Temporalis muscle vasculature directly derived of the middle meningeal artery: a case report and review.

Pedicled temporalis muscular flap is a common procedure nowadays in reconstructive head and neck surgery, especially for oral or orbital cavity defects. We present a case of temporalis muscle and skull base dissection of a seventy-year-old fresh female cadaver with single temporal muscle vessels directly derived of the middle meningeal artery throughout the calvaria, therefore jeopardizing the harvest of the flap, which has never been described to our knowledge. Such a variation must be known of the reconstructive surgeon to plan the ideal reconstruction procedure.

Critical role of platelet-derived growth factor-α in angiogenesis after indirect bypass in a murine moyamoya disease model.

OBJECTIVE: This study aimed to clarify the underlying mechanism of pathognomonic angiogenesis between the temporal muscle and neocortex after indirect bypass for moyamoya disease by shedding light on the role of platelet-derived growth factor receptor-α (PDGFRα) in angiogenesis. METHODS: The gene for PDGFRα was systemically inactivated in adult mice (α-KO mice). The Pdgfra-preserving mice (Flox mice) and α-KO mice were exposed to bilateral common carotid artery stenosis (BCAS) by using microcoils. One week later the animals underwent encephalomyosynangiosis (EMS) on the right side. Cerebral blood flow (CBF) was serially measured using a laser Doppler flowmeter. Histological analysis was performed on the distribution of CD31-positive vessels and collagen deposit at 28 days after BCAS. Reverse transcription polymerase chain reaction (RT-PCR) was performed to assess the expression of collagen mRNA in the skin fibroblasts derived from Flox and α-KO mice. RESULTS: BCAS significantly reduced CBF up to approximately 70% of the control level at 28 days after the onset. There was no significant difference in CBF between Flox and α-KO mice. EMS significantly enhanced the improvement of CBF on the ipsilateral side of Flox mice, but not α-KO mice. EMS significantly induced the development of CD31-positive vessels in both the neocortex and temporal muscle on the ipsilateral side of Flox mice, but not α-KO mice. Deposition of collagen was distinctly observed between them in Flox mice, but not α-KO mice. Expression of mRNA of collagen type 1 alpha 1 (Col1a1) and collagen type 3 alpha 1 (Col3a1) was significantly downregulated in the skin fibroblasts from α-KO mice. CONCLUSIONS: This is the first study that denotes the role of a specific growth factor in angiogenesis after EMS for moyamoya disease by inactivating its gene in mice. The findings strongly suggest that PDGFRα signal may play an important role in developing spontaneous angiogenesis between the temporal muscle and neocortex after EMS in moyamoya disease.

High-Mobility Group Box-1-Induced Angiogenesis After Indirect Bypass Surgery in a Chronic Cerebral Hypoperfusion Model.

High-mobility group box-1 (HMGB1) is a nuclear protein that promotes inflammation during the acute phase post-stroke, and enhances angiogenesis during the delayed phase. Here, we evaluated whether indirect revascularization surgery with HMGB1 accelerates brain angiogenesis in a chronic cerebral hypoperfusion model. Seven days after hypoperfusion induction, encephalo-myo-synangiosis (EMS) was performed with or without HMGB1 treatment into the temporal muscle. We detected significant increments in cortical vasculature (p < 0.01), vascular endothelial growth factor (VEGF) expression in the temporal muscle (p < 0.05), and ratio of radiation intensity on the operated side compared with the non-operated side after EMS in the HMGB1-treated group than in the control group (p < 0.01). Altogether, HMGB1 with EMS in a chronic hypoperfusion model promoted brain angiogenesis in a VEGF-dependent manner, resulting in cerebral blood flow improvement. This treatment may be an effective therapy for patients with moyamoya disease.

Arteriovenous Malformations of the Temporalis Muscle: A Comprehensive Review.

Arteriovenous malformations of the temporalis muscle (TM-AVMs) are rare lesions commonly considered as a variant of scalp AVMs. A study was designed in order to analyze TM-AVMs features and to confirm them as a certain entity different from scalp AVMs. Seven TM-AVMs cases (5 from literature plus 2 from our database) were studied. Clinical, epidemiological, radiological, and therapeutic data were analyzed and compared to common scalp AVMs features. All TM-AVMs presented as large soft tumor-like masses on the temporal region (mean diameter: 6 cm). Pain was referred in half of cases, while overlying cutaneous stigmas were described only once. No masticatory malfunction was reported. TM-AVMs tend to appear in young patients (mean: 29 yr), commonly as longstanding and slow-evolving lesions (mean evolution time before diagnosis: 5 yr). All cases displayed a diffuse slow-flow blush on angiogram. All TM-AVMs were completely located within the TM, with no involvement of scalp or bone. The pathological analysis of all cases demonstrated the presence of striate muscular bundles intermingled with fairly mature arterial and venous vessels. No clearly distorted vessel was found within the TM-AVMs. Surgery was performed for all cases with complete removal. Preoperative embolization was done in 4 cases to reduce blood loss during surgery. No clinical/radiological recurrence was reported. Opposite to TM-AVMs, scalp AVMs commonly present as high-flow lesions with no evident tumor mass, mainly located in the subcutaneous tissue. TM-AVMs present clearly distinct features compared to scalp AVMs, for which they should be considered as a certain pathological entity and not as a variant of scalp AVMs.

Chimeric Reverse Temporal Muscle and Pericranial Flap for Double-Layer Closure of Deep Facial Defects.

PURPOSE: Volumetric or multiplane defects of the upper and midface remain a challenge for reconstruction because of limited regional flap options. In this study, the authors harvested the reverse temporalis muscle flap and pericranial flap (RTMP flap) based on the same vascular pedicle, the superficial temporal artery, in a chimeric manner to obtain double-layer closure of deep facial defects. MATERIALS AND METHODS: This study was a prospective case series performed in the Department of Plastic Surgery of Ataturk University (Erzurum, Turkey). The outcomes, including flap survival, postoperative complications, reconstructive success, esthetic appearance, and donor site morbidity, were clinically evaluated. RESULTS: Fourteen patients (10 male and 4 female) with deep defects of the middle third of the face underwent reconstruction using the chimeric RTMP flap. All chimeric RTMP flaps survived without postoperative complications. All defects were successfully repaired and covered with chimeric RTMP flaps. Patients were satisfied with the esthetic results. CONCLUSION: The chimeric RTMP flap is a good reconstruction option and can be used safely for moderate to large 3-dimensional defects of the middle and upper face. Smooth and durable coverage over the bulky muscle flap used to fill the volume defect and a larger flap for larger volume defects can be obtained by including the pericranial segment of the chimeric RTMP flap.

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 2/3rd 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.

Anatomical recommendations for safe botulinum toxin injection into temporalis muscle: a simplified reproducible approach.

PURPOSE: The objective of this study was to simplify the anatomically safe and reproducible approach for BoNT injection and to generate a detailed topographic map of the important anatomical structures of the temporal region by dividing the temporalis into nine equally sized compartments. METHODS: Nineteen sides of temporalis muscle were used. The topographies of the superficial temporal artery, middle temporal vein, temporalis tendon, and the temporalis muscle were evaluated. Also evaluated was the postural relations among the foregoing anatomical structures in the temporalis muscle, pivoted upon a total of nine compartments. RESULTS: The temporalis above the zygomatic arch exhibited an oblique quadrangular shape with rounded upper right and left corners. The distance between the anterior and posterior margins of the temporalis muscle was equal to the width of the temporalis rectangle, and the distance between the reference line and the superior temporalis margin was equal to its height. The mean ratio of width to height was 5:4. CONCLUSIONS: We recommend compartments Am, Mu, and Pm (coordinates of the rectangular outline) as areas in the temporal region for BoNT injection, because using these sites will avoid large blood vessels and tendons, thus improving the safety and reproducibility of the injection.

Anatomic basis of the middle temporal artery periosteal rotational flap in otologic surgery.

OBJECTIVES/HYPOTHESIS: To describe the elements critical to successful middle temporal artery periosteal rotational flap harvest and utilization based on the anatomic features of the middle temporal artery. STUDY DESIGN: Description of anatomy based on cadaver dissection. METHODS: Seventy temporal fossa dissections were performed on 35 adult human cadavers. RESULTS: Sixty-nine of 70 dissections had an identifiable middle temporal artery muscular branch pedicle in the periosteum deep to the temporalis muscle. Pedicle length was at least 7 cm in 32 of 38 (84%) male cadavers and in 20 of 31 (65%) female cadavers (P = 0.054), whereas the average length required to reach the digastric ridge from the pedicle base to the digastric ridge in a mastoidectomy cavity was 5.2 cm. The pedicle sharply transitions from a posterior to a posterior-superior course 0.93 cm superior (range: 0.5-1.9 cm) and 0.04 cm posterior (range: 1.4 cm posterior-0.7 cm anterior) to the spine of Henle. Branching occurred in 26 of 69 pedicles (38%), and 20 of 31 (65%) branches were oriented posteriorly. If temporalis muscle fibers are not incorporated into the flap, the thickness is roughly three times that of a standard temporalis fascia graft. CONCLUSION: The muscular branch of the middle temporal artery is reliably identified in the periosteum deep to the posterior aspect of the temporalis muscle, and this vessel is sufficiently robust to provide axial blood supply to a rotational periosteal flap that has sufficient thickness and length to allow a variety of applications in otologic surgery. LEVEL OF EVIDENCE: NA. Laryngoscope, 126:1426-1432, 2016.

An Anatomical Study of the Middle Temporal Vein and the Drainage Vascular Networks to Assess the Potential Complications and the Preventive Maneuver During Temporal Augmentation Using Both Anterograde and Retrograde Injections.

BACKGROUND: Non-thrombotic pulmonary embolism has recently been reported as a remote complication of filler injections to correct hollowing in the temporal region. The middle temporal vein (MTV) has been identified as being highly susceptible to accidental injection. METHODS: The anatomy and tributaries of the MTV were investigated in six soft embalmed cadavers. The MTV was cannulated and injected in both anterograde and retrograde directions in ten additional cadavers using saline and black filler, respectively. RESULTS: The course and tributaries of the MTV were described. Regarding the infusion experiment, manual injection of saline was easily infused into the MTV toward the internal jugular vein, resulting in continuous flow of saline drainage. This revealed a direct channel from the MTV to the internal jugular vein. Assessment of a preventive maneuver during filler injections was effectively performed by pressing at the preauricular venous confluent point against the zygomatic process. Sudden retardation of saline flow from the drainage tube situated in the internal jugular vein was observed when the preauricular confluent point was compressed. Injection of black gel filler into the MTV and the tributaries through the cannulated tube directed toward the eye proved difficult. CONCLUSION: The mechanism of venous filler emboli in a clinical setting occurs when the MTV is accidentally cannulated. The filler emboli follow the anterograde venous blood stream to the pulmonary artery causing non-thrombotic pulmonary embolism. Pressing of the pretragal confluent point is strongly recommended during temporal injection to help prevent filler complications, but does not totally eliminate complication occurrence. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Combined flaps based on the superficial temporal vascular system for reconstruction of facial defects.

BACKGROUND: Facial defects are multicomponent deficiencies rather than simple soft-tissue defects. Based on different branches of the superficial temporal vascular system, various tissue components can be obtained to reconstruct facial defects individually. METHODS: From January 2004 to December 2013, 31 patients underwent reconstruction of facial defects with composite flaps based on the superficial temporal vascular system. RESULTS: Twenty cases of nasal defects were repaired with skin and cartilage components, six cases of facial defects were treated with double island flaps of the skin and fascia, three patients underwent eyebrow and lower eyelid reconstruction with hairy and hairless flaps simultaneously, and two patients underwent soft-tissue repair with auricular combined flaps and cranial bone grafts. All flaps survived completely. Donor-site morbidity is minimal, closed primarily. Donor areas healed with acceptable cosmetic results. The final outcome was satisfactory. CONCLUSION: Combined flaps based on the superficial temporal vascular system are a useful and versatile option in facial soft-tissue reconstruction.

The temporalis muscle flap and temporoparietal fascial flap.

The temporal arterial system provides reliable vascular anatomy for the temporalis muscle flap and temporoparietal fascial flap that can support multiple reconstructive needs of the oral and maxillofacial region. The minimal donor site morbidity and ease of development of these flaps result in their predictable and successful transfer for reconstructive surgery of the oral and maxillofacial region.

Clinical implications of the middle temporal vein with regard to temporal fossa augmentation.

BACKGROUND: The middle temporal vein (MTV) traverses the temporal fossa between the superficial and deep layers of the deep temporal fascia. During filler injection into a deficient temporal fossa, filling agents may be inadvertently injected into the MTV, which results in vascular complications. OBJECTIVE: To investigate the course of the MTV to enable safe filler injection in the temple area. MATERIALS AND MATERIALS: The course and diameter of the MTV were measured in 18 hemifaces from 9 Korean cadavers. RESULTS: The MTV was located 23.5 and 18.5 mm above the zygomatic arch at the jugale and the zygion, respectively. The diameter of the MTV at its thickest point was 5.1 mm. A splitting and reuniting pattern, such that the MTV occupied more space than a single trunk, was observed in 28% of cases. CONCLUSION: We propose that the safest area for filler injection in temporal fossa augmentation is one finger width above the zygomatic arch.

Radiological characteristics and management of intramuscular myxoma of the temporal muscle: case report.

The patient was a 51-year-old male with a 3-year history of a slow-growing, asymptomatic, subcutaneous mass in the left temporal region. Magnetic resonance imaging revealed a well-defined extracranial lesion with heterogeneous enhancement and without invasion of the skull. A variety of soft tissue tumors were included in the differential diagnosis. The patient underwent total resection of the tumor, and a diagnosis of intramuscular myxoma was confirmed histologically. There was no evidence of recurrence at 6-month follow-up. The present case is the first characterization of the radiological appearance of intramuscular myxoma in the temporal muscle. I emphasize that increased awareness of this rare lesion and a careful clinical and radiological preoperative assessment are crucial in determining an appropriate treatment strategy for patients with a soft tissue tumor of the head.

Hemimasticatory spasm treated with microvascular decompression of the trigeminal nerve.

Hemimasticatory spasm is a very rare disorder of the trigeminal nerve characterized by paroxysmal involuntary contraction of the jaw-closing muscles. The mechanisms leading to hemimasticatory spasm are still unclear. Recently, injection of botulinum toxin has become the treatment of choice due to its excellent results. We report a case of a successful treatment of hemimasticatory spasm via microvascular decompression of the motor branch of the trigeminal nerve.

Endoscopic reconstruction of the middle cranial fossa through a subtemporal keyhole using a pedicled deep temporal fascial flap: a cadaveric study.

BACKGROUND: Reconstruction of the skull base is essential to prevent postoperative leakage of cerebrospinal fluid (CSF). However, a reliable method of reconstructing the middle cranial fossa via a subtemporal keyhole is not available. OBJECTIVE: To determine whether less invasive reconstruction of the middle cranial fossa under endoscopic guidance with a pedicled deep temporal fascia approach via a subtemporal keyhole is feasible and useful. METHODS: The middle cranial fossa in 4 fresh cadaver heads was reconstructed with a 4-mm 0° rigid endoscope. RESULTS: A subtemporal skin incision (subtemporal incision) was followed by 2 small skin incisions (temporal line incisions) made on the superior temporal line. The endoscope was inserted through the temporal line incisions, and then the deep temporal fascia was separated from the superficial temporal fascia and temporal muscle under endoscopic view. A pedicled flap was harvested from the subtemporal incision and applied to the middle cranial fossa after subtemporal keyhole craniotomy. The pedicled deep temporal fascial flap was flexible, long, and large enough to overlay skull base defects. CONCLUSION: This purely endoscopic technique using a pedicled deep temporal fascial flap provided reliable reconstruction of the middle cranial fossa through a subtemporal keyhole. This technique would also be applicable in preventing CSF leakage or treating traumatic, acquired nontraumatic, or congenital encephalocele in the middle cranial fossa.

Multiple radio-opacities in an OPG: a case report of cavernous haemangioma of temporalis muscle with multiple phleboliths.

Intramuscular haemangiomas of the head and neck region are rare. They may present as an incidental finding, a mass or swelling, pain, tenderness, limitation of movement or cosmetic deformity. Treatment depends on the clinical signs and symptoms. Because of the apparent rarity of this lesion, we report a case of an incidental finding of multiple radio-opacities in a dental panoramic tomograph that was diagnosed as cavernous haemangioma in temporalis muscle with multiple phleboliths.

Novel bypass surgery for moyamoya disease using pericranial flap: its impacts on cerebral hemodynamics and long-term outcome.

OBJECTIVE: We reviewed our 11-year experience with a novel bypass procedure, superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-arterio-pericranio-synangiosis (EDMAPS), for moyamoya disease regarding cerebral hemodynamics and long-term outcome. METHODS: This prospective study included 75 patients with moyamoya disease, including 28 children and 47 adults. We performed STA-MCA anastomosis and EDMAPS on 123 hemispheres of 75 patients. In addition to conventional STA-MCA anastomosis and indirect bypass for the MCA territory, the medial frontal lobe was revascularized using the frontal pericranial flap through medial frontal craniotomy. Surgical results were analyzed with magnetic resonance imaging, cerebral angiography, and single-photon emission computed tomography/positron emission tomography. RESULTS: Overall incidences of mortality and morbidity were 0% and 5.7%, respectively. The annual risk of cerebrovascular events during the follow-up periods was very low: 0% in pediatric patients and 0.4% in adults over approximately 67 months. Postoperative cerebral angiography showed that the pericranial flap functioned well as donor tissue for indirect bypass, especially in pediatric patients. Follow-up single-photon emission computed tomography/positron emission tomography studies revealed that cerebral blood flow and its reactivity to acetazolamide markedly improved in both the MCA and anterior cerebral artery territories. CONCLUSION: These findings strongly suggest that STA-MCA anastomosis and EDMAPS using a frontal pericranial flap is a safe and effective surgical procedure to further improve the long-term prognosis in moyamoya disease by improving cerebral hemodynamics in both the MCA and anterior cerebral artery territories.

Imaging characteristics of arteriovenous malformations simulating vascular tumors of the temporalis muscle: a report of two cases.

Arteriovenous malformations (AVMs) of the temporalis muscle are an extremely rare subgroup of head and neck AVMs. The authors report two cases presenting with temporal fossa tumor-like lesions. MRI demonstrated enlargement of the temporalis muscle with hypointensity on T1, hyperintensity on T2 and moderate contrast enhancement. Angiography shows slow arteriovenous shunting with a dense capillary blush of the entire muscle before draining into facial veins. The arterial supply is characteristic of being restricted to the temporalis muscle.

[Anatomic study of mandibular bone flap pedicled with temporal muscle for midface bone defect].

OBJECTIVE: To study the anatomy of mandibular bone flap pedicled with temporal muscle for midfacial bone defects. METHODS: The shape and blood supply of the temporal muscle and mandibular ramus, as well as their relationship, were observed and measured in 30 sides of adult head specimens. RESULTS: The temporal muscle has a fan-shaped main portion, then is scattered into three bundles as anterolateral, anteromedial, posterior bundles, which end respectively at anterior border of ramus, the temporal ridge and posterior portion of coronoid process. Then the muscle goes downward until it reaches the distal side of the third medial surface molar and attaches the 3/4 of medial surface of anterior portion of ramus. The blood supply of temporal muscle includes the medial temporal artery with external diameter of (0.76 +/- 0.20) mm, the anterior deep temporal arteries with external diameter of (0.79 +/- 0.21) mm, posterior deep temporal arteries with external diameter of (0.98 +/- 0.64) mm, the accessory deep temporal artery formed by many little branches. The anterior part of ramus is supplied by the periosteal arteries and the bony perforator of the deep temporal arteries. Rectangular ramus of mandible was divided into anterior portion and posterior portion by the line linking the lowest point of mandibular notch, mandibular foramen and mandibular canal. Anterior portion can supply a bone flap with a size of (46.67 +/- 6.85) mm x (17.98 +/- 2.64) mm x (11.49 +/- 0.99) mm. CONCLUSIONS: The mandibular bone flap pedicled with temporal muscle has a reliable blood supply and abundant bone volume. It is feasible to design a mandibular bone flap pedicled with temporal muscle for midfacial bone defect.