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Journal of Cranio-Maxillofacial Surgery (2009) 37, 96e101 Ó 2008 European Association for Cranio-Maxillofacial Surgery doi:10.

1016/j.jcms.2008.11.004, available online at http://www.sciencedirect.com

Temporalis myofascial flap in maxillary reconstruction: anatomical study and clinical application
Iacopo DALLAN1, Riccardo LENZI1, Stefano SELLARI-FRANCESCHINI1, Manfred TSCHABITSCHER2, Luca MUSCATELLO1 ENT Unit (Head: Prof. S. Sellari-Franceschini), Azienda Ospedaliero Universitaria Pisana, Pisa, Italy; 2 Center of Anatomy and Cell Biology (Head: Prof. M. Tschabitscher), Medical University of Vienna, Austria
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SUMMARY. The authors describe indications and advantages of temporalis myofascial flap in the reconstruction of surgical defects after partial maxillectomies. This flap is thin and reliable and can be used as an alternative to free flap tissue transfer in the reconstruction of partial defects of the upper maxilla. The surgical steps to raise the flap are simple, but the dissection must be careful to avoid damages to the fronto-temporal branches of the facial nerve on the outer surface, and to the feeding vessels on the inner surface of the temporal muscle. In the present series no major surgical complications were observed. No injuries to the facial nerve branches were reported. Neither total nor partial flap losses were experienced. Post-operative aesthetic and functional results were satisfying. Temporalis muscle flap can be considered as a first-line reconstructive option for limited resection of the upper maxilla with sparing of the orbital floor and of the anterior alveolar crest. Ó 2008 European Association for Cranio-Maxillofacial Surgery

Keywords: temporal muscle, surgical flap, reconstructive surgical procedures, maxilla

INTRODUCTION Oncological surgery in the maxillary region is often aggressive and functionally mutilating given the fact that the two maxillae are the most important bones of the mid-facial skeleton. Maxillary defects are inherently complex because they generally involve more than one mid-facial component, and most of them are composite in nature. In this respect, and in agreement with others (Cenzi and Carinci, 2006), we believe that these defects should be reconstructed in order to offer the patient a better aesthetic and functional outcome. A great number of local flaps, pedicled flaps and microvascular free flaps have been employed over the years for the reconstruction of mid-facial defects. Nevertheless, reconstruction of the mid-face remains a challenging and still varied problem due to the different defects and the complex three-dimensionality of the region. It is important that the palatal defect after maxillectomy must be repaired and it is advisable to perform this immediately (Cordeiro and Santamaria, 2000; Cenzi and Carinci, 2006). Among the flaps proposed, the temporalis muscle flap (TMF) is a reliable and safe myofascial flap that has been used for the reconstruction of various maxillofacial defects (Cordeiro and Santamaria, 2000; Hanasono et al., 2001; Cenzi and Carinci, 2006). Since the first report by Bakamjian (1963), many other authors have used the TMF for the reconstruction of a defect including part or all of the hemi-maxilla (Cordeiro and Wolfe, 1996; Cordeiro and Santamaria, 2000; Hanasono et al., 2001; Mani and Panda, 2003; Cenzi and Carinci, 2006). From a functional point of view, TMF-based
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reconstructive procedures are effective in palatal closure. However, one must keep in mind that this kind of reconstruction can only be used if a resection of the cutaneous tissues and orbital exenteration are not deemed necessary. The aim of this paper is to describe anatomical landmarks useful in TMF harvesting procedures and to present our clinical experience with the use of TMF for reconstruction of maxillary defects following oncological procedures. MATERIAL AND METHODS Two fresh injected cadaver dissections were performed in order to illustrate better the surgical anatomy of the temporalis fossa with particular regard to the important surgical aspects during TMF harvesting procedures. We retrospectively reviewed the medical charts of 9 consecutive patients who had undergone subtotal maxillectomy and immediate reconstruction with TMF at a tertiary referral medical centre over the last 3 years. Demographic data, features of the disease, follow-up, outcome and complications were all collected and analysed. Functional and aesthetic outcomes were evaluated by physical examination at a minimum of 6 months after surgery. Aesthetic results were graded as excellent, good, fair or poor based on facial symmetry, malar prominence, cheek contour, scars and eyelid position, according to the clinicians’ point of view. Speech was graded as normal, good, fair, or unintelligible. The patient’s ability to eat an unrestricted, soft or liquid diet was also evaluated. The study met with the approval of the local Ethical Committee.

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Surgical technique The procedure begins with a hemi-coronal incision starting from the pre-auricular area. The dissection is carried out, in a superioreinferior direction, on a superficial plane below the temporo-parietal fascia (that is, the superior continuation of the superficial musculo-aponeurotic system, SMAS). Care must be taken to avoid damaging the temporal and frontal branches of the facial nerve in the orbital-zygomatic region (Fig. 1). It is advisable to dissect under the plane of the deep temporal fascia when reaching the zygomatic arch in order to preserve the facial nerve branches, given that they are superficial to the deep temporal fascia (Fig. 2). When in proximity of the zygomatic arch, a horizontal incision through the temporalis fat pad is made, and a careful subperiosteal dissection above the zygoma should be performed. Removal of the zygomatic arch facilitates elevation of the myofascial flap. For this, anterior and posterior osteotomies can be made in the zygomatic arch after pre-drilling holes for subsequent wire fixation. However, clinical experience shows that it is not essential to replace the osteotomised bone or to perform the zygomatic osteotomy. To free the flap completely, a careful subperiosteal dissec-

Fig. 2 e Anatomical dissection: upper half e temporalis muscle fascia (*) is elevated from the muscle. The middle temporal artery, coming from the superficial temporal artery, is visible in front of the tragus (black arrowhead). Temporal facial branch (black arrow) is visible. Lower half e temporalis muscle fascia is elevated. Temporalis muscle is clearly visible (black arrowhead).

tion in the temporalis fossa must be made, as far as the infratemporal inlet. Attention must be paid to the vascular pedicle of the flap, which runs into the medial surface of the muscle. The paired deep temporalis arteries, anterior and posterior, are clearly identifiable when the flap is elevated to a level below the zygoma, within the infratemporal fossa (Fig. 3). During dissection, some bleeding can occur, usually from pterygoid vessels, requiring accurate cautery. In order to preserve the blood supply to the flap, blind manoeuvres must be avoided. Using blunt dissection along the lateral surface of the temporalis muscle, a tunnel connecting the zygomatic region and the oral cavity is developed. With the use of strong sutures, fixed into the superior portion of the flap, the flap itself is transposed into the oral cavity and fixed. RESULTS Of these 9 patients included in our study, 6 were males and mean age at surgery was 67 years. Tumour characteristics, surgical approaches and extent of resections are described in Table 1. The harvesting time was less than 1 h in all cases. The procedures including the zygomatic

Fig. 1 e Anatomical dissection: upper half e facial branches are clearly visible above the temporalis muscle fascia (black arrowheads). Lower half e superficial temporalis fascia (*) is harvested and superficial temporal artery is visible within the fascia (black arrow).

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6 patients and fair in 2; 1 patient previously had a laryngectomy and was therefore non-classifiable. Facial appearance was excellent in 4 patients, good in 2, fair in 2 and poor in 1. Ocular function remained unchanged in all but 1, who complained of a slight ptosis of the eyeglobe. This patient did not complain vertical diplopia. As regards complications, we experienced one slight dehiscence of the flap and two cases of oro-nasal fistula, both promptly corrected under local anaesthesia. A seroma of the cheek resolved spontaneously in 2 weeks. No injuries to the temporal and frontal branches of the facial nerve were noted. No further surgery was necessary for TMF complications. Post-operative results regarding appearance and functional outcomes and complications are summarized in Table 2. DISCUSSION
Fig. 3 e Anatomical dissection: TMF is elevated from temporalis fossa (*). Anterior (black arrowhead) and posterior (black arrow) deep temporal arteries are clearly seen in the deep surface of the muscle.

arch osteotomy (3 out of 9 patients) did not require longer since transposition of the flap is quicker after the osteotomy, and the length of time taken to fracture the zygomatic arch is then recovered when the transposition is performed. Temporal filler was never used. Neither partial nor total flap losses were observed in our series. All the patients underwent post-operative radiotherapy, which did not seem to influence the outcome of this reconstructive procedure (mean dose: 55.8 ^ 7.8 Gy). No patients underwent post-operative denture construction and all but two had good post-operative swallowing of a semisolid diet. Post-operative speech was good in

The maxilla is a critical structure of the mid-face, since it has a crucial role in facial appearance and provides the lateral wall of the nasal cavity, the hard palate, and the floor of the orbit. Therefore, it is important for speaking, chewing, swallowing and for supporting the eye. For these reasons, when dealing with patients affected by oral or sinonasal tumours involving the maxilla, reconstruction of the surgical defect is essential. Nowadays, it does not make sense to leave the palatal defect open either to detect local recurrences or to ease the construction and use of a dental prosthesis. Both of these considerations are incorrect since local recurrences are better detected using CT or MRI, and the use of a dental prosthesis is more comfortable when the palatal defect is closed. Many reconstructive options are available today, each with its own advantages and disadvantages. Although traditional surgical techniques seem to be being

Table 1 e Demographic data, tumour characteristics and surgical approaches Patient’s number 1 2 3 Sex Age at surgery 67 61 43 Diagnosis Site of origin Left alveolar bone Hard palate Maxillary sinus Hard palate Hard palate Hard palate Hard palate Hard palate Left alveolar bone TNM Rt (Gy) 60 60 54 Surgical approach (including hemi-coronal) Mid-facial degloving Mid-facial degloving WebereFerguson Resection (Cordeiro and Santamaria, 2000) Subtotal (type II) Partial (type I) Subtotal (type II) Outcome Followup (mo) 10 22 10

M M M

4 5 6 7 8 9

M M M F F F

50 76 61 75 52 77

Squamous cell carcinoma Adenoid cystic carcinoma High grade neoplasia with plasmacellular differentiation Adenoid cystic carcinoma Squamous cell carcinoma Squamous cell carcinoma Squamous cell carcinoma Adenoid cystic carcinoma Squamous cell carcinoma

pT4a N2b pT3 N0 e

DOD NED DOD

pT4a N0 pT4a N0 pT4 N0 pT4 N0 pT4 N0 pT4a N2b

60 36 56 56 60 60

Mid-facial degloving Mid-facial degloving Fergusone Dieffenbach Modified Webere Ferguson Modified Webere Fergusone Dieffenbach Extended transoral according to Ollier

Partial (type I) Partial (type I) Partial (type I) Partial (type I) Partial (type I) Partial (type I)

NED DOD NED NED AWD NED

16 11 12 12 6 6

NED, no evidence of disease; AWD, alive with disease; DOD, dead of disease.

Temporalis myofascial flap 99 Table 2 e Post-operative results regarding aesthetic and functional outcomes and complications Patient’s number 1 2 3 4 5 6 7 8 9 Sex M M M M M M F F F Age at surgery 67 61 43 50 76 61 75 52 77 Post-operative facial appearance Excellent Excellent Fair Excellent Excellent Fair Poor Good Good Post-operative speech Good Good Good Good Previous laryngectomy Fair Fair Good Good Post-operative swallowing Good Good Good Good Good Sufficient Sufficient Good Good Ocular function Unchanged Unchanged Eyeglobe ptosis Unchanged Unchanged Unchanged Unchanged Unchanged Unchanged Oro-nasal fistula Oro-nasal fistula Surgical closure under local anaesthesia Surgical closure under local anaesthesia Complication Anterior dehiscence Treatment Surgical closure under local anaesthesia

replaced by microvascular flaps, this is not altogether rational. As the technical aspects are rapidly improving, many surgeons now prefer microvascular flaps to reconstruct mid-facial defects because they can be better adapted to the clinical needs of the patients and can perfectly suit almost all the surgical defects. Unfortunately, however, a micro-vascularised free flap is not the appropriate solution for all the patients. Older people, patients with cardiovascular risk factors, or patients who are candidates to receive pre- or post-operative radiotherapy, may have a high risk of failure of the vascular anastomoses, with possible consequent flap loss and the need for a new surgical procedure. Furthermore, patients with a poor prognosis, requiring aggressive and rapid post-operative radiotherapy, are not ideal candidates for microvascular reconstruction. Moreover, the duration of a microvascular flap reconstruction operation necessitates prolonged anaesthesia that cannot be performed in all the patients. In this kind of patient, a safe and rapid reconstruction is preferable. The TMF is a locally available, thin and well-vascularised flap that can be raised easily and quickly from the temporal fossa and can be transposed (with or without a zygomatic arch osteotomy) to repair a wide range of surgical defects in the mid-facial area. After maxillectomy, the TMF can reach the contralateral palate as well, allowing complete coverage of hemi-palatal defects. The hemi-coronal scar provides satisfactory cosmetic results since it starts in the pretragal region and extends superiorly often within the hairline. Furthermore, the TMF has an efficient blood supply that enables flap rotation through an effective arc of 120e130 (Bradley and Brockbank, 1981; Birt et al., 1987). Many authors have used TMF for the reconstruction of maxillary defects after oncological procedures, with good results in speech, swallowing and appearance (Hanasono et al., 2001; Mani and Panda, 2003; Cenzi and Carinci, 2006). In our series, no orbital exenteration and no radical maxillectomy (type IIIa according to Cordeiro (Cordeiro and Santamaria, 2000)) have been performed and the defects were more or less limited to the five inferior walls of the maxilla. In three patients, an antero-inferior bony ‘‘baguette’’ was left. No orbital floor

reconstruction was deemed necessary, although it was partially removed in one patient. The use of a TMF in our series allowed closure of the palatal defects and at least partial restoration of the functions of the maxilla. We believe, in agreement with Mani and Panda (2003), that palatal closure with TMF, though not ideal, makes sense because these patients can usually speak well and eat soft solids without even requiring dentures. None of our patients wear dental prostheses but every one regained sufficient masticatory function, even though no bony reconstruction was performed. Nevertheless, upon request we are able to provide a stable denture supported on the contralateral teeth and palate. In our series, all but 2 patients regained normal or near-normal speech and none of them has complained of any social discomfort regarding this aspect. Facial appearance has been evaluated as being fair to excellent in all but one patients. In that patient symmetry and malar prominence were significantly impaired. Regarding complications the literature report a 13.4% incidence of partial flap loss, a 19.2% of temporal branch paresis and a 2.7% incidence of paralysis (Clauser et al., 1995). Other reports are more favourable (Smith et al., 2005). In our experience, no injuries to the temporal and frontal branches of the facial nerve were noted, and no partial or total flap loss was seen. A slight ptosis of the eyeglobe was seen in the patient in whom the floor of the orbit was partially removed, but no vertical diplopia was evident and hence no further surgery was necessary. Even if we used most of the muscle and hollowing of the temporal fossa was evident in most cases, no patient complained about this. In our opinion, a sound knowledge of the anatomy and a delicate surgical dissection are required to minimize the occurrence of complications. Crucial steps during dissection are identification and respect for the fascial and subperiosteal planes. After the cutaneous incision, the surgeon must identify the superficial temporal fascia and dissect deep to this plane. When in the proximity of the zygomatic arch the dissection must be carried out beneath the deep temporal fascia, in order to preserve the frontal branches of the facial nerve, that lies superficial to it. When zygomatic

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Fig. 4 e Clinical pictures: A, extent of the defect, including the whole bony hemi-palate. B, temporalis muscle is rotated and fixed in the oral cavity. C, early post-operative period. D, late post-operative aspect demonstrating a good symmetry of the facial appearance.

osteotomy is necessary to optimise flap transposition, it is possible to expose almost the entire arch without damaging the facial branches, by performing a careful subperiosteal dissection. Irksome venous bleeding can occur around or within the temporal fat pad. Since the deep temporal arteries arise from the internal maxillary artery and reach the deep surface of the temporalis muscle, dissection of the deep face of the temporalis muscle from the temporal bone must be carried out subperiosteally. During this procedure, venous bleeding coming from the pterygoid plexus usually occurs and needs a careful management under direct visual control. Another important aspect favouring the use of this flap after oncological procedures is the excellent viability of the flap that permits very early post-operative radiotherapy; this complementary treatment can be administered much earlier than with any other type of reconstruction and may be critical when dealing with cancer patients. Our experience confirms this, as post-operative radiotherapy was given to all these patients (mean dose 55.8 ^ 7.8 Gy) and no complication regarding flap viability was observed. In all cases, we saw a regression in the size of the flap in about 4e6 weeks, after which it remained stable. Hence, on the basis of the data presented it is felt that TMF allows reconstruction of the hard and soft palate with good recovery of swallowing and speech functions. Obviously, the value of free flaps reconstruction after oncological surgery of the facial skeleton is not under discussion. Free-tissue transfer provides a most effective

and reliable form of immediate reconstruction for complex maxillectomy defects (Cordeiro and Santamaria, 2000). Based on this experience, it is believed that the TMF should not be considered as only an alternative to free flap reconstruction, but also as a first-chioce reconstruction in patients with severe comorbidities or poor prognosis. Moreover, after partial maxillectomy with sparing of the orbital floor, and when a bony baguette is left anteriorly (that is oncologically sound in cases of small and middle sized lesion of the posterior part of the hard palate or the alveolar crest), the aesthetic and functional results of TMF are good and, in our opinion, free-tissue transfer is not warranted (Fig. 4). CONCLUSIONS In our experience, the TMF is a safe and reliable flap that can be used to reconstruct many surgical defects of the mid-facial skeleton. The reconstructive procedure is quick and easy and can be performed even in patients who cannot tolerate lengthy anaesthetics or in patients with a high risk of microvascular flap loss. We think that the TMF is most useful for reconstructing defects in which the requirements include a flexible, tailored muscle flap with moderate thickness. A TMF is an alternative solution to free flap reconstruction and one that a head and neck surgeon should always consider when planning an oncological procedure.

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CONFLICT OF INTEREST All the authors certify that they have no potential conflicts of interest with any entity mentioned in this manuscript, and that they received no specific financial support for this work. References
Bakamjian V: A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Plast Reconstr Surg 31: 103e117, 1963 Birt BD, Shyn A, Gruss JS: The temporalis muscle flap for head and neck reconstruction. J Otolaryngol 16: 179e184, 1987 Bradley P, Brockbank J: The temporalis muscle flap in oral reconstruction. J Maxillofac Surg 9: 139e145, 1981 Cenzi R, Carinci F: Calvarial bone grafts and temporalis muscle flap for midfacial reconstruction after maxillary tumor resection: a longterm retrospective evaluation of 17 patients. J Craniofac Surg 17(6): 1092e1104, 2006 Clauser L, Curioni C, Spanio S: The use of the temporalis muscle flap in facial and craniofacial reconstructive surgery. A review of 182 cases. J Craniomaxillofac Surg 52: 143e147, 1995 Cordeiro PG, Santamaria E: A classification system and algorithm for reconstruction of maxillectomy and midfacial defect. Plast Reconstr Surg 105: 2331e2346, 2000

Cordeiro PG, Wolfe SA: The temporalis muscle flap revisited on its centennial: advantages, newer uses, and disadvantages. Plast Reconstr Surg 98: 980e987, 1996 Hanasono MM, Utley DS, Goode RL: The temporalis muscle flap for reconstruction after head and neck oncologic surgery. Laryngoscope 111: 1719e1725, 2001 Mani V, Panda AK: Versatility of temporalis myofascial flap in maxillofacial reconstruction-analysis of 30 cases. Int J Oral Maxillofac Surg 32: 368e372, 2003 Smith JE, Ducic Y, Adelson R: The utility of the temporalis muscle flap for oropharyngeal, base of tongue, and nasopharyngeal reconstruction. Otolaryngol Head Neck Surg 132: 373e380, 2005

Dr. Riccardo LENZI ENT Unit Azienda Ospedaliero Universitaria Pisana Via Savi 10, 56126 Pisa Italy Tel.: +39 50 993284 Fax: +39 050 993239 E-mail: riclenzi@gmail.com Paper received 13 January 2008 Accepted 17 November 2008