The temporalis muscle flap: an evaluation and review of 38 cases

Temporal Flap as an Option for Buconasal Fistula Closure

Maxillary defects with buconasal/businusal communications are situations difficult to manage and solve. Several treatment options are available on the literature, each one with its indication. Temporal muscle flap is one of these options, being a technique that requires more experience of the surgeon to be properly performed and that is mainly indicated for difficult cases, large defects and those nonresponsive to simpler techniques. The main purpose of this paper is to report 3 clinical patients of the application of the temporal muscle flap for the closure of extensive oral defects. None of the patients had necrosis, nervous deficits, or any long-term changes. The authors conclude that the use of this flap was shown to be a viable, safe technique with low complication and high success rates, which may contribute to the rehabilitation of well-indicated patients.

Continuous Validity of Temporalis Muscle Flap in Reconstruction of Postablative Palatomaxillary Defects

INTRODUCTION

Postablative palatomaxillary defects (PAPMDs) represent a challenging reconstructive problem. Temporalis muscle flap (TMF) has been widely used for reconstruction of these defects with minimal morbidity and satisfactory outcome.

AIM OF THE STUDY

To presents the authors' experience in the reconstruction of PAPMDs with TMF and to evaluate the validity of TMF in the reconstruction of such defects.

METHODS

This prospective study was conducted between July 2011 and July 2016 on selected patients for primary reconstruction of PAPMDs with TMF. Temporalis muscle flaps were assessed during surgery and postoperatively. Patients were followed up to evaluate functional and esthetic outcomes and detect complications.

RESULTS

This study included 32 patients with mean age 48.3 years. The pathology was squamous cell carcinoma in 15 patients (46.9%). Twenty-one patients (65.6%) had type II maxillectomy. Mean time of flap harvesting was 43 minutes. Zygomatic arch osteotomy was done in 3 patients while Coronoid osteotomy in 4 patients. Postoperatively, flaps were viable in 31 patients (96.9%) with good healing of recipient site. Flap epithelization completed within 28 to 59 days. Follow-up period was 13 to 55 months. Satisfactory functional and esthetic outcomes were reported in most of patients with no recurrence. Transient temporal nerve palsy occurred in 2 patients, limited mouth opening in 5 patients. One patient had Transient diplopia with enopthalmos and hypophthalmos. Flap failure occurred in another patient.

CONCLUSIONS

Temporalis muscle flap is still a valid reliable and versatile reconstructive tool in palatomaxillary reconstruction after ablative surgery. It has a good cosmetic and functional outcomes and minimal morbidity.

Pedicled Temporalis Muscle Flap for Craniofacial Reconstruction: A 35-Year Clinical Experience with 366 Flaps

BACKGROUND

In the past 130 years, the temporalis muscle flap has been used for a variety of different indications. In this age of microsurgery and perforator flaps, the temporalis muscle flap still has many useful applications for craniofacial reconstruction.

METHODS

Three hundred sixty-six temporalis muscle flaps were performed in a single center between 1978 and 2012. The authors divided the cases into two series-before and after 1994-because, after 1994, they started to perform free flap reconstructions, and indications for reconstruction with a temporalis muscle flap were changed RESULTS:: In the series after 1994, flaps were most commonly used for reconstruction of defects in the maxilla, mandible, and oropharynx, in addition to facial reanimation and filling of orbital defects. Complications included total flap necrosis (1.6 percent) and partial flap necrosis (10.7 percent). The rate of material extrusion at the donor site decreased after porous polyethylene was uniformly used for reconstruction from 17.1 to 7.9 percent.

CONCLUSIONS

The pedicled temporalis muscle flap continues to have many applications in craniofacial reconstruction. With increasing use of free flaps, the authors' indications for the pedicled temporalis muscle flap are now restricted to (1) orbital filling for congenital or acquired anophthalmia; (2) filling of unilateral maxillectomy defects; and (3) facial reanimation in selected cases of facial nerve palsy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Temporalis Muscle Flap for Palate Reconstruction: Case Series and Review of the Literature

Introduction  The temporalis myofascial (TM) is an important reconstructive flap in palate reconstruction. Past studies have shown the temporalis myofascial flap to be safe as well as effective. Free flap reconstruction of palate defects is also a popular method used by contemporary surgeons. We aim to reaffirm the temporalis myofascial flap as a viable alternative to free flaps for palate reconstruction.

Objective  We report our results using the temporalis flap for palate reconstruction in one of the largest case series reported. Our literature review is the first to describe complication rates of palate reconstruction using the TM flap.

Methods  Retrospective chart review and review of the literature.

Results  Fifteen patients underwent palate reconstruction with the TM flap. There were no cases of facial nerve injury. Five (33%) of these patients underwent secondary cranioplasty to address temporal hollowing after the TM flap. Three out of fifteen (20%) had flap related complications. Fourteen (93%) of the palate defects were successfully reconstructed, with the remaining case pending a secondary procedure to close the defect. Ultimately, all of the flaps (100%) survived.

Conclusion  The TM flap is a viable method of palate defect closure with a high defect closure rate and flap survival rate. TM flaps are versatile in repairing palate defects of all sizes, in all regions of the palate. Cosmetic deformity created from TM flap harvest may be addressed using cranioplasty implant placement, either primarily or during a second stage procedure.

The utility of the temporalis muscle flap for oropharyngeal, base of tongue, and nasopharyngeal reconstruction

OBJECTIVE:

To determine the efficacy of temporalis muscle flap reconstruction of various defects of the oropharynx, nasopharynx, and base of tongue.

STUDY DESIGN:

Retrospective chart review of a consecutive series of 24 patients who underwent a total of 26 temporalis flaps (2 bilateral) by the senior author (Y.D.) from September 1997 to August 2003 for reconstruction of defects of the oropharynx, nasopharynx, and base of tongue.

METHODS:

Variables and outcomes that were examined included defect location, size, adjunctive therapy, complications, and ability to tolerate oral intake at follow-up.

RESULTS:

There was no evidence of flap failure in our series of patients. There were 2 cases of minor flap loss related to early prosthetic rehabilitation. Two cases of transient frontal nerve paralysis were noted. A 30.8% rate of complication (all minor) was noted in this study. At a mean follow-up of 12 months, 54.2% of patients were tolerating a full diet, 37.5% were tolerating most of their nutrition by mouth, and 8.3% were g-tube dependent.

CONCLUSION:

The temporalis muscle flap represents an excellent alternative in reconstruction of otherwise difficult-to-reconstruct defects of the nasopharynx, oropharynx, and base of tongue. Donor site aesthetics are well accepted by patients with primary hydroxyapatite cement cranioplasty with or without secondary lipotransfer.

Surgical anatomy and utility of pedicled vascularized tissue flaps for multilayered repair of skull base defects

OBJECT The objective of this study was to describe the surgical anatomy and technical nuances of various vascularized tissue flaps. METHODS The surgical anatomy of various tissue flaps and their vascular pedicles was studied in 5 colored silicone-injected anatomical specimens. Medical records were reviewed of 11 consecutive patients who underwent repair of extensive skull base defects with a combination of various vascularized flaps. RESULTS The supraorbital, supratrochlear, superficial temporal, greater auricular, and occipital arteries contribute to the vascular supply of the pericranium. The pericranial flap can be designed based on an axial blood supply. Laterally, various flaps are supplied by the deep or superficial temporal arteries. The nasoseptal flap is a vascular pedicled flap based on the nasoseptal artery. Patients with extensive skull base defects can undergo effective repair with dual flaps or triple flaps using these pedicled vascularized flaps. CONCLUSIONS Multiple pedicled flaps are available for reconstitution of the skull base. Knowledge of the surgical anatomy of these flaps is crucial for the skull base surgeon. These vascularized tissue flaps can be used effectively as single or combination flaps. Multilayered closure of cranial base defects with vascularized tissue can be used safely and may lead to excellent repair outcomes.

Reconstruction of composite oral cavity defects with temporalis flaps after prior treatment

BACKGROUND

Reconstruction of composite oral cavity defects in the setting of prior surgery and radiotherapy presents a significant challenge. Although free tissue transfer has shown success in such situations, it is not without considerable risk. Regional pedicled flaps may provide a more suitable alternative. In certain patients, however, severe soft tissue fibrosis makes more conventional regional flaps impractical or impossible. In these situations, temporalis flaps (temporalis muscle and temporoparietal fascia flaps) are versatile options for coverage of complex defects.

OBJECTIVE

To report our experience using pedicled temporalis flaps for reconstruction of composite oral cavity defects in patients with significant co-morbidities and prior treatment.

METHODS

Three patients were identified and their medical records were reviewed. Their clinical courses and functional outcomes are described. We include a discussion of the operative technique and relevant literature.

RESULTS

All patients had previously undergone extensive treatment. One patient needed reconstruction after resection of a third head and neck malignancy and two patients presented for treatment of osteoradionecrosis. A temporalis muscle flap was used to reconstruct composite oral cavity defects in two patients and a combined temporalis muscle and temporoparietal fascia flap was used for independent defects in one patient. All flaps survived. Functional status and pain improved or stabilized in all patients. There were no major or minor complications.

CONCLUSION

In previously treated fields, where more conventional flaps are impractical, temporalis flaps are a suitable alternative to achieve a stable healing wound and prevent worsening of functional status.

Temporal muscle flap in reconstruction of maxillo-facial tissues

Aim of the study

Presents our experience in reconstruction of postsurgical defects with use of temporal muscle flap.

Material and methods

In the years 1996–2010 we treated 10 patients with malignant neoplasms of maxillo-facial region. Following tumor removal the fascia-muscle flaps of temporal muscle were used for reconstruction. Temporal muscle flaps were applied in 5 cases for reconstructing the defect of eye socket tissue after extensive resections and in the other 5 patients was used for reconstructing the defect of palate following maxillary resections.

Results

All the flaps of temporal muscle that were used for reconstructing eye sockets incorporated with no local reaction. In one case of flap applied into the oral cavity for tightly separate from nasal, partial necrosis of flap's edge and oro-nasal fistula occurred.

Conclusions

Fascia-muscular flap of temporal muscle is a simple, easy and effective method of tissue reconstruction in maxillo-facial region following extensive oncologic procedures.

Temporalis myofascial flap for primary cranial base reconstruction after tumor resection

OBJECTIVE

To evaluate the use of the temporalis myofascial flap in primary cranial base reconstruction following surgical tumor ablation and to explain technical issues, potential complications, and donor site consequences along with their management.

DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PARTICIPANTS

Forty-one consecutive patients receiving primary temporalis myofascial flap reconstructions following cranial base tumor resections in a 4-year period.

MAIN OUTCOME MEASURES

Flap survival, postoperative complications, and donor site morbidity.

RESULTS

Patients included 37 males and 4 females ranging in age from 10 to 65 years. Two patients received preoperative and 18 postoperative radiation therapy. Patient follow-up ranged from 4 to 39 months. The whole temporalis muscle was used in 26 patients (63.4%) and only part of a coronally split muscle was used in 15 patients (36.6%). Nine patients had primary donor site reconstruction using a Medpor((R)) (Porex Surgical, Inc., Newnan, GA) temporal fossa implant; these had excellent aesthetic results. There were no cases of complete flap loss. Partial flap dehiscence was seen in six patients (14.6%); only two required surgical débridement. None of the patients developed cerebrospinal leaks or meningitis. One patient was left with complete paralysis of the temporal branch of the facial nerve. Three patients (all had received postoperative irradiation) developed permanent trismus.

CONCLUSIONS

The temporalis myofascial flap was found to be an excellent reconstructive alternative for a wide variety of skull base defects following tumor ablation. It is a very reliable, versatile flap that is usually available in the operative field with relatively low donor site aesthetic and functional morbidity.

Functional outcomes and suitability of the temporalis myofascial flap for palatal and maxillary reconstruction after oncologic resection

OBJECTIVES/HYPOTHESIS

The temporalis myofascial flap (TMF) is a method of palatal reconstruction that offers a single-stage, reliable, and functional technique to repair oncologic defects involving the oral cavity following tumor removal. It is hypothesized that both speech and swallowing function are preserved following TMF.

STUDY DESIGN

In a retrospective and prospective case series, this study evaluated the surgical outcomes of 72 patients undergoing surgical resection and reconstruction of the hard and soft palate using a TMF. Of this series, 25 patients underwent nasalence and swallowing quality-of-life testing to determine speech and swallowing function following this procedure.

METHODS

Reliability, safety, and effectiveness data endpoints on TMF reconstruction were collected and analyzed. Instrumental measures of nasalence (KayPentax Nasometer, Lincoln Park, NJ) and swallowing quality of life measures (MD Anderson Dysphagia Inventory [MDADI] were acquired.

RESULTS

All TMF's were successfully transferred with complete healing of the oncologic defect. The group mean nasalence for connected speech tasks were within normal limits for connected speech--high- and low-pressure tasks (M = 21% and M = 17%). The group mean nasalence scores for sustained vowels were mildly affected (M = 26%). The group mean MDADI score was 79 (SD = 16), indicating good to mildly affected swallowing quality of life. Neither nasalence nor MDADI scores appeared to vary as a function of defect region.

CONCLUSIONS

The TMF is an oncologically safe and effective method of palate reconstruction that affords excellent quality of life to appropriately selected patients without reliance on other reconstructive techniques.

Temporalis muscle flap for reconstruction of skull base defects

BACKGROUND

The temporalis muscle flap (TMF) is a valuable reconstructive technique utilized in a variety of challenging defects. However, its use for repair of skull base defects is less commonly reported.

METHODS

A retrospective chart review was conducted for 35 patients who underwent reconstruction of skull base defects between March 1999 and July 2006 at a tertiary referral hospital. Patients with skull base defects after trauma or extirpative surgery underwent reconstruction with a TMF. The measured outcomes were as follows: defect size/location, need for additional flaps, bone necrosis, hardware exposure, dehiscence, cerebrospinal fluid (CSF) leak, and meningitis.

RESULTS

Forty-two patients underwent reconstruction with a TMF, and 35/42 patient records were available for review. No flap failures, 1 transient CSF leak, 3 hardware exposures distant from the temporalis recipient site, and 3 hydroxyapatite cement infections or foreign body reaction were observed.

CONCLUSION

The TMF represents a versatile reconstructive technique employed with minimal morbidity and a low complication rate to repair defects of the skull base.

The Surgical Management of Oral Cancer

Oral cavity cancers represent an area of head and neck oncology with some unique and interesting management themes. In spite of a significant paradigm shift in the treatment of many head and neck cancers toward us-ing primary chemoradiation, this treatment is not frequently applied to the oral cavity. Small cancers of the oral cavity are usually managed by surgery alone. Larger cancers are usually treated with primary surgery followed by chemoradiation. Neck treatment is offered to patients who have a greater than 20% chance of having lymph node metastasis or who have neck disease at the time of presentation. Neck treatment may involve surgery, radiation therapy, or both. Reconstruction of surgical defects of the oral cavity runs the gamut of techniques from the most simple to the most complex three-dimensional microvascular composite flaps. A multidisciplinary setting with a tumor board and multiple supportive services provides the best care for patients who have advanced-stage cancers.

Microvascular radial forearm fasciocutaneous free flap in hard palate reconstruction

THE AIM OF THIS STUDY

To report the reconstruction of palatal defects by microvascular radial forearm fasciocutaneous free flap (RFFF) and to report patient's quality of life outcomes after this procedure.

MATERIAL AND METHODS

During the period 1990-2002, 30 cases of palatal defects were reconstructed using RFFF in our institution. RFFF allowed restoration of a vestibular sulcus to maintain dental prostheses. Outcome measurements included post-operative assessment of speech, swallowing and diet evaluation 6 months, 1 year and 2 years after reconstruction. Quality of life outcomes were measured 1 and 2 years post-reconstruction.

RESULTS

RFFF surgery was successful in 28 cases. Six months after resection 28 patients reported satisfactory speech and swallowing. Two years after surgery, 92% (n=26) of patients resumed a normal diet. All patients underwent dental evaluation and 68% (n=19) of patients required dental rehabilitation over a post-operative period of 3-18 months. Patients self assessed their quality of life on a scale of 0-2. First year post-operatively, 21 patients reported a good quality of life (score=2). After the second year, 26 patients reported a good quality of life and the remaining two patients reported an intermediate quality of life (score=1) because they did not resume a normal diet.

CONCLUSION

RFFF for palatal reconstruction is a reliable technique and provides a definitive separation between oral and sinusonasal cavities. Furthermore, it improves quality of life by improving speech, swallowing and chewing. It should be considered an integral component of head and neck cancer therapy and rehabilitation.

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.

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.

[The temporal periosteum: anatomical study and surgical implications]

The periosteum of the temporal area is mentioned at different places in the literature: either against the osseous plane like everywhere in the human body, or between the deep and the superficial temporal fascia. The subperiosteal subtemporal approach in craniofacial surgery in children is in favour of a juxta-osseous localization of the periosteum. Ten premature still-born neonates and two adults cadavers have been dissected for this study and, permit anatomical and histological (with HES coloration) studies. With every specimen, the authors concluded that the temporal periosteum is against the outer table of the calvarium. It became thinner in adults because of direct insertions of the temporalis muscle in the calvaria. An anatomical description of the layers of the temporal area is realised and discussed with an extensive review of the literature. The authors have proposed a subperiosteal subtemporal approach in craniostenosis surgery.

The temporalis muscle flap for reconstruction after head and neck oncologic surgery

OBJECTIVE

To explain the applications, technique, and potential complications of the temporalis muscle flap used for immediate or delayed reconstruction of head and neck oncologic defects.

STUDY DESIGN

Fresh cadaver dissection and 5-year retrospective chart review.

METHODS

A fresh cadaver dissection was performed to illustrate the surgical anatomy of the temporalis muscle flap with attention to specific techniques useful in avoiding donor site morbidity (facial nerve injury and temporal hollowing). A chart review was performed for 13 consecutive patients from the last 5 years who underwent temporalis muscle flap reconstruction after oncologic resection of the lateral and posterior pharyngeal wall, hard and soft palate, buccal space, retromolar trigone, and skull base.

RESULTS

Patient follow-up ranged from 2 to 45 months. Nine patients had radiation therapy. There were no cases of flap loss. Resection of the zygomatic arch followed by wire fixation facilitates flap rotation and minimizes trauma to the flap during placement into the oropharynx. Preservation of the temporal fat pad attachment to the scalp flap decreases temporal hollowing and protects the facial nerve. Replacing the zygoma and preserving the anterior third of the temporalis muscle in situ further diminishes donor-site hollowing.

CONCLUSIONS

Compared with other regional flaps, such as the pectoralis myocutaneous flap, the temporalis muscle flap is associated with low donor-site esthetic and functional morbidity and offers great flexibility in reconstruction. The temporalis muscle flap is a useful, reliable flap that belongs in the armamentarium of surgeons who are involved with reconstruction of head and neck tissue defects.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.

A comparative study of epithelialization of subcutaneous fascial flaps and muscle-only flaps in the oral cavity. A rabbit model

Epithelialization of subcutaneous fascial flaps and muscle-only flaps used for reconstruction of the oral mucosa were studied in a rabbit model. Angiography was performed to help to design a subcutaneous cervical fascial flap and a cleidomastoid muscle-only flap. These flaps were transferred into a mucoperiosteal defect on the mandibular alveolus. The flaps were gradually infiltrated by acute inflammatory cells from the periphery and then replaced by granulation tissue originating from the oral mucosa. The epithelialization was by secondary intention. An epithelial tongue from the surrounding epithelium migrated onto the granulating flaps with eventual coverage after three weeks. After two months, the muscle-only flap was covered by a poorly organized epithelium, different from the highly uniform epithelium in the fascial flap. The granulation tissue which replaced the muscle-only flap matured to fibrous tissue, associated with severe contraction. This was characterized by dense regular collagen fibers, no elastic fibers, and few capillaries, while the fibrous tissue which replaced the fascial flap was characterized by random collagen and elastic fiber morphology and numerous dilated blood vessels, and was associated with mild contraction. This experiment supports the view that the different extracellular matrices of these flaps may play a role in epithelial configuration and contraction.

The temporalis muscle flap in intraoral reconstruction

BACKGROUND

Reconstruction following excision of intraoral tumours presents a challenge to the head and neck surgeon. The purpose of hte present study was to review the authors' initial experience with the temporalis muscle flap.

METHODS

A retrospective review fo the use of 21 temporalis muscle flaps in intraoral reconstruction at Christchurch Hospital was performed. The muscle was used to reconstruct defects of the oral tongue, tongue base, buccal mucosa, maxilla, soft palate, retromolar trigone and tonsillar region. Epithelial cover was provided by either split-skin grafting or ingrowth from adjacent mucosa.

RESULTS

One flap necrosed and one patient developed a wound haematoma requiring drainage. One patient developed a transient frontal weakness. The long-term functional results were excellent, except for one patient with slight tongue tethering. In one patient bilateral flaps were used to reconstruct a bilateral maxillectomy defect.

CONCLUSION

The temporalis muscle flap is a useful option for reconstruction of moderate defects in the posterior oral cavity and oropharynx.

Experimental study of epithelialization of the muscle-only flap in the oral cavity

PURPOSE

The purpose of this study was to observe the epithelialization process of the muscle-only flap used for reconstruction of the oral mucosal defects.

MATERIALS AND METHODS

Forty-three male adult Japanese rabbits were used. A superiorly based cleidomastoid muscle flap was designed after vascular assessment. The flap was transferred into the oral cavity to cover a mucoperiosteal defect made in the mandibular alveolus. Epithelialization of the flap was histologically evaluated at designated intervals.

RESULTS

The flaps survived without ischemic necrosis. By 8 days postoperation, the flap was infiltrated by acute inflammatory cells and being replaced by granulation tissue originating from the adjacent tissues. The oral epithelial cells advanced onto this granulating muscle flap, with eventual coverage by 21 days. The granulation tissue matured to fibrous tissue with significant contraction by 2 months. At 6 months postoperation, abnormally hyperkeratinized epithelium was seen on the flap. This differed from the surrounding parakeratinized oral epithelium.

CONCLUSIONS

The muscle-only flap in the oral cavity epithelializes after the granulation process.

Temporalis myofascial flap in maxillofacial reconstruction: clinical and histological studies of the oral healing process

OBJECTIVES

To report our experience with temporalis myofascial flaps (TMF), describe the healing process of uncovered flaps in the mouth, and the histology of the repaired mucosa in the long term.

DESIGN

Prospective clinical and histological study.

SUBJECTS

36 patients who received a TMF over a 6.5 year period for serial assessment of the oral healing, 24 patients whose scars over the reconstructed area were assessed clinically, and 11 whose repaired mucosa was assessed histologically.

MAIN OUTCOME MEASURES

To follow the clinical process of oral healing of the TMF and describe the repaired mucosa healed over the flap.

RESULTS

The uncovered TMF in the mouth healed gradually starting with an acute inflammatory phase, going through chronic inflammatory and proliferative phases with eventual epithelialisation of the oral mucosa. There were no major complications. The healed mucosa showed mild scarring in 70% of cases and the repaired mucosa had characteristic histological features that were distinct from the normal mucosa.

CONCLUSION

The TMF is an extremely reliable and versatile flap for maxillofacial reconstruction which heals gradually with eventual coverage by mildly scarred repaired mucosa.

Trans-antral temporalis transfer for the repair of adult cleft palates

Temporalis muscle transfer is a versatile technique frequently used for reconstructive procedures in the maxillofacial region. However the thickness of the pedicle may interfere with masticatory function when used anteriorly in the oral cavity. To repair full-length mid-palatal defects in fully dentate patients the flap can be passed through the maxillary sinus and combined with local repair of the soft palate, thus avoiding any occlusal trauma from the posterior teeth. The operation is a single stage procedure with low morbidity and few complications, and is a useful technique for repairing the large untreated clefts frequently encountered in developing countries. The procedure is used by members of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons Bangladesh Project who have operated in Dhaka teaching hospitals on a regular basis since 1991.

The infrahyoid flap. A technique for defect closure in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall

The surgical technique, indications, and results of the infrahyoid muscle flap are presented. This flap is fed by the superior thyroid vessels and innervated by the ansa cervicalis. The flap is indicated in case of medium-sized defects in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall. The advantages of the technique presented include the rapid flap elevation close to the original operating field, the ability to use the motor capability of the flap, and the ability to combine it with other local flaps--for example, the platysma flap. This technique appeared to render excellent function for swallowing and speech. Safe flap grafting is possible only if the internal jugular vein is preserved.

An animal model for maxillary reconstruction using a temporalis muscle flap

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

The cat proved to be a useful model for this type of study.

The use of the temporalis muscle flap in facial and craniofacial reconstructive surgery. A review of 182 cases

The authors report on their 16-year experience of reconstruction with the temporalis myofascial flap in 182 cases. All aspects of reconstructive cranio-maxillofacial surgery are covered: trauma, deformities, tumours, TMJ ankylosis, facial paralysis. The temporalis myofascial flap was used both as a single and as a composite flap with cranial bone, coronoid process or skin island. Major complications were not observed. On the basis of their experience, the authors confirm the reliability, versatility and reproducibility of the use of this flap. This is due both to its rich blood supply and to its proximity to the reconstruction site. It is suggested that the use of the temporalis muscle flap should be taken into consideration before deciding on more extensive reconstructive procedures.

Intraoral defect coverage with muscle flaps

PURPOSE

This study investigated whether wound healing after the use of purely muscular flaps for intraoral defect coverage is negatively influenced by insipient muscular atrophy and the absence of a covering layer.

MATERIALS AND METHODS

In an experimental study, microsurgical transplantation of muscle flaps from the anterior abdominal wall was carried out in 18 Lewis rats. A nerve anastomosis for motor reinnervation was not performed. Atrophy of the muscle flaps was determined by measuring the reduction of their size and weight after 3, 8, and 20 weeks. In the clinical part of the study, free muscle transplants from different donor regions (vastus lateralis, pectoralis major, internal oblique, and temporalis muscles) were used for defect coverage in various areas of the oral cavity. To study epithelization, punch biopsy specimens from the muscle surface were taken at periods of 2 to 4 weeks up to 6 months for histologic evaluation. Final evaluation of reconstruction results with special regard to speech, tongue mobility, mouth opening, chewing, and swallowing took place after 6 months.

RESULTS

In the experimental study, average weight loss of the muscle flaps was 67% after 20 weeks, and the remaining surface area was 71%. The number of myocytes was only about 30% compared with control muscles, and parts of the flap appeared as a thin fibrous membrane. Clinically, this atrophy led to restricted mobility in such areas as the floor of the mouth, the buccal plane, and the tongue. Muscle flaps covering solid structures such as bones or reconstruction plates adapted well to the transplant bed, and the atrophy of the muscle led to no constriction of the surrounding tissue. Atrophy also did not have a negative effect when muscle flaps were placed in the region of the pharyngeal wall. Epithelization started from the edges after 2 weeks and was concluded after 8 weeks in all transplants if no additional radiation was performed. The muscle tissue was sufficiently resistant so that infection, fistulization, and necrosis did not occur.

CONCLUSIONS

Muscle flaps undergo considerable atrophy with a cicatricial transformation and reduction of flexibility. Despite these disadvantages they can be used in the hard palate, the alveolar crest, and in the pharyngeal wall without causing functional restriction. Because of constriction of the surrounding tissues, mobile areas such as the buccal plane, the floor of the mouth, and the tongue are not suitable as sites for muscle transplants.