The inverted temporalis muscle flap for intraoral reconstruction: its rationale and the results of its application.

PURPOSE: The purpose of this article was to show the discrepancies among the different parts of the temporalis muscle flap (TMF), to introduce a new rotational arc for the TMF based on these findings, and to examine the outcomes associated with the use of this modified method. MATERIALS AND METHODS: Two models were established on 5 human skulls to mimic the situations with the usual dissection technique or the extended dissection technique for the TMF. The lengths of the anterior part, the middle part, and the posterior part of the flap were measured and analyzed for statistical significance. A new rotational arc for the TMF was introduced, in which the flap was inverted beneath the zygomatic arch, placing the temporalis fascia away from the oral side. Seventeen consecutive oral cancer cases treated with either the traditional method or the inverted method of flap transposition were reviewed and divided into 2 groups dictated by the rotational arcs of their flaps. The traditional TMF was used in 11 cases and the inverted TMF was used in 6 cases. Clinical examination and imaging studies were used for assessment of outcome, and the results from the 2 patient groups were compared. RESULTS: The middle and posterior parts of the temporalis muscle were significantly longer than the anterior part on the skull models. However, the middle and posterior parts did not differ greatly in length. The extended dissection technique increased the flap length except for the anterior part. Both flaps were successful in closing the defects in all cases and healed well. No muscle necrosis was observed. However, the patients receiving the traditional TMF developed noticeable cheek fullness in 4 instances, sialocele in 3, significant reduction of range of mouth opening in 2, and distinct velopharyngeal insufficiency in 2, whereas only 1 case in which the inverted TMF was used developed cheek fullness. CONCLUSIONS: The middle or posterior part of the temporalis flap is preferred over the anterior part for covering distant defects because of its extra length. The inverted TMF is simple and safe to apply. It can extend farther in the posterior oral cavity and has fewer complications than the traditional TMF.     

An animal model for maxillary reconstruction using a temporalis muscle flap

This article describes the feasibility of using the temporalis muscle flap to cover a defect after maxillectomy in cats and to evaluate the clinical healing process of this flap in the oral environment. The material consisted of 30 cats of the Felis catus species. A standardized unilateral maxillectomy was performed and the resulting defect immediately closed with a pedicled temporalis flap. The healing of this flap was clinically assessed at determined intervals. Healing of the temporalis flap in the oral environment of cats progressed from an inflammatory to a proliferative phase, with eventual coverage by a smooth oral mucosa 18 to 24 weeks after surgery. The cat proved to be a useful model for this type of study.     

The role of a temporalis fascia and muscle flap in temporomandibular joint surgery

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 muscle-fascia flap in temporomandibular joint surgery are described.     

Treatment of temporomandibular joint ankylosis with temporalis muscle and fascia flap.

This study sought to determine the efficacy of interpositional arthroplasty with temporalis muscle and fascia flap in the treatment of unilateral temporomandibular joint (TMJ) ankylosis in adults. This retrospective study of seven cases evaluated the postoperative results of interpositional arthroplasty on temporalis muscle and fascia flap in adults. The operative protocol for unilateral TMJ ankylosis entailed, (1) resection of ankylotic mass, (2) intraoral ipsilateral coronoidectomy, (3) contralateral coronoidectomy when necessary, (4) interpositional tissue transfer to the TMJ with temporalis muscle and fascia flap, (5) maxillomandibular fixation (MMF), and (6) early mobilization and aggressive physiotherapy. The results of this protocol were encouraging, while the functional results of interpositional arthroplasty on temporalis muscle and fascia flap were satisfactory. The findings of this study support the use of temporalis muscle and fascia flap in adult patients with unilateral TMJ ankylosis. Early postoperative initial exercise, physiotherapy, and strict follow-up play an important role in preventing postoperative adhesions.     

The use of mouldable acrylic for restoration of the temporalis flap donor site

Despite the wide popularity of the pedicled temporalis myofascial flap, aesthetic management of the temporalis donor site has received little attention. A technique for immediate camouflage of the temporalis flap donor site with cold-cure methyl methacrylate, either alone or in combination with residual muscle in the temporal fossa, is presented. A retrospective evaluation of this technique in 34 consecutive patients was undertaken, with particular reference to the aesthetic results and morbidity associated with the use of cold-cure acrylic for this form of reconstruction. Apart from transient postoperative swelling and neuropraxia, no major or lasting complications associated with the use of cold-cure acrylic were recorded. The aesthetics of the camouflaged temporalis donor site by acrylic alone, or when combined with part of the temporalis muscle, was judged objectively to be excellent in 25 patients, satisfactory in 3 patients, and poor in 2 patients. 4 patients who did not have acrylic reconstruction, but had part of the temporalis muscle transposed to conceal the anterior fossa depression, leaving the posterior fossa unreconstructed, were judged mostly as satisfactory. Histology of the soft tissues around an acrylic implant after nearly 2 years confirmed the good biocompatibility of this material. It is concluded that this technique is a safe and reliable method for immediate camouflaging of the temporal fossa after harvesting a temporalis muscle flap.     

Modified temporalis anchorage in craniomandibular reankylosis

This study evaluates the long-term outcomes and clinical results of costochondral graft and temporalis muscle flap interpositioning with submandibular anchorage in the management of TMJ re-ankylosis. Thirty-one patients, 9 children and 22 adults, with recurrence of ankylosis after gap arthroplasty, with a mouth opening less than 5 mm were evaluated. The management protocol consisted of resection of the ankylotic mass through an Al-Kayat and Bramley incision; contralateral coronoidectomy in unilateral cases; replacement of the condyle in children by means of a costochondral graft through Risdon's approach and interpositional temporalis muscle flap and submandibular anchorage of the temporalis flap in children and adults. Regular clinical and radiological follow up was done for 6 years during which the average mouth opening of 38 mm was maintained, with good occlusion and proper function. The temporalis muscle flap was seen to be an ideal interpositional material due to its close proximity to the site, good vascular supply, ease of access to the condyle area and minimal risk of nerve damage. Submandibular anchorage of the broad temporalis muscle flap prevents reankylosis by inhibiting flap contraction, and decreases need for rigorous physiotherapy.     

Use of Palacos R-40 with gentamicin to reconstruct temporal defects after maxillofacial reconstructions with temporalis flaps

The temporalis muscle flap is a useful flap for the reconstruction of oral ablative defects. A complication of its use that was overlooked was the crater-like defect created when the muscle is stripped from its attachment on the temporal fossa. The cold-cure acrylic we use is Palacos R-40 with Gentamicin (Heraeus Kulzer GmbH). This material is radio-opaque, rapidly setting and contains gentamicin. We present a total of 41 cases over an 11-year period (1994-2005). We have a 97.6% (n = 40) success rate. Infection developed in only one case, which leads to the removal of the acrylic implant. The use of Palacos R-40 with Gentamicin is easy to use, it can be custom-moulded to fit and fill the defect any of shape and size. It has minimal complications and high success rate with acceptable results to the patients.     

钛网填以松质骨修复上颌骨的临床探讨

目的 体验和探讨在预制钛网支架内填塞自体髂骨松质骨,并以颞肌瓣进行覆盖,修复上颌骨缺损的治疗方法、效果以及其临床意义。方法 6例上颌骨缺损患者,术前预制钛网支架。术中采用钛钉固定在缺损处,网架内填塞自体髂骨松质骨,颞肌瓣包绕钛网支架修复上颌骨缺损。结果 6例患者植入的松质骨及覆盖的颞肌瓣全部存活。术后6个月X片显示:松质骨生长良好。结论 上颌骨不同类型的缺损均可应用此方法进行功能性修复,此方法与其它游离骨复合瓣比较而言,安全系数高,对患者的创伤小,充分体现个性化特点。     

Intramuscular temporalis fascia: a guide to procurement of temporalis myofascial flaps.

The purpose of this study is to demonstrate an intramuscular fascial layer within the temporalis muscle. This can be used as an inferior plane when developing a temporalis myofascial flap for temporomandibular joint reconstruction. The advantages of using this plane include relatively bloodless zone, adequate thickness of flap for reconstructive purposes, and residual temporalis muscle to prevent the temporal concavity deformity. Cadaveric and clinical examples are presented.     

颞肌血管分布及其外科应用研究

本研究目的是详尽研究应用于外科手术的人类颞肌的血管构筑。作者采用３０具新鲜尸体颞肌标本，分别用墨汁、氧化铅或甲基丙烯酸树脂进行脉管灌注，其血管构筑用立体显微镜、放射线片及扫描电镜观察分析。结果显示颞肌血供主要来自３支动脉、通常有双静脉与一支动脉相伴行，并沿肌纤维行走形成丰富且相互吻合的毛细血管网。在冠状面，血管主要位于肌肉外侧及内侧，中间部位血管密度则明显减低。     

The versatility of the temporalis muscle flap in reconstructive surgery

The temporalis muscle flap recently has become widely used in reconstructive surgery of the maxillo-facial region, although it was described around the turn of the century. We review the work which led to its development, and to illustrate its versatility, we describe some of its uses.     

带蒂颞肌颅骨瓣修复上颌骨上份的缺损

目的探讨带蒂颞肌颅骨瓣修复上颌骨上份缺损的优缺点。方法对6例上颌骨缺损的患者,用带蒂颞肌颅骨瓣修复上颌骨上份（眶底）缺损,同时封闭口鼻瘘。结果术后患者的伤口均一期愈合,皮瓣成活,术后随访12个月,其面部外形满意,能够正常进食,进食时无食物从鼻腔返流,语音清晰。结论应用带蒂颞肌颅骨瓣重建上颌骨上份（眶下区）缺损,术后患者上颌骨外形和语音恢复正常,值得推广应用。     

Vascularized cranial bone grafts for mandibular and maxillary reconstruction. The parietal osteofascial flap

The authors have performed 13 cases of vascularized cranial bone grafts for reconstruction of maxillofacial defects since 1986. Two types of flaps were used: the parietal osteofascial flap pedicled to the parieto-temporal fascia based on the superficial temporal artery and the temporalis osteomuscular flap pedicled to the temporalis muscle based on the deep temporal artery. Zygomatico-orbital complex, maxilla and mandible were reconstructed and hemifacial microsomia was also treated. The results of vascularized cranial bone grafts pedicled to fascia were as good as those of grafts pedicled to muscle. There were no major complications. Two types of vascularized cranial bone grafts seem to be useful in reconstruction of maxillofacial defects with avascular recipient beds because of their good blood supply. The parietal osteofascial flap has additional advantages including easy rotation of the flap to the defect, particularly a mandibular defect, and versatile use of fascia without bulkiness for reconstruction of soft tissue defects. This flap can be designed as a full- or partial-thickness cranial bone graft with good vascularity. In this paper, our technique for mandibular and maxillary reconstruction using the parietal osteofascial flap is introduced, and the results compared with our temporalis osteomuscular flap technique are reported.     

The temporalis muscle flap in reconstruction of intraoral defects: an appraisal of the technique

PURPOSE: The purpose of this article is to review the experience of the authors in the use of the temporalis muscle flap for reconstruction of intraoral defects. PATIENTS AND METHODS: This is a retrospective review of the use of the temporalis muscle flap for reconstruction of different types of intraoral defects in 8 patients. All patients in this series previously wore obturators as a nonsurgical treatment of their defects. Criteria used to evaluate the results of this technique included flap necrosis, facial nerve deficit, limitation of mandibular range of motion, and cosmetic deformity from scarring of the incision line or from loss of muscle volume in the temporal fossa. The patients were also evaluated for their degree of satisfaction with their speech and mastication with the obturator preoperatively and with the flap postoperatively. This article also reviews the success rates and complications with use of the temporalis muscle flap reported in the English-language literature during the past 14 years. RESULTS: All 8 patients in this series had their defects successfully reconstructed, completely eliminating any further need for prosthetic obturation of the defect. There were no incidents of flap necrosis, facial nerve deficit, or long-term changes in mandibular range of motion. Slight temporal hollowing was seen in the first 3 patients. Results of the literature review also showed a high success rate and a low incidence of complications with use of this flap. CONCLUSIONS: The temporalis flap is a useful, reliable, and versatile option for reconstruction of moderate to large sized defects. The muscle can provide abundant tissue, with minimal to no functional morbidity or esthetic deformity in the donor site.     

Free Dermal Fat Graft for Restoration of Soft Tissue Defects in Maxillofacial Surgery

Various local flaps have been used for reconstruction of developmental and post surgical soft tissue defects of maxillofacial region. They include nasolabial flap, palatal pedicled flap, buccal fat pad, temporalis muscle and fascia flap. An ideal flap for all indications is yet to be found. Our experience with free dermal fat graft in the correction of deformities associated with Parry Romberg syndrome and oral submucous fibrosis is presented.     

颞肌瓣修复上颌骨及腭部缺损的语音功能评价

目的　分析颞肌瓣即刻修复上颌骨及腭部术后缺损患者的语音功能恢复情况。方法　通过对 19例应用颞肌瓣修复上颌骨及腭部缺损的患者进行腭咽闭合功能、头颅腭咽侧位X线片测量和语音清晰度测定 ,分析评价颞肌瓣即刻修复上颌骨及软腭部术后缺损患者的语音功能恢复情况。结果　 19例患者中 ,有 15例 (78.0 0 % )为完全腭咽闭合 ,3例 (15 80 % )为边缘性腭咽闭合 ,1例 (5 2 6 % )为腭咽闭合不全 ,平均语音清晰度为 94 3% ,接近正常人语音清晰水平。结论　颞肌瓣修复上颌骨及腭部缺损能够较好地重建口腔发音结构 ,维持腭部功能 ,较好地恢复术后语音功能     

Second reconstruction of the posterior maxilla with a free latissimus dorsi muscle flap. Case report.

This paper reports a case in which a latissimus dorsi free muscle flap was used for a second reconstruction following resection of a maxillary ameloblastoma when the ipsilateral temporalis muscle flap had already been used. The case illustrates the dilemma of immediate versus delayed reconstruction following excision of maxillary tumours.     

Tumour implantation to a temporalis muscle flap donor site

A rare case of tumour implantation to the donor site of a temporalis muscle flap is described. This flap was used for intra-oral reconstruction following resection of a squamous cell carcinoma of the retromolar fossa. This surprisingly uncommon complication of ablative cancer surgery should largely be preventable by strict adherence to well established surgical principles.     

Reconstruction of the defect at the donor site of the temporalis muscle flap

A method for the immediate correction of the defect created at the donor site of the temporalis muscle flap is described. It uses a performed acrylic prosthesis. A case is presented in which the prosthesis could have been used to good effect, and two cases are reported to show the successful use of this technique.     

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 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.