Temporalis Muscle Flap in Head and Neck Reconstructions Is That Forgotten or Forbidden? Our Case Series and Review of Literature

Abstract

Temporalis muscle flap is a versatile flap which can be used for reconstruction after major head and neck resections, owing to its optimal bulk, constant and reliable vascularity, ease of access to recipient site, minimal donor site morbidity and relatively better cosmetic outcome compared to more bulky flaps like pectoralis major myocutaneous flap or deltopectoral flap. The flap can be used as a muscle flap, myofascial flap (muscle with temporalis fascia). We present our series of 12 cases of temporalis muscle flap reconstruction for various head and neck reconstructions. The aim of this study was to analyse the application of temporalis muscle flap in head and neck reconstructions and its outcome.

Full text

1 23
Indian Journal of Surgical Oncology
ISSN 0975-7651
Indian J Surg Oncol
DOI 10.1007/s13193-017-0656-z
Temporalis Muscle Flap in Head and
Neck Reconstructions Is That Forgotten or
Forbidden? Our Case Series and Review of
Literature
Subbiah Shanmugam, Gopu
Govindasamy, Syed Afroze Hussain &
Satishkumar Maheswaran

1 23
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ORIGINAL ARTICLE
Temporalis Muscle Flap in Head and Neck Reconstructions
Is That Forgotten or Forbidden? Our Case Series
and Review of Literature
Subbiah Shanmugam
1
&Gopu Govindasamy
1
&Syed Afroze Hussain
1
&
Satishkumar Maheswaran
1
Received: 3 February 2017 /Accepted: 12 April 2017
#Indian Association of Surgical Oncology 2017
Abstract Temporalis muscle flap is a versatile flap which can
be used for reconstruction after major head and neck resec-
tions, owing to its optimal bulk, constant and reliable vascu-
larity, ease of access to recipient site, minimal donor site mor-
bidity and relatively better cosmetic outcome compared to
more bulky flaps like pectoralis major myocutaneous flap or
deltopectoral flap. The flap can be used as a muscle flap,
myofascial flap (muscle with temporalis fascia). We present
our series of 12 cases of temporalis muscle flap reconstruction
for various head and neck reconstructions. The aim of this
study was to analyse the application of temporalis muscle flap
in head and neck reconstructions and its outcome.
Keywords Temporalis muscle .Maxillectomy .Craniofacial
resection .Deep temporal artery .Orbital exenteration
Introduction
Temporalis muscle flap is an excellent regional flap for head
and reconstruction, which is hardly described in literature and
rarely practised in oncological resections. Whether this flap is
forgotten or forbidden—is an unanswered question. While use
of this flap for orbital reconstruction and facial reanimation is
familiar to most reconstructive surgeons, less attention has
been paid to this highly versatile flap in oncological recon-
structions. The muscle has a reliable vascularity, and is clas-
sified under Mathes—Nahai type III, with two dominant vas-
cular pedicles—the deep and superficial temporal artery (mid-
dle temporal branch) [1]. The flap can be used as a muscle
flap, myofascial flap or rarely as composite flap with under-
lying bone following skull base and craniofacial resection
where use of microvascular flap is not feasible owing to tech-
nical and cost constraints. The recipient and donor site mor-
bidity associated with the flap are acceptable.
History of the Temporalis Flap
The temporalis muscle flap was first described by Lentz in
1895 who used it after resection of the condylar neck for
temporomandibular joint ankylosis [2]. Golovine used the flap
to repair an orbital exenteration defect. Gilles used the
temporalis muscle flap for an external cheek defect in 1920
[3]. Subsequently, this flap has been described for the recon-
struction of defects of the orbital region, the mastoid, maxilla,
cranial base and oral cavity. In the oral cavity, the temporalis
has been used specifically for reconstructing the palate,
retromolar trigone defects [4]. Following these, many cadav-
eric dissection studies have been reported, studying the vas-
cular pattern of this flap.
Aims and Objectives
To evaluate the various malignancies for which, after onco-
logical resections, the temporalis flap was used for reconstruc-
tion of post excisional defects, in our centre for oncology is the
aim of this study.
*Subbiah Shanmugam
subbiahshanmugam67@gmail.com
1
Surgical Oncology, Centre For Oncology, Government Royapettah
Hospital, Chennai, Tamilnadu 600014, India
Indian J Surg Oncol
DOI 10.1007/s13193-017-0656-z
Author's personal copy

Materials and Methods
The data from our master case sheets, operation records and
cancer data book for the past 12 years (2005–2016) were
studied and analysed in detail, to collect data on cases for
which temporalis muscle flap was used for reconstruction of
defects following resections of various head and neck malig-
nancies. The following data was collected: the location of the
tumour, the type of oncological resection that was performed,
the area of the defect post resection, donor site morbidity after
temporalis flap was harvested, the local flap survival and long-
term outcome.
Operative Procedure
The patient is placed in supine position with head turned to the
opposite side. The incision is made along the superior tempo-
ral line, extending below in front of the tragus (preauricular
region). The preauricular incision must be kept close to the
tragus (with in 1 cm) to avoid injury to the facial nerve trunk.
The scalp flap is raised beyond the temporalis muscle bound-
aries [5]. The glistening temporalis fascia is identified, and
care is taken to preserve the superficial temporal vessels.
The temporalis fascia is incised and dissection is carried out
in sub periosteal plane. The dissection is carried down to ex-
pose the zygomatic arch, where care is taken to identify and
preserve the facial nerve. The temporalis muscle is identified,
and dissection is carried out in sub periosteal plane preserving
the deep temporal arteries (anterior and posterior branches)
[6]. The muscle is divided at its origin and is rotated under
zygomatic arch after its osteotomy and is brought down and
sutured to the defect. The donor area is then closed primarily
with a drain.
Review of Our Case Series
We have performed 12 cases of temporalis muscle flap so far.
Our series included seven cases of maxillary tumours, of
which, one is rhabdomyosarcoma of maxilla, one is muco
epidermoid carcinoma, five cases are squamous cell carcino-
mas (one recurrent case), three cases of squamous cell carci-
noma of upper alveolus, one case of recurrent squamous cell
carcinoma of right ear, one case of basal cell carcinoma left
temporozygomatic area with orbital involvement. The appli-
cations of this flap in our series were mainly to cover the
defects following maxillectomy and alveolar resection. In
two cases—total and extended maxillectomy, the muscle
was used to cover mainly the orbital floor to prevent sagging
of the eye ball. In one case of craniofacial resection, the
temporalis muscle was used to cover the post resection-
orbital defect by fashioning the muscle as a sling to support
the orbital contents and was also used to cover bony defect
which was reinforced with T plate and screws. Following
lateral temporal bone resection in our series, the temporalis
muscle was used to cover the defect of mastoid and auditory
canal. Following orbital exenteration in one of our case series
for basal cell carcinoma involving the orbit, the muscle was
used to cover the orbital defect. All our patients, underwent
routine osteotomy of the zygomatic bone to facilitate bringing
the flap without undue tension there by achieving adequate
length without vascular compromise.
Among the 12 cases of temporalis muscle flap recon-
structions performed, seven cases are maxillary tumours,
of which, one is rhabdomyosarcoma of maxilla, one is
muco epidermoid carcinoma, five cases are squamous cell
carcinomas (one recurrent case), three cases of squamous
cell carcinoma of upper alveolus, one case of recurrent
squamous cell carcinoma of right ear treated with lateral
bone resection, one case of basal cell carcinoma left
temporozygomatic region involving the left eye.
Resections included subtotal maxillectomy (four cases),
total maxillectomy (one case), extended maxillectomy
(one case), craniofacial resection (one case), palatoalveolar
resections in three cases, lateral temporal bone resection in
one case, wide excision and left orbital exenteration (one
case). Our flap survival rate was 100%. Morbidity in the
form of temporal hollowing was present in nine cases
(75%), mouth opening difficulty in five patients (41.6%),
temporomandibular neuralgia in two patients (16.6%), fa-
cial nerve neuropraxia in three cases (25%), facial nerve
palsy involving the zygomaticotemporal branch, following
craniofacial resection, one patient (8.3%) and donor site
minor wound infection in four patients (33.3%) which
was managed conservatively.
Indian J Surg Oncol
Author's personal copy

Discussion
The aim of presenting this series on temporalis flap is to bring
out the utility and application of this versatile flap, which can
be safely and conveniently used in head and neck reconstruc-
tions after major oncological resections. A detailed review of
literature, for this, yielded only few case reports and case
series that are published so far. Hanasano et al. in their land
mark paper published in Laryngoscope, 2001 [7,8] has retro-
spectively analysed 13 cases of temporalis muscle flap for
reconstruction of palate, retromolar trigone defects, and they
have concluded that temporalis muscle flap has better aesthet-
ic outcome and is a reliable flap post oncological resections of
the head and neck. However, this study has not made much
detailed analysis of morbidity, complications and outcome.
The temporalis muscle is a fan shaped muscle which orig-
inates from the temporal fossa and the temporal lines and gets
inserted into the coronoid process of the mandible. It is clas-
sified under Mathes and Nahai type III, based on two domi-
nant vascular pedicles from deep temporal artery (a branch
from internal maxillary artery)—anterior and posterior
branches and the middle temporal artery (branch from super-
ficial temporal artery) [1]. The deep temporal vessels supply
around 60% of the muscle, and remaining 40% is supplied by
middle temporal artery, which can be sacrificed during flap
harvesting without compromising the muscle viability [1,9].
Tabl e 1 Case description
S.
no
Malignancy (case) No of
cases
performed
Procedure done Defect for which
TM was used
Average defect size Flap survival/morbidity
1 Squamous cell
carcinoma of
maxilla
4 Maxillectomy Palate, alveolus 7.54 cm (average of 5) Temporal hollowing—3, mouth
opening difficulty—2, facial
neuropraxia—1
2 Rhabdomyosarcoma
of maxilla
1 Total
maxillectomy
Orbital defect 5 cm Temporal hollowing, minor
wound infection
3 Mucoepidermoid
carcinoma of
maxilla
1 Total
maxillectomy
Orbital floor to
support eye ball
5.6 cm Temporal hollowing, facial nerve
neuropraxia, wound infection,
mouth opening difficulty
4 Squamous cell
carcinoma of
upper alveolus
3Partial
maxillectomy
Palatal defect 8.4 cm (average of 3) Temporal hollowing—1, wound
infection—1, mouth opening,
articulation difficulty—1
5 Recurrent squamous
cell carcinoma
right ear
1 Lateral
temporal
bone
resection
Defect over
mastoid and
auditory canal
12.96 cm Temporal hollowing,
temporomandibular neuralgia,
facial nerve neuropraxia
(recovered in 3 months),
minor wound infection
6 Basal cell carcinoma
left
temporozygomatic
region extending
to left orbit
1 Wide excision
with left
orbital
exenteration
Temporalis
muscle used to
fill orbital
contents, and
cover bone
defect.
10.2 cm Temporal hollowing, mouth
opening difficulty, TMJ
neuralgia
7 Recurrent carcinoma
maxilla
1 Craniofacial
resection
(middle
cranial)
Temporalis
muscle
fashioned as
sling to support
orbital contents
The muscle was used as sling to
support the orbital contents with
bony defect reconstructed with T
plate and screws reinforced with
the muscle
Facial nerve weakness involving
the zygomaticotemporal
branch, minor wound
infection, temporal hollowing
Tabl e 2 Showing details of temporalis muscle flap reconstruction in
this study
Total no of patients who underwent temporalis flap reconstruction
(2005–2016)—12
Mean age (in years)—40.2 (range 29–68)
Average size of defect—8.78 cm (range 5.43–12.96 cm)
Flap survival rate—100%
Tabl e 3 Showing complications, morbidity
Temporal hollowing—9 (75%)
Mouth opening and articulation difficulties—5(41.6%)
Temporomandibular neuralgia—2 (16.6%)
Minor wound infections—4(33.3%)
Facial nerve neuropraxia—(25%)—average time to recovery 3.4 months
Facial nerve palsy (zygomaticotemporal branch) following craniofacial
resection—1 (8.3%)
Indian J Surg Oncol
Author's personal copy

The muscle is covered by temporal fascia which has superfi-
cial and deep layers, and the muscle lies deep to deep temporal
fascia.
Temporalis muscle flap is a versatile flap, which can be
used in reconstructions following maxillectomy [6], palate
alveolar resections [5] and craniofacial resections. The
major advantage of this flap is that it is less bulky, has
reliable vascularity, with minimal donor site morbidity
[9]. Although microvascular flap has become the order
of the day, temporalis muscle flap is an excellent alterna-
tive, in major head and neck resections where expertise
and technical feasibility to microvascular flaps are not
readily available. It has definite advantage over pectoralis
major myocutaneous flap or deltopectoral flap which is
more bulky and carries significant donor site morbidity
as well as recipient site complications. Another advantage
of this muscle is that, it has a tough facia which can be
used as myofascial flap and as composite flap with the
underlying temporal bone following major craniofacial
resections. We have used the temporalis muscle flap for
various reconstructions like alveolus, palate [10], orbital
floor, defect of mastoid and auditory canal and following
craniofacial resection as myofascial flap. An important
application of temporalis flap is in orbital reconstruction
and filling of orbital cavity following orbital exenteration
and resections involving the floor of orbit. We have used,
the temporalis muscle to fill the orbital floor defect in a
case of rhabdomyosarcoma of maxilla, another case of
total maxillectomy where the muscle was used to recon-
struct the orbital floor. In yet, another case (Table 1), we
have used the temporalis muscle which was fashioned as a
sling to support the orbital contents following craniofacial
resection. This technique is a simple, effective and reli-
able method of supporting the orbital contents and pre-
vents it from sagging, where micro vascular flap or pros-
thesis was not feasible due to huge soft tissue defects and
techn ical issues (Table 2).
Yavuz et al., in their retrospective analysis on use of
temporalis muscle flap for orbital reconstruction following
oncological resections, have reported acceptable cosmetic
and functional outcome with use of temporalis muscle to fill
the orbital defects. They have also mentioned that use of this
muscle did not make any difficulty with monitoring for
recurrences.
All the three cases in our series had acceptable cosmesis
and functional outcome in terms of preventing the orbital con-
tents from sagging, diplopia and also in terms of cavity oblit-
eration providing soft tissue cover.
The complications (Table 3) are acceptable. Nearly
75% had temporal hollowing, which was hidden in hair-
line. Mouth opening and articulation difficulty was seen
in 41.6%, which was managed with physiotherapy and
mouth opening exercises and dental advice. Facial nerve
neuropraxia was seen in three patients (25%), as a conse-
quence of resection rather than the result of flap harvest.
All cases recovered in average time of 3.4 months. There
was one case of facial nerve injury involving the
zygomaticotemporal branch, following middle craniofa-
cial resection. Our flap survival was 100%. Djae, Li
et al., in their retrospective study on complications fol-
lowing temporalis muscle flap, in 39 cases, reported ac-
ceptable complications, 100% flap survival. They have
reported, complications such as oroantral fistula (14.2%),
flap hematoma (11.6%) which were not seen in our series.
We have tried to elucidate all the possible complications
and outcome in this study which are not reported in detail
in other studies in literature. Our cosmetic outcome was in
par with other reported studies which are reported till
date, with acceptable morbidities.
The contraindications to use of this flap are previous sur-
geries in scalp, trauma to scalp or previous radiation to the
scalp area which jeopardizes the vascularity, gross temporal
wasting.
Our aim of presenting this case series is that, temporalis
muscle flap in oncological reconstructions is not widely re-
ported, in currently available literature. It is a versatile flap
which remains forgotten and underutilized in the armamentar-
ium of an oncosurgeon. It is an excellent alternate option to
free flap, as it readily available, easy to perform with very
minimal morbidity.
Conclusion
Temporalis muscle flap is an excellent alternative to microvas-
cular flap following various complex head and neck resections
like post maxillectomy, orbital reconstructions. The flap is less
bulky, provides adequate cover, has a reliable vascularity and
easy to harvest with minimal donor site morbidity.
References
1. Cheung LK (1996) The vascular anatomy of the human temporalis
muscle: implications of surgical splitting techniques. Int J Oral
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2. Speculand B (1992) The origin of the temporalis muscle flap. Br J
Oral Maxillofac Surg 30:390–392
3. Gilles HD (1920) In: Frowde H (ed) Plastic surgery of the face.
Oxford University Press, London, p 54–55
4. Visscher JGAM, van der Wal KGH (1997) Temporalis muscle flap
revisited on its centennial: advantages, newer uses, and disadvan-
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5. Abubaker AO, Abouzgia MB (2002) The temporalis muscle flap in
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6. Ward BB (2007) Temporalis system in maxillary reconstruction:
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