Temporal myofascial segmentation for multilayer reconstruction of middle cranial fossa floor after extradural subtemporal approach to the clival and paraclival region

Abstract

Background Skull‐base reconstruction represents a concern after resection of middle fossa (MF) tumors by the extradural subtemporal transzygomatic approach (ESTZ). Regional pedicled flaps appear to be the best option. This study describes a technique for temporal myofascial segmentation to harvest a multilayered vascularized flap for MF reconstruction, which might preserve temporal muscle (TM) function and its blood supply. Methods The technique to harvest a combined segmented temporal myofascial flap (CSTMF) is described. The flap consists in a temporal fascial (TFF) and a muscle flap (TMF), composed by TM anterior‐medial bundle (AMB). Results CSTMF provides wide coverage of dural lining, through the TFF, and of dead‐space, through the TMF. The possibility to tailor TMF according to the need, anatomically preserving the blood supply, enables to significantly increase its volume. Conclusion CSTMF represents an effective option as regional multilayered pedicled flap for MF reconstruction, potentially preserving TM function and minimizing the cosmetic impact.

Advances in Multidisciplinary Management of Skull Base Meningiomas

“…Reconstruction of the anterior skull base has the main role of restoring the separation between the intracranial and the extracranial space, in particular to prevent leakage of CSF and related threatened complications, above all meningitis. A variety of techniques have been described [ 60 ], accounting for the use of dural substitutes and local flaps, used to restore separation between the brain and extracranial space [ 61 ]. In the case of wider defects, free flaps also represent an option [ 62 ].…”

Temporal Flaps in Head and Neck Reconstructive Surgery: A Systematic Review of Surgical Techniques

“…Each bundle is supplied by a specific vascular peduncle, making each of them as functionally independent. 14,17,18 The AMB, the upper part of the MP, and the MLB are supplied by branches arising from the anterior deep temporal artery (ADTA). The main part of the MLB is supplied by branches of the posterior deep temporal artery (PDTA), whereas the MP is supplied by branches arising from the transverse facial artery (TFA), which anyway plays only a marginal role.…”

“…A coronal skin incision is performed. 17 A subgaleal dissection is made and the skin flap is reflected forward. A TM interfascial dissection is performed.…”

“…Segmentation has maximized flap shape versatility and reconstruction capabilities, thus optimizing cosmetic results. 14,17,18,21,22 Historically, each flap has had its own proponents and opponents, mostly based upon personal experience and surgeon's prevalent field of interest; nevertheless, a pointy review, systematizing techniques and comparatively analyzing different flaps, was still missing in the literature.…”

“…To overcome this limit, over the years, many techniques to reverse and split the muscle have been proposed. [16][17][18][19][20] Nevertheless, muscle splitting and reversing should be reserved for very selected cases due to the potential risk of impairment in flap's vascular supply, which may become particularly crucial in reconstruction reliability of radiated settings.…”