia were done with a 2-0 Ethibond suture (Ethicon, Somerville, NJ, USA). After confirming sufficient overcorrection of the TFL sling, the operation was completed (Fig. 2). The operation time was 95 minutes.
The patient had no complication such as hematoma, skin necrosis or donor site complications. Then, 83 days postoperatively, resting lip symmetry and smiling vector were adequately improved compared to initial finding (Fig. 3). The patient was satisfied with the result of TFL sling technique.
▒ DISCUSSION
Traditionally, TFL is a commonly used autologous material for reconstructive procedures, particularly in frontalis sling, abdominal wall reconstruction and Achilles tendon repair.
[1-3] It has been popularly used in sling procedures owing
Fig. 3
A B C D
(A) Preoperative photographic finding of resting smile. (B) Postoperative photographic finding of resting smile (3 months after surgery). (C) Preoperative photographic finding of lip movement. (D) Postoperative photographic finding of lip movement (3 months after surgery).
to its adequate width, thickness, and durability. As a sling component, TFL is wider than palmaris longus, thus allowing for more efficient management and fixation. Furthermore, a previous study has shown that palmaris longus is absent in up to 34% cases compared to TFL tendon, which was found to be never absent.[4] Synthetic materials, such as GoreTEX™
(W.L Gore & Associates Inc., Flagstaff, AZ, USA) have also been used.[5] By its durability, less overcorrection is necessary and also the patient has no donor site morbidity by using this material. However, foreign body reaction and frequent infection remain as major problems.
A few studies have used cross-face nerve graft and temporalis muscle transfer for incomplete facial paralysis.
Hontanilla et al. [6] reported a two-stage cross-face nerve grafting method for patients with unilateral incomplete facial paralysis. Qualitative evaluation revealed high- grade satisfaction in 6/8 patients (75%) who underwent this method. Frey et al. [7] performed the cross-face nerve grafting method by coaptation to the zygomatic branch of the healthy side. However, translocation amplitude decline of the oral commissure of the healthy side was noticed after 6 months. Although temporalis muscle transfer is still a popular procedure, the hollowing of the temporal region may be an inevitable concern.[8]
In the last decade, many authors have reported facial reanimation using free functional muscle transfer.[9-12]
However, the amplitude of transposition of mouth corner is unpredictable and if the outcome is unsatisfactory, bulkiness of functionless muscle flap remains as a “disastrous mass.”
In addition, it has a long operating time and is a relatively aggressive procedure, which is burdensome for the elderly and patients with co-morbidities.
By using TFL as the sling material, resting symmetry and smiling vector can be easily corrected. Autologous TFL acts as an “internal suspender” as it supports lip elements and counteracts the over-pull of contralateral muscles. Particularly in incomplete paralysis, the result of decreased excursion requirement after sling helps muscle to more effectively pull against forces of gravity. With this method, operation time
is much shorter and the risk of donor site morbidity is lower than it is using functional muscle flap methods. Furthermore, if loosening of fascia graft occurs over time or if under- correction was is noticed after surgery, it is relatively easier to correct with office-based surgery.
There are still few limitations of using a TFL sling as the reanimation method. It leaves new scars on the face and the outcome may be less satisfactory than that of successful free functional muscle transfer with dual innervation method.
However, the outcomes of free transfers are variable and unpredictable. In addition, if the result is unsatisfactory, it will lead to a huge concern for both surgeons and patients in terms of whether to try free flap again or return to static treatment such as sling operation. Although nasolabial incision leaves a new scar, the scar can be barely seen by delicate sutures and can also be concealed in the fold region.
▒ CONCLUSION
Static sling operation using TFL is not an old fashioned method for facial paralysis patient. Especially for smile rehabilitation of patients with incomplete facial paralysis, physicians should focus on what is missing and what the patient wants. Rather than aggressive free functional muscle transfer, TFL sling remains to be one of the most valuable tool for reanimation in patient with incomplete facial paralysis.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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