J Oral Maxillcfac

Surg

49:1067-1073, 1991

mporalis Myofasci Maxillofacial Ret nstructi Cf%AR COLMENERO, MD,* VICENTE MARTORELL, MD, DDS,jARTOLOMi$ COLMENERO, MD, DDS,$ AND GNACIO SIERRA, To date, the temporalis myofascial flap has been used only to a limited extent for reconstruction in the maxillofacial region. Experience gained with 26 temporalis flaps in reconstruction of tissue defects in the periorbital region, skull base, maxilla, and oral cavity is presented. Only one patient developed total necrosis of the flap; significant necrosis did not occur in any other patient. The anatomy of the flap and surgical technique are briefly presented.

Surgical

treatment

Demas and Soteranos13 transferred the temporalis muscle for closure of an unrepaired adult cleft palate. The temporalis has also been used as a composite osteomyofascial flap. ‘a215 In the last 10 years, we have been using the temporalis flap in 26 patients for reconstruction of periorbital defects after exenteration, for maxillary defects, and for sealing the cranial cavity after craniofacial resection. The following report describes our results in these cases.

of cancer in the maxillofacial

region has improved with advances in reconstructive techniques. With a thorough knowledge of the anatomy of the flaps and their clinical applications, oral and maxillofacial surgeons can be more aggressive in removing cancer while still having the opportunity for rehabilitation by immediate reconstruction. The temporalis myofascial flap was first used by Golovine in 8898’ for reconstruction after exenteration of the eye and to close petiorbital defects. Campbell,* Webster,3 Bakamjiam and Souther,4 and Holmes and Marshall’ have used this flap as a recipient for maxillary bone grafts and for orbital and maxiHary reconstruction after ablative surgery. Renner and colleagues6 used the flap for reconstruction of the lateral face and head and applied skin grafts over the flap with good results. Jackson and coworkers,’ Shagets and associates,’ and Antonyshin and colleagues’ have used the temporalis flap after skull base tkamor resection and sealing of the cranial cavity. Bradley and Brockbank,” Hutterbrink,” and Koranda and coworkers’* have used the fIap for oral and oropharyngeal reconstruction.

Twenty-six patients with maxllofacial defects after ablative cancer surgery bad immediate reconstruction with a temporalis flap. Twelve patients had squamous or basal cell skin carcinoma of the lids and/or periosbital region that infiltrated the orbital skeleton, and seven patients had had many previous surgical resections and radiotherapy (Table 1). Ten patients had maxillary tumors Ikewhich the Rap was used for reconstructioln ofthe maxillary defects and/or the palate. In one patient, bilateral temporalis flaps were used for reconstruction of the maxilla and palate (Table 2). Four flaps were used for reconstruction of the skull base, two were used for the anterior fossa, and two were used for the middle fossa (Table 3). The anatomy and operative technique for the myofascial temporalis are we11 documented. 1o,14 The muscle inserts in the superior temporal line and temporal fossa and descends deep to the zygomatic arch ts the coronoid process and anterior, edge of the agcending mandibular ramus. MuscBe size in sagit+ dimension is 9 to’10 cm and extends BOto 12

Received from the Department of Oral and Maxillofacial Surgery, La Paz, General Hospital, Madrid, Spain. * Fifth Year Resident. 7 Staff Surgeon. $ Chief of the Service of Alcala Hospital. 0 Chief of the Service of La Paz Hospital. Address correspondence and reprint requests to Dr Colmenero: Department of Oral and Maxillofacial Surgery, La Paz General Hospital, Paseo de la Castellana 261, 28046, Madrid, Spain. 0 1991 American geons 0278-2391/91/491

Association

of Oral and Maxillofacial

Sur-

O-0007$3.043/0

1067

1068 Table 1. Case

TEMPORALIS

Age (yr)/Sex

81/M 59rM

Location

Previous Treatment

Orbital recurrence lid squamous Ca Squamous Ca zygomatic and eyelid skin Basal cell Ca temporal fossa

Eyelid resection

Squamous Ca recurrence of eyelid Basal cell Ca orbit and temporal fossa Basal cell Ca lateral orbital wall and supraorbital ridge

4 previous surgical resections None

None None

4

71iM

5

86/F

6

76/F

7

73/M

Squamous Ca of cheek, nose, and lids

8

62/M

Squamous Ca periorbital recurrence

6 previous failures XRT (5,000 rad)

9

84/F

Squamous Ca periorbital recurrence

4 previous surgical attempts

10

82/M

Orbital recurrence of basal cell Ca of the cheek

11

44/F

12

67/M

Squamous Ca eyelid recurrence with orbital invasion Squamous Ca of eyelid and cheek; recurrence, with invasion of the orbit and maxilla

3 previous surgical failures; XRT (6,000 rad) 2 previous surgical excisions 2 surgical excisions XRT (5,000 rad)

Abbreviations:

None

Surgical Procechlre Orbital exenteration, skin graft over the flap Orbital exenteration, skiu graft over the flap Wide resection of temporal fossa and lateral orbital wah; orbital exenteration including maxilla Orbital exenteration inchming maxilla Orbital exenteration with wide excision of zygomatic arch Exenteration including part of the frond bone; bone gtafts nourished by the temporalis Orbital exenteration with maxillary extension induding etmoids; deltopectoral and temporalis flaps Wide local excision including exental exenteration; skin graft over the flap Wide excision includmg exenteration and resection of the maxilla and lateral wall of the nose Orbital exenteration

Orbital exenteration Orbital exenteration en bloc with tumor and maxilla

Ca, carcinoma; XRT, radiotherapy.

Maxillary and Oral Tumors Previous Treatment

Age (yr)/Sex

Location

1

56/M

Squamous Ca sinus and orbit

None

2 3 4

52/M 62/M 74/M

Adenoid cystic Ca palate Colonic type cell Ca maxilla Squamous Ca maxillary sinus

None None None

5

7llM

None

6

53/F

Squamous Ca alveolar process of maxilla invading sinus Squamous Ca maxitiary sinus

7

64/F

None

8

34/F

9

63/M

10

37/F

Adenoid cystic Ca palate and maxilla Malignant fibrous histiocytoma maxillary sinus Local recurrence of oropharyngeal squamous Ca in tonsil and palate Local recurrence of squamous Ca of buccal mucosa in palate and maxilla bilaterally

Case

FLAP

Periorbital Tumors

49/F

Table 2.

MYOPASCIAL

Abbreviations:

Ca, carcinoma; XRT, radiotherapy.

None

Surgicai Procedures Radical maxihectomy and orbital exenteration Radical maxillectomy Radical maxihectomy Radical maxilbctomy and orbital exenteration Maxillectomy

Radical maxiflectomy and orbital exenteration Maxillectomy

None

Radical maxillectomy orbital exenteration

and

Previous neck disection and hemimandibulectomy; XRT (5,000 rad) Composite resection, Lingual flap for reconstruction; XRT (5,000 rad)

Wide local excision palate and tonsillar fossa Radical maxillectomy, bilateral temporalii flaps

CQLMENERG

Table 3, Case

ET AL

Skull Base Invasion Age (yr)/Sex

Location

Previous Treatment

Surgical Resection

69iM

Squamous Ca of the forehead; invasion of the supraorbital ridge, roof of orbit, and floor of anterior fossa Squamous Ca of upper eyelid; invasion of frontal sinus, nose, ethmoid, and floor of the anterior cranial fossa

4 previous surgical procedures with multiple local flaps; XRT (4,500 rad) 2 previous surgical resections; XRT (6,000 rad)

Adenoid cystic Ca; infrasphenotemporal fossa, floor of middle cranial fossa Adenoid cystic Ca, infrasphenotemporal fossa, Boor of middle cranial fossa, anterior pole of temporal lobe

None

Orbital exenteration encompassing forehead, zygoma, and fIoor of anterior fossa Qrbital exenteration including frontal and nasal bone, ethmoidectomy, maxilla, and fl0or of the anterior cranial fossa Infratemporal fossa approach; frontotemporal craniotomy

XfP

54/F

62lP

Abbreviations:

None

Infratemporal fossa approach; craniotomy; dural and brain resection

Ca, carcinoma; XRT, radiotherapy.

cm from the coronoid process to the superior temporal crest. The thickness is 0.5 cm at the temporal line and 1.5 cm at the level of the arch. The blood is supphed from the deep temporal branches of the maxillary artery, which travel deep to the muscle in close contact with the bone of the temporal fossa. Subperiosteal elevation of the flap is essential to avoid damage to the vascular supply (Figs 1 and 2).

Most often, the flap has been approached by a hemicoronal incision going deep to the temporalis fascia. According to Abdul-Hassan and coworkers, I7 the skin scalp flap will contam skin, subcutaneous connective tissue, galea, temporoparietal fascia, and innominate fascia. The temporal and

\

/

.

/

FIGURE 1. Location of temporalis muscle and different arcs of rotation when the temporalis myofascial flap is used in the orbit (A), in the maxilla and palate (B), and in the oropharynx (c). Reconstruction of the orbit will often require a fenestration or resection of the lateral orbital wall. For reconstruction of the maxilla and palate, temporary resection of the zygoma is frequently necessary. Transection of the coronoid process increases the arc of rotation.

MAXILLARY ARTERY.

FIGURE 2. Coronal view of the way in which the temporalis myofascial ffap is developed (A).Origin of blood supply entering the muscle (E). The plane of elevation of the flap is directly over the bone of Ehe temporal fossa. The deep temporalis fascia is sectioned above the arch (c). The deep temporalis vessels leave from the maxillary artery 1.5 cm below the zygoma and travel in the deep surface of the muscle. Subperiosteal elevation of the flap is mandatory.

1870

TEMPOWALlS

MYOFASCIAL FLAP

frontal branches of the facial nerve are included in the scalp flap. The temporalis flap can be designed with or without periosteal extensions over the skull vault. Elevation of periosteum is followed in continuity with the myofascial flap over the entire temporal fossa, maintaining close contact with the bone to preserve the vessels. The fascia is released from its zygomatic attachments, and subperiosteal dissection is performed over the arch. This increases the arc of rotation of the. flap and, especially in reconstruction of the oral cavity, decreases the possibility of pedicle strangulation. Sectioning the coronoid process, leaving the flap as an island, will also increase the arc of rotation and the length of the flap and is frequently necessary for intraoral reconstruction. If necessary, the flap can be split into anterior and posterior parts; the anterior part is used for the reconstructive procedure, and the posterior part is transposed anteriorly to fill the defect. The flap is easily transposed into the periorbital region and skull base after ablative surgery. For intraoral reconstruction, a tunnel is created in the infratemporal fossa and the flap is guided with two silk sutures. The zygoma is reinserted as a bone graft and is wired in place, and the donor site is closed in two layers. Results

Twenty-five patients had primary healing of the flap and satisfactory recovery despite the extensive excisions. Only one patient had complete necrosis of the flap. No other significant necrosis occurred. All grafts placed over the flap survived. In a patient whose external carotid artery was ligated during a previous radical neck dissection necrosis did not develop. Complications were 14 cases of paralysis of the temporal branch of the facial nerve (8 due to oncologic necessity); restricted mouth opening in three patients, in all of whom the flap was used for palatal reconstruction; velopharyngeal incompetence in one patient; and cerebrospinal fluid leak that resolved with a lumbar drainage procedure in one patient (Table 4, Figs 3 to 6). Table 4.

FIGURE 3. A, Eyelid recurrence with invasion of the globe and orbital skeleton. B, Result after orbital exenteration and reconstruction of the defect with a skin graft over the temporalis flap.

Complications Complication

n

Total necrosis of the flap Paralysis of the frontal branch of the facial nerve Oncologic necessity Technical error Restricted mouth opening Velopharyngeal incompetence Cerebrospinal fluid leak

14 8 6 3 1 1

1

The ability of the oral and maxillofacial surgeon to perform flaps successfully has allowed performance of more aggressive operations in tihich better control of cancer is possible, but primary reconstruction immediately after tumor resection is often necessary. Many different reconstructive proce-

FIGURE 4. A, Maxillary squamous cell carcinoma invading the alveolar process and hard palate. B, Postoperative view after 6 months. The palate has been reconstructed with a temporalis myofascial flap. The fascia has been perfectly epitheliaiized. This reconstruction enables early recovery of eating, especially in edentulous patients.

dures are available for this purpose. Musculocutaneous flaps, such as the pectoralis major and trapezius Raps, are based on a reliable dominant vascular pedicle that nourishes the overlying skin through the musculocutaneous perforators. These flaps are safe, versatile, and reliable; the technical ease of the surgical procedure makes them very attractive for a wide variety of reconstruction sites. Disadvantages of the myocutaneous flaps are related to the morbidity at the donor site, the excessive bulk of the flap, and the distance from the defect to the pedicle that requires positional changes and extensive dissection over the chest, neck, and face. Microvascular free flap transfer to the maxillofacial region is now being performed to correct a great number of defects after tumor resection, but free flap surgery is time-consuming and requires specific microvascular techniques. Frequently, a two-team approach is necessary. The advantages of microvascular free flaps are the large number of different flaps’, the single tissue or compound tissue transfer that can be performed, and the large amount of tissue that can be transferred. The disadvantages are related to the functional and cosmetic morbidity at the donor site, Bong operative time, and the need for sophistication in microvascular anastomosis techniques.

FIGURE 5. A, Postoperative view after a radical maxiliectomy with orbital exenteration. The temporalis Rap donor site is covered with hair. The patient rejected reconstruction of the orb&d socket. B, Palatal reconstruction with perfect function of the velopharyngeal sphincter.

We believe that the temporalis myofascial flap is easier to handle than musculocutaneous or microvascular free flaps and is safe owing to its I-5-Avascularization. The flap has many advantages. It is

thin and pliable, without the subcutaneous tissue of the musculocutaneous flaps. The fascia in csntact with the oral cavity will epitheliahze in 3 weeks, and the flap is able to support skin grafts and nourish bone grafts. The muscle can be pedicled only to the deep temporal arteries after it is released from the temporal fossa and zygomatic arch and the corontid process is sectioned; these maneuvers increase the flap’s mobility and arc of rotation. The proximity to the oral cavity, the cheek, oropharynx, and palate, the middle third of the fake, and the orbit and skull base, as well as the safety of the vascular pedicle, make the temporal myofascid flap very useful for one-stage reconstruction of these locations. The flap is rapidly formed, is Iocated close to the operative field, and does not need positional changes. The donor site is closed primarily, and the functional deficit is negligible. The esthetic sequelae are limited to a depression in the temporaf fossa that will be covered by hair. Necrosis of the flap is rare, and complications such as facial paralysis and veHopharyngeal incompetence can be decreased if attention is paid to technical details. Masticatory physiotherapy will decrease the possibility sf restricted mouth opening. Conclusions The temporalis myofascial flap is a valuable adjunct for reconstruction of tbe skull base, middle third of the face, and Ural cavity. Flap pliability, arc of rotation, vascularization, and minilmal functional and esthetic sequelae are qualities that make the flap suitable for immediate reconstruction of defects of the maxillofacial region. References

FIGURE 6. A, Recurrence ofa squamous cell carcinoma of the forehead with invasion of the supraorbital ridge, frontal bone, orbital roof, and upper eyelid. Multiple scalp flaps had been used previously. B, Final postoperative view. A skin graft was placed over the temporalis flap, and the forehead was reconstructed with a bipedicled flap.

1. Golovine SS: Procedure de cloture plastique de l’orblte apres l’exenteration. Arch Gphtahnol~ 18:679, 1898 2. Campbell HH: Reconstruction of the left maxiha. Plast Reconstr Surg 3:67, 1948 3. Webster JP: Temporalis muscle transplants for -defects fellowing orbital exenteration, in Sallander II, Skoog ‘T (eds): Transactions of the International Society of Plastic Surgery, Fist Congress, 1955. Baltimore, Williams & Wilkins, 1957 4. Bakamjiam VY, Souter SC: Wse of temporalis muscle flap for reconstruction after orbitomaxillary resection for cancer. Plast Reconstr Surg 56:17l, 1975 5. Holmes AD, Marshall KA: Uses of temporalis muscle flap in blanking out orbits. Plast Reconstr Surg 63:336, I979 6. Rennet’ 6, Davis WE, Templer J: Temporalis pericranid muscle flap for reconstruction of the lateral face and head. Earyngoscope 94:1418, 1984 7. Jackson IT, Somers P, Marsh WR: Esthesioneuroblastoma: treatment of skull base recurrence. Plast Reconstr Surg 76:195, 1985

CGLMENERO

ET AL

8. Shagets MF, Pange WR, Shore JW: Use of temporalis muscle flap in comphcated defects of the head and face. Arch Otolaryngol Head Neck Surg 112:60, 1986 9. Antonyshin 0, Gruss JS, Bitt BD: Versatility of temporal muscle and fascial flaps. Br J Plast Surg 41:118, 1988 10. Bradley P, Brockbank J: The temporalis muscle flap in oral reconstruction. J Maxillofac Surg 9~139, 1981 11. Hutterbrink KB: Temporahs muscle flap: an alternative in oropharyngeal reconstruction. Laryngoscope 96: 1034, 1986 12. Koranda FC, McMahon MF, Jemstrom VR: The temporalis muscle flap for intraoral reconstruction. Arch Otolaryngol Head Neck Surg 113:740, 1987 13. Demas PN, Soteranos GC: Transmaxillary temporalis trans-

14.

15.

16. 17.

fer for reconstmction of a large palatal defect. 9 Oral Maxihofac Surg 47:192, 1989 Van der Meulen JC, Hanben DJ, Vaandrager JM: The uses of the temporal osteo-petiostal flap for reconstruction of malar hypoplasia in Treacher-Collins syndrome. PEast Reconstr Surg 74:687, 1984 Furnas DW: Temporal osteocutanesus island flap for complete reconstruction of cleft palate defects. Scand J Ptast Reconstr Surg 21: 119, 1987 Mathes SJ, Nahai F: Clinical Applicaticans for Muscle and Musculocutaneous Flaps. St Louis, Mosby, 1982 Abdul-Hassan MS, Von Drasek Ascher G, Acland RD: Surgical anatomy and blood supply of the facial layers of the temporal region. Blast Reconstr Surg 77:17, 1986

Temporalis myofascial flap for maxillofacial reconstruction.

To date, the temporalis myofascial flap has been used only to a limited extent for reconstruction in the maxillofacial region. Experience gained with ...
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