Artículo Clínico

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Use of the temporalis muscle flap in maxillofacial reconstruction surgery.
A review of 104 cases
Utilización del colgajo de músculo temporal en cirugía reconstructiva maxilofacial.
Revisión de 104 casos

 

I. Zubillaga Rodríguez¹, G. Sánchez Aniceto², I. García Recuero², J.J. Montalvo Moreno³

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Abstract: Introduction: Temporalis miofascial flap has been used for craniofacial reconstruction since more than 100 years. The first described case in the medical literature was published by Lentz in 1895. The use of pedicled temporalis muscular flaps in cranial or facial reconstruction seems to be shifted nowadays by microvascular free flaps. Nevertheless, in our experience, this miofascial pedicled flap demonstrates to be a safe option for midfacial and lateral cranial base defects. Aims: To show our indications and results using the temporalis flap in craniofacial reconstruction. Material and methods: A retrospective analysis of our experience with temporalis flap along the last decade. Results: A total of 108 flaps have been used in the following situations: postmaxillectomy defect reconstruction (44); cranial base (25) including anterior, middle and posterior cranial fossas; oral cavity and oropharynx (23); orbital exenteration (6); Temporomandibular joint ankylosis (6); others (2) with an overall success rate (no partial or total flap failure) over 94 %. Conclussions: Temporalis muscle flap is one of the "first choice" elections in reconstructive craniofacial surgery, for midfacial and cranial base indications. Non-careful surgical dissection and flap suture under tension predispose to complications such as flap necrosis (common

umen: Introducción: el colgajo de músculo temporal ha sido empleado en reconstrucción craneofacial desde hace más de 100 años. El primer caso descrito en la literatura fue publicado por Lentz en 1895. Hoy en día el uso de colgajos locales con músculo temporal parece ser desplazado por el uso de colgajos libres microvascularizados en la reconstrucción craneofacial. En nuestra experiencia dichos colgajos locales constituyen una opción segura en muchos de nuestros pacientes. Objetivos: mostrar nuestras indicaciones y resultados en reconstrucción craneofacial con el empleo del colgajo de músculo temporal. Material y método: análisis retrospectivo de nuestra experiencia con el colgajo de músculo temporal en la última década. Resultados: hemos empleado un total de 108 colgajos miofasciales temporales en pacientes adultos con las siguientes indicaciones: reconstrucción de defectos postmaxilectomía (44); cirugía de base de cráneo (25) incluyendo fosa craneal anterior, media y posterior; cavidad oral y orofaringe (23); tras exenteración orbitaria en pacientes oncológicos (6); anquilosis de ATM (6); secuelas faciales postraumáticas (2); reanimación facial (2). Conclusiones: el colgajo de músculo temporal es una de las primeras opciones en cirugía reconstructiva oncológica craneofacial, de la ATM y base de cráneo. La disección traumática del colgajo y la sutura a tensión predisponen la aparición de complicaciones como necrosis o dehiscencia de la sutura. Palabras clave: Músculo temporal; Cirugía reconstructiva craneofacial; Maxilectomía; Base de cráneo.

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1 Médico Residente
2 Médico Adjunto
3 Jefe de Servicio
Servicio de Cirugía Oral y Maxilofacial, Hospital Universitario 12 de Octubre, Madrid

Correspondencia:
Ignacio Zubillaga Rodríguez
Servicio de Cirugía Oral y Maxilofacial.
Hospital Universitario 12 de Octubre.
Avenida de Córdoba s/n. 28041 Madrid
E-mail: ignaciozubillaga@yahoo.es

 

Introduction

The temporalis muscle has been used in craniofacial reconstructive surgery for more than a hundred years. Lentz was the first in 1895 in publishing the use of this muscle in a patient with temporomandibular ankylosis, and it was one of the first muscular flaps described.¹ Golovine described its use after carrying out an orbital exenteration in 1898.² Gillies³ used the muscle in 1919 for reconstructing a defect of the jugal mucosa and, in 1930 he used it for facial reanimation.

Campbell⁴ in 1948 used it as a post-maxillectomy reconstructive technique, it being a recipient bed for bone grafts. It has also been used to isolate the central nervous system after oncological surgery on the base of the skull^5,6 and for closing cleft palates not separated in adulthood.

Today the use of local flaps such as the temporalis muscle flap seems to have been supplanted by the use of microvascular free flaps in maxillofacial reconstruction but, in our experience, it constitutes a reliable and versatile option for our patients.

Objectives

1. To discuss the indications in our view for the use of the temporalis muscle in reconstructive maxillofacial surgery and to set out our results.

2. [To give] a brief anatomical description, to explain the different flaps and the surgical technique with its refinements. 3. To analyze complications.

Material and method

A retrospective analysis was carried out of 104 patients with defects in the maxillofacial area reconstructed with 108 myofascial flaps from the temporalis muscle from January 1991 until June 2003 in the service of Oral and Maxillofacial Surgery of the University Hospital "12 de Octubre" of Madrid.

The age range of the patients was between 16 to 87 years, with a mean age of 53. With regard to different sexes, 68 were male and 35 were female. Postoperative followup ranged between 4 and 120 months, with an average of 40 months. The temporalis muscle was used for bilateral [reconstruction] in 4 patients due to there being bilateral ankylosis of the temporomandibular joint.

Anatomy and surgical technique

The temporalis muscle inserts onto the superior temporal line occupying the temporal fossa. It passes under the zygomatic arch and the tapering portion attaches to the coronoid process and anterior border of the ramus of the mandible. It is fanshaped and it has an average anteroposterior length of 8 cm. and a craniocaudal length of 6 cm. Its thickness increases on nearing the zygomatic arch (1.5 cm), its peripheral area being 0.5 cm.

It receives innervation through the temporal branches coming from the third division of the trigeminal nerve which penetrate, three to four in number, through the deep surface. It is necessary to keep in mind that denervation atrophy will be produced at a muscular level when the temporalis muscle is used in reconstructive surgery of the skull base if there has been a lesion and/or resection of the trigeminus nerve.

From the point of view of vascularization, it is a type III muscle in Mathes and Nahai's⁷ classification with the following vascular pedicles. ^8,9

a. Anterior, deep, temporal artery responsible for 20% of the vascularization of the anterior muscle area. It penetrates the deep muscular surface 1 cm. and is anterior to the coronoid process.

b. Posterior, deep, temporal artery, responsible for 40% of middle part of the muscle area. With a larger diameter than the former, it penetrates 1.7 cm. and is posterior to the coronoid process. Both branches proceed from the internal maxillary artery.

c. Middle temporal artery, responsible for 40%, of the posterior muscle area. It proceeds from the superficial temporal artery.

d. Additional branches that leave directly from the internal maxillary artery in the lower third of the muscle.

Muscle vascularization is situated principally in the lateral and medial areas of the muscle in the coronary plane, with a vascular density which is significantly lower than in the medial area. This distribution allows a sagittal division of the muscles which ensures vascularization and guarantees a reconstructive technique that is reliable. The vascular distribution in the sagittal plane, as explained, permits therefore, a coronal division and adequate reconstruction according to the defect created. ⁸

The venous return is produced generally through two veins that accompany each artery. Venovenous and arterioarterial intramuscular anastomosis, typical of the muscles of the periphery, is frequent. The development of anastomosis leads to local muscle edema that impedes the movement the temporalis muscle under the zygomatic arch, which is sometimes necessary for a precise reconstruction.

With regard to surgical technique, all the flaps from the temporalis muscle were harvested via a coronal approach including the necessary perfections designed to avoid damaging the frontal branch of the pair of cranial nerves VII (Fig. 1). On occasions the parietotemporal fascia is harvested if necessary during the same approach, generally to increase vascularization of the grafts used in orbital reconstruction¹⁰ (Fig. 2).

The temporalis muscle flap has five basic forms: pure muscle, myofascial, myoperiosteal, myocutaneous and myoosseous.¹¹

In our series all flaps were myofascial-periosteal over the temporal fossa in order to preserve the temporalis muscle's own vascularization.

The temporal fascia is freed of its zygomatic parts in order to increase the arc of rotation and, with regard to intraoral reconstruction, the possibility of strangling the pedicle is in this way reduced. In this type of intraoral reconstruction a tunnel is created through the infratemporal fossa and the flap is moved towards the oral cavity with two silk sutures. Sometimes an osteotomy of the zygomatic arch is performed in order to facilitate moving the flap, and it is later replaced by means of osteosynthesis (Fig. 3). Increasing the arc of rotation of the flap is necessary on occasions, in order to reach the defect that is to be reconstructed with no tension. In order to do this a coronoidectomy can be performed which occurs more frequently in intraoral reconstruction¹² (Fig. 4).

The proportion of temporalis muscle that has to be harvested depends on the localization and size of the defect to be reconstructed. A coronal or sagittal division, or using the muscle completely, is possible.⁸ When the muscle is to be partially utilized, the anterior portion is used in the reconstruction process and the remaining posterior portion is rotated anteriorly in the temporal fossa. A small muscular strap+ on the anterior temporal crest is preserved which allows the suture of the remaining posterior temporalis muscle after rotation.

Indications

The anatomical proximity of the temporalis muscle to the upper third and middle third of the face means that it is used relatively frequently in the field of craniofacial reconstruction surgery. We have used a total of 108 temporalis myofascial flaps with the following indications:

A. Reconstruction of post-maxillectomy defects (n = 44)¹³ (Figs. 5-8).

The use of only the anterior portion or all of the temporalis muscle depends on the type of maxillectomy performed (partial or extended). This postresection defect allows transposing the temporalis muscle directly, from its insertion in the temporal fossa under the zygomatic arch until it reaches the oral cavity. The fascia temporal is sutured firmly to the intraoral defect in such a way that the temporalis muscle seals the defect.

Some authors are of the opinion that the zygomatic arch should have a pedicle to the masseter muscle so that the strap of the temporalis muscle is transposed in those patients that have previously received local radiotherapy. Reconstruction of the alveolar bone rim is possible by joining the infraorbital rim and the pterygoid process with grafts from the iliac crest six months after surgery. Later rehabilitation with prostheses will be completed using osseointegrated implants six months later. On occasions carrying out vestibuloplasties is necessary in this surgical act.

B. Surgery of the skull base (n=25)

Postsurgical defects are divided as follows:

B1. Anterior cranial fossa (n=15)

• Anterolateral resection (n=9)

• Lateral resection (n=6)

B2. Medial cranial fossa (n=5)

B3. Posterior cranial fossa (n=2)

B4. Clivus (n=3)

Adequate isolation is the fundamental objective pursued, in order to avoid dead spaces between the central nervous system and the upper aerodigestive tract¹⁴ (Fig. 9-10). In this way the appearance of a fistula of cephalorrhachidian liquid and the resulting risk of associated meningitis is avoided.

The temporalis muscle provides a substantial amount of well-vascularized tissue that enables sealing the skull base efficiently, and it can be extended even further than the medial line, to the contralateral side, eliminating in this way any existing dead spaces. In this type of surgical proceedings of the skull base, associated resection is frequent of one or several orbital walls. The temporalis muscle provides a suitable vascular supply for these free bone grafts (Figs. 11 and 12).

C. Oral cavity-oropharynx (n=23).

The defects to be reconstructed were divided in the following way:

• Jugal mucosa (n=8)

• Soft palate (n=7)

• Retromolar trigone (n=5)

• Oropharynx (n=3)

The transposition of the temporalis muscle is done through the tunnel created in the infratemporal fossa under the zygomatic arch. In order to reach the defect that has to be reconstructed properly, a zygomatic osteotomy is sometimes mandatory to pass the flap.¹⁵

The fascia of the temporalis muscle which is in contact with the oral cavity undergoes a process of metaplasia (Fig. 13) from the peripheral area of the flap, which is noticeable three weeks after surgery.

D. Orbital exenteration (n=6)

Bone fenestration is carried out on the orbital wall at the level of the sphenozygomatic suture in order to fix the temporalis muscle to the remaining periorbital soft tissues (Figs. 14-15). The harvesting of a dermoepidermic free graft from the thigh will cover the external portion of the temporalis muscle and close the orbital cavity.

The indications described so far belong to the area of oncological pathology (n=98). 75 patients presented malignant tumors and 53 had postoperative radiotherapy.

E. Ankylosis of the temporomandibular joint (n=6) Following resection of the ankylotic block (bilateral in four patients) by means of a preauricular incision, a central temporal strap was then harvested and the remaining condylar neck was sutured so as to create a temporomandibular neo-articulation.

F. Post-traumatic facial sequelae (n=2) following fire arms aggression. Used for comminuted bone defects and soft tissues associated with the middle third of the face.

G. Facial reanimation (n=2) using Rubin's technique.

Results

Of the 108 temporalis myofascial flaps harvested, total necrosis occurred in three cases and partial necrosis in four, due to ischemia secondary to mechanical problems in intraoral reconstruction cases because of the pedicle passing under the zygomatic arch. Likewise, in this group of patients partial dehiscence of the intraoral suture was observed in 19 cases. Eight patients presented postoperative trismus; in all of them the temporalis muscle was used to reconstruct the oncological defects in the retromolar trigone and/or the jugal mucosa. A strict and prolonged program of masticatory exercises aids postsurgical improvement in these patients. In the cases that required resection of the base of the skull, a fistula of cephalothoracopagus liquid appeared in seven patients. The process was resolved with the application of conservative measures (rest and/or lumbar drainage). Deformity, as in obvious aesthetic sequelae, was observed in the temporal fossa of 13 patients belonging to the first group in which the temporalis muscle was used as a reconstructive method. They had not been given treatment regarding additional filling of the temporal fossa. Following the use of alloplastic material (n=20) for filling the temporal fossa, five cases of hyperinfection were detected with this material and removal was necessary following prescription of antibiotics. In two patients paralysis of the frontal branch was noted as a consequence of the surgical technique.

Discussion

In spite of having a history of more than 100 years, the temporalis muscle is to date still a valid option. Its anatomical proximity to the middle and superior third of the face, make it a reliable and versatile option as a locoregional, pedicled reconstruction method.¹⁶ However, other therapeutic reconstructive possibilities exist. Some authors defend the use of obturators of the palate avoiding in this way having to reconstruct the middle third of the face. This avoids complications if there is a diagnosis of tumor relapse following reconstruction with the temporalis muscle. Currently, periodic check-ups of the patient, together with the advances in imaging tests, allow for the tracking and early diagnosis of any new and related oncological processes, and the number of patients susceptible to receiving this therapeutic option is reduced to a minimum.

On the other hand [the temporalis muscle] provides bulk, having both quality and quantity together with well-vascularized soft tissue,17 and it is suitable for minimizing the aesthetic sequelae associated with the lack of reconstruction in the middle third of the face.

Other reconstructive options consist in scalp flaps, which generate considerable aesthetic deformity and supply capillary tissue in areas that lack it, and regional pedicled musculocutaneous flaps, either trapezius or pectoral, which provide too much bulk and which require extensive thoracocervicofacial dissection due being located at a distance from the defect.¹¹

Lastly, compared with microvascularized free flaps, there is lower donor site morbidity, less surgical time is required given the relatively simple technique, and postural changes are avoided in the patient during the surgical act. However, for a strict anatomical, aesthetic/functional reconstruction the quantity and variety of tissues that can be used is inferior. In this way, the use of microvascularized free flaps would be indicated in patients with extensive and complex tri-dimensional defects, and in those in which the temporalis muscle was not available.

The greatest disadvantage of the temporalis muscle is the resulting aesthetic sequelae due to the hollow that appears in the temple.¹³ Various techniques have been proposed in order to minimize the deformity created in the fossa temporal:

• The anterior temporal hairline starts approximately 4 cm. behind the lateral orbital rim. It is in this area that deformity is most commonly found. After the harvesting of the temporalis muscle, a muscular strap is preserved and fixed to the temporal fossa at the point of insertion into the anterior temporal crest is preserved. If all of the temporalis muscle has not been used, it is rotated and sutured to the anterior muscular strap and the residual deformity is in this way reduced.

• Using alloplastic material for filling the temporal fossa in cases where the temporalis muscle has been used completely (Figs. 16-17). Its use in patients that are going to receive postoperative radiotherapy increases the possibility of infection in these materials due to related mobility.

• Parietotemporal fascia harvesting for filling in the defect created and/or frontoparietal galea-pericranial flaps.

• Dissection of the temporal fat sac and its transposition to the temporal fossa.¹⁸

Conclusions

1. The temporalis muscle flap is still today a safe and versatile option in reconstructive surgery of the upper and middle third of the face.

2. It provides well-vascularized muscular material which is useful for covering bone grafts used in the reconstruction of the middle third of the face and which are susceptible to treatment with additional radiotherapy.

3. Complications such as necrosis or dehiscence of the suture are more likely to arise following traumatic dissection of the flap and tension to the suture.

4. It ensures efficient isolation of the central nervous system in skull base surgery, eliminating dead spaces and avoiding the appearance of postsurgical fistula of cephalorrahachidian liquid.

References

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