Three-dimensional Analysis of the Muscles Related to the So-Called "Pterygomandibular Raphe": An Anatomical and Histological Study.

The pterygomandibular raphe (PMR) is a tendinous bundle between the bucinator (BM) and the superior constrictor of pharynx (SC) and has been considered essential for swallowing. Despite its functional significance, previous studies reported that the PMR is not always present. Another study reported presence of the connecting fascia between the BM and deep temporalis tendon (dTT). Therefore, the present study analyzed the three-dimensional relationship between the BM, SC, and dTT. We examined 13 halves of 11 heads from adult Japanese and Caucasian cadavers: eight halves macroscopically and five halves histologically. There was no clear border between the BM and SC in any specimens macroscopically. The BM attachment varied depending on its levels. At the level of the superior part of the internal oblique line, the BM fused with the SC with no clear border. At the level of the midpart of the internal oblique line of the mandible, the BM attached to the dTT directly, and the SC attached to the dTT via collagen fibers and the BM. Based on these results, these muscles should be described as the BM/dTT/SC (BTS) complex. The three-dimensional relationship of the BTS complex might result in the so-called "pterygomandibular raphe." The BTS complex could be important as a muscle coordination center in chewing and swallowing.

Anatomical consideration of ultrasonography-guided intraoral injection for temporal tendinitis.

Temporal tendinitis is characterized by acute inflammation often resulting from mechanical stress, such as repetitive jaw movements associated with jaw opening and closing and teeth clenching. Treatment for temporal tendinitis typically involves the administration of local anesthetic or corticosteroid injections. However, the complex anatomical structure of the coronoid process, to which the temporalis tendon attaches, located deep within the zygomatic arch, poses challenges for accurate injections. In this study, we aimed to establish guidelines for the safe and effective treatment of temporal tendinitis by using intraoral ultrasonography (US) to identify the anatomical structures surrounding the temporalis tendon and coronoid process. US was performed using an intraoral transducer on 58 volunteers without temporomandibular joint disease. The procedure involved placing the transducer below the occlusal plane of the maxillary second molar. Measurements were taken for the horizontal distance from the anterior border of the coronoid process, observed at the midpoint (MP) of the US images, and the depth of the coronoid process and temporalis muscle from the oral mucosa. The anterior border of the coronoid process was visualized on all US images and classified into three observed patterns at the MP: type A (anterior to the MP, 56.2%), type B (at the MP, 16.1%), and type C (posterior to the MP, 27.7%). The temporalis muscle was located at a mean depth of 3.12 ± 0.68 mm from the oral mucosa. The maxillary second molar is an intraoral landmark for visualizing the anterior border of the coronoid process. The new location information obtained using intraoral US could help identify the safest and most effective injection sites for the treatment of temporal tendinitis.

Minimally invasive temporalis tendon transposition and upper lid lipofilling for immediate and secondary facial reanimation in patients treated for malignant tumors of the parotid gland.

Treatment for facial nerve-invading parotid malignancies usually results in complete facial palsy. The authors present a novel technique to treat facial palsy following radical parotid surgery and retrospectively evaluate results in terms of soft tissue symmetry at rest and during smiling and eyelid closure using the eFACE system. 9 patients with facial palsy following parotid malignancies resection or undergoing parotidectomy with planned facial nerve resection for tumor invasion were treated with the association of mini-invasive temporalis flap rotation and upper lid lipofilling to restore symmetry of the middle facial third at rest and during smiling and eyelid closure. The technique was employed during the same surgical session as the tumor removal or for secondary facial reanimation. Systematic eFACE evaluation demonstrated significant improvement in static nasolabial fold depth orientation and oral commissure position, palpebral fissure narrowing during eye closure, and oral commissure movement and nasolabial fold depth and orientation with smile (p respectively .008, .011, 0.008, 0.035, 0.011, 0.008, and 0.011, Wilcoxon's test). Furthermore, all patients described subjective improvement of corneal discomfort. The presented technique appears promising in treating facial palsy in oncological patients, representing a potential alternative to other more complex reconstructive techniques.

Smile Outcomes of an Externally Scarless, Intraoral Orthodromic Temporalis Tendon Transfer.

Background: Temporalis tendon transfer (TTT) often relies on external incisions in the nasolabial fold, temporal region, or both. Herein, we studied smile outcomes of a TTT technique via a single intraoral incision without external skin incisions. Objective: To measure the difference in static perioral positions before and after intraoral TTT. Methods: Five patients underwent an externally scarless TTT technique via an intraoral approach. Iris measurements were used to estimate pixel-to-millimeter conversion for facial analysis of vertical and horizontal oral commissure excursion vectors using the JAVA-based program Facegram version 1.0 (Massachusetts Eye & Ear Infirmary). Results: After surgery, mean vertical height on the affected side significantly increased from 3.4 mm to a postoperative value of 20.6 mm, p = 0.016. There was no difference in horizontal smile excursion after surgery (35.7 mm vs. 32.2 mm, p = 0.37). Smile angle difference between affected and healthy smile (Δα) reduced from 27.0° preoperative to 3.5°, representing a decrease in facial asymmetry (p = 0.002). Conclusion: Intraoral, externally scarless TTT is an effective option for dynamic facial reanimation, obviating external incisions in select patients.

Morphology of the temporalis muscle focusing on the tendinous attachment onto the coronoid process.

The temporalis muscle is usually described as a single layer originating at the temporal line, converging to a tendon, and inserting onto a narrow site of the coronoid process. However, recent studies have shown that the temporalis muscle can be divided into two or three separate segments and the distal attachment continues inferiorly beyond the coronoid process. Therefore, the aims of this study were to analyze the morphology of the temporalis muscle focusing on the tendinous attachment onto the coronoid process and to provide educational values. The temporalis muscle was carefully dissected in 26 cadavers and classified based on the muscle fascicle direction. Each divided part was sketched and measured based on bony landmarks to elucidate its tendinous insertion site onto the coronoid process, and the results obtained were reviewed through the literature. The temporalis muscle ends at two distinct terminal tendons with wider insertion sites than usually presented in textbooks and atlases and separates into two parts that combine to act as a single structural unit. The superficial part is a large fan-shaped muscle commonly recognized as the temporalis muscle. This converges infero-medially to form the superficial tendon and the lateral boundary of the retromolar triangle. Meanwhile, the deep part is a narrow vertically oriented rectangular muscle that converges postero-laterally to form the deep tendon and the medial boundary of the retromolar triangle. These results indicate that understanding the temporalis muscle's insertion site onto the coronoid process will be useful clinically with educational values during surgical procedures.

Temporalis Tendon Transfer Versus Gracilis Free Muscle Transfer: When and Why?

Temporalis tendon transfer (T3) and gracilis free muscle transfer (GFMT) are popular techniques in lower facial rehabilitation when reinnervation techniques are unavailable. T3 involves a single-stage outpatient procedure resulting in immediate improvement in resting symmetry and a volitional smile. GFMT allows a spontaneous smile, customized vectors, and increased excursion but requires longer surgical time, a delay before movement, and specialized equipment. Ultimately, shared decision making between the clinician and patient should focus on the patient's goals and unique medical condition.

Facial nerve management in patients with malignant skull base tumors.

INTRODUCTION: The course of the facial nerve through the cerebellopontine angle, temporal bone, and parotid gland puts the nerve at risk in cases of malignancy. In contrast to Bell's palsy, which presents with acute facial paralysis, malignancies cause gradual or fluctuating weakness. METHODS: We review malignancies affecting the facial nerve, including those involving the temporal bone, parotid gland, and cerebellopontine angle, in addition to metastatic disease. Intraoperative management of the facial nerve and long term management of facial palsy are reviewed. RESULTS: Intraoperative management of the facial nerve in cases of skull base malignancy may involve extensive exposure, mobilization, or rerouting of the nerve. In cases of nerve sacrifice, primary neurorrhaphy or interposition grafting may be used. Cranial nerve substitution, gracilis free functional muscle transfer, and orthodromic temporalis tendon transfer are management options for long term facial paralysis. CONCLUSION: Temporal bone, parotid gland, and cerebellopontine angle malignancies pose a tremendous risk to the facial nerve. When possible, the facial nerve is preserved. If the facial nerve is sacrificed, static and dynamic reanimation strategies are used to enhance facial function.

Management of the paralyzed face using temporalis tendon transfer via intraoral and transcutaneous approach: Temporalis tendon transfer.

Temporalis tendon transfer is a technique for dynamic facial reanimation. Since its inception, nearly 80 years ago, it has undergone a wealth of innovation to produce the modern operation. Temporalis tendon transfer is a relatively minimally invasive technique for the dynamic reanimation of the paralyzed face. This technique can produce significant and appropriate movement of the lateral oral commissure, more closely mimicking the normal side. The aim of this article is to review the technique of temporalis tendon transfer involving transferring of the coronoid process of the mandible with the insertion of the temporalis tendon via intra-oral and transcutaneous approach.

Management of Long-Standing Flaccid Facial Palsy: Midface/Smile: Locoregional Muscle Transfer.

Masseter and temporalis muscle transfer is an effective technique for restoring facial symmetry and commissure excursion in flaccid facial paralysis. Adherence to the principles and biomechanics of muscle transfer is essential for achieving optimal results. Muscle transfer has the advantage of being single staged with fast recovery of function. It is particularly useful in patients with low life expectancy or multiple comorbidities where a more complex, multiple stage procedure may be detrimental.

Facial Paralysis Discussion and Debate.

This article examines 6 questions about facial paralysis answered by 3 experts in their field of facial plastic surgery. The topics covered include routine assessment, neuromuscular training, nonsurgical management, and the future of this field. All the authors answered these questions in a "How I do it" manner to provide the reader with a true understanding of their thoughts and techniques. This article provides a practical resource to all physicians and practitioners treating patients with facial paralysis on some of the most common questions and issues.

Ultrasound-Guided Injection of the Temporalis Tendon: A Novel Technique.

A novel technique, ultrasound-guided injection of the temporalis tendon in adults, is described. Ultrasound-guided injection of the temporalis tendon is based on visualization of the temporalis muscle, temporalis tendon, and coronoid process. A practical step-by-step guide to doing the procedure is given. This technique is effective and reproducible. Two patients successfully treated with this technique will be briefly discussed. The anatomic location and size of the temporalis tendon make it mandatory to use ultrasound to ensure precision.

Microvascular Reconstruction of the Parotidectomy Defect.

Parotidectomy is a commonly performed procedure for both benign and malignant lesions. When a significant portion of the gland is resected and the lost tissue volume is not replaced, a disfiguring contour defect can result. This defect can be disfiguring and have a profound impact on quality of life. Large defects are best replaced with vascularized tissue to provide stable volume.

Temporalis Muscle Tendon Unit Transfer for Smile Restoration After Facial Paralysis.

Temporalis muscle tendon unit (MTU) transfer may be used as a single-stage procedure for dynamic reanimation of the paralyzed face. Principles and biomechanics of muscle function and tendon transposition are essential in optimizing outcome. Critical steps and pearls for success include minimizing scarring, maintaining glide plains, mobilizing adequate tendon length, insertion of MTU at ideal tension based on intraoperative dynamic tension-excursion relationship, and insertion of tendon as close to the lip margin as possible. Because muscles adapt to tension, load, and task changes by altering their sarcomere arrangement and muscle fiber composition, physiotherapy should be initiated to use the repurposed temporalis MTU for smile restoration.

Facial nerve trauma: evaluation and considerations in management.

The management of facial paralysis continues to evolve. Understanding the facial nerve anatomy and the different methods of evaluating the degree of facial nerve injury are crucial for successful management. When the facial nerve is transected, direct coaptation leads to the best outcome, followed by interpositional nerve grafting. In cases where motor end plates are still intact but a primary repair or graft is not feasible, a nerve transfer should be employed. When complete muscle atrophy has occurred, regional muscle transfer or free flap reconstruction is an option. When dynamic reanimation cannot be undertaken, static procedures offer some benefit. Adjunctive tools such as botulinum toxin injection and biofeedback can be helpful. Several new treatment modalities lie on the horizon which hold potential to alter the current treatment algorithm.