posterior fusion in patients with trauma

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Temporalis myofascial ap in maxillary reconstruction: anatomical studyand clinical application

Iacopo DALLAN 1 , Riccardo LENZI 1 , Stefano SELLARI-FRANCESCHINI 1 , Manfred TSCHABITSCHER 2 ,Luca MUSCATELLO 1

1 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

SUMMARY. The authors describe indications and advantages of temporalis myofascial ap in the reconstructionof surgical defects after partial maxillectomies. This ap is thin and reliable and can be used as an alternative tofree ap tissue transfer in the reconstruction of partial defects of the upper maxilla. The surgical steps to raise theap are simple, but the dissection must be careful to avoid damages to the fronto-temporal branches of the facialnerve 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 ap losses were experienced. Post-operative aesthetic and functional results were satis-fying. Temporalis muscle ap can be considered as a rst-line reconstructive option for limited resection of theupper maxilla with sparing of the orbital oor and of the anterior alveolar crest. 2008 European Associationfor Cranio-Maxillofacial Surgery

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

INTRODUCTION

Oncological surgery in the maxillary region is often ag-gressive and functionally mutilating given the fact that the two maxillae are the most important bones of themid-facial skeleton. Maxillary defects are inherentlycomplex because they generally involve more than onemid-facial component, and most of them are compositein nature. In this respect, and in agreement with others(Cenzi and Carinci , 2006 ), we believe that these defectsshould be reconstructed in order to offer the patient a bet-ter aesthetic and functional outcome. A great number of local aps, pedicled aps and microvascular free apshave been employed over the years for the reconstructionof mid-facial defects. Nevertheless, reconstruction of themid-face remains a challenging and still varied problemdue to the different defects and the complex three-dimen-

sionality of the region. It is important that the palatal de-fect after maxillectomy must be repaired and it isadvisable to perform this immediately ( Cordeiro andSantamaria , 2000; Cenzi and Carinci , 2006 ). Amongthe aps proposed, the temporalis muscle ap (TMF) isa reliable and safe myofascial ap that has been usedfor the reconstruction of various maxillofacial defects(Cordeiro and Santamaria , 2000; Hanasono et al.,2001; Cenzi and Carinci , 2006 ). Since the rst report by Bakamjian (1963) , many other authors have usedthe TMF for the reconstruction of a defect includingpart or all of the hemi-maxilla ( Cordeiro and Wolfe,1996; Cordeiro and Santamaria , 2000; Hanasonoet al., 2001; Mani and Panda , 2003; Cenzi and Carinci ,

2006 ). From a functional point of view, TMF-based

reconstructive procedures are effective in palatal closure.However, one must keep in mind that this kind of recon-struction can only be used if a resection of the cutaneoustissues and orbital exenteration are not deemed neces-sary. The aim of this paper is to describe anatomicallandmarks useful in TMF harvesting procedures and topresent our clinical experience with the use of TMF for reconstruction of maxillary defects following oncologicalprocedures.

MATERIAL AND METHODS

Two fresh injected cadaver dissections were performedin order to illustrate better the surgical anatomy of thetemporalis 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 maxil-lectomy and immediate reconstruction with TMF at a ter-tiary referral medical centre over the last 3 years.Demographic data, features of the disease, follow-up,outcome and complications were all collected and ana-lysed. Functional and aesthetic outcomes were evaluatedby 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 theclinicians point of view. Speech was graded as normal,good, fair, or unintelligible. The patients ability to eat an unrestricted, soft or liquid diet was also evaluated.The study met with the approval of the local EthicalCommittee.

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Journal of Cranio-Maxillofacial Surgery (2009) 37 , 96e 101 2008 European Association for Cranio-Maxillofacial Surgerydoi:10.1016/j.jcms.2008.11.004, available online at http://www.sciencedirect.com
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arch osteotomy (3 out of 9 patients) did not require lon-ger since transposition of the ap is quicker after the os-teotomy, and the length of time taken to fracture thezygomatic arch is then recovered when the transpositionis performed. Temporal ller was never used. Neither partial nor total ap losses were observed in our series.All the patients underwent post-operative radiotherapy,which did not seem to inuence the outcome of this re-constructive procedure (mean dose: 55.8 ^ 7.8 Gy). Nopatients underwent post-operative denture construction

and all but two had good post-operative swallowingof a semisolid diet. Post-operative speech was good in

6 patients and fair in 2; 1 patient previously had a laryn-gectomy and was therefore non-classiable. Facial ap-pearance was excellent in 4 patients, good in 2, fair in2 and poor in 1. Ocular function remained unchangedin all but 1, who complained of a slight ptosis of the eye-globe. This patient did not complain vertical diplopia. Asregards complications, we experienced one slight dehis-cence of the ap and two cases of oro-nasal stula,both promptly corrected under local anaesthesia. A se-roma of the cheek resolved spontaneously in 2 weeks.No injuries to the temporal and frontal branches of thefacial nerve were noted. No further surgery was neces-sary for TMF complications. Post-operative results re-garding appearance and functional outcomes andcomplications are summarized in Table 2 .

DISCUSSION

The maxilla is a critical structure of the mid-face, since it has a crucial role in facial appearance and provides thelateral wall of the nasal cavity, the hard palate, and theoor of the orbit. Therefore, it is important for speaking,chewing, swallowing and for supporting the eye. For these reasons, when dealing with patients affected byoral or sinonasal tumours involving the maxilla, recon-struction of the surgical defect is essential. Nowadays,it does not make sense to leave the palatal defect openeither to detect local recurrences or to ease the construc-tion and use of a dental prosthesis. Both of these consid-erations are incorrect since local recurrences are better detected using CT or MRI, and the use of a dental pros-thesis is more comfortable when the palatal defect isclosed. Many reconstructive options are available today,

each with its own advantages and disadvantages. Al-though traditional surgical techniques seem to be being

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.

Table 1 e Demographic data, tumour characteristics and surgical approaches

Patientsnumber

Sex Age at surgery

Diagnosis Site of origin

TNM Rt (Gy)

Surgical approach(includinghemi-coronal)

Resection(Cordeiro andSantamaria , 2000)

Outcome Follow-up (mo)

1 M 67 Squamous cellcarcinoma

Left alveolar bone

pT4a N2b 60 Mid-facialdegloving

Subto tal ( type II ) DOD 10

2 M 61 Adenoid cysticcarcinoma

Hard palate pT3 N0 60 Mid-facia ldegloving

Partial (type I) NED 22

3 M 43 High gradeneoplasia with

plasmacellular differentiation

Maxillarysinus

e 54 Weber e Ferguson Subtotal ( type II) DOD 10

4 M 50 Adenoid cysticcarcinoma

Hard palate pT4a N0 60 Mid-facialdegloving



Hard palate pT4a N0 36 Mid-facialdegloving

Partial (type I) DOD 11


Hard palate pT4 N0 56 Ferguson eDieffenbach


7 F 75 Squamous cellcarcinoma

Hard palate pT4 N0 56 Modied Weber eFerguson


8 F 52 Adenoid cysticcarcinoma

Hard palate pT4 N0 60 Modied Weber eFerguson eDieffenbach

Partial (type I) AWD 6

9 F 77 Squamous cellcarcinoma

Left alveolar bone

pT4a N2b 60 Extended transoralaccording toOllier


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

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replaced by microvascular aps, this is not altogether ra-tional. As the technical aspects are rapidly improving,many surgeons now prefer microvascular aps to recon-struct mid-facial defects because they can be better adap-ted to the clinical needs of the patients and can perfectlysuit almost all the surgical defects. Unfortunately, how-ever, a micro-vascularised free ap is not the appropriatesolution for all the patients. Older people, patients withcardiovascular risk factors, or patients who are candi-dates to receive pre- or post-operative radiotherapy,may have a high risk of failure of the vascular anastomo-ses, with possible consequent ap loss and the need for a new surgical procedure. Furthermore, patients witha poor prognosis, requiring aggressive and rapid post-op-erative radiotherapy, are not ideal candidates for micro-vascular reconstruction. Moreover, the duration of a microvascular ap reconstruction operation necessitatesprolonged anaesthesia that cannot be performed in all thepatients. In this kind of patient, a safe and rapid recon-struction is preferable. The TMF is a locally available,thin and well-vascularised ap that can be raised easilyand quickly from the temporal fossa and can be trans-posed (with or without a zygomatic arch osteotomy) torepair a wide range of surgical defects in the mid-facialarea. After maxillectomy, the TMF can reach the contra-lateral palate as well, allowing complete coverage of hemi-palatal defects. The hemi-coronal scar provides sat-

isfactory cosmetic results since it starts in the pretragalregion and extends superiorly often within the hairline.Furthermore, the TMF has an efcient blood supplythat enables ap rotation through an effective arc of 120e 130 ( Bradley and Brockbank , 1981; Birt et al.,1987 ). Many authors have used TMF for the reconstruc-tion of maxillary defects after oncological procedures,with good results in speech, swallowing and appearance( Hanasono et al., 2001; Mani and Panda , 2003; Cenziand Carinci , 2006 ). In our series, no orbital exenterationand no radical maxillectomy (type IIIa according to Cor-deiro ( Cordeiro and Santamaria , 2000 )) have been per-formed and the defects were more or less limited to theve inferior walls of the maxilla. In three patients, an an-tero-inferior bony baguette was left. No orbital oor

reconstruction was deemed necessary, although it waspartially 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 func-tions of the maxilla. We believe, in agreement with Maniand Panda (2003) , that palatal closure with TMF, thoughnot ideal, makes sense because these patients can usuallyspeak well and eat soft solids without even requiring den-tures. None of our patients wear dental prostheses but ev-ery one regained sufcient masticatory function, eventhough no bony reconstruction was performed. Neverthe-less, upon request we are able to provide a stable denturesupported on the contralateral teeth and palate. In our se-ries, all but 2 patients regained normal or near-normalspeech and none of them has complained of any socialdiscomfort regarding this aspect. Facial appearance hasbeen evaluated as being fair to excellent in all but one pa-tients. In that patient symmetry and malar prominencewere signicantly impaired.

Regarding complications the literature report a 13.4 %incidence of partial ap loss, a 19.2 % of temporal branchparesis 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 temporaland frontal branches of the facial nerve were noted,and no partial or total ap loss was seen. A slight ptosisof the eyeglobe was seen in the patient in whom the oor

of the orbit was partially removed, but no vertical diplo-pia was evident and hence no further surgery was neces-sary. Even if we used most of the muscle and hollowingof the temporal fossa was evident in most cases, no pa-tient complained about this. In our opinion, a soundknowledge of the anatomy and a delicate surgical dissec-tion are required to minimize the occurrence of complica-tions. Crucial steps during dissection are identicationand respect for the fascial and subperiosteal planes. After the cutaneous incision, the surgeon must identify the su-percial temporal fascia and dissect deep to this plane.When in the proximity of the zygomatic arch the dissec-tion must be carried out beneath the deep temporal fascia,in order to preserve the frontal branches of the facialnerve, that lies supercial to it. When zygomatic

Table 2 e Post-operative results regarding aesthetic and functional outcomes and complications

Patientsnumber

Sex Age at surgery

Post-operativefacial appearance

Post-operativespeech

Post-operativeswallowing

Ocular function Complication Treatment

1 M 67 Excellent Good Good Unchanged Anterior dehiscence

Surgical closureunder localanaesthesia

2 M 61 Excellent Good Good Unchanged3 M 43 Fair Good Good Eyeglobe ptosis4 M 50 Excellent Good Good Unchanged5 M 76 Excellent Previous

laryngectomyGood Unchanged

6 M 61 Fair Fair Sufcient Unchanged Oro-nasal stula Surgical closureunder localanaesthesia

7 F 75 Poor Fair Sufcient Unchanged Oro-nasal stula Surgical closureunder localanaesthesia

8 F 52 Good Good Good Unchanged9 F 77 Good Good Good Unchanged

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osteotomy is necessary to optimise ap transposition, it ispossible to expose almost the entire arch without damag-ing the facial branches, by performing a careful subper-iosteal dissection. Irksome venous bleeding can occur around or within the temporal fat pad. Since the deeptemporal arteries arise from the internal maxillary arteryand reach the deep surface of the temporalis muscle, dis-section of the deep face of the temporalis muscle fromthe temporal bone must be carried out subperiosteally.During this procedure, venous bleeding coming fromthe pterygoid plexus usually occurs and needs a carefulmanagement under direct visual control.

Another important aspect favouring the use of this apafter oncological procedures is the excellent viability of the ap that permits very early post-operative radiother-

apy; this complementary treatment can be administeredmuch earlier than with any other type of reconstructionand may be critical when dealing with cancer patients.Our experience conrms this, as post-operative radiother-apy was given to all these patients (mean dose55.8 ^ 7.8 Gy) and no complication regarding ap via-bility was observed. In all cases, we saw a regressionin the size of the ap in about 4 e 6 weeks, after whichit remained stable. Hence, on the basis of the data pre-sented it is felt that TMF allows reconstruction of thehard and soft palate with good recovery of swallowingand speech functions.

Obviously, the value of free aps 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 com-plex maxillectomy defects ( Cordeiro and Santamaria ,2000 ). Based on this experience, it is believed that theTMF should not be considered as only an alternative tofree ap reconstruction, but also as a rst-chioce recon-struction in patients with severe comorbidities or poor prognosis. Moreover, after partial maxillectomy withsparing of the orbital oor, and when a bony baguetteis 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 andfunctional 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 ap that can be used to reconstruct many surgical defects of themid-facial skeleton. The reconstructive procedure isquick and easy and can be performed even in patientswho cannot tolerate lengthy anaesthetics or in patientswith a high risk of microvascular ap loss. We thinkthat the TMF is most useful for reconstructing defectsin which the requirements include a exible, tailoredmuscle ap with moderate thickness.

A TMF is an alternative solution to free ap recon-struction and one that a head and neck surgeon shouldalways consider when planning an oncological proce-dure.

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

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CONFLICT OF INTEREST

All the authors certify that they have no potential con-icts of interest with any entity mentioned in this manu-script, and that they received no specic nancial support for this work.

References

Bakamjian V: A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Plast Reconstr Surg 31: 103 e 117,1963

Birt BD, Shyn A, Gruss JS: The temporalis muscle ap for head andneck reconstruction. J Otolaryngol 16: 179 e 184, 1987

Bradley P, Brockbank J: The temporalis muscle ap in oralreconstruction. J Maxillofac Surg 9: 139 e 145, 1981

Cenzi R, Carinci F: Calvarial bone grafts and temporalis muscle apfor midfacial reconstruction after maxillary tumor resection: a long-term retrospective evaluation of 17 patients. J Craniofac Surg17(6): 1092 e 1104, 2006

Clauser L, Curioni C, Spanio S: The use of the temporalis muscle apin facial and craniofacial reconstructive surgery. A review of 182cases. J Craniomaxillofac Surg 52: 143 e 147, 1995

Cordeiro PG, Santamaria E: A classication system and algorithm for reconstruction of maxillectomy and midfacial defect. Plast Reconstr Surg 105: 2331 e 2346, 2000

Cordeiro PG, Wolfe SA: The temporalis muscle ap revisited on itscentennial: advantages, newer uses, and disadvantages. Plast Reconstr Surg 98: 980 e 987, 1996

Hanasono MM, Utley DS, Goode RL: The temporalis muscle ap for reconstruction after head and neck oncologic surgery.Laryngoscope 111: 1719 e 1725, 2001

Mani V, Panda AK: Versatility of temporalis myofascial ap inmaxillofacial reconstruction-analysis of 30 cases. Int J Oral

Maxillofac Surg 32: 368 e 372, 2003Smith JE, Ducic Y, Adelson R: The utility of the temporalismuscle ap for oropharyngeal, base of tongue, andnasopharyngeal reconstruction. Otolaryngol Head Neck Surg132: 373 e 380, 2005

Dr. Riccardo LENZIENT Unit Azienda Ospedaliero Universitaria Pisana Via Savi 10, 56126 Pisa Italy

Tel.: +39 50 993284Fax: +39 050 993239E-mail: [email protected]

Paper received 13 January 2008Accepted 17 November 2008

Temporalis myofascial ap 101
mailto:[email protected]:[email protected]

posterior fusion in patients with trauma

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