Transinfratemporal Fossa Transposition of the Temporalis Muscle Flap for Skull Base Reconstruction after Endoscopic Expanded Nasopharyngectomy: Anatomical Study and Clinical Application.

Objective Temporalis muscle flap (TMF) is widely used in traditional skull base surgery, but its application in endoscopic skull base surgery remains rarely reported. We aimed to investigate the surgical anatomy and clinical application of TMF for reconstruction of skull base defects after expanded endoscopic nasopharyngectomy. Methods Nine fresh cadaver heads (18 sides) were used for endoscopic dissection at the University of Pittsburgh School of Medicine in the United States. TMF was harvested using a traditional open approach and then transposed into the maxillary sinus and nasal cavity through the infratemporal fossa using an endoscopic transnasal transmaxillary approach. TMF length was then measured. Moreover, TMF was used for the reconstruction of skull base defects of six patients with recurrent nasopharyngeal carcinoma after expanded endoscopic nasopharyngectomy. Results The length of TMF harvested from the temporal line to the tip of the coronoid process of the mandible was 11.8 ± 0.9 cm. The widest part of the flap was 9.0 ± 0.4 cm. When TMF was dislocated from the coronoid process of the mandible, approximately another 2 cm of reach could be obtained. When the superficial layer of the temporalis muscle was split from the deep layer, the pedicle length could be extended 1.9 ± 0.2 cm. TMF could cover skull base defects in the anterior skull base, sellar, and clivus regions. Conclusion TMF can be used to reconstruct skull base defects after endoscopic expanded nasopharyngectomy and can effectively prevent the occurrence of serious complications in patients with recurrent nasopharyngeal carcinoma.

The Infratemporal Retro-Eustachian Transposition of the Temporoparietal Fascial Flap for Clival Reconstruction After Endoscopic Endonasal Approach: An Anatomic Conceptual Technique.

BACKGROUND: Reconstruction after endoscopic endonasal approaches is a key element. Lower clivus reconstruction is difficult and most of the times a pedicled flap is not available. As the complexity and the dimensions of the exposure increase, a reliable reconstruction technique becomes more and more important. OBJECTIVE: To describe the anatomic and technical nuances of the transposition of the temporoparietal fascial flap for lower clivus reconstruction. METHODS: A specific temporoparietal fascial flap (TPFF) design and tunneling technique has been studied using 4 head specimens, microscopic and endoscopic surgical techniques, and neuronavigation. RESULTS: The L-shaped flap offers several advantages. It can be tunneled directly toward the lower clivus passing through the infratemporal fossa. CONCLUSION: The infratemporal retro-eustachian transposition of an L-shaped TPFF provides a vascularized tissue virtually without dimension limits. This is the only technique that allows the flap to be tunneled directly in the lower clivus with the most vascular portion being at the bottom of the defect. Clinical validation is still required since more issues may become relevant in a real-surgery setting. Though, due to its possible complications, this methodology needs further testing and should not be attempted in less experienced hands.