Surgery That Restores a Smile

Ask people with longstanding facial paralysis what bothers them most, and they usually won’t mention droopy or teary eyes, nasal obstruction, or any other of the myriad functional problems this devastating condition produces.

“Instead,” says Patrick Byrne, director of facial plastic and reconstructive surgery in the Department of Otolaryngology—Head and Neck Surgery, “by far the most common complaint they have is that they’re unable to smile.” So Byrne, along with facial plastic surgeon Kofi Boahene, addressed that most troubling aspect of facial paralysis by developing a new procedure in which a muscle used for chewing is detached, rerouted and reattached to the smile musculature.

In the operation, known as temporalis tendon transfer, or T3, the temporalis is released and mobilized at the insertion into the coronoid and then transferred to the oral commissure. The end result is orthodromic transfer of the temporalis muscle insertion.

Byrne and Boahene have performed about 26 of these procedures to date, and in just the last year, they have refined the technique considerably. “It now can be done in a minimally invasive manner through a single incision with much less dissection and in less than an hour,” says Byrne. “We think that’s quite a big advance, and patients are thrilled.”

The T3 is always combined with intense physical therapy—not only after the operation, but also beforehand so that patients can get accustomed to contracting the temporalis to create a smile.

The T3 differs from the traditional temporalis muscle transfer in that it uses the tendon and produces none of the facial asymmetry typically associated with the classic technique. To achieve the best symmetry, Byrne and Boahene will sometimes also do extensive cosmetic surgery on the face following T3.

The T3 also differs from another option for longstanding facial paralysis: free tissue transfer. With FTT, a muscle along with its vein and motor nerve supply are harvested most commonly from the gracilis and implanted to replace the smile musculature.

“Although this is a very long operation with several days of hospital stay and up to 12 months before benefits are seen, patients don’t have to retrain themselves to smile,” says Byrne. “The smile is spontaneous.”

And that smile is important because the emotions shown on the face affect a person’s state of mind, Byrne says. “The change this T3 procedure has made in patients’ self-confidence and ability to interact with others has been outstanding.”

To refer a patient: 410-955-4985