J Oral Maxillofac 48:14-19,
Surg
1990
The Role of a Temporalis Fascia and Muscle Flap in Temporomandibular Joint Surgery M.A. POGREL,
MB, CHB, BDS, FDS, RCS (ENG), L.B. KABAN, DMD, MDT
FRCS
(ED)* AND
Temporalis fascia, with a varying thickness of temporalis muscle, may be harvested as an axial flap based on the middle and deep temporal arteries and veins. The dependable blood supply, the proximity to the temporomandibular joint, and the ability to alter the arc of rotation by basing the flap inferiorly or posteriorly make this a versatile flap for lining the temporomandibular joint. In this report, the anatomy is reviewed, the harvesting technique is described, and multiple uses of the temporalis musclefascia flap in temporomandibular joint surgery are described.
The temporalis muscle has a dual origin from the inner temporal line of the temporal fossa and the deep temporal fascia. The muscle inserts into the coronoid process and lateral oblique ridge of the mandible as far anterior as the second molar tooth. It elevates and retrudes the mandible.’ Abdul Hassan et al have defined the anatomy of the temporal fossa on fresh cadavers.* The parietotemporal fascia (superficial temporal fascia) is located beneath the skin and subcutaneous connective tissue (Fig I). It is continuous with the galea aponeurotica superiorly and the superficial musculoaponeurotic system inferiorly. The superficial temporal artery is located within the parietotemporal fascia, whereas the superficial temporal vein lies on its outer surface. The next layer, a loose areolar tissue, contains the facial nerve. The deep temporal fascia (temporalis fascia), which arises from the pericranium overlying the outer temporal line of the temporal fossa, is encountered beneath
the areolar tissue. It is loosely adherent to the temporalis muscle on its deep surface and fuses inferiorly with the periosteum of the zygomatic arch. This anatomic relationship between the temporalis fascia and muscle, at the arch of the zygoma, is the basis for Gillies et al’s approach to the zygomatic arch.3 The middle temporal artery, a branch of the superficial temporal artery, provides the blood supply to the temporalis fascia. Perforating branches enter the superficial portion of the temporalis muscle and provide a minor portion of the blood supply to it. The vascular and nerve supply to the temporalis muscle have been described by Bradley and Brockbank.4 The primary blood supply is from the anterior and posterior deep temporal arteries, which are branches of the second portion of the internal maxillary artery. Thus, the temporalis fascia and muscle each have an independent vascular supply and may be dissected separately or as a single unit (Fig 2). The temporalis muscle is innervated by the anterior and posterior deep temporal, and occasionally the middle temporal, nerves. These are all branches of the anterior portion of the mandibular division of the trigeminal nerve. The vascular and nerve supply enter the muscle and fascia from an inferior, medial, and posterior direction. For this reason, both inferior and posterior based flaps can be created. The temporalis muscle and fascia flap has been used to support’ and replace6 orbital contents and to reanimate the paralyzed face.’ Its use in soft tis-
Received from the Department of Oral and Maxillofacial Surgery, University of California, San Francisco. * Assistant Professor. t Professor and Chairman, This work was supported in part by the UCSF Oral and Maxillofacial Research Fund. Address correspondence and reprint requests to Dr Pogrel: Box 0440, University of California, San Francisco, 513 Pamassus Ave, San Francisco, CA %143-0440. 0 1990 American
Association
of Oral
and Maxillofacial
Sur-
geons 0278-2391/90/4801-0003$3.00/O
14
15
POGREL AND KABAN
TMJ surgery are to provide a lining for the joint and to occupy dead space. ANKYLOSIS
v FIGURE 1.
Temporalis
M.
Following excision of bony ankylosis, with or without a coronoidectomy, a temporalis muscle and fascia flap can be used to line the glenoid fossa. This may prevent reankylosis between the bony surfaces of the mandible and the fossa.
The anatomy of the tissue planes deep to the skin
in the temporal fossa. P-T, Parieto-temporal fascia or superficial temporal fascia containing the superficial temporal artery. Fascia of temporalis M. deep temporal fascia.
sue reconstruction of the oral cavity and maxillofacial region following tumor surgery has also been described.4.8-‘0 In this report we describe the role of the temporalis flap in temporomandibular joint (TMJ) surgery. Indications for the Temporalis Muscle and Fascia Flap in TMJ Surgery Regardless of the specific indication, the common fundamental uses of temporalis fascia-muscle in
TOTAL TEMPOROMANDIBULAR JOINT RECONSTRUCTION FOR CONGENITAL ANOMALIES
Temporomandibular joint and ramus construction with a costochondral graft and temporalis fascia (when present) is required for type IIB and III hemifacial microsomia.” Kaban et all2 and Murray et alI3 stressed the use of perichondrium to line the constructed glenoid fossa. However, when temporalis muscle and fascia are present, they provide a more predictable result. TOTAL JOINT RECONSTRUCTIONFOLLOWING TUMOR OR TRAUMA Costochondral grafting is currently the most predictable means of reconstruction in these cases when coupled with a temporalis flap to line the glenoid fossa and create a barrier against bony fusion. DISC REPLACEMENT
When the TMJ disc is removed, replacement is often advocated to maintain occlusion and to prevent development of degenerative changes. 14-16The inferiorly based temporalis fascia and muscle flap, which is turned over the arch of the zygoma, makes an excellent disc replacement. OTHER USES
A temporalis flap has also been used to support the lateral capsule” and to maintain denervation procedures of the temporomandibular joint. I8 Technique
FIGURE 2. The anatomy and blood supply of the temporalis fascia (turned down over the zygomatic arch) and the temporalis muscle. The vascular supply to the fascia runs on its deep surface and is derived from the middle temporal branch of the superficial temporal artery. The vascular supply to the temporalis muscle (dotted lines) lies on the deep surface of the muscle and is derived from the anterior and posterior deep temporal branches of the second part of the internal maxillary artery.
The hair in the temporal region is clipped. Gentle forward displacement of the auricle helps to define the crease in the glabrous preauricular skin. The incision in this preauricular crease should curve along the crus of the helix, scallop in front of the tragus, and include two well-defined darts, one at the superior helical rim and the other at the junction of the m-us helicis and the tragus.
16
TEMPORALIS
FIGURE 3. Diagram of the incision. It provides access to the temporalis fascia and muscle as well as to the temporomandibular joint.
The incision is started in the temporal fossa and curved inferiorly to the external ear and then into the preauricular skin crease parallel to the crus helix. The knife blade is angled, beveling the cut, to spare as many hair follicles as possible. The inferior extent of the incision is the junction of the tragus and lobule (Fig 3). At the superior aspect of the wound, the dissection is directed through the superficial temporal fascia down to the temporalis fascia proper. The dissection continues inferiorly in this plane, directly over the fascia, to the zygomatic arch. The inferior dissection is performed bluntly, anterior to the external auditory canal in the avascular plane superficial to the tragal cartilage. In this manner the upper and lower dissections are joined. The parotid gland, fascia, and facial nerve are retracted anteriorly. The periosteum of the zygomatic arch is then incised, and the articular tubercle and capsule of the TMJ are identified. The TMJ is entered via a T-shaped incision in the capsule and the upper and lower joint space, and the articular disc
FIGURE 4. The finger-like flap is outlined. I?, The inferiorly based flap is then turned outward and downward over the zygomatic arch and placed in the temporomandibular joint.
\
and condyle are visualized. The TMJ procedure is completed, and attention is then turned to the temporal region. The flap is outlined on the fascia using a skin marker. It is finger-like in shape and extends as far superiorly as necessary to give proper length for lining the joint, remembering that it contracts as it is raised. The dissection is carried to the proper depth, including fascia only or muscle and fascia. The flap is extended only to the level of the zygomatic arch. Occasionally the zygomatic arch has to be reduced in thickness to permit rotation of the flap without producing excessive contour (Figs 4,5, 6, and 7). The flap is secured with six sutures (5-O resorbable suture such as polyglycolic acid), two in the medical capsule region, two in the anterior attachment, and two in the posterior attachment. Hemostasis is achieved in the donor area with electrocautery. A suction drain is used for 24 to 48 hours. For disc replacement, the medial attachment of the disc should be retained whenever possible so that the temporalis flap can be sutured medially. When the medial attachment cannot be retained, the flap is secured only to the anterior and posterior attachments. The capsule is then repaired and sutured to the lateral aspect of the flap. Results All patients who had temporalis fascia and muscle flaps at the University of California, San Francisco Department of Oral and Maxillofacial Surgery from July 1, 1985 through June 30, 1988, were retrospectively reviewed. Altogether there were 55 patients. The indications were anklyosis (n = 16), trauma (n = 5), congenital disorders (n = 4), disc replacement (n = 26), tumor (n = l), and support for the lateral capsule (n = 3). The mean follow-up time was 19 months, with a range of 8 months to 3 years. No patients required
\
A
FLAP IN TMJ SURGERY
B
17
POGREL AND KABAN
reoperation. There were no cases of postoperative hemorrhage or infection. All patients had vigorous postoperative physiotherapy, including massage, stretching, and active opening exercises. Although a small number of patients noted the contour change in temporalis area and over the zygomatic arch postoperatively, in no case was it a concern 3 months postoperatively. There was one case of permanent upper-division facial nerve weakness (occurring in a patient who had a large osteochondroma resected) and three cases of transient nerve weakness (one of these patients also had a coronoidectomy performed). In the ankylosis group (n = 16) the mean preoperative interincisal opening was 18.3 mm (range 2 to 30 mm). This group included fibrous and bony ankylosis. Opening at 3 months was an average of 31.2 mm (range 21 to 40 mm). At 6 months postoperatively, opening was 34.8 mm (range 29 to 42 mm), and at 1 year (n = 11) opening was 38 mm (range 33 to 43 mm). In the disc replacement group, no patient had an interincisal opening of less than 35 mm at 3 months postoperatively.
FIGURE 5. fascia.
The temporalis flap is outlined on the temporalis
Discussion The first description of the temporalis muscle and/or fascia flap was by Yolovine in 1898,i9 who used it for orbital reconstruction. Its first use in TMJ surgery was by J.B. Murphy in 1912,20 and there have been other advocates of its use over the years. ‘7.2’-23The majority of investigators have recommended that the flap be based inferiorly as described in this report. The flap is turned over the zygomatic arch so that the fascia lines the glenoid fossa and the muscle faces the condyle. Rowe,23 however, recommends that the flap be anteriorly based and passed under the zygomatic arch. It is then rotated so that the fascia lines the glenoid fossa and muscle faces the condyle. Toller” recommended that it be posteriorly based and passed over the arch of the zygoma. All techniques appear to maintain the viability of the flap. DISC REPLACEMENT The exact function of the disc of the TMJ is still in doubt, although it has been extensively de-
FIGURE 6. The inferiorly based temporalis fascia and muscle flap is raised and turned down over the arch of the zygoma.
18
TEMPORALIS
FLAP IN TMJ SURGERY
donor site, if TMJ surgery is carried out via the extended incision described or that of Al-Kayat and Bramley.42 3) The plane of dissection is directly on the deep temporal fascia, and this protects the facial nerve from injury. 4) Morbidity at the donor area, both cosmetically and functionally, is minimal. 5) The flap can consist of fascia only or can be of fascia plus muscle for greater bulk. References
FIGURE 7. The temporalis muscle and fascia flap is turned into the temporomandibular joint after release of an ankylosis.
scribed.24 It divides the TMJ into two compartments, allowing rotation to occur in the lower compartment and translation in the upper.25 It may function as a shock absorber or hydrostatic cushion in the joint,26 particularly to protect the condyle as it translates down the slope of eminence.27 The disc may also aid in lubrication of the joint28 and the self-repair mechanism.29 Suggested disc replacements include alloplastic materials such as Proplast (Vitek Inc, Houston, TX)30 or Silastic (Dow Coming, Midland, MI)3’*32 and autogenous dermis33,34 and cartilage.35 However, recently it has been noted that the use of alloplastic materials results in severe degenerative changes and possible systemic release of particles.3G38 The use of dermis39 has provided acceptable results according to some reportsN However, it often requires a distant donor site and is placed as a free graft on a nonvascular bed with movement over it. Healing, therefore, may result in scar formation and the potential for hypomobility.41 On the other hand, the temporalis fascia and muscle flap has a local donor site, is vascularized, and the areolar plane on the muscle side may provide lubrication. The advantages of the temporalis fascia-muscle flap over alternate methods for reconstruction in the TMJ area are as follows: 1) The flap is well vascularized; it may be based inferiorly or posteriorly. 2) It can be obtained through the same incision used for the TMJ procedure; ie, there is no distant
1. Last RJ: The temporal fossa and zygomatic arch, in Last RJ (ed): Anatomy Regional and Applied. London, England, Churchill, 1963, p 545 2. Abdul Hassan HS, Von Drasek Asher G, Acland RD: Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 77:17, 1986 3. Gillies HJ, Kilner TP, Stone D: Fractures of the malarzygomatic compound with a description of a new x-ray position. Br J Surg 14:651, 1927 4. Bradley P, Brockbank J: The temporalis muscle flap in oral reconstruction. J Maxillofac Surg 9: 139, 1981 5. Wise RA, Baker HW (eds): Surgery of the Head and Neck (ed 3). Chicago, IL, Year Book Medical, 1968, p 186 6. Holmes AD, Marshall KA: Uses of the temporalis muscle flap in blanking out orbits. Plast Reconstr Surg 63:336, 1979 7. Freeman BS: Facial palsy, in Converse JM (ed): Reconstructive Plastic Surgery. Philadelphia, PA, Saunders, 1977, p 1810 8. Habal G, Hensher R: The versatility of the temporalis muscle flap in reconstructive surgery. Br J Oral Maxillofac Surg 24:96, 1986 9. Bakamjian V, Souther BG: Use of the temporalis muscle flap for reconstruction after orbital maxillary resections for cancer. Plast Reconstr Surg 8:171, 1975 10. Cornah J: Immediate reconstruction following maxillectomy. J R Co11Surg Edinb 29:278, 1984 11. Swanson LT, Murray JE: Asymmetries of the lower part of the face, in Whitaker LA, Randall P (eds): Symposium on Reconstruction of Jaw Deformities. St Louis, MO, Mosby, 1978, p 171 12. Kaban LB, Moses MH, Mulliken JB: Surgical correction of hemifacial microsomia in the growing child. Plast Reconstr Surg 82:9, 1988 13. Murray JE, Kaban LB, Mulliken JB: Analysis and treatment of hemifacial microsomia. Plast Reconstr Surg 74:186, 1984 14. Sprinz R: Further observations on the effect of surgery on the meniscus of the mandibular joint in rabbits. Arch Oral Biol 5: 195, 1961 15. Sprinz R: Role of the meniscus in the healing process following excision of the articular surface of the mandibular joint in rabbits. J Anat 97:345, 1963 16. Yaillen DM, Shapiro PA, Luschei ES, et al: Temporomandibular joint meniscectomy: Effects on joint structure and masticatory function in Mucaca fascicularis. J Maxillofac Surg 7~25.5, 1979 17. Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg 11:207, 1974 18. Bradley PF: Conservative treatment for temporomandibular joint pain dysfunction. Br J Oral Maxillofac Surg 25:125, 1987 19. Yolovine SS: Procede
de cloture plastique de l’orbit apres l’extenteration. Arch d’ophthamol 18:679, 1898 20. Murphy JB: Ankylosis of the temporomandibular joints. Surg Clin J.B. Murphy 1905, 1912 21. Murphy JB: Bony ankylosis ofjaw with interposition of flaps from temporal fascia. Surg Clin J.B. Murphy 2:659, 1913
19
POGREL AND KABAN
22. Wakeley C: The mandibular joint. Ann R Co11 Surg Engl 2:111, 1948 23. Rowe NL: Ankylosis of the temporomandibular joint. J R Coil Surg Edinb 27:209, 1982 24. Grifftn CJ, Sharpe CJ: The structure of the adult human temporomandibualr joint meniscus. Aust Dent J 5:190, 1960 25. Rees LA: The structure and function of the mandibular joint. Br Dent J 96:125, 1954 26. Osbom JW: The disc of the human temporomandibularjoint: Design, function and failure. J Oral Rehabil 12:279, 1985 27. Hjortsjo CH: The significance of the articular disc and the accentuated grinding joint. Odontologisk Rev 4:203, 1953 28. Toller PA: The synovial apparatus and temporomandibular joint function. Br Dent J 111:355, 1961 29. Ogus HD, Toller PA: Common disorders of the temporomandibular joint. Bristol, Wright, 1981. p 94 30. Heffez L, Mafee MF, Rosenberg H, et al: CT evaluation of TMJ disc replacement with a Proplast Teflon laminate. J Oral Maxillofac Surg 45:657, 1987 31. Hansen WC, Deshazo BW: Silastic reconstruction of the temporomandibular joint meniscus. Plast Reconstr Surg 43:388, 1969 32. Howe DJ: Preformed Silastic temporomandibular joint implant. J Oral Surg 37:59, 1979 33. Zetz MR. lrby WB: Repair of the adult temporomandibular
34.
35.
36.
37.
38.
39.
40. 41. 42.
joint meniscus with an autogenous dermal graft. J Oral MaxiUofac Surg 42: 167, 1984 Georgiade N: The surgical correction of temporomandibular joint dysfunction by means of autogenous dermal grafts. Plast Reconstr Surg 3068, 1%2 Witsenberg B, Freihoffer PM: Replacement of the pathological temporomandibular articular disc using autogenous cartilage of the external ear. Int J Oral Surg 13401, 1984 Heffaz L, Mafee MF, Rosenberg H, et al: CT evaluation of TMJ disc replacement with a Proplast-Teflon laminate. J Oral Maxillofac Surg 45:657, 1987 Gallagher DM. Wolford LM: Comoarison of Silastic and Proplast implants in the TMJ after condylectomy for osteoarthritis. J Oral Maxillofac Surg 40:627, 1982 Timmus DP, Aragon SB, Van Sickels JE, et al: Comparative study of alloplastic materials for temporomandibular joint disc replacement in rabbits. J Oral Maxillofac Surg 44:541, 1986 Stewart HM, Hann JR, DeTomasi DC, et al: Histologic fate of dermal grafts following implantation for temporomandibular joint meniscal perforation: A preliminary study. Oral Surg 62:481, 1986 Meyer RA: The autogenous dermal graft in temporomandibularjoint disc surgery. J Oral Maxillofac Surg 46:948, 1988 McGregor IA: Fundamental Techniques of Plastic Surgery. Edinburgh, Churchill Livingstone, 1980, pp 55-63 Al-Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979
Surg
1990
The Role of a Temporalis Fascia and Muscle Flap in Temporomandibular Joint Surgery M.A. POGREL,
MB, CHB, BDS, FDS, RCS (ENG), L.B. KABAN, DMD, MDT
FRCS
(ED)* AND
Temporalis fascia, with a varying thickness of temporalis muscle, may be harvested as an axial flap based on the middle and deep temporal arteries and veins. The dependable blood supply, the proximity to the temporomandibular joint, and the ability to alter the arc of rotation by basing the flap inferiorly or posteriorly make this a versatile flap for lining the temporomandibular joint. In this report, the anatomy is reviewed, the harvesting technique is described, and multiple uses of the temporalis musclefascia flap in temporomandibular joint surgery are described.
The temporalis muscle has a dual origin from the inner temporal line of the temporal fossa and the deep temporal fascia. The muscle inserts into the coronoid process and lateral oblique ridge of the mandible as far anterior as the second molar tooth. It elevates and retrudes the mandible.’ Abdul Hassan et al have defined the anatomy of the temporal fossa on fresh cadavers.* The parietotemporal fascia (superficial temporal fascia) is located beneath the skin and subcutaneous connective tissue (Fig I). It is continuous with the galea aponeurotica superiorly and the superficial musculoaponeurotic system inferiorly. The superficial temporal artery is located within the parietotemporal fascia, whereas the superficial temporal vein lies on its outer surface. The next layer, a loose areolar tissue, contains the facial nerve. The deep temporal fascia (temporalis fascia), which arises from the pericranium overlying the outer temporal line of the temporal fossa, is encountered beneath
the areolar tissue. It is loosely adherent to the temporalis muscle on its deep surface and fuses inferiorly with the periosteum of the zygomatic arch. This anatomic relationship between the temporalis fascia and muscle, at the arch of the zygoma, is the basis for Gillies et al’s approach to the zygomatic arch.3 The middle temporal artery, a branch of the superficial temporal artery, provides the blood supply to the temporalis fascia. Perforating branches enter the superficial portion of the temporalis muscle and provide a minor portion of the blood supply to it. The vascular and nerve supply to the temporalis muscle have been described by Bradley and Brockbank.4 The primary blood supply is from the anterior and posterior deep temporal arteries, which are branches of the second portion of the internal maxillary artery. Thus, the temporalis fascia and muscle each have an independent vascular supply and may be dissected separately or as a single unit (Fig 2). The temporalis muscle is innervated by the anterior and posterior deep temporal, and occasionally the middle temporal, nerves. These are all branches of the anterior portion of the mandibular division of the trigeminal nerve. The vascular and nerve supply enter the muscle and fascia from an inferior, medial, and posterior direction. For this reason, both inferior and posterior based flaps can be created. The temporalis muscle and fascia flap has been used to support’ and replace6 orbital contents and to reanimate the paralyzed face.’ Its use in soft tis-
Received from the Department of Oral and Maxillofacial Surgery, University of California, San Francisco. * Assistant Professor. t Professor and Chairman, This work was supported in part by the UCSF Oral and Maxillofacial Research Fund. Address correspondence and reprint requests to Dr Pogrel: Box 0440, University of California, San Francisco, 513 Pamassus Ave, San Francisco, CA %143-0440. 0 1990 American
Association
of Oral
and Maxillofacial
Sur-
geons 0278-2391/90/4801-0003$3.00/O
14
15
POGREL AND KABAN
TMJ surgery are to provide a lining for the joint and to occupy dead space. ANKYLOSIS
v FIGURE 1.
Temporalis
M.
Following excision of bony ankylosis, with or without a coronoidectomy, a temporalis muscle and fascia flap can be used to line the glenoid fossa. This may prevent reankylosis between the bony surfaces of the mandible and the fossa.
The anatomy of the tissue planes deep to the skin
in the temporal fossa. P-T, Parieto-temporal fascia or superficial temporal fascia containing the superficial temporal artery. Fascia of temporalis M. deep temporal fascia.
sue reconstruction of the oral cavity and maxillofacial region following tumor surgery has also been described.4.8-‘0 In this report we describe the role of the temporalis flap in temporomandibular joint (TMJ) surgery. Indications for the Temporalis Muscle and Fascia Flap in TMJ Surgery Regardless of the specific indication, the common fundamental uses of temporalis fascia-muscle in
TOTAL TEMPOROMANDIBULAR JOINT RECONSTRUCTION FOR CONGENITAL ANOMALIES
Temporomandibular joint and ramus construction with a costochondral graft and temporalis fascia (when present) is required for type IIB and III hemifacial microsomia.” Kaban et all2 and Murray et alI3 stressed the use of perichondrium to line the constructed glenoid fossa. However, when temporalis muscle and fascia are present, they provide a more predictable result. TOTAL JOINT RECONSTRUCTIONFOLLOWING TUMOR OR TRAUMA Costochondral grafting is currently the most predictable means of reconstruction in these cases when coupled with a temporalis flap to line the glenoid fossa and create a barrier against bony fusion. DISC REPLACEMENT
When the TMJ disc is removed, replacement is often advocated to maintain occlusion and to prevent development of degenerative changes. 14-16The inferiorly based temporalis fascia and muscle flap, which is turned over the arch of the zygoma, makes an excellent disc replacement. OTHER USES
A temporalis flap has also been used to support the lateral capsule” and to maintain denervation procedures of the temporomandibular joint. I8 Technique
FIGURE 2. The anatomy and blood supply of the temporalis fascia (turned down over the zygomatic arch) and the temporalis muscle. The vascular supply to the fascia runs on its deep surface and is derived from the middle temporal branch of the superficial temporal artery. The vascular supply to the temporalis muscle (dotted lines) lies on the deep surface of the muscle and is derived from the anterior and posterior deep temporal branches of the second part of the internal maxillary artery.
The hair in the temporal region is clipped. Gentle forward displacement of the auricle helps to define the crease in the glabrous preauricular skin. The incision in this preauricular crease should curve along the crus of the helix, scallop in front of the tragus, and include two well-defined darts, one at the superior helical rim and the other at the junction of the m-us helicis and the tragus.
16
TEMPORALIS
FIGURE 3. Diagram of the incision. It provides access to the temporalis fascia and muscle as well as to the temporomandibular joint.
The incision is started in the temporal fossa and curved inferiorly to the external ear and then into the preauricular skin crease parallel to the crus helix. The knife blade is angled, beveling the cut, to spare as many hair follicles as possible. The inferior extent of the incision is the junction of the tragus and lobule (Fig 3). At the superior aspect of the wound, the dissection is directed through the superficial temporal fascia down to the temporalis fascia proper. The dissection continues inferiorly in this plane, directly over the fascia, to the zygomatic arch. The inferior dissection is performed bluntly, anterior to the external auditory canal in the avascular plane superficial to the tragal cartilage. In this manner the upper and lower dissections are joined. The parotid gland, fascia, and facial nerve are retracted anteriorly. The periosteum of the zygomatic arch is then incised, and the articular tubercle and capsule of the TMJ are identified. The TMJ is entered via a T-shaped incision in the capsule and the upper and lower joint space, and the articular disc
FIGURE 4. The finger-like flap is outlined. I?, The inferiorly based flap is then turned outward and downward over the zygomatic arch and placed in the temporomandibular joint.
\
and condyle are visualized. The TMJ procedure is completed, and attention is then turned to the temporal region. The flap is outlined on the fascia using a skin marker. It is finger-like in shape and extends as far superiorly as necessary to give proper length for lining the joint, remembering that it contracts as it is raised. The dissection is carried to the proper depth, including fascia only or muscle and fascia. The flap is extended only to the level of the zygomatic arch. Occasionally the zygomatic arch has to be reduced in thickness to permit rotation of the flap without producing excessive contour (Figs 4,5, 6, and 7). The flap is secured with six sutures (5-O resorbable suture such as polyglycolic acid), two in the medical capsule region, two in the anterior attachment, and two in the posterior attachment. Hemostasis is achieved in the donor area with electrocautery. A suction drain is used for 24 to 48 hours. For disc replacement, the medial attachment of the disc should be retained whenever possible so that the temporalis flap can be sutured medially. When the medial attachment cannot be retained, the flap is secured only to the anterior and posterior attachments. The capsule is then repaired and sutured to the lateral aspect of the flap. Results All patients who had temporalis fascia and muscle flaps at the University of California, San Francisco Department of Oral and Maxillofacial Surgery from July 1, 1985 through June 30, 1988, were retrospectively reviewed. Altogether there were 55 patients. The indications were anklyosis (n = 16), trauma (n = 5), congenital disorders (n = 4), disc replacement (n = 26), tumor (n = l), and support for the lateral capsule (n = 3). The mean follow-up time was 19 months, with a range of 8 months to 3 years. No patients required
\
A
FLAP IN TMJ SURGERY
B
17
POGREL AND KABAN
reoperation. There were no cases of postoperative hemorrhage or infection. All patients had vigorous postoperative physiotherapy, including massage, stretching, and active opening exercises. Although a small number of patients noted the contour change in temporalis area and over the zygomatic arch postoperatively, in no case was it a concern 3 months postoperatively. There was one case of permanent upper-division facial nerve weakness (occurring in a patient who had a large osteochondroma resected) and three cases of transient nerve weakness (one of these patients also had a coronoidectomy performed). In the ankylosis group (n = 16) the mean preoperative interincisal opening was 18.3 mm (range 2 to 30 mm). This group included fibrous and bony ankylosis. Opening at 3 months was an average of 31.2 mm (range 21 to 40 mm). At 6 months postoperatively, opening was 34.8 mm (range 29 to 42 mm), and at 1 year (n = 11) opening was 38 mm (range 33 to 43 mm). In the disc replacement group, no patient had an interincisal opening of less than 35 mm at 3 months postoperatively.
FIGURE 5. fascia.
The temporalis flap is outlined on the temporalis
Discussion The first description of the temporalis muscle and/or fascia flap was by Yolovine in 1898,i9 who used it for orbital reconstruction. Its first use in TMJ surgery was by J.B. Murphy in 1912,20 and there have been other advocates of its use over the years. ‘7.2’-23The majority of investigators have recommended that the flap be based inferiorly as described in this report. The flap is turned over the zygomatic arch so that the fascia lines the glenoid fossa and the muscle faces the condyle. Rowe,23 however, recommends that the flap be anteriorly based and passed under the zygomatic arch. It is then rotated so that the fascia lines the glenoid fossa and muscle faces the condyle. Toller” recommended that it be posteriorly based and passed over the arch of the zygoma. All techniques appear to maintain the viability of the flap. DISC REPLACEMENT The exact function of the disc of the TMJ is still in doubt, although it has been extensively de-
FIGURE 6. The inferiorly based temporalis fascia and muscle flap is raised and turned down over the arch of the zygoma.
18
TEMPORALIS
FLAP IN TMJ SURGERY
donor site, if TMJ surgery is carried out via the extended incision described or that of Al-Kayat and Bramley.42 3) The plane of dissection is directly on the deep temporal fascia, and this protects the facial nerve from injury. 4) Morbidity at the donor area, both cosmetically and functionally, is minimal. 5) The flap can consist of fascia only or can be of fascia plus muscle for greater bulk. References
FIGURE 7. The temporalis muscle and fascia flap is turned into the temporomandibular joint after release of an ankylosis.
scribed.24 It divides the TMJ into two compartments, allowing rotation to occur in the lower compartment and translation in the upper.25 It may function as a shock absorber or hydrostatic cushion in the joint,26 particularly to protect the condyle as it translates down the slope of eminence.27 The disc may also aid in lubrication of the joint28 and the self-repair mechanism.29 Suggested disc replacements include alloplastic materials such as Proplast (Vitek Inc, Houston, TX)30 or Silastic (Dow Coming, Midland, MI)3’*32 and autogenous dermis33,34 and cartilage.35 However, recently it has been noted that the use of alloplastic materials results in severe degenerative changes and possible systemic release of particles.3G38 The use of dermis39 has provided acceptable results according to some reportsN However, it often requires a distant donor site and is placed as a free graft on a nonvascular bed with movement over it. Healing, therefore, may result in scar formation and the potential for hypomobility.41 On the other hand, the temporalis fascia and muscle flap has a local donor site, is vascularized, and the areolar plane on the muscle side may provide lubrication. The advantages of the temporalis fascia-muscle flap over alternate methods for reconstruction in the TMJ area are as follows: 1) The flap is well vascularized; it may be based inferiorly or posteriorly. 2) It can be obtained through the same incision used for the TMJ procedure; ie, there is no distant
1. Last RJ: The temporal fossa and zygomatic arch, in Last RJ (ed): Anatomy Regional and Applied. London, England, Churchill, 1963, p 545 2. Abdul Hassan HS, Von Drasek Asher G, Acland RD: Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 77:17, 1986 3. Gillies HJ, Kilner TP, Stone D: Fractures of the malarzygomatic compound with a description of a new x-ray position. Br J Surg 14:651, 1927 4. Bradley P, Brockbank J: The temporalis muscle flap in oral reconstruction. J Maxillofac Surg 9: 139, 1981 5. Wise RA, Baker HW (eds): Surgery of the Head and Neck (ed 3). Chicago, IL, Year Book Medical, 1968, p 186 6. Holmes AD, Marshall KA: Uses of the temporalis muscle flap in blanking out orbits. Plast Reconstr Surg 63:336, 1979 7. Freeman BS: Facial palsy, in Converse JM (ed): Reconstructive Plastic Surgery. Philadelphia, PA, Saunders, 1977, p 1810 8. Habal G, Hensher R: The versatility of the temporalis muscle flap in reconstructive surgery. Br J Oral Maxillofac Surg 24:96, 1986 9. Bakamjian V, Souther BG: Use of the temporalis muscle flap for reconstruction after orbital maxillary resections for cancer. Plast Reconstr Surg 8:171, 1975 10. Cornah J: Immediate reconstruction following maxillectomy. J R Co11Surg Edinb 29:278, 1984 11. Swanson LT, Murray JE: Asymmetries of the lower part of the face, in Whitaker LA, Randall P (eds): Symposium on Reconstruction of Jaw Deformities. St Louis, MO, Mosby, 1978, p 171 12. Kaban LB, Moses MH, Mulliken JB: Surgical correction of hemifacial microsomia in the growing child. Plast Reconstr Surg 82:9, 1988 13. Murray JE, Kaban LB, Mulliken JB: Analysis and treatment of hemifacial microsomia. Plast Reconstr Surg 74:186, 1984 14. Sprinz R: Further observations on the effect of surgery on the meniscus of the mandibular joint in rabbits. Arch Oral Biol 5: 195, 1961 15. Sprinz R: Role of the meniscus in the healing process following excision of the articular surface of the mandibular joint in rabbits. J Anat 97:345, 1963 16. Yaillen DM, Shapiro PA, Luschei ES, et al: Temporomandibular joint meniscectomy: Effects on joint structure and masticatory function in Mucaca fascicularis. J Maxillofac Surg 7~25.5, 1979 17. Toller PA: Temporomandibular capsular rearrangement. Br J Oral Surg 11:207, 1974 18. Bradley PF: Conservative treatment for temporomandibular joint pain dysfunction. Br J Oral Maxillofac Surg 25:125, 1987 19. Yolovine SS: Procede
de cloture plastique de l’orbit apres l’extenteration. Arch d’ophthamol 18:679, 1898 20. Murphy JB: Ankylosis of the temporomandibular joints. Surg Clin J.B. Murphy 1905, 1912 21. Murphy JB: Bony ankylosis ofjaw with interposition of flaps from temporal fascia. Surg Clin J.B. Murphy 2:659, 1913
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22. Wakeley C: The mandibular joint. Ann R Co11 Surg Engl 2:111, 1948 23. Rowe NL: Ankylosis of the temporomandibular joint. J R Coil Surg Edinb 27:209, 1982 24. Grifftn CJ, Sharpe CJ: The structure of the adult human temporomandibualr joint meniscus. Aust Dent J 5:190, 1960 25. Rees LA: The structure and function of the mandibular joint. Br Dent J 96:125, 1954 26. Osbom JW: The disc of the human temporomandibularjoint: Design, function and failure. J Oral Rehabil 12:279, 1985 27. Hjortsjo CH: The significance of the articular disc and the accentuated grinding joint. Odontologisk Rev 4:203, 1953 28. Toller PA: The synovial apparatus and temporomandibular joint function. Br Dent J 111:355, 1961 29. Ogus HD, Toller PA: Common disorders of the temporomandibular joint. Bristol, Wright, 1981. p 94 30. Heffez L, Mafee MF, Rosenberg H, et al: CT evaluation of TMJ disc replacement with a Proplast Teflon laminate. J Oral Maxillofac Surg 45:657, 1987 31. Hansen WC, Deshazo BW: Silastic reconstruction of the temporomandibular joint meniscus. Plast Reconstr Surg 43:388, 1969 32. Howe DJ: Preformed Silastic temporomandibular joint implant. J Oral Surg 37:59, 1979 33. Zetz MR. lrby WB: Repair of the adult temporomandibular
34.
35.
36.
37.
38.
39.
40. 41. 42.
joint meniscus with an autogenous dermal graft. J Oral MaxiUofac Surg 42: 167, 1984 Georgiade N: The surgical correction of temporomandibular joint dysfunction by means of autogenous dermal grafts. Plast Reconstr Surg 3068, 1%2 Witsenberg B, Freihoffer PM: Replacement of the pathological temporomandibular articular disc using autogenous cartilage of the external ear. Int J Oral Surg 13401, 1984 Heffaz L, Mafee MF, Rosenberg H, et al: CT evaluation of TMJ disc replacement with a Proplast-Teflon laminate. J Oral Maxillofac Surg 45:657, 1987 Gallagher DM. Wolford LM: Comoarison of Silastic and Proplast implants in the TMJ after condylectomy for osteoarthritis. J Oral Maxillofac Surg 40:627, 1982 Timmus DP, Aragon SB, Van Sickels JE, et al: Comparative study of alloplastic materials for temporomandibular joint disc replacement in rabbits. J Oral Maxillofac Surg 44:541, 1986 Stewart HM, Hann JR, DeTomasi DC, et al: Histologic fate of dermal grafts following implantation for temporomandibular joint meniscal perforation: A preliminary study. Oral Surg 62:481, 1986 Meyer RA: The autogenous dermal graft in temporomandibularjoint disc surgery. J Oral Maxillofac Surg 46:948, 1988 McGregor IA: Fundamental Techniques of Plastic Surgery. Edinburgh, Churchill Livingstone, 1980, pp 55-63 Al-Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979
