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National Journal of Maxillofacial Surgery
 
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Table of Contents
TECHNICAL NOTE
Year : 2013  |  Volume : 4  |  Issue : 2  |  Page : 229-231  

Temporalis myofascial flap transfer into the oral cavity without zygomatic arch osteotomy


1 The Taulins Clinic, Center for Cranio-Maxillofacial, Plastic and Reconstructive Surgery, Bangalore, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication21-Feb-2014

Correspondence Address:
Madan Mishra
Department of Oral and Maxillofacial Surgery, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh - 226 025
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.127657

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   Abstract 

Among plethora of options, the temporalis myofascial flap remains a workhorse for the maxillofacial reconstruction. The inherent advantages include reliable vascularity, adequate size, and proximity to the defect. Although contemporary surgical techniques provide fair surgical results with low rate of complications, their intraoral transposition involve additional surgical trauma by intentional fracturing of the zygomatic arch. We have proposed herein a simpler technique of temporalis myofascial flap transposition into the oral cavity without zygomatic arch osteotomy.

Keywords: Osteotomy, temporalis myofascial flap, zygomatic arch


How to cite this article:
Tauro DP, Mishra M, Singh G. Temporalis myofascial flap transfer into the oral cavity without zygomatic arch osteotomy. Natl J Maxillofac Surg 2013;4:229-31

How to cite this URL:
Tauro DP, Mishra M, Singh G. Temporalis myofascial flap transfer into the oral cavity without zygomatic arch osteotomy. Natl J Maxillofac Surg [serial online] 2013 [cited 2021 Aug 4];4:229-31. Available from: https://www.njms.in/text.asp?2013/4/2/229/127657


   Introduction Top


Temporalis myofascial flap was first used by Golovine more than 100 years ago, and it remains a very reliable regional flap for the reconstruction of the maxillofacial defects. The proximity of the oral cavity, palate, oropharynx, and the middle third of the face in addition to the reliable vascular pedicle makes the temporalis myofascial flap valuable for reconstruction. [1]

The anatomy and surgical technique of the temporalis myofascial flap has been well documented. [2],[3],[4],[5] Most of the contemporary techniques require intentional fracture of zygomatic arch and its refixation once the temporalis myofascial flap is harvested through the defect created by fracture of the zygomatic arch. Although the intentional fracture of the zygomatic arch facilitates intraoral transposition of the flap, it results in additional surgical trauma. Furthermore, this procedure requires hardware for refixation that ultimately increases overall duration and cost of the surgery. We have proposed a new method of intraoral transposition of the temporalis myofascial flap without zygomatic arch osteotomy.


   Description of the Technique Top


The temporalis fascia overlying the termporalis muscle is exposed through a hemicoronal incision. The flap is elevated and it includes temporal and frontal branches of the facial nerve. Then, periosteal elevation is made in continuity with the myofascial flap in whole of the temporal fossa maintain a close contact with the bone to preserve the vessels. The temporal fascia is freed from its insertion on the upper border of the zygomatic arch. This increases the arc of rotation of the flap. If required, one can perform coronoidotomy through intraoral access to further increase the arc of rotation and the length of the flap.

Two long silk sutures (anterior and posterior) are secured to the myofascial flap at its thickest portion that is just above the zygomatic arch [Figure 1]. A 1-inch width malleable retractor is inserted from above, lateral to the temporais fascia and medial to the zygomatic arch, to reach the intraoral region [Figure 2]. Antero-posterior sweeping of the malleable retractor creates a tunnel medial to the zygomatic arch. Two long and narrow beak hemostats are then clamped to the oral end of the malleable retractor, and the temporal end of the malleable retractor is then pulled out gently, bringing the hemoststs along with it [Figure 3]. Once the beaks of hemoststs exit through the temporal region, the anterior and posterior silk sutures are clamped to the hemoststs [Figure 4]. Then, both the hemostats are pulled simultaneously intraorally. Gentle traction applied to the sutures that bring the thickest portion of the myofascial flap intraorally. Occasionally, an assistant can do gentle manipulation with the fingers at the thickest portion of the flap to facilitate the intraoral transposition of the flap. Now, rest of the portion of the flap can easily be transposed intraorally with the help of the traction sutures [Figure 5]. In this way, whole of the flap can easily be transposed intraorally through a tunnel created medial to the intact zygomatic arch and sutured to fill the defect [Figure 6].
Figure 1: Two long traction sutures tied at the thickest portion of the flap

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Figure 2: Malleable retractor creating tunnel for intraoral transposition of the flap

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Figure 3: Two narrow and long hemostats clamped to the oral end of malleable retractor

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Figure 4: Traction sutures clamped to the haemostats

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Figure 5: Transposition of the temporalis myofascial flap intraorally

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Figure 6: Temporalis myofascial flap sutured to the intraoral defect

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   Discussion Top


Of the various regional flaps, the temporalis muscle provides one of the best options because of its reliability, vascularity, adequate bulk, and proximity to the defects in the oral and maxillofacial region. [6]

It has been used for reconstruction of defects in the oral and maxillofacial region, including the base of skull, orbit and eyelids, cheek, chin, tongue, maxilla, palate, and mandible. [2],[4],[7],[8],[9]

The popularity of the temporalis flap is due to the success of the flap, the minimal complications at the donor site, and the adaptability at the recipient site.

Abubaker and Abouzgia reviewed 11 published case series in the English literature between 1987 and 2000 on the use of this flap for reconstruction of intraoral defects. They showed that the flap failure rate was very low (1.6%) and the incidence of complications associated with the technique was minimal and mostly transient. [6]

Undoubtedly, it is the technique responsible for the success of any flap. There seems no flaw in the inherent characteristics of temporalis myofascial flap; it is the surgical technique which can be further improved to further reduce the failure rates and complications. There has been consistent improvement in the surgical techniques to harvest the temporalis myofascial flap, mostly practice fracture, and refixation of the zygomatic arch for transposition of the flap. The disadvantages of this conventional technique include additional surgical trauma during exposure of the zygomatic arch and its intentional fracture, increased risk of facial nerve damage during exposure of the zygomatic arch, and an overall increase in the cost factor due to increased surgical time and hardware required for the fixation of the zygomatic arch.

We practiced a relatively newer and simpler technique for transposition of temporalis myofascial flap into the oral cavity without fracturing the zygomatic arch, thereby eliminating all the possibilities of complications and disadvantages of the conventional terchnique that involve intentional fracture of the zygomatic arch.

Another technique that does not involve the intentional fracture of the zygomatic arch is rotation of the flap over the arch, but it causes unaesthetic bulk in the region of the zygomatic arch and also results in temporomandibular joint movement difficulty. In addition, there might be a risk of strangulation of the vascular pedicle that can lead to flap necrosis. In contrast, these problems are not seen with the technique we have advocated.


   Conclusion Top


The temporomyofascial flap is a versatile flap for the maxillofacial reconstruction as far as the proximity, size, reliability of vascularity, and the technical ease are concerned. Although currently existing techniques provide surgical ease with low rate of complications, search for better and easier techniques should always be welcomed and practiced. We feel that technique explained in this text would help surgeons to harvest the temporalis myofascial flap in a more prudent way.

 
   References Top

1.Estelles Ferriol JE, Carrasco Llatas M, Ferrer Ramírez MJ, López Mollá C, Baviera Granel N, Dalmau Galofre J. Temporalis myofascial flap: Technique description and results in our patients. Acta Otorrinolaringol Esp 2005;56:257-60.  Back to cited text no. 1
    
2.Bradley P, Brockbank J. The temporalis muscle flap in oral reconstruction. A cadaveric, animal and clinical study. J Maxillofac Surg 1981;9:139-45.  Back to cited text no. 2
    
3.Koranda FC, McMahon MF, Jernstrom VR. The temporalis muscle flap for intraoral reconstruction. Arch Otolaryngol Head Neck Surg 1987;113:740-3.  Back to cited text no. 3
    
4.Huttenbrink KB. Temporalis muscle flap: An alternative in oropharyngeal reconstruction. Laryngoscope 1986;96:1034-8.  Back to cited text no. 4
    
5.Abdul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the facial layers of the temporal region. Plast Reconstr Surg 1986;77:17-28.  Back to cited text no. 5
    
6.Abubaker AO, Abouzgia MB. The temporalis muscle flap in reconstruction of intraoral defects: An appraisal of the technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:24-30.  Back to cited text no. 6
    
7.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 1995;23:203-14.  Back to cited text no. 7
    
8.Gupta AK, Jain S. Temporalis mucle sling revisited: A technique to restore ocular sphincter function. Ann Plast Surg 1994;33:496-9.  Back to cited text no. 8
    
9.van der Wal KG, Mulder JW. The temporal muscle flap for closure of large palatal defects in CLP patients. Int J Oral Maxillofac Surg 1992;21:3-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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