If you have permanent paralysis of the muscles that allow you to smile, you may be offered a procedure to recreate the smile. The Labbé procedure is one of the procedures that can be used for this purpose.
This webpage explains more about the procedure and what to expect, including the benefits, risks, any alternatives and what you can expect when you come to hospital.
If you have any further questions, please speak to the doctor or nurse looking after you.
What is the Labbé technique?
This a dynamic facial reanimation operation first developed many years ago, but recently re-introduced by Dr Daniel Labbé in France. It is also called the Lengthening Temporalis Myoplasty. It aims to improve facial symmetry both at rest and when smiling by lengthening and transferring a muscle, on the side of the head, that usually moves the jawbone. There is usually no significant long term effect on your jaw function.
The operation typically involves a scar over the top of your head from ear to ear which is usually hidden by your hair. A modified version uses a scar on the temple of the affected side and without involving the cheekbone. There is also scar in line with the crease between the lower corner of the nose and the corner of the mouth.
Who is a suitable candidate?
The operation is suitable for those with a flaccid paralysis and in whom there is good function of the nerve which supplies the temporalis muscle. Many patients with facial palsy avoid chewing on the affected side (due to food becoming trapped in the cheek. If this disuse leaves the muscle weak, temporalis strengthening exercises may be prescribed.
What are the risks?
In general the risks of any operation relate both to the anaesthetic and to the operation itself. The operation is performed under general anaesthetic, which means that you are asleep throughout. Your anaesthetist will go through the risks relating to the general anaesthetic with you before the operation.
Before suggesting the operation, your surgeon will have considered that the benefits of the procedure outweigh any disadvantages. However, in order to make an informed decision and give your consent, you need to know and be aware of the possible side effects, risks and complications.
- Bleeding at or soon after surgery- minimised by avoiding blood thinning medication such as aspirin, warfarin, etc.
- Your face will be bruised and swollen, particularly on the paralysed side and around the lip. Much of the swelling will have gone within 2 weeks after surgery, but there will still be a little swelling for up to 6 weeks. Sleeping propped up will aid the resolution of swelling.
- Surgery inevitably means scarring. However, these scars will certainly fade with time and vary in their visibility. The areas of your body, which may receive scarring, are:-
- From the corner of the nostril of the nose to the corner of the mouth (nasolabial fold). This scar is to allow the muscle to be attached to the paralysed lip and helps to create the fold that otherwise tends to be poorly defined. This scar may seem more prominent in younger patients.
- Over the top of your scalp a zig-zag scar is created which is usually well hidden in your hair. Your hair is not shaved but occasionally some hair can be lost with the scarring.
- A scar may need to be created on the lower lip to tighten it. This usually fades well, particularly in older patients.
- If your eyelid needs improvement then you may have a scar here. These generally heal very well.
- Infection- minimised by use of antibiotics
- Prolonged swelling- minimised by sleeping propped up to facilitate gravity
- Over/ under-correction – i.e. too tight, or not tight enough
- Detachment of the tendon- this is where the muscle pulls itself out of your lips
- Trismus (difficulty opening the mouth)
- Poor smile due to poor muscle excursion or overactivity of the unaffected side of the face- previous radiotherapy, poor compliance with the exercise program are amongst the factors that will lead to a less than ideal result. Patients lacking molar teeth (at the back of the mouth) may find the post operative exercises more challenging.
Are there any alternatives?
This is not a life-saving procedure and, therefore, the main alternative is to have no surgery at all. If you have decided that you would like surgery to improve your appearance and the function of your face, other alternatives do exist. Broadly speaking these can split into those that improve the symmetry of your face at rest but do not produce any movement (static procedures) and those that improve the position at rest and can produce movement of the face to express emotions (dynamic procedures). The Labbé procedure is a dynamic procedure. The main advantages of static procedures are the shorter length of surgery and hospital stay and the reduced risk of failure. Many options exist in both categories and your surgeon can discuss these with you.
How can I prepare for a Labbé procedure?
A series of assessments will be carried out before your operation. The main aim is to ensure that you are are fit as possible for the operation and may involve seeing the Anaesthetist or pre-op assessment nurse. You will usually have clinical photographs and/or videos performed.
You will need to take time off work for the surgery. We would recommend that you take a further 2-3 weeks off work to recover. If your job involves heavy exertion, you should take a total of one month off work.
Any sports should be avoiding for 4-6 weeks and you should try to stop or cut down any smoking in the lead up to the operation and for the six weeks following surgery. Smoking will increase the risk of the muscle not working and the wound not healing.
With this being an operation performed under general anaesthetic, you will need to avoid any food in the six hours before surgery. You may drink water up until two hours before surgery.
What does the surgery involve?
The operation is performed under a general anaesthetic. The operation may last from 2-4 hours depending on the level of complexity. Sometimes additional procedures are performed at the same time, which lengthens the operation.
An incision is made in the scalp to gain access to the temporalis muscle. The cheekbone (zygomatic arch) may be lifted up temporarily to give better access to the muscle tendon, which is detached and slid through the cheek to the lips. The muscle is freed from the skull to allow it to slide forward thus allowing the tendon to reach the lips without undue tension. An incision near the lips allows the tendon to be re-attached to the corner of the mouth such that when the teeth are clenched, a ‘Mona Lisa’ smile is produced. The cheekbone is re-attached using miniature screws and the muscle re-attached to the skull. Drains are inserted before closure to avoid excessive bleeding under the skin, and a bandage is applied overnight.
Will I feel any pain or discomfort?
After the surgery it is likely that you will feel some pain, although you will be given a number of different painkillers to reduce and ideally remove this pain. The pain is normally around the wounds themselves and should begin to subside in the first 72 hours after surgery. By the time you go home your pain should be low enough to be controlled by paracetamol alone.
What happens after the surgery?
On the first morning after surgery you will be reviewed by the surgical team. Your head will be bandaged and there will be plastic tubes (called drains) leading to a plastic bottle to collect any excess blood or tissue fluid from under the wounds. Once you are comfortable, you can gently walk around your bed and sit in your chair. Over the next couple of days you will increase your activity and the drains will be removed as the amount of fluid coming out reduces. At this point your head may be quite swollen; within reason, this is normal.
Chewing may feel a little uncomfortable for the first week or two so a soft diet is recommended. Once all of the drains have been removed, you will usually be able to wash your hair and return home.
Your scalp wounds will have been closed with surgical staples (which are removed at your outpatient appointment approximately two weeks after surgery), or dissolving stitches. It is safe to gently wash your hair with either, and you may be given some ointment to gently apply to the scars.
At this point you may start to gently exercise and massage your face as directed by the team. By getting used to looking at yourself in the mirror and practising movements you will learn how to recognise desirable movements and avoid unwanted movements. You will be given advice about exercises to start at home.
Week 6 onwards
By this time much of the swelling should have gone and your face should be more symmetrical.
Over the next few weeks and months as you continue your exercises in the mirror you should be able to see movement on the operated side. The benefits of the surgery depend largely on how frequently you practice your exercises.
Eventually, by clenching your teeth you should be able to make the temporalis muscle contract and lift the corner of the mouth. Over time (many months or years) you may learn how to contract the muscle and lift the corner of the mouth without clenching the teeth – a voluntary smile.
What should I do if I have any concerns?
If, following the surgery, you have any concerns you should contact your surgical team or the ward that you were admitted to during your stay. They will then be able to give you further advice on what to do and whether they need to see you back at the hospital or not.
Last reviewed: 08-02-2016 || Next review due: 08-02-2018