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

Jovana Cosic
Dec 1, 2025
4 min read

Abstract

Objective

To describe and evaluate a modified orthodromic temporalis tendon transfer technique for facial reanimation in patients with long-standing facial paralysis, incorporating transfer of the coronoid process to improve stability and aesthetic outcomes.

Study Design

Retrospective case series.

Setting

Tertiary care teaching hospital.

Subjects and Methods

Ten consecutive patients with long-standing facial paralysis (>2 years) or irreversible facial nerve injury underwent orthodromic transfer of the temporalis tendon with the attached coronoid process. Outcomes included patient satisfaction, objective measurements of oral commissure elevation during smiling, independent surgeon photographic grading, and complication reporting.

Results

Patient satisfaction was high, with a mean score of 7.0/10. Commissure excursion ranged from 2.1 to 9.3 mm (mean 5.12 mm). Four patients achieved excellent-to-superb results; six had fair-to-good outcomes. Complications were minimal, with one seroma at the fascia lata harvest site.

Conclusions

This modified facial reanimation technique is minimally invasive, preserves the natural vector of temporalis muscle contraction, provides immediate results, and may reduce variability in aesthetic outcomes.

Introduction

Reanimation of the paralyzed face remains one of the most complex challenges in reconstructive surgery. Facial expression relies on 23 paired mimetic muscles and the orbicularis oris, all innervated by the facial nerve. Because facial paralysis varies widely in etiology, duration, and severity, no single procedure serves as a universal standard.

Dynamic reanimation techniques are preferred over static suspension when possible. Early interventions typically include nerve repair, grafting, or substitution. However, after approximately two years of denervation, reinnervation becomes unreliable owing to motor end-plate degeneration, making muscle substitution the best available option.

The temporalis tendon transfer has seen renewed interest due to its relative simplicity, single-stage nature, and immediate results. Orthodromic transfer of the tendon preserves the natural contraction vector of the temporalis muscle and avoids the cosmetic deformities associated with temporalis muscle origin transfer or free tissue transfer.

Surgical Technique

Overview

This modified technique differs from traditional approaches by transferring the coronoid process together with the attached temporalis tendon, and by passing a fascia lata graft through a drilled aperture in the coronoid, creating a stable pulley mechanism that allows precise tensioning.

Fascia Lata Harvest (Figure 1A)

A strip of fascia lata measuring approximately 8 cm × 1 cm is harvested from the upper thigh via a short incision parallel to a line between the anterior superior iliac spine and lateral tibial condyle. The wound is closed in layers and typically not drained.

Nasolabial Approach and Coronoid Osteotomy

A 3–4 cm incision is placed within the nasolabial fold of the paralyzed side, marked preoperatively while the patient is upright to ensure proper camouflage. Blunt dissection is carried into the buccal space, where the buccal fat pad and Stensen’s duct are carefully identified and retracted.

The coronoid process is palpated manually. Using electrocautery for exposure and a reciprocating surgical saw, the coronoid process is osteotomized without detaching the temporalis tendon.

Coronoid Preparation and Fascial Pulley (Figures 1B–1C)

A 3–4 mm hole is drilled through the center of the freed coronoid process. The fascia lata graft is passed through this opening, allowing it to slide freely and function as a pulley mechanism that facilitates fine adjustment of commissure elevation.

Perioral Fixation and Smile Tensioning (Figure 1D)

One end of the fascia lata graft is sutured to the modiolus using a 3-0 braided polyester mattress stitch. The graft is then tensioned through the coronoid pulley until the first premolar tooth becomes visible, which is used as an intraoperative landmark. The second limb of the graft is secured near the ipsilateral philtral column of the upper lip.

Adjunctive procedures (brow lift, eyelid loading, or tarsal strip) were performed in selected patients. Postoperatively, patients were placed on a soft diet for two weeks.

Outcome Measures and Analysis

Subjective Outcomes

Patients completed the validated FaCE (Facial Clinimetric Evaluation) scale, assessing facial function and quality of life. Results were analyzed using the Wilcoxon signed-rank test.

Objective Evaluation

Three independent physicians evaluated standardized preoperative and postoperative photographs using the May grading scale (I = superb to VI = failure). Only photographs taken ≥3 months postoperatively were included.

Commissure Movement Measurement

(Figure 2)

Using Canfield Mirror Imaging Software, measurement was standardized by interpupillary distance. Commissure excursion was defined as the change in distance from the lateral canthus to the ipsilateral oral commissure between rest and smile.

Figure (3)

Results

Patient age range: 25–77 years (mean 56.5)
Gender: 6 male, 4 female
Mean oral commissure movement: 5.1 mm
FaCE scale improvement: Median score improved from 1 to 3 (P = .017)
Observer grading:
- Excellent/Superb: 4 patients
- Fair/Good: 6 patients
Complications: One fascia lata donor-site seroma, resolved with drainage

Figures 2 and 3 demonstrate representative preoperative and postoperative facial symmetry at rest and during smile.

Discussion

This study demonstrates that the modified orthodromic temporalis tendon transfer offers reliable, immediate facial reanimation with minimal morbidity. The fascia lata pulley system improves tension control, reduces the need for overcorrection, and provides a broad, anatomically appropriate attachment to the mimetic musculature.

Compared with free gracilis muscle transfer, this technique is:

Single-stage
Less invasive
Immediately effective
Free of donor-site facial deformities

Reduced outcomes were observed in patients who had received prior radiation therapy, likely due to tissue fibrosis and reduced tendon mobility.

Conclusion

The modified orthodromic temporalis tendon transfer with coronoid process attachment is a safe, effective, and minimally invasive solution for long-standing facial paralysis. It provides immediate volitional movement, high patient satisfaction, and consistent aesthetic improvement.

Figures Included in the Original Article

Figure 1: Fascia lata harvest, drilling of coronoid process, creation of fascial pulley, and intraoperative smile tensioning
Figure 2: Objective commissure movement measurements using calibrated photographic analysis
Figure 3: Preoperative vs postoperative smile comparison