Discussion

Use oftemporalis muscle flap
Utilización del colgajo de músculo temporal en cirugía reconstructiva maxilofacial

In this work, the authors carry out a thorough re-examination an important series of more than a hundred cases in which the temporalis muscle flap is used as a reconstructive technique in the cranio-maxillofacial area.

After a brief but complete historical review, which includes the first publication by Lenz in 1895 on the use of this flap in our field, the paper goes on to give a detailed description of the anatomy and [various] surgical techniques. In our experience, this flap is a regional, simple and versatile flap.¹ Its principal source of irrigation is through temporary pedicles which are deep, anterior, posterior and medial. We share the view of the authors of this work regarding the indications for primary reconstruction after oncological excision in the cranio-maxillofacial area, as well as the basic indications for the use of this type of flap.

We use more complex microsurgical flaps for the reconstruction of large defects, or in those areas in which we need to provide bone in order to carry out posterior implant rehabilitation using intraosseous implants. In these cases the most useful flaps are from the iliac crest, the fibula and the scapula, the later being very useful in complex tri-dimensional reconstructions in which bone is required and a large amount of soft tissue.² The temporalis myofascial flap is an excellent alternative for the reconstruction of the hard palate and other neighboring areas, although it has the disadvantage of not providing any bone. In these cases prosthetic rehabilitation has to be based on contralateral teeth or on implants which are placed in the remaining bone in partial defects of the superior maxilla. An additional possibility would be including cranial bone grafts in the temporalis muscle flap. This is particularly useful in orbital defects as, on occasions, the vascularized bone can be used as a parietal osteofascial flap, which can be particularly useful for avoiding complications in those cases in which postoperative radiotherapy is going to be given.

Likewise, the temporalis muscle flap is useful in our experience in other indications mentioned by the authors, such as in surgery of the skull base or in orbital exenteration as, on many occasions, a cutaneous flap can be added in order to cover the defect, such as the cervico-pectoral flap.^3,4 However, the use of the temporalis flap in jugal mucosa defects which the authors mention in 8 of the 23 cases of oral cancer, can lead to problems, due to thickness and posterior retraction. In our opinion, the radial free flap is preferable in these cases. In this sense, the authors report a high percentage of trismus and dehiscence with the temporalis muscle flap in this indication.

After the use of this flap, an important aspect covered is the repair of the defect that is left in the temporal fossa, which is in accordance with our opinion. Not carrying out this repair frequently leads to a considerable aesthetic defect in the temporozygomatic area. This can occasionally be repaired by displacing a muscular segment if the temporalis [muscle] was not used completely, or by implanting biomaterial for filling the temporal fossa. This aspect is not clarified in the paper we are commenting on, as the authors refer to 13 cases of residual deformity of the temporal fossa corresponding to the first patients of the series, and they describe the use of alloplastic material for filling in this area only in 20 patients, with hyperinfection in five of them. This complication can be relatively frequent, especially following radiotherapy, and in many cases the filling has to be removed.

To sum up, this work offers a revision of a classic topic in our field, even though it is little used in certain areas, such as the temporalis muscle flap. The experience of the authors is based on an extensive series of cases. They highlight the simplicity and efficiency of this means of reconstruction in a variety of situations within the cranio-maxillofacial area.

Julio Acero
Servicio de Cirugía Oral y Maxilofacial.
Hospital Universitario Gregorio Marañón, Madrid.

References