Interfascial approach for pterional craniotomy: technique and adjustments to prevent cosmetic complications.

BACKGROUND: Interfascial dissection for pterional craniotomy is one of the main techniques to expose the pterional region. METHOD: A step-by-step optimized method of interfascial dissection to avoid three main esthetic complications of the pterional approach-upper facial nerve palsy, temporal muscle atrophy, and retro-orbital depression. A video of the interfascial dissection and three artistic drawings are provided in support of this technique. CONCLUSION: A safe method of interfascial dissection, respecting anatomy, and avoiding cosmetic complications has been proposed.

Delayed rupture of a vertebral artery laceration: a case report and challenges for the forensic pathologist.

Vertebral artery laceration/dissection (VALD) resulting in fatal subarachnoid hemorrhage (SAH) is a rare, but well-known phenomenon encountered in the forensic setting. Delayed ruptures are exceptionally rare, and pose several challenges to the forensic pathologist. In this paper we present a case of a 47-year-old male who collapsed suddenly following recent complaints of a headache and a reported seizure. He had a reported history of potential head trauma that occurred several days prior. Attempts at resuscitation were unsuccessful, and an autopsy examination was ordered. Computer tomography (CT), autopsy, histological and ancillary studies were performed. External examination showed mild, healing trauma to the head and upper limbs, and pre-autopsy CT demonstrated a SAH. Examination of the brain showed basally oriented SAH, and there was a laceration of the left vertebral artery. Histological examination demonstrated a delayed rupture, and there was no significant blood vessel abnormality. Molecular testing was negative for collagen vascular disorders. Delayed rupture of the vertebral arteries following head trauma is rare. The presence of remote and/or mild trauma may be difficult to establish at autopsy, and it is important to identify underlying aortopathies. Several autopsy techniques and ancillary studies should be performed in these cases.

Analysis of masseter and temporal muscles during surgical extraction of impacted third molars.

With the aim of contributing to the discussion on stomatognathic system dysfunction after surgical procedures, this study compared the electromyographic activity of the superficial masseter and temporal masticatory muscles before, during, and after impacted mandibular third molar extractions. Muscular activity was recorded presurgery, transsurgery, immediately postoperatively, and on postoperative days 7, 15, and 30. Twenty patients requiring extraction of impacted mandibular third molars were selected and evaluated. In 20 patients who underwent mandibular third molar extractions, electromyography showed no alterations in muscle tone, and no statistically significant differences were observed in the left and right temporal and masseter muscles at any of the experimental periods at either mandibular rest or isometric contraction position. However, the degree of mouth opening increased 11.76% from pretreatment to 30 days after surgery. These results may reflect the shorter, careful extraction procedure performed by the surgeon.

Investigating the cause of late deformity following fronto-orbital remodelling for metopic synostosis using 3D CT imaging.

PURPOSE: Late deformity/indentation is well-recognised following fronto-orbital remodelling (FOR) for metopic synostosis. We hypothesise that if damage to temporalis muscle were a contributor, the thickness of soft tissue and bone in the affected area would be reduced. MATERIALS AND METHODS: Soft tissues and bone were separately segmented and reconstructed three-dimensionally from computed tomograms of 8 patients 1.5-18 years post-FOR performed at 16 ± 2 months for metopic synostosis and from 8 age-matched controls. Soft tissue (taken as proxy for temporalis muscle) and bone thickness overall and in the indented areas were computed. RESULTS: Post-FOR, three-dimensional soft tissue thickness maps demonstrated temporalis extending upwards but falling short of the indented area. Overall skull thickness increased with age post-FOR (logarithmic fit R2 = 0.71) and for controls (R2 = 0.90). Although immediately post-FOR the future indented area had a thickness of 98% of control, it decreased linearly to 64% 16 years later (Pearson's r = 0.84). CONCLUSION: These findings suggest that late post-FOR deformity/indentation is enhanced by limited upward extension (or retraction downwards) of temporalis muscle, while bone thickness in the affected area gradually decreases. This supports the hypothesis that aberrant re-attachment of the temporalis muscle makes a material contribution to late deformity following FOR for metopic synostosis.

Reconstruction of the temporal contour for traumatic tissue loss using a CAD/CAM-prefabricated titanium implant-case report.

INTRODUCTION: A 16-year-old Arab boy had suffered from a severe head injury including an intracranial haematoma. Despite replantation of the bone flap later on, the cosmetic result was very unfavourable due to partial resorption of the reinserted bone and atrophy of the right temporalis muscle. AIM: For contour reconstruction of both soft and hard tissues the boy was transferred from Saudi Arabia. METHOD: A spiral CT was obtained and the contour was reconstructed using a new algorithm for surface generation. RESULT: The resulting titanium implant was inserted without complications or the need for revision. The cosmetic result was good and corresponded to the preoperative digital planning. CONCLUSION: Techniques of computer-assisted implant prefabrication and surgery may include special algorithms for considering soft tissues including contour deficits of the temporalis muscle.

Severe limitation in mouth opening following transtemporal neurosurgical procedures: diagnosis, treatment, and prevention.

Five new patients and six previously described patients with severe limitation in maximum mouth opening following transtemporal neurosurgical procedures are described. Six patients underwent an operation for epidural hematoma and three for skull-base meningloma; two were treated with a pterional craniotomy for an aneurysm. Limited maximum mouth opening in these circumstances is caused by temporal muscle scarring and shortening. Aggressive physiotherapy is potentially beneficial if started early. If, however, diagnosis is delayed, the efficacy of physiotherapy declines, and surgical treatments such as temporal muscle detachment and coronoidectomy are fully indicated. The differential diagnosis, prevention, and treatment of limited maximum mouth opening following neurosurgical procedures are discussed.

Myositis ossificans traumatica of the temporal muscle: a case report.

Myositis ossificans traumatica (MOT) is a pathological condition characterized by extraskeletal formation of bony tissue, induced by violent or repeated trauma. Reports of this pathology occurring in the region of the head and neck are rare, and even more so in the muscles of mastication. We present the case of patient with MOT of the temporal muscle, the etiology of which seems to be related to traumatic manipulations during dental treatment. A review of the literature is presented and the surgical approach, which resolved this case is discussed.

[Examples of controlled use of computerized tomography in soft tissue injuries of the area of the head and neck]. / Beispiele zum gezielten Gebrauch der Computertomographie bei Weichteilverletzungen im Kopf-Hals-Schulterbereich.

CT can be utilised in a selective manner in soft tissue injuries presented in the head, neck and shoulder regions.

Effects of temporal muscle detachment and coronoidotomy on facial growth in young rats.

This study analyzed the effects of unilateral detachment of the temporal muscle and coronoidotomy on facial growth in young rats. Thirty one-month-old Wistar rats were distributed into three groups: detachment, coronoidotomy and sham-operated. Under general anesthesia, unilateral detachment of the temporal muscle was performed for the detachment group, unilateral coronoidotomy was performed for the coronoidotomy group, and only surgical access was performed for the sham-operated group. The animals were sacrificed at three months of age. Their soft tissues were removed, and the mandible was disarticulated. Radiographic projections-axial views of the skulls and lateral views of hemimandibles-were taken. Cephalometric evaluations were performed, and the values obtained were submitted to statistical analyses. There was a significant homolateral difference in the length of the premaxilla, height of the mandibular ramus and body, and the length of the mandible in all three groups. However, comparisons among the groups revealed no significant differences between the detachment and coronoidotomy groups for most measurements. It was concluded that both experimental detachment of the temporal muscle and coronoidotomy during the growth period in rats induced asymmetry of the mandible and affected the premaxilla.

Temporal hollowing following coronal incision: a prospective, randomized, controlled trial.

BACKGROUND: Coronal incisions are used in traumatic, reconstructive, and cosmetic procedures to access the lateral facial skeleton. Temporal hollowing is a common complication following coronal incision that affects the patient both physically and psychologically. Several dissections have been recommended through this area to avoid injury to the frontal branch of the facial nerve and the temporal fat pad, which is thought to be the cause of hollowing. The purpose of this study was to identify the cause of postoperative temporal hollowing. METHODS: Patients requiring a coronal incision were recruited prospectively. Each side of the head in all patients was randomized to suprafascial, subfascial, or deep dissection. An unmarked envelope containing the type of dissection to be performed for each side was used. All envelopes contained equal distributions of all groups. The incidence and severity of temporal hollowing 6 months postoperatively were measured clinically and by computed tomographic volume analysis. RESULTS: Twenty-seven patients with 54 sides (18 suprafascial, 15 subfascial, and 21 deep) completed the study. There were no demographic differences among the three groups. The incidence and severity of temporal hollowing were lowest with suprafascial dissection. Other factors associated with the presence of temporal hollowing included a reduction in body mass index. There were no injuries to the frontal nerve in any of the dissections. Postoperative temporal hollowing was associated with surgical approach and postoperative weight loss. CONCLUSION: Elevation of a coronal flap in the suprafascial plane and minimization of patient weight loss may decrease the incidence of postoperative temporal hollowing.

Effects of temporal muscle detachment and coronoidotomy on facial growth in young rats

This study analyzed the effects of unilateral detachment of the temporal muscle and coronoidotomy on facial growth in young rats. Thirty one-month-old Wistar rats were distributed into three groups: detachment, coronoidotomy and sham-operated. Under general anesthesia, unilateral detachment of the temporal muscle was performed for the detachment group, unilateral coronoidotomy was performed for the coronoidotomy group, and only surgical access was performed for the sham-operated group. The animals were sacrificed at three months of age. Their soft tissues were removed, and the mandible was disarticulated. Radiographic projections-axial views of the skulls and lateral views of hemimandibles-were taken. Cephalometric evaluations were performed, and the values obtained were submitted to statistical analyses. There was a significant homolateral difference in the length of the premaxilla, height of the mandibular ramus and body, and the length of the mandible in all three groups. However, comparisons among the groups revealed no significant differences between the detachment and coronoidotomy groups for most measurements. It was concluded that both experimental detachment of the temporal muscle and coronoidotomy during the growth period in rats induced asymmetry of the mandible and affected the premaxilla.

Post-mortem forensic neuroimaging: correlation of MSCT and MRI findings with autopsy results.

Multislice-computed tomography (MSCT) and magnetic resonance imaging (MRI) are increasingly used for forensic purposes. Based on broad experience in clinical neuroimaging, post-mortem MSCT and MRI were performed in 57 forensic cases with the goal to evaluate the radiological methods concerning their usability for forensic head and brain examination. An experienced clinical radiologist evaluated the imaging data. The results were compared to the autopsy findings that served as the gold standard with regard to common forensic neurotrauma findings such as skull fractures, soft tissue lesions of the scalp, various forms of intracranial hemorrhage or signs of increased brain pressure. The sensitivity of the imaging methods ranged from 100% (e.g., heat-induced alterations, intracranial gas) to zero (e.g., mediobasal impression marks as a sign of increased brain pressure, plaques jaunes). The agreement between MRI and CT was 69%. The radiological methods prevalently failed in the detection of lesions smaller than 3mm of size, whereas they were generally satisfactory concerning the evaluation of intracranial hemorrhage. Due to its advanced 2D and 3D post-processing possibilities, CT in particular possessed certain advantages in comparison with autopsy with regard to forensic reconstruction. MRI showed forensically relevant findings not seen during autopsy in several cases. The partly limited sensitivity of imaging that was observed in this retrospective study was based on several factors: besides general technical limitations it became apparent that clinical radiologists require a sound basic forensic background in order to detect specific signs. Focused teaching sessions will be essential to improve the outcome in future examinations. On the other hand, the autopsy protocols should be further standardized to allow an exact comparison of imaging and autopsy data. In consideration of these facts, MRI and CT have the power to play an important role in future forensic neuropathological examination.

Chronic expanding hematoma in the temporal region.

We report a rare case of chronic expanding hematoma in the right temporal region that developed into a large mass during 12 years. The patient, who had a history of blunt trauma in her right temporal region at the age of 4 months, noticed a slowly growing mass at the same site in the last few months. Computed tomography revealed a well-circumscribed subcutaneous tumor. The tumor was completely resected. Histopathologically, this tumor was confirmed in the diagnosis of chronic expanding hematoma.

Pathoses of coronoid process as a cause of mouth-opening restrictions.

The mandible coronoid process is another site subject to various pathoses that may result in limited jaw movement. Six different pathoses that prevented the free rotation of the coronoid are presented. Differential diagnosis and treatment approach are emphasized.

Traumatic myositis ossificans in masticatory muscles.

3 cases of traumatic myositis ossificans circumscripta, located within the masticatory muscles are presented. Two of the lesions involved the masseter muscle, and exceptionally, 1 involved the temporalis muscle. Three pathognomonic histological zones, permitting the differential diagnosis of myositis ossificans from sarcomatous lesions, are described, and treatment incorporating ideally early surgical intervention with wide excisional biopsy of the lesion is stressed.