Combined Subgaleal/Myocutaneous Technique for Temporalis Muscle Dissection

Abstract

Background The frontal branch of the facial nerve (FBFN) is the most susceptible neural structure to injury during frontotemporal craniotomies. The balance between adequate temporalis muscle mobilization and frontal branch protection with minimal anatomical alteration is the philosophy behind our approach to temporalis muscle dissection.

Objective To describe a combined subgaleal/myocutaneous technique for dissection and mobilization of the temporalis muscle in anterolateral cranial approaches.

Methods Interdisciplinary literature review of the anatomical course of the FBFN was performed. Retrospective analysis of anterolateral craniotomies performed at our institution in which the combined subgaleal/myocutaneous (CSGMC) technique was performed.

Results A total of 71 cases of anterolateral craniotomies (excluding full variant orbitozygomatic) were performed with the successful application of a CSGMC technique (36 pterional, 31 orbitopterional, and 4 fronto-orbital). Partial frontalis weakness was transient in one case.

Conclusion The CSGMC technique provides sufficient protection for the FBFN and allows for adequate mobilization for a variety of skull base exposures while minimally violating myofascial anatomy. This is the first reported technique that allows both adequate temporalis muscle mobilization with performance of the one-piece orbitofrontal and orbitopterional approaches, without disruption of the superficial/deep temporalis fascia and fat-pad complex.

Keywords

temporalis - interfascial - subfascial - frontalis palsy - facial nerve

• References

• 1 Dandy WE. Contributions to brain surgery: A. Removal of certain deep-seated brain tumors; B. Intracranial approach with concealed incisions. Ann Surg 1925; 82: 513-525
• 2 Yasargil MG, Antic J, Laciga R, Jain KK, Hodosh RM, Smith RD. Microsurgical pterional approach to aneurysms of the basilar bifurcation. Surg Neurol 1976; 6: 83-91
• 3 Spetzler RF, Lee KS. Reconstruction of the temporalis muscle for the pterional craniotomy. Technical note. J Neurosurg 1990; 73: 636-637
• 4 Oikawa S, Mizuno M, Muraoka S, Kobayashi S. Retrograde dissection of the temporalis muscle preventing muscle atrophy for pterional craniotomy. Technical note. J Neurosurg 1996; 84: 297-299
• 5 Ammirati M, Spallone A, Ma J, Cheatham M, Becker D. An anatomicosurgical study of the temporal branch of the facial nerve. Neurosurgery 1993; 33: 1038-1043 , discussion 1044
• 6 Gonzalez LF, Crawford NR, Horgan MA, Deshmukh P, Zabramski JM, Spetzler RF. Working area and angle of attack in three cranial base approaches: pterional, orbitozygomatic, and maxillary extension of the orbitozygomatic approach. Neurosurgery 2002; 50: 550-555 , discussion 555–557
• 7 Coscarella E, Vishteh AG, Spetzler RF, Seoane E, Zabramski JM. Subfascial and submuscular methods of temporal muscle dissection and their relationship to the frontal branch of the facial nerve. Technical note. J Neurosurg 2000; 92: 877-880
• 8 Aoki N. Incision of facial nerve branch at aneurysm surgery. J Neurosurg 1987; 66: 482
• 9 Yaşargil MG, Reichman MV, Kubik S. Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. Technical article. J Neurosurg 1987; 67: 463-466
• 10 Yasargil MG. Microneurosurgery. 4 Vols. Stuttgart, New York: Thieme Stratton: 1984. :v
• 11 Salas E, Ziyal IM, Bejjani GK, Sekhar LN. Anatomy of the frontotemporal branch of the facial nerve and indications for interfascial dissection. Neurosurgery 1998; 43: 563-568 , discussion 568–569
• 12 Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg 1966; 38: 352-356
• 13 Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial nerve: how reliably can we predict its path?. Plast Reconstr Surg 1997; 99: 1224-1233 , discussion 1234–1236
• 14 Bernstein L, Nelson RH. Surgical anatomy of the extraparotid distribution of the facial nerve. Arch Otolaryngol 1984; 110: 177-183
• 15 Krayenbühl N, Isolan GR, Hafez A, Yaşargil MG. The relationship of the fronto-temporal branches of the facial nerve to the fascias of the temporal region: a literature review applied to practical anatomical dissection. Neurosurg Rev 2007; 30: 8-15 , discussion 15
• 16 Agarwal CA, Mendenhall III SD, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg 2010; 125: 532-537
• 17 Trussler AP, Stephan P, Hatef D, Schaverien M, Meade R, Barton FE. The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique. Plast Reconstr Surg 2010; 125: 1221-1229
• 18 Tzafetta K, Terzis JK. Essays on the facial nerve: Part I. Microanatomy. Plast Reconstr Surg 2010; 125: 879-889