The temporalis muscle flap revisited on its centennial: advantages, newer uses, and disadvantages

Orbital Extenteration Defects: Ablative and Reconstructive Flowchart Proposal

ABSTRACT

Orbital exenteration is a radical and disfiguring operation. It is still under debate the absence of correlation between the term describing the resulting orbital defect and the type of reconstruction. Authors' goal was to propose a consistent and uniform terminology for Orbital Exenteration surgery in anticipation of patients' tailored management. Twenty-five patients who underwent orbital exenteration between 2014 and 2020 were reviewed. A parallel comprehensive literature review was carried on. Five different types of orbital exenteration where outlined. Multiple reconstructive procedures were enclosed. An algorithm for orbital reconstruction was proposed based on anatomic boundaries restoration. Eyelid removal was first considered as an independent reconstructive factor, and both orbital roof and floor were indicated as independent reconstructive goals, which deserve different defect classification. In our opinion, this algorithm could be a useful tool for patient counseling and treatment selection, which might allow a more tailored patient care protocol.

LEVEL OF EVIDENCE

Level III.

Current trends in craniofacial reconstruction

Reconstruction of the head and neck continues to pose a variety of difficult functional and aesthetic challenges to the plastic surgeon. While the surgical treatment for midfacial and skull base tumours continues to advance, the three-dimensional reconstruction predicaments continue to increase in complexity. Reconstructive strategies of the head and neck require the restoration of intricate skeletal architecture and large volumes of both internal and external soft tissue envelopes that can withstand adjuvant therapies. Vascularized bone grafts in combination with microsurgical techniques is the current trend of most reconstruction and has replaced local and pedicle flaps as the preferred modality for large defects. This article will focus on concise areas of difficulty in craniofacial reconstruction, including mandibular, midfacial, scalp and base of skull reconstruction. As our goals now move from flap survival to refinement, more complex and innovative reconstructions are executed. The problems with each modality are examined, and the frontiers of head and neck reconstruction are explored. With the potential combination of virtual surgery and tissue engineered biotechnology, we may someday be able to expand our reconstructive capabilities beyond free tissue transfer.

High Voltage Electric Burn Repair of the Forehead by Reverse Flow Temporalis Muscle Flap

Repairing soft tissue defects of the forehead which exposes the bare bone is a dilemma with few reconstructive techniques for plastic surgeons. Forehead is an important aesthetic unit of the face which is covered with the glabrous skin. Due to the relative lack of similar mobile tissue locally, reconstruction of large soft tissue defects of the forehead region by local flaps is demanding. Temporalis muscle flap does not reach to the midline of the forehead region because of the insufficient length of the deep temporal vascular system. During the transfer of the muscle, only a small volume and size of the muscle can reach to the defect, remaining most of the muscle bulk in the pedicle and a relatively limited arc of rotation, thus a small volume of usable tissue at the distal portion of the flap. We successfully used reverse flow temporalis muscle flap for the purpose of eliminating the above-mentioned disadvantage of temporalis muscle flap in a 23-year-old male patient who sustained a high-voltage electrical burn resulting 12 × 8 cm left forehead defect exposing the bare bone.

Huge Anterior Skull Base Defect Reconstruction on Communicating Between Cranium and Nasal Cavity: Combination Flap of Galeal Flap and Reverse Temporalis Flap

INTRODUCTION

Traditionally, galeal flap or cranialization was often used to reconstruct the skull base defect caused by trauma or tumor removal. However, in the case of huge skull base defect, galeal flap is not enough to block the communication between nasal cavity and intracranial space. In this study, authors suggest combination flap of galea and reverse temporalis muscle as a method for reconstruction of huge skull base defect.

MATERIALS AND METHODS

From 2016 to 2019, retrospective review was conducted, assessing 7 patients with bone defect which is not just opening of frontal sinus but extends to frontal sinus and cribriform plate. Reconstructions were done by combination of galeal flap and reverse temporalis muscle flap transposition.

RESULTS

Defects were caused by nasal cavity tumor with intracranial extension or brain tumor with nasal cavity extension. There was no major complication in every case. During the follow up period, no patient had signs of complication such as ascending infection, herniation and CSF rhinorrhea. Postoperative radiologic images of all patients that were taken at least 6 months after the surgery showed that flaps maintained the lining and the volume well.

DISCUSSION

Conventional reconstruction of skull base defect with galeal flap is not effective enough to cover the large sized defect. In conclusion, galeal flap in combination with reverse temporalis muscle flap can effectively block the communication of nasal cavity and intracranium.

Reconstruction of the Midface and Palate

The midface is a complex anatomic structure that is fundamental to many physiologic and homeostatic functions. It may be involved in many pathologic processes that require partial or complete removal. When this happens, reconstruction is mandatory to improve cosmetic outcome with its effect on social interaction as well as to provide an opportunity for complete orodental rehabilitation with restoration of all physiologic functions. This article will review the different reconstructive options available for complex defects of the maxillofacial complex. It will highlight the surgical options available to maximize functional restoration. Finally, it will discuss computer modeling to optimize reconstructive planning.

Temporal Muscle Flap as a Treatment of an Extensive Cleft Palate in an Adult Patient

For the management of cleft palate, the surgical approach has been suggested at an early stage even in childhood, varying in the number of interventions. Once the interventions are not performed at appropriate times, such as sequences that may accompany specific psychological, functional, and aesthetic effects. Since it has been indicated, temporal muscle flap is a technique with satisfactory results for a resolution of extensive clef palate in adult patients. The purpose of this paper is reporting a case of temporal muscle flap in the soft and hard palate of an adult with a reconstruction of the donor area with a titanium mesh. A 37 year old male patient with cleft lip/palate, complained of difficulty in speech, chewing, swallowing, and breathing. Clinically, it was observed oroantral communication in the region of the hard and soft palate, with a previous cheiloplasty. A temporal rotation was planned to close the fissure for the treatment. The modified coronal approach was used. Temporal muscle traction and its interposition in the palate region were performed through the tunneling technique, and mass suturing was performed. After 3 years, he presented satisfactory results, with the improvement of the quality of life, as well as the area of exposure. In conclusion, since it has been indicated, temporal muscle flap is a technique with satisfactory results for a resolution of extensive cleft palate in adult patients.

Reconstruction of Orbital Suprastructure Maxillectomy Defects by Temporalis Myofascial Flap

Oncological surgery being radical is often mutilating in form and function especially in the maxillary/orbit region reconstruction of maxillo-orbit defects are challenging due to the complex three dimensional anatomy. Free flaps are de-rigueur but a technical resource with constraints. The temporalis myofascial flap (TMFF) is a locally available, safe and reliable flap which can be used for the reconstruction of various orbital and supramaxillary facial defects. To study the use of the temporalis myofascial flap in the reconstruction of various orbital and supramaxillary facial defects. Temporalis myofascial flap was harvested and successfully used in reconstruction of three patients who had undergone orbital exenteration with or without suprastructural maxillectomy. There was no morbidity related to flap loss. Temporalis flap (TMFF) can be considered as a first line reconstructive option for limited resection of upper maxilla with palatal preservation. Its proximity to the oral cavity, palate and mid third face and the technical ease makes the TMFF valuable for reconstruction. The techniques and outcomes of TMFF are discussed.

Keeping the fat on the right spot prevents contour deformity in temporalis muscle transposition

The temporalis muscle transposition is a reliable, one-stage reanimation technique for longstanding facial paralysis. In the variation described by Rubin, the muscle is released from the temporal bone and folded over the zygomatic arch towards the modiolus. This results in unsightly temporal hollowing and zygomatic bulging. We present a modification of this technique, which preserves the temporal fat pad in its anatomical location as well as conceals temporal hollowing and prevents zygomatic bulging.  The data of 23 patients treated with this modification were analysed. May classification was used for evaluation of mouth reanimation. Experts and patients scored visibility of the contour deformity on a 100-mm visual analogue scale (VAS) (score 0 = poor/100 = best). 3D images of the face were used to measure temporal hollowing and zygomatic bulging. 3D images were compared to those of controls with a similar gender and age distribution.  After a median follow-up of 5.7 years, all patients achieved symmetry at rest. Eleven patients achieved symmetry while smiling with closed lips (May classification "Good"). A median (interquartile range [IQR]) VAS score of 19 (6; 41) was given by experts and 25 (5; 59) by patients themselves. 3D volumes of zygomatic bulging differed from those of control subjects, although all volume differences were small (median <3.3 ml) and temporal hollowing did not differ significantly. On the basis of our results, we conclude that our modified Rubin temporalis transposition technique provides an elegant way to conceal bulging over the zygomatic arch and prevents temporal hollowing, without the need for fascial extensions to reach the modiolus.

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.

Single-stage socket reconstruction with vascularised temporalis muscle flap following total orbital exenteration: Description of 3 surgical approaches

We describe the techniques and outcome of three different approaches to transfer the posterior 2/3^rd temporalis muscle pedicle flap for orbital socket reconstruction following total orbital exenteration. A retrospective interventional series of 9 patients operated between February of 2000 and 2006. We describe three different techniques, namely supraorbital, transorbital and transorbitectomy approach. All patients were followed for minimum of 3 years and muscle trophism with periorbital contour was clinically studied for outcome. There were 6 males and 3 females with a mean age of 42 years. Three patients each underwent the three mentioned approaches of socket reconstruction following total orbital exenteration performed mainly for oculo-adenexal malignancies with orbital extension (77.78%). Intraoperative, tumor-free histopathological margins were ensured. Postoperatively, bulky lateral orbital rim was noticed in all 3 patients of supraorbital approach, while progressive temporalis flap atrophy was noticed in all with transorbital approach over a period of 6 months. No such complications were observed in transorbitectomy approach and reasonably good periorbital cosmetic appearance with optimum preservation of muscle trophism was obtained. The mean follow-up period was 7 years. Temporalis muscle flap provides adequate orbital volume restoration in an exenterated socket. It also helps in better skin graft uptake, socket health and appearance. The transorbitectomy approach appeared as a reliable one stage surgical technique with reasonably acceptable anatomical and cosmetic outcome over a long-term follow-up. The choice of posterior portion of temporalis muscle as a flap offers satisfactory temporal fossa appearance.

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.

Flap Necrosis after Palatoplasty in Patients with Cleft Palate

Palatal necrosis after palatoplasty in patients with cleft palate is a rare but significant problem encountered by any cleft surgeon. Few studies have addressed this disastrous complication and the prevalence of this problem remains unknown. Failure of a palatal flap may be attributed to different factors like kinking or section of the pedicle, anatomical variations, tension, vascular thrombosis, type of cleft, used surgical technique, surgeon's experience, infection, and malnutrition. Palatal flap necrosis can be prevented through identification of the risk factors and a careful surgical planning should be done before any palatoplasty. Management of severe fistulas observed as a consequence of palatal flap necrosis is a big challenge for any cleft surgeon. Different techniques as facial artery flaps, tongue flaps, and microvascular flaps have been described with this purpose. This review article discusses the current status of this serious complication in patients with cleft palate.

Immediate reconstruction of palato-maxillary defect following tumor ablation using temporalis myofascial flap

The resection of oral cavity tumor and malignancies often causes functional disabilities like deglutition and articulation. Maxillectomy is a very common surgical procedure carried out for the management of benign and malignant tumors of maxilla. Irrespective of the procedure, there is a common end result that is the defect. Several soft tissue flaps can be used for reconstruction of maxillectomy defect. Keeping the parameters of reconstruction in mind it is ideal to reconstruct the maxillary defect with either the free flaps or the regional flaps. Of all regional flaps, the temporalis myofascial flap (TMF) provides a high degree of reliability, vascularity, adequate bulk, and proximity to the defect in the oral and maxillofacial region.

A novel route for placing free flap pedicle from a palatal defect

One of the better options available to repair a large palatal defect is by employing a free flap. Almost all the times such free flaps are plumbed to facial vessels. The greatest challenge in such cases is the placement of the pedicle from palatal shelf to recipient vessels because there is no direct route available. As majority of large palatal fistulae are encountered in operated cleft palates there is a possibility of routing the pedicle through a cleft in the maxillary arch or via pyriform aperture. When such a possibility doesn’t exist the pedicle is routed behind the maxillary arch. We describe a novel technique of pedicle placement through a maxillary antrostomy, in this case report, where a large palatal fistula in a 16 year old boy was repaired employing a free radial artery forearm flap. The direct route provided by maxillary antrostomy is considered the most expeditious of all possibilities mentioned above.

Comprehensive surgical management of cocaine-induced midline destructive lesions

PURPOSE

This article presents a review of the literature and proposes a protocol for managing acute and chronic midfacial cocaine-induced injuries.

MATERIALS AND METHODS

This report describes a series of 4 patients affected by cocaine-induced midline destructive lesions. Three patients came to the authors' attention after 18 months of drug withdrawal and underwent surgical treatments to restore nasal and palatal morphology and function, and the fourth patient was referred because of acute cocaine-induced destructive lesions and was treated by aggressive debridement. An 18-month drug-free period is planned before beginning any reconstructive procedures in this latter patient.

RESULTS

Long-term follow-up showed stable results without relapse of palatal fistulas and good esthetic nasal appearance in all 3 patients undergoing reconstruction. The fourth patient did not show any disease progression and will be monitored for drug withdrawal.

CONCLUSION

Chronic cocaine consumption may cause multiple types of damage to the soft and hard tissues of the midface. Acute lesions must be addressed with aggressive debridement. As a result of chronic injury, the palate and nose are deformed in a very complex way and the vascularity of the remaining local tissues may be compromised or inadequate for flap harvesting. Palatal and nasal reconstructions are very delicate operations and should be addressed separately to maximize the predictability of the result.

Split, temporalis muscle flap for repair of recalcitrant cerebrospinal fluid leaks of the anterior cranial fossa

Cerebrospinal fluid repair after dural disruption is critical in preventing morbidity and mortality in trauma and cancer patients. Among reconstructive options, coverage with the temporalis muscle has been a staple in many surgeons' armamentarium. However, the donor-site morbidity has been a major drawback in the use of this technique. Here, we present our method of split, temporalis harvest for anterior cranial base reconstruction, which seeks to regain dural integrity, while maintaining aesthetic and functional elements of the donor site. We present 2 patients, demonstrating the ease of harvest, fulfillment of both cosmetic and reconstructive goals, widespread applicability, and versatility of our split, temporalis muscle flap.

Anterior cranial base reconstruction with a reverse temporalis muscle flap and calvarial bone graft

Background

Cranial base defects are challenging to reconstruct without serious complications. Although free tissue transfer has been used widely and efficiently, it still has the limitation of requiring a long operation time along with the burden of microanastomosis and donor site morbidity. We propose using a reverse temporalis muscle flap and calvarial bone graft as an alternative option to a free flap for anterior cranial base reconstruction.

Methods

Between April 2009 and February 2012, cranial base reconstructions using an autologous calvarial split bone graft combined with a reverse temporalis muscle flap were performed in five patients. Medical records were retrospectively analyzed and postoperative computed tomography scans, magnetic resonance imaging, and angiography findings were examined to evaluate graft survival and flap viability.

Results

The mean follow-up period was 11.8 months and the mean operation time for reconstruction was 8.4±3.36 hours. The defects involved the anterior cranial base, including the orbital roof and the frontal and ethmoidal sinus. All reconstructions were successful. Viable flap vascularity and bone survival were observed. There were no serious complications except for acceptable donor site depressions, which were easily corrected with minor procedures.

Conclusions

The reverse temporalis muscle flap could provide sufficient bulkiness to fill dead space and sufficient vascularity to endure infection. The calvarial bone graft provides a rigid framework, which is critical for maintaining the cranial base structure. Combined anterior cranial base reconstruction with a reverse temporalis muscle flap and calvarial bone graft could be a viable alternative to free tissue transfer.

Repair of Recurrent Cleft Palate with Free Vastus Lateralis Muscle Flap

A 6-year-old girl presented with a large recalcitrant oronasal fistula after bilateral cleft lip and palate repair and numerous secondary attempts at fistula closure. Incomplete palmar arches precluded a free radial forearm flap. A free vastus lateralis muscle flap was successfully transferred. No fistula recurrence was observed at 18 months. There was no perceived thigh weakness. The surgical scar healed inconspicuously. Free flaps should no longer be considered the last resort for treatment of recalcitrant fistulas after cleft palate repair. A free vastus lateralis muscle flap is an excellent alternative, and possibly a superior option, to other previously described free flaps.

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.

A novel technique for cheek mucosa defect reconstruction using a pedicled buccal fat pad and buccinator myomucosal island flap

Reconstruction of cheek mucosa defects following tumor resections can be approached with several techniques, depending on size of the defect. Fasciocutaneous and perforators free flaps are widely employed today for such reconstructions. However, small defects or general health of the patient may limit their indications. Furthermore, approaching moderate size defects, some techniques, like temporalis muscle or fascia pedicled flaps, lead to contracture with limitation of mouth opening or trisma, and others, like intraoral local flaps, do not provide enough tissue for the reconstructions. In this work the authors propose, for reconstructing these kind of defects, the use of a buccinator myomucosal island flap and a buccal fat pad pedicled flap association. A case is reported and the surgical technique is explained. This new reconstructive technique can easily be used for reconstructing moderate-sized cheek defects, achieving optimal results: the internal mucosal lining is restored in few weeks without any retraction, contracture, of scars on the face limiting the aesthetic outcome and mouth opening.

Cocaine-related syndrome and palatal reconstruction: report of a series of cases

Intranasal cocaine abuse may cause significant local ischaemic necrosis and destruction of the nasal and midfacial bones and soft tissue, leading to development of a cocaine-induced midline destructive lesion. Review of the English-language literature reveals only a few case reports describing hard and/or soft palatal perforation related to cocaine inhalation. To date, among the reconstructive techniques of the palate, different surgical options have been reported such as local, regional and free flaps. Common prosthetic obturators have also been used. Presented here are six cases of cocaine abuse showing different types of cocaine-related palatal lesions treated with different surgical approaches including local and free flaps. Mean follow-up was 3 years. A surgical variation of Marshall's classic technique for insetting a free flap in such lesions is proposed.

Use of Palacos®R-40 with gentamicin to reconstruct temporal defects after maxillofacial reconstructions with temporalis flaps

The temporalis muscle flap is a useful flap for the reconstruction of oral ablative defects. A complication of its use that was overlooked was the crater-like defect created when the muscle is stripped from its attachment on the temporal fossa. The cold-cure acrylic we use is Palacos R-40 with Gentamicin (Heraeus Kulzer GmbH). This material is radio-opaque, rapidly setting and contains gentamicin. We present a total of 41 cases over an 11-year period (1994-2005). We have a 97.6% (n = 40) success rate. Infection developed in only one case, which leads to the removal of the acrylic implant. The use of Palacos R-40 with Gentamicin is easy to use, it can be custom-moulded to fit and fill the defect any of shape and size. It has minimal complications and high success rate with acceptable results to the patients.

Reconstruction of maxillectomy and midfacial defects with free tissue transfer

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.

Free Rectus Abdominis Myocutaneous Flap With Anterior Rectus Sheath to Provide the Orbital Support in Globe-Sparing Total Maxillectomy

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. It results in severe complications if the orbital content is not supported. We would like to introduce a new technique using free rectus abdominis myocutaneous (RAM) flap with anterior rectus sheath to support the orbital content in a patient who underwent globe-sparing total maxillectomy. The large resection of the recurrent maxillary peripheral nerve sheath tumor was performed in a 34-year-old male patient. Right free RAM flap was harvested simultaneously with the tumor resection. The anterior sheath of upper portion of the rectus muscle was also incorporated into the flap. The free edge of the upper anterior rectus sheath was anchored to three different points: Lateral rim, medial rim and the posterior remnant of the bony orbital floor with non-absorbable suture. Consequently, orbital support was achieved with well-vascularized, thin, strong fascia with smooth surface. Right facial artery and vein were chosen as recipient vessel. Duration of the operation was 5.5 hours. Postoperative period was uneventful. Six months after the surgery, the right eye was in good position without inferior dystopia. Eyeball movement could be done without restriction. The patient also denied diplopia. Reconstruction of globe-sparing total maxillectomy defects with free RAM flap with anterior rectus sheath has several advantages that enable the reconstructive surgeon to solve the multiple complex reconstructive task with one flap: 1) elimination of the secondary donor site morbidity; 2) more simply addressing the challenging task of the eye support than the other techniques; 3) obliterating the maxillectomy defect and closing the palate; 4) restoring the large skin defect; and 5) reducing the operation time. It is difficult to conclude that this technique is the best choice in such cases based on a report of the single case. However, presented technique should be kept in mind as a practical and effective reconstructive option in cases that have underwent the total maxillectomy with the preservation of the orbit.

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.

Role of Free-Tissue Transfer in the Treatment of Recalcitrant Palatal Fistulae among Patients with Cleft Palates

Recurrent palatal fistulae present a particularly vexing problem for patients with cleft lips and palates and their surgeons. When primary closure fails, conventional wisdom and the standard of care suggest local flap techniques for defect closure. For the large majority of patients, this approach is successful. There is, however, a small subset of patients who undergo multiple surgical procedures in unsuccessful attempts to close recalcitrant fistulae, particularly at the anterior, densely scarred, hard palate. In this setting, repair calls for the introduction of well-vascularized pliable tissue to close the defect and to avoid hampering further palatal growth. Local muscle flaps and oral axial pattern flaps have been advocated and used successfully. However, those approaches have their own drawbacks, such as multiple surgical interventions, patient compliance, and intraoral scarring. In an effort to avoid the problems associated with local flaps, distant microvascular tissue transfers were investigated. During a 6-year period, six free-tissue transfers were performed as a primary means of treating recalcitrant palatal fistulae. Three dorsalis pedis flaps and three osseous angular scapular flaps were used. The conditions of all patients improved, with five patients achieving complete long-term closure of the palatal defect. This experience indicates that modern microvascular techniques have reached a level of success commensurate with that of other flap techniques; therefore, it is concluded that free-tissue transfer should be considered as a primary means of addressing these difficult cleft problems.

Use of radial forearm free flap with palmaris longus tendon in reconstruction of total maxillectomy with sparing of orbital contents

Nasal paragangliomas are extremely rare. The most adequate treatment is total excision. After surgical excision requiring total maxillectomy, there has been no ideal technique for reconstruction. A 47-year-old man was admitted to our clinic because of recurrent epistaxis, which lasted for 2 months. He was also suffering from nasal airway obstruction. The physical examination revealed a mass originating from the medial aspect of the middle turbinate of the right nasal cavity. It invaded the anterior maxillary wall and hard and soft palate. Endoscopic examination showed that the mass pushed the nasal septum to the left side and protruded into the nasopharynx. The mass was fleshy and had a rich capillary network. Conventional paranasal sinus radiographs were normal. Computerized tomography of the skull showed the mass protruding into the nasopharynx. A total maxillectomy was performed. Histopathological evaluation showed neoplastic tissue consisting of round, oval, or slightly elongated cells, altogether of a rather monomorphous appearance, tending to arrange themselves in clusters adjacent to or around capillary blood vessels. The blood vessels were numerous and branched. Reticulum staining showed a typical Zellballen arrangement of the neoplastic cells to provide a firmer basis for the diagnosis of paraganglioma. To reconstruct the total maxillectomy defect, a radial forearm free flap with the palmaris longus tendon was elevated to inlay the nasal cavity and the oral cavity and to suspend the ocular globe. The flap was placed into the defect, and the palmaris longus tendon was medially and laterally anchored to the periosteum of the frontal bone to suspend the ocular globe in the orbital cavity. One part of the skin island was used to close the defect of the nasal mucosal cavity, and the other part was used to repair the oral mucosal defect of the palate. Consequently, speech was considered near normal; the patient was able to eat an unrestricted diet and to retain both solid and liquid food inside the oral cavity without drooling, and there was no diplopia or enophthalmos. Six months later, porous polyethylene was inserted and fixed to the zygomatic bone with a miniplate and miniscrews to restore malar contour. No further procedure was believed to be necessary later on. Two years later, a satisfactory and functional esthetic result was obtained, providing an acceptable suspension of the ocular globe and filling of the total maxillectomy defect. We believe that a total maxillectomy is indicated if it is needed in nasal paragangliomas and that microsurgical repair with the composite radial forearm-palmaris longus free flap has several advantages: 1) it can offer en bloc reconstruction of the entire defect after a total maxillectomy in terms of good function and cosmesis; 2) it can repair mucosal defects; and 3) it can anchor and suspend the ocular globe in its original anatomical location, protecting against gravity through the sling effect of the palmaris longus tendon. The composite radial forearm-palmaris longus free flap has not been described previously for suspension of the ocular globe.