The arterial supply of the temporalis muscle

Ischemia of the parotid gland and adjacent muscles of mastication following middle meningeal artery embolization

Middle meningeal artery (MMA) embolization is commonly performed as either a first-line or adjunct treatment for chronic subdural hematomas (cSDH). We present the case of a 59 year-old male patient who presented with right hemibody weakness and cognitive impairment and was diagnosed with left-sided cSDH. A left MMA embolization was performed due to the recurrent nature of the chronic subdural hemorrhage and the history of prior craniotomy. On postoperative day 1, the patient developed sudden onset left facial swelling and tenderness, and a contrast computed tomography (CT) of the neck revealed acute ischemia in the left parotid gland, adjacent superior aspect of the left masseter muscle, the left lateral pterygoid, and left temporalis muscles. The patient was treated conservatively with antibiotics, steroids, and analgesics and reported resolution of symptoms on the three-month follow-up. To our knowledge, this is the first reported case of the ipsilateral parotid gland, temporalis muscle, adjacent superior aspect of the masseter muscle, and pterygoid muscle ischemia secondary to non-target particle embolization following MMA embolization in cSDH. Knowledge of normal and variant origin of the MMA and various anastomoses of this vessel with branches of the internal carotid artery (ICA), external carotid artery (ECA), and vertebrobasilar system is crucial to avoid complications during embolization.

Repair of exposure and fracture of the porous high-density polyethylene framework after ear reconstruction

OBJECTIVE

To assess the repair method of exposure or fracture of the porous high-density polyethylene ear framework after total auricle reconstruction.

STUDY DESIGN

A prospective case study.

METHODS

From April 2018 to October 2021, 11 patients with framework exposure or fracture after total auricle reconstruction were admitted to the hospital for repair. In these 11 patients, the repair was performed using (1) a temporal muscle flap combined with free skin graft in 5 patients, (2) a mastoid fascia flap combined with free skin graft in 2 patients, (3) a simple local skin flap in 1 patient, (4) combination of a temporalis muscle flap and a mastoid fascia flap together with free skin graft in 2 patients, and (5) a Su-Por helix material combined with a temporal muscle flap and free skin graft in 1 patient.

RESULTS

After follow-up for 3-36 months, except for one patient in whom local exposure again occurred at the same site, the framework was in a good shape in the other patients, and all the skin graft survived.

CONCLUSION

The defect of the upper part of the auricle can be repaired using a temporal muscle flap combined with temporal muscle fascia and skin graft. The defect of the middle and lower part of the auricle can be repaired using a mastoid fascia flap combined with skin graft. For framework fracture, the damaged site can be first strengthened with another ear material and then combined with the adjacent fascia flap and free skin graft.

Strategic tunnelling of superficial temporal artery during bypass surgery for moyamoya disease

BACKGROUND

The superficial temporal artery to middle cerebral artery bypass remains the favoured direct technique of cerebral revascularization in moyamoya angiopathy. We describe a novel technique of tunnelling the superficial temporal artery through the temporalis muscle.

METHODS

The temporalis muscle is raised as a flap off the temporal bone. A triangular window is created on the temporalis fascia, and a tunnel is created for the superficial temporal artery to pass through the muscle belly.

CONCLUSION

This innovative technique allows passage of the superficial temporal artery to the brain without kink or compression ensuring good bypass function and improves long-term patency.

Ultrasound to Improve the Safety and Efficacy of Lipofilling of the Temples

BACKGROUND

Autologous fat is known for a reliable and natural safety profile, but complications do occur-even serious vascular adverse events.

OBJECTIVES

The authors sought to examine doppler-ultrasound (DUS) imaging for the harvesting and subsequent facial implantation of autologous fat tissue.

METHODS

All patients underwent lipofilling treatment of the temporal fosse of the face. DUS examination was performed for preprocedural vascular mapping and imaging of previously injected (permanent) fillers. In addition, the injection of autologous fat was performed DUS-guided.

RESULTS

Twenty patients (all female; mean age, 57.9 years; range, 35-64 years). DUS examination showed that 16 of the 20 patients (80%) had been injected with resorbable or nonresorbable fillers elsewhere in the past. The temporal artery could be visualized and avoided in all cases. An average of 1.1 cc of autologous fat was injected in the temporal fossa per side. One case of edema and nodules was described, but no other adverse events were reported.

CONCLUSIONS

The utilization of DUS can add valuable information to a lipofilling procedure and should be considered an integral part of a safe lipofilling treatment.

LEVEL OF EVIDENCE: 4

Temporalis muscle vasculature directly derived of the middle meningeal artery: a case report and review

Pedicled temporalis muscular flap is a common procedure nowadays in reconstructive head and neck surgery, especially for oral or orbital cavity defects. We present a case of temporalis muscle and skull base dissection of a seventy-year-old fresh female cadaver with single temporal muscle vessels directly derived of the middle meningeal artery throughout the calvaria, therefore jeopardizing the harvest of the flap, which has never been described to our knowledge. Such a variation must be known of the reconstructive surgeon to plan the ideal reconstruction procedure.

Clinical importance of the superficial temporal artery in neurovascular diseases: A PRISMA-compliant systematic review

The superficial temporal artery (STA) plays a very important role in neurovascular diseases and procedures. However, until now, no comprehensive review of the role of STA in neurovascular diseases from a neurosurgical perspective has ever been published. To review research on the clinical importance of STA in neurovascular diseases, a literature search was performed using the PubMed database. Articles were screened for suitability and data relevance. This paper was organized following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. According to the literature, STA is one of the terminal branches of the external carotid artery and can give off scalp, muscle, and transosseous branches. STA-middle cerebral artery (MCA) bypass is very useful for intracranial ischemic diseases, including moyamoya disease, chronic ICA and MCA insufficiency, and even acute ischemic stroke. For intracranial complex aneurysms, STA bypass remains a major option that can serve as flow replacement bypass during aneurysmal trapping or insurance bypass during temporary parent artery occlusion. Occasionally, the STA can also be involved in dural AVFs (DAVFs) via to its transosseous branches. In addition, the STA can be used as an intraoperative angiography path and the path to provide endovascular treatments. Therefore, STA is a very important artery in neurovascular diseases.

Novel Indirect Revascularization Technique with Preservation of Temporal Muscle Function for Moyamoya Disease Encephalo-Duro-Fascio-Arterio-Pericranial-Synangiosis: A Case Series and Technical Note

BACKGROUND

Direct and/or indirect bypass surgery is the established approach for preventing stroke in patients with moyamoya disease. However, conventional indirect revascularization, including encephalo-myo-synangiosis, has some disadvantages associated with the mass effect of the temporal muscle under the bone flap and postsurgical depression in the temporal region. We devised a novel indirect revascularization method, using only the temporal fascia, to address the aforementioned disadvantages.

METHODS

A skin incision was performed along the superficial temporal artery. The temporal fascia was cut such that the base of the fascia flap was on the posterior side. The fascia and temporal muscles were dissected separately. After turning over the fascia, the muscle was cut such that the base of the muscle flap was on the anterior side. Craniotomy, direct bypass, and encephalo-duro-synangiosis were performed conventionally. Only the temporal fascia was used for indirect revascularization and duraplasty. The muscle was replaced in the anatomically correct position after replacing the bone flap.

RESULTS

We performed the aforementioned surgery on 18 (13 women and 5 men) consecutive patients (21 cerebral hemispheres) enrolled between 2012 and 2016. The average age was 28.7 years. The mean follow-up period was 31.6 months. In 17 patients (94%), the symptoms and cerebral blood flow improved. Digital subtraction angiography showed satisfactory angiogenesis from the temporal fascia. Depression in the temporal region and atrophy of the temporal muscle were negligible.

CONCLUSIONS

This surgical technique provides good clinical and cosmetic outcomes. It may also be one of the good surgical treatments available for symptomatic moyamoya disease.

Arteriovenous Malformations of the Temporalis Muscle: A Comprehensive Review

Arteriovenous malformations of the temporalis muscle (TM-AVMs) are rare lesions commonly considered as a variant of scalp AVMs. A study was designed in order to analyze TM-AVMs features and to confirm them as a certain entity different from scalp AVMs. Seven TM-AVMs cases (5 from literature plus 2 from our database) were studied. Clinical, epidemiological, radiological, and therapeutic data were analyzed and compared to common scalp AVMs features. All TM-AVMs presented as large soft tumor-like masses on the temporal region (mean diameter: 6 cm). Pain was referred in half of cases, while overlying cutaneous stigmas were described only once. No masticatory malfunction was reported. TM-AVMs tend to appear in young patients (mean: 29 yr), commonly as longstanding and slow-evolving lesions (mean evolution time before diagnosis: 5 yr). All cases displayed a diffuse slow-flow blush on angiogram. All TM-AVMs were completely located within the TM, with no involvement of scalp or bone. The pathological analysis of all cases demonstrated the presence of striate muscular bundles intermingled with fairly mature arterial and venous vessels. No clearly distorted vessel was found within the TM-AVMs. Surgery was performed for all cases with complete removal. Preoperative embolization was done in 4 cases to reduce blood loss during surgery. No clinical/radiological recurrence was reported. Opposite to TM-AVMs, scalp AVMs commonly present as high-flow lesions with no evident tumor mass, mainly located in the subcutaneous tissue. TM-AVMs present clearly distinct features compared to scalp AVMs, for which they should be considered as a certain pathological entity and not as a variant of scalp AVMs.

Fronto-orbitozygomatic approach: functional and cosmetic outcomes in a series of 169 patients

OBJECTIVE Advantages of the fronto-orbitozygomatic (FOZ) approach have been reported extensively in the literature; nevertheless, restoration of normal anatomy and the esthetic impact of surgery are increasingly important issues for patients and neurosurgeons. The aim of this study was to analyze functional and cosmetic outcomes in a series of 169 patients with different pathologies who underwent surgery in which the FOZ approach was used. METHODS Between January 2000 and December 2014, 250 consecutive patients underwent surgery with an FOZ approach as the primary surgical treatment. Follow-up data were available for only 169 patients; 103 (60.9%) of these patients were female and 66 (39.1%) were male, and their ages ranged from 6 to 77 years (mean 46.9 years; SD 15.6 years). Mean follow-up time was 66 months (range 6-179 months; SD 49.5 months). Evaluation of clinical outcomes was performed with a focus on 4 main issues: surgical complications, functional outcome, cosmetic outcome, and patient satisfaction. The additional time needed to perform orbitotomy and orbital reconstruction was also evaluated. RESULTS The permanent postoperative complications included forehead hypesthesia (41.4%) and dysesthesia (15.3%), frontal muscle weakness (10.3%), exophthalmos (1.4%), enophthalmos (4.1%), diplopia (6.6%; 2% were related to surgical approach), and persistent periorbital and eyelid swelling (3%). Approximately 90% of the patients reported subjectively that surgery did not affect their quality of life or complained of only minor problems that did not influence their quality of life significantly. The mean time needed for orbitotomy and orbital reconstruction was approximately half an hour. CONCLUSIONS Comprehensive knowledge of the potential complications and overall clinical outcomes of the FOZ approach can be of great utility to neurosurgeons in balancing the well-known benefits of the approach with potential additional morbidities.

Spontaneous fracture of cranioplastic titanium implants without head trauma in an adult: A case report

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The dynamic load was generated at basitemporal skull if prosthesis was not anchored to this loci.

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Via the parietal tuber-temporozygomatic suture line, this dynamic load was passed to the proximal pterion point region, which eventually generated fatigue effects on the prosthesis and eventually fracture.

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The cranioplasty prosthesis shall be well anchored onto the basitemporal skull to prevent fatigue effects of the prosthesis.

Introduction

The cranioplasty is a classical surgical procedure to repair large skull defects. The prosthesis fracture was one rare complication following cranioplasty, which was only known to happen in traumatic head injury or child growing skull.

Presentation of case

In the current report, we documented the first reported case of cranioplasty prosthesis fracture in an adult neurological trauma patient at the proximal pterion point region without head trauma. During the first cranioplasty, due to the cerebromalacia at temporal lobe, patient’s temporalis muscle was not stripped from the dura mater and the prosthesis was anchored outside the temporalis muscle. Thus, no screw was used for anchoring the prosthesis at the basitemporal skull. The prosthesis fracture was observed on 12^th-month post-surgically at the proximal pterion point region. During the second cranioplasty, the temporalis muscle was semi-partitioned from the back due to cerebromalacia recovery and five screws were used to anchor the prosthesis onto the basitemporal skull. The follow-up result was unremarkable on 21^st-month post-second-cranioplasty.

Discussion

A dynamic load was generated on the prosthesis due to head-pillow contact during sleeping. Via the parietal tuber-temporozygomatic suture line, this inward load generates an outward force at the proximal pterion point region, where became a shearing force locating just right below the lowest screw anchoring in this region. This shearing force eventually led to prosthesis fracture at the proximal pterion point due to the fatigue effect.

Conclusion

This case presented the importance of prosthesis anchoring location on the skull, especially when temporalis muscle was required to be preserved due to clinical necessity.

Microsurgical anatomy of subtotal temporal bone resection en bloc with the parotid gland and temporomandibular joint

BACKGROUND

Subtotal temporal bone resection (STBR) has been used for half a century to remove temporal bone malignancies. However, there are few reports on the detailed anatomy involved in the resection.

OBJECTIVE

To describe the microsurgical anatomy of STBR combined en bloc with the resection of the parotid gland and temporomandibular joint (TMJ).

METHODS

Cadaveric specimens were dissected in a stepwise manner using 3× to 40× magnification.

RESULTS

STBR can be combined with the total parotidectomy and the resection of the TMJ if the tumor extends into the parotid gland, TMJ, or facial nerve. In this study, we describe the step-by-step microsurgical anatomy of STBR en bloc with the parotid gland and TMJ. The surgical technique described combines 3 approaches: the high cervical, subtemporal-infratemporal fossa, and retromastoid-paracondylar approaches. Combining these 3 approaches aided in efficiently completing this modified approach.

CONCLUSION

STBR is a complicated and technically challenging procedure. This study highlights the importance of understanding the surgical anatomy of STBR and will serve as a catalyst for improvement of the surgical technique for temporal bone resection.

Anatomy of the infratemporal crest: implications for cross-facial nerve grafting in temporal myoplasty

Temporalis transfers for reanimation in facial palsy have been criticised for the lack of neural input from a functioning facial nerve. Cross-facial nerve grafting to the deep temporal nerves may provide a solution. An anatomical study was performed to further elucidate the deep temporal nerves (DTN) and arteries, examining anatomical variation and infratemporal distribution. Seventeen temporalis muscles were dissected from 13 cadavers as part of a BSc project. The number, branching pattern, length and diameter of DTN were recorded. Arteries supplying the deep surface of temporalis and their relation to DTN were noted. Six specimens were processed using Sihler's staining technique. Arteries were injected with Iodixanol X-ray contrast medium and radiographs taken. All specimens displayed a single DTN originating from the anterior branch of V(3). A mean of 3 branches was observed. The nerve length was 14.22±3.95 mm. The point of entry of DTN into temporalis showed great consistency. Upon exiting the infratemporal fossa, the posterior deep temporal artery was deep and posterior to DTN in 65% of specimens. The branching pattern of DTN can be classified into three types. The deep arterial supply to temporalis was constant in all specimens. This study provides an anatomical basis for the planning and execution of cross-facial nerve grafting to temporalis, and for protection of vital structures. Furthermore, it helps to clarify inconsistencies in the literature regarding nomenclature of the nerve branching pattern of the deep temporal nerves.

The maxillary artery and the lateral pterygoid muscle: the New Zealand story

OBJECTIVE

The most recent study of the relationship between the maxillary artery and the lateral pterygoid muscle was published in this journal in 2008.(1) Given the controversy surrounding this relationship, our purpose was to present data gathered from New Zealand caucasoid cadavers over several years.

STUDY DESIGN

Both sides of 92 caucasoid adult cadaveric heads (45 male, 47 female) were dissected by 3 successive years of third-year medical students and second-year dental students. The infratemporal approach was used. Once the dissections reached the plane of the maxillary artery and lateral pterygoid muscle, their relationship was recorded, together with exemplary images. Sexual and symmetrical differences were noted.

RESULTS

In the 53 cases where bilateral dissection had been successful, the second part of the maxillary artery was found superficial to the lower head of the lateral pterygoid muscle in 30 cases (57%)-in 70% of the males and 39% of the females. One male and 1 female presented bilateral asymmetry.

CONCLUSIONS

The finding of 2 cases of bilateral asymmetry among the 53 bilaterally dissected cadavers led to the consideration of each "hemi-head" as a single entity. This increased the sample size. Statistical analysis of the data, systematically broken down by sex and by side, showed that the second part of the maxillary artery is more likely to lie deep to the lower head of the lateral pterygoid muscle in females than in males, and that "side" is irrelevant.

MR angiography at 3 T for assessment of the external carotid artery system

OBJECTIVE

A number of clinical situations exist in which high-resolution depiction of the external carotid artery system is required, a task not previously addressed by MR angiography. The purpose of this study was to evaluate the extent to which high-spatial-resolution MR angiography at 3 T can be used to map the normal external carotid artery system.

SUBJECTS AND METHODS

Twenty-three consenting adult patients were prospectively evaluated. Images acquired were evaluated by two independent observers, and each branch vessel was scored with regard to image quality, presence and grade of stenoses, and artifacts. Interobserver agreement regarding image quality and the presence and degree of stenosis was tested using the kappa coefficient. Differences in quality ratings between the two observers were assessed using the paired Student's t test.

RESULTS

Of 828 vessels analyzed, 92.63% were designated of diagnostic quality with no significant difference between the observers' image quality scores (p = 0.63). Good agreement was determined regarding image quality achieved (kappa = 0.716). All examinations were free of artifact sufficient to interfere with confident interpretation. Excellent correlation was seen with regard to stenosis detection and grading (kappa = 0.857). Of the external carotid artery systems assessed, 82.6% showed conventional anatomic vascular branching.

CONCLUSION

High-spatial-resolution, 3D contrast-enhanced MR angiography at 3 T using sagittal source data acquisition and an advanced acceleration factor of 6 allows high-quality (92.63% of arterial segments) visualization of the external carotid artery system, with complete head and neck vascular coverage.

The relationship of the fronto-temporal branches of the facial nerve to the fascias of the temporal region: a literature review applied to practical anatomical dissection

The understanding of the course of the facial nerve and its relationship to the different connective tissue layers in the temporal area is paramount to preserving this nerve during surgery. But the use of different nomenclatures for anatomical structures such as for the different fascial layers or fat pads in the temporal region as well as the difference in description of the course of the fronto-temporal branches of the facial nerve in relationship to the fascial layers can lead to confusion. Therefore we have reviewed the literature about this topic and tried to apply the information to practical anatomical dissection.