Temporal muscle and fascia transplantation for unilateral vocal fold paralysis: short- and medium-term results in a case series

Temporal muscle and fascia transplantation for unilateral vocal fold paralysis: short- and medium-term results in a case series | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 3 September 2025 V1 Latest version Share on Temporal muscle and fascia transplantation for unilateral vocal fold paralysis: short- and medium-term results in a case series Authors : Wenting Deng , Jiawang Tian , Haifeng Liang , Faya Liang 0000-0002-9515-9238 , Wenting Liang , Shibei Zheng , Jinshan Yang , Zhong Guan 0000-0003-1965-1279 , and Qian Cai [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175692114.46223930/v1 148 views 92 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Key Points: 1. Autologous temporal muscle-fascia transplantation effectively addresses glottic insufficiency in UVFP, improving vocal fold structure and closure. 2. Autologous temporalis fascia offers low antigenicity, resistance to absorption, and optimal pliability. 3. Incision design 3-4 mm from vocal fold edges prevented scarring-related vibration issues, while muscle-fascia mixture enabled precise. 4. Phonation improved one month post-surgery, with a significant enhancement observed by three months and stabilization noted at six months across all 23 patients. 5. Pre/postoperative evaluations via dynamic laryngoscopy, vocal acoustics, and aerodynamics demonstrated significant objective and subjective improvements. Temporal muscle and fascia transplantation for unilateral vocal fold paralysis: short- and medium-term results in a case series Keywords: Unilateral Vocal Fold Paralysis, Transplant Surgery, Temporal Muscle, Fascia, Voice. Key Points: 1. Autologous temporal muscle-fascia transplantation effectively addresses glottic insufficiency in UVFP, improving vocal fold structure and closure. 2. Autologous temporalis fascia offers low antigenicity, resistance to absorption, and optimal pliability. 3. Incision design 3-4 mm from vocal fold edges prevented scarring-related vibration issues, while muscle-fascia mixture enabled precise. 4. Phonation improved one month post-surgery, with a significant enhancement observed by three months and stabilization noted at six months across all 23 patients. 5. Pre/postoperative evaluations via dynamic laryngoscopy, vocal acoustics, and aerodynamics demonstrated significant objective and subjective improvements. Introduction Unilateral vocal fold paralysis (UVFP) induced by nerve injury commonly manifests as hoarseness and accidental aspiration, resulting from glottic insufficiency 1 . Surgical options for treating UVFP include laryngeal framework surgery, vocal fold injection augmentation, and recurrent laryngeal nerve repair 2 . Vocal fold injection augmentation, characterized by minimal trauma and simplicity of operation, is widely used to address glottic insufficiency. Common injectable materials include autologous substances (such as fat and fascia) and allogeneic materials (such as hyaluronic acid and collagen-based products) 3,4 . Tsunoda et al. 4 proposed autologous fascia transplantation into the vocal fold (ATFV) for treating sulcus vocalis and vocal fold scarring, reporting satisfactory clinical outcomes. Compared to autologous fat, which is commonly used as a filler, autologous fascia is more resistant to absorption. Michael et al. 5 reported promising outcomes using ATFV for repairing vocal fold closure insufficiency. Building on this, we applied and further refined this technique to repair UVFP resulting from nerve injury. To ensure adequate volume and resistance to resorption, we combined the temporalis muscle with fascia. Our findings indicate that autologous temporalis muscle and fascia grafting is an effective treatment for UVFP with vocal fold closure insufficiency, yielding satisfactory results. Materials and Methods Case Selection This study included 23 patients diagnosed with UVFP between January 2019 and December 2024. The cohort consisted of 16 males and 7 females, aged 20 to 66 years, with disease durations ranging from 9 to 50 months. Clinically, patients presented with hoarseness, difficulty swallowing, and vocal fatigue. Dynamic laryngoscopy revealed that the affected vocal fold was positioned paramedian, with a loose and arcuate appearance, and a spindle-shaped glottic insufficiency was observed during phonation. Surgical Procedure All patients underwent general anesthesia and received transplantation of the temporal muscle and fascia under suspension microlaryngoscopy. Preparation of the Temporal Muscle and Fascia A transverse incision, approximately 2 cm in length, was made along the hairline above the anterior auricle. Layer-by-layer dissection was performed to reach the temporal fascial layer. A sample of the temporal muscle and fascia (1.5 × 0.6 × 0.3 cm³) was harvested and divided into small tissue blocks (2-3 mm³) for subsequent use (Fig 1 A and B). Preparation of the Vocal Fold Pocket A suspension laryngoscope was inserted to visualize the glottic region. A longitudinal incision, approximately 3-4 mm from the edge of the vocal fold, was made using a laser (2-2.5W, Super Pulse Mode). The excision, approximately 8-12 mm in length, and 4-5 mm in depth, extended through the vocal ligament and vocalis muscle to create a pocket (Fig 1C). Vocal Fold Augmentation with Temporal Muscle and Fascia Tissues The prepared muscle and fascia tissues were used to fill the vocal fold pocket (Fig 1D). The volume of the tissue was adjusted to ensure that the free edge of the vocal fold bulged evenly inward. The incision in the vocal fold was then sutured using 3-4 stitches with a 7-0 suture to prevent any extrusion of muscle and fascia tissue (Fig 1E). Postoperative Follow-Up and Voice Assessment Dynamic Laryngoscopy Twenty-three patients underwent dynamic laryngoscopy before the operation and at 1, 3, 6, and 12 months postoperatively to assess the recovery of the surgical site. (Fig 2) Subjective Voice Assessment The Voice Handicap Index-10 (VHI-10) was used for self-assessment. Total hoarseness was evaluated by two experienced voice physicians using the Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) scale. Objective Voice Assessment Voice Acoustic Assessment: The multidimensional voice program (MDVP) system was utilized to assess voice characteristics. A microphone was positioned 15 cm from the patient’s lips. Phonation was sustained for 5 seconds per trial, with 2 seconds of stable audio collected for analysis of jitter and shimmer levels. Maximum Phonation Time (MPT) Test: The Phonatory Aerodynamic System (PAS) was used to assess MPT. Patients were instructed to take a deep breath, then secure a mask over the mouth and nose to prevent air leakage. They were asked to phonate the vowel “a” for as long as possible in a comfortable manner, and this was repeated three times. The system automatically recorded the MPT, and the longest value was used for analysis. Statistical Methods Statistical analysis was performed using SPSS 25.0 software. Data are presented as mean ± standard deviation (χ ± s). One-way repeated-measures analysis of variance and paired t-tests were used to compare voice parameters before and after the operation. A p-value of Dynamic Laryngoscopy Regular postoperative laryngoscopy was performed to monitor the recovery of the laryngeal wound. The wound was dry, clean, and exhibited a pale red appearance, with slight edema observed in the mucosa near the incision margin. Subjective Voice Assessment A significant improvement in hoarseness (as measured by GRBAS and VHI scores) was observed at three months postoperatively compared to preoperative levels, with the difference being statistically significant (p < 0.05) (Fig. 3). Twelve patients showed marked improvement in voice quality, with the vocal fold mucosal vibration on the surgical side approaching normal, and the glottis exhibiting near-complete closure. Objective Voice Assessment Significant changes in vocal acoustic parameters (jitter and shimmer) and maximum phonation time (MPT) were observed postoperatively compared to preoperative values (p < 0.05) (Table 1). In fifteen patients (65.22%), acoustic parameters reached the normal range, and seventeen patients (73.91%) showed normal MPT. Three months after surgery, vocal fold morphology gradually returned to normal, and phonation progressively improved. By six months postoperatively, voice quality stabilized, and both subjective and objective assessments of acoustic and aerodynamic parameters demonstrated significant improvement compared to preoperative values. All twenty-three patients were followed for more than one year. The most significant improvement in voice quality occurred within the first three months after surgery. Mild deterioration in voice quality was observed in some patients between 3 and 6 months postoperatively, with stabilization of voice quality thereafter. Discussion The patients in this study all presented with UVFP due to nerve injury. The results of this study indicate that autologous temporal muscle and fascia transplantation can effectively augment the vocal fold volume and displace the free edge of the vocal fold inward. This approach facilitates better closure of the vocal folds during phonation, improving vocal function in patients with UVFP caused by glottic insufficiency. Long-term follow-up demonstrated stable efficacy of the temporal muscle and fascia transplant, as evidenced by consistent improvements in VHI and GRBAS scores, acoustic parameters, and stroboscopic laryngoscopy findings. Autologous fascia has been extensively utilized in tympanoplasty and plastic reconstructive surgery, yielding favorable outcomes 6 . Temporal muscle is commonly employed in craniofacial surgery 7 and has demonstrated efficacy in repairing skull base defects, providing both functional and cosmetic benefits. Moreover, temporal muscle tissue enhances the volume of the vocal fold. Its superior plasticity and filling capacity ensure that the vocal fold pocket is adequately filled with muscle tissue in all positions, thereby facilitating optimal adjustments to the vocal fold shape and promoting a uniform inward bulging of the glottal free edge. While previous studies have predominantly focused on the use of fat, fascia, or a combination of both for vocal fold injections, to our knowledge, muscle transplantation has not been reported. The long-term efficacy of fat injections remains inconsistent in the literature 3,8 . In contrast, the technique employed in this study involved opening the vocal fold and filling it with a mixture of temporal muscle and fascia. This approach proved to be technically straightforward, provided enhanced visualization, and allowed for more uniform and complete filling of the vocal fold. Although vocal cord incision may lead to scarring that could affect pronunciation, we utilized a careful incision design. Specifically, we made the incision 3 to 4 mm from the free edge of the vocal fold to preserve its plasticity and mitigate the impact of scarring on the vibratory function of the free edge. In 1998, Rihkanen 9 first reported the use of autologous fascia lata for vocal fold augmentation in 11 patients with UVFP. In 1999, Tsunoda 4 et al. highlighted that autologous fascia augmentation could effectively treat vocal fold grooves, given the fascia’s similarity to the lamina propria of the vocal fold, which facilitates the restoration of vocal fold vibration. In 2005, Tsunoda 10 examined patients who received temporal muscle tamponade of the vocal fold groove, with follow-up periods ranging from six months to three years. The results indicated improvements in voice quality, glottal closure, and vocal fold vibration, as well as stability over time. In the present study, the use of temporal muscle and fascia for vocal fold transplantation resulted in significant improvements in phonation for patients with nerve injury-induced UVFP. Postoperative assessments revealed notable reductions in GRBAS and VHI-10 scores, with the most significant improvement observed at three months. Although some decline was noted at six months, the results gradually stabilized thereafter. One year following the augmentation with the temporal muscle and fascia mixture, patients continued to exhibit relatively stable voice quality, favorable glottal closure, and stable objective parameters of jitter, shimmer, and MPT. Conclusion Transplantation of temporal muscle and fascia offers an effective treatment for nerve injury-induced UVFP, resulting in relatively stable voice quality postoperatively. References 1.Vinson KN, Zraick RI, Ragland FJ. Injection versus medialization laryngoplasty for the treatment of unilateral vocal fold paralysis: follow‑up at six months. Laryngoscope.2010;120:1802‑1807.doi: 10.1002/lary.20982 2. Hu H, Hung Y, Lin S, etal. Office-Based Autologous Fat Injection Laryngoplasty for Glottic Insufficiency in Patients Under 50 Years Old. Journal of Voice. 2019;33:747-750. doi:10.1016/j.jvoice.2018.03.012 3. Zeleník K, Formánek M, Walderová R, et al. Five-year results of vocal fold augmentation using autologous fat or calcium hydroxylapatite. Eur Arch Otorhinolaryngol. 2021; 278 :1139-1144. doi:10.1007/s00405-020-06479-6 4. K Tsunoda, M Takanosawa, S Niimi. Autologous transplantation of fascia into the vocal fold: a new phonosurgical technique for glottal incompetence. Laryngoscope . 1999 Mar;109(3):504-8. doi: 10.1097/00005537-199903000-00030. 5. Michael J Pitman, Shaina M Rubino, Amy L Cooper. Temporalis fascia transplant for vocal fold scar and sulcus vocalis. Laryngoscope . 2014 Jul;124(7):1653-8. doi: 10.1002/lary.24536. Epub 2014 Jan 15. 6. Cueva RA, Areolar temporalis fascia: a reliable graft for tympanoplasty. Am J Otol.1999:20(6):709-711. 7. Lam D, Carlson ER. The temporalis muscle flap and temporoparietal fascial flap. Oral Maxil Surg Clin. 2014;26(3):359-369.doi:10.1016/j.coms.2014.05.004 8. Brandenburg JH, Kirkham W, Koschkee D. Vocal cord augmentation with autologous fat. Laryngoscope. 1992;102:495-500. 9. Rihkanen H. Vocal fold augmentation by injection of autologous fascia. Laryngoscope.1998, 108: 51⁃54.doi:10.1097/00005537-199801000-00010 10. Koichi Tsunoda, Kenji Kondou, Kimitaka Kaga, et al. Autologous transplantation of fascia into the vocal fold: long-term result of type-1 transplantation and the future. Laryngoscope . 2005 Dec;115(12 Pt 2 Suppl 108):1-10. doi: 10.1097/01.mlg.0000183966.72921.31 Figure captions Fig 1 . Preparation of autologous temporal muscle ( A ) and fascia ( B ). C. Preparation of the vocal fold pocket. D. Autologous temporal muscle and fascia transplantation. E. Sutured with 7-0 suture. Fig 2 . Left vocal fold paralysis, before and after unilateral autologous temporal muscle and fascia transplantation. A. Preoperative abduction. Note left vocal fold concavity. B. Preoperative adduction with incomplete glottal gap. C. One-month postoperative abduction. D. One-month postoperative adduction. E . Three-month postoperative abduction. F . Three-month postoperative adduction. G. Two-year postoperative abduction. H . Two-year postoperative adduction. Fig 3. Comparison of VHI-10 Grade before and after surgery. * : paired t -test indicates that the difference between one postoperative time point and the preoperative time point is statistically significant ( * : p 0.05). Table 1. Preoperation and postoperation objective acoustic parameters assessment. Preoperation 5.13±1.58 9.81±3.82 5.56±1.08 1 month after operation 2.95±0.85 6.40±0.82 9.31±2.47 3 months after operation 1.55±0.27 3.62±1.06 13.97±2.48 6 months after operation 1.50±0.26 3.88±1.06 13.83±2.48 12 months after operation 1.44±0.26 3.71±1.07 13.94±2.49 χ: mean value, s:standard deviation. Supplementary Material File (table 1.docx) Download 15.63 KB Information & Authors Information Version history V1 Version 1 03 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Wenting Deng Sun Yat-Sen Memorial Hospital View all articles by this author Jiawang Tian Sun Yat-Sen Memorial Hospital View all articles by this author Haifeng Liang Sun Yat-Sen Memorial Hospital View all articles by this author Faya Liang 0000-0002-9515-9238 Sun Yat-Sen Memorial Hospital View all articles by this author Wenting Liang Sun Yat-Sen Memorial Hospital View all articles by this author Shibei Zheng Sun Yat-Sen Memorial Hospital View all articles by this author Jinshan Yang Sun Yat-Sen Memorial Hospital View all articles by this author Zhong Guan 0000-0003-1965-1279 Sun Yat-Sen Memorial Hospital View all articles by this author Qian Cai [email protected] Sun Yat-Sen Memorial Hospital View all articles by this author Metrics & Citations Metrics Article Usage 148 views 92 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Wenting Deng, Jiawang Tian, Haifeng Liang, et al. 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