Deep Subfascial Approach to the Temporal Area

Location of the split line of the deep temporal fascia when reducing a zygomatic arch fracture

BACKGROUND

The deep temporal fascia (DTF) is known to separate into two layers that descend to attach to the zygomatic arch. When surgeons reduce an isolated fracture of the zygomatic arch through a temporal approach, the temporal incision site needs to be superior to the split line of the DTF.

MATERIALS AND METHODS

Sixty-seven hemifacial cadavers were investigated after removing the skin, subcutaneous tissue, and superficial temporal fascia. The superficial layer of the DTF was exposed. We cut the superficial layer along the line along, which it adhered to the deep layer inseparably. The heights of the split line of the DTF from the superior border of the zygomatic arch and from the top of the helix were measured at three points: at the jugale, zygion, and 3 cm from the tragus.

RESULTS

In all cases there were thick identifiable deep layers of the DTF. The mean heights of the split line of the DTF from the superior border of the zygomatic arch were 49.8, 46.7, and 42.6 mm at the jugale, zygion, and 3 cm from the tragus, respectively; the corresponding mean heights of the split line from the top of the helix were 19.1, 15.6, and 11.4 mm.

CONCLUSIONS

Knowledge of the mean height of the split line of the DTF will be helpful for surgeons to determine the temporal incision site for ensuring the safe reduction of a zygomatic arch fracture.

A Modified Pre-Auricular Approach in the Treatment of Orbital Zygomatic Maxillary Complex Fractures

OBJECTIVE

This study aimed to evaluate the safety of a modified pre-aricular approach in the treatment of orbital zygomatic maxillary complex fractures.

METHODS

This was a retrospective study of clinical data from 108 adults who were diagnosed with orbital zygomatic maxillary complex fractures and undergo open reduction and internal fixation through a modified pre-auricular approach. Exophthalmometry and limitation of extraocular muscle movement were determined using a Hertel exophthalmometer or synoptophore examination respectively. Primary complications were recorded, and postoperative facial nerve injury was tested by electrophysiologic analysis.

RESULTS

All patients received satisfied functional and cosmetic results at least 6 moths postoperatively. There were 2 cases (1.85%) involving complete or incomplete facial nerve injury confirmed by electrophysiologic analysis. The incidence of other postoperative complications including a hematoma rate of 1.85% patients and permanent hypesthesia or paresthesia in 2.78% of patients, and no cases of clinically significant temporal hollowing, alopecia, infection, or unacceptable scars encountered during a mean follow-up period of 2 years.

CONCLUSION

A modified pre-auricular approach with dissection deep to the temporalis fascia offers a safe and reliable surgical technique for accessing the malar arch in orbital zygomatic maxillary complex fractures.

[Application of modified coronal approach in treatment of craniomaxillofacial fractures]

OBJECTIVE

This study aimed to investigate clinical efficacy of a modified coronal approach in treatment of craniomaxillofacial fractures.

METHODS

Thirty-seven cases of craniomaxillofacial fractures underwent open reduction and rigid internal fixation through modified coronal approach. Clinical follow-up visits were conducted to evaluate facial nerve functional status, temporal shape, appearance restoration, and reduction of fracture and surgical area scars.

RESULTS

During follow-up period of 6-36 months, appearance and function of all 37 patients recovered well without facial nerve injury and temporal depression deformity. All cases presented hidden scars, except for one case with hypertrophic scar.

CONCLUSIONS

Applying modified coronal approach to craniomaxillofacial surgery effectively reduces incidence of temporal depression and facial nerve injury compared with traditional approach. The modified coronal approach produced more subtle scars compared with traditional approach and should be applied to treatment of craniomaxillofacial fractures.

Assessment of facial nerve injury with "House and Brackmann facial nerve grading system" in patients of temporomandibular joint ankylosis operated using deep subfascial approach

Background:

Preservation of the functional integrity of the facial nerve (FN) is a critical measure of success in temporomandibular joint (TMJ) surgery. In spite of the development of a myriad of surgical approaches to the TMJ, FN remains at risk. The deep subfascial approach provides an additional layer of protection (the deep layer of the temporalis fascia and the superficial temporal fat pad) to the temporal and zygomatic branches of the FN and thus, is the safest method to avoid FN injury.

Objectives:

To assess FN injury following TMJ surgery using deep subfascial approach and measuring it on House and Brackman facial nerve grading system (HBFNGS).

Materials and Methods:

Twenty TMJs in 18 patients were operated for TMJ ankylosis, using “the deep subfascial approach.” FN function was assessed postoperatively at 24 h, 1 week, 1 month, 3 months, 6 months using HBFNGS. Statistical analysis was done using SPSS 16.0.

Results:

Of 20 surgical sites 3 sites showed Grade III (moderate) FN injury and 17 sites showed Grade II (mild) FN injury at 24 h. The condition improved with time with full recovery of FN at all surgical sites at 6 months.

Conclusion:

The deep subfascial approach has a distinct advantage over the conventional approaches when dissecting the temporal region and is the safest method to avoid injury to FN.

Safety of Modified Coronal Approach with Dissection Deep to Temporalis Fascia for Facial Nerve Preservation

Objective

To evaluate the safety of a modified coronal approach to the upper craniofacial skeleton with dissection deep to the temporalis fascia for enhanced preservation of the frontal branch of the facial nerve.

Study Design

Case series with chart review.

Setting

Tertiary academic medical center.

Subjects and Methods

In total, 271 patients undergoing coronal flap approaches to the upper craniofacial skeleton by a single surgeon from January 2008 through December 2013 were included. Primary outcomes are temporary or permanent weakness of the frontal branch of the facial nerve as well as the incidence of temporal hollowing following surgery. Secondary outcomes include the presence of postoperative hematoma, seroma, infection, scarring, and alopecia.

Results

There were no cases involving either temporary or permanent facial nerve weakness. The incidence of other postoperative complications was also exceedingly low, including a hematoma rate of less than 1%, widened scarring in 2.6% of patients, and no cases of clinically significant temporal hollowing encountered during a mean follow-up period of 3 years.

Conclusion

A modified coronal approach with dissection deep to the temporalis fascia offers a safe and reliable surgical technique for accessing the upper craniofacial skeleton. Observed complications were minimal, and despite this deeper plane of dissection, there were no cases of either temporary or permanent facial nerve weakness in a large retrospective series of patients from over the past 6 years. Consideration should be given for the routine use of this modified coronal approach for both reconstructive as well as cosmetic indications.