A new coronal scalp technique to treat craniofacial fracture: the supratemporalis approach

Modified Tragus Edge and Transmasseteric Anteroparotid Approach for Intracapsular and Condylar Neck Fractures

The aim of this study was to evaluate the effects of protecting the facial nerve and reducing the scar visibility using a modified tragus edge and transmasseteric anteroparotid approach compared to classic preauricular approach for intracapsular and condylar neck fractures. This retrospective study included 64 patients (78 sides) who underwent surgical treatment for intracapsular or condylar neck fractures from January 2014 to June 2018. Patients were divided into the experimental group (treated via a modified tragus edge and transmasseteric anteroparotid approach), and the control group (treated via the classical preauricular approach). Therapeutic outcome assessment parameters included facial nerve injury, salivary fistulae, wound infection, restricted mouth opening, postoperative occlusion disorders, and scar visibility. In the control group, there were 3 cases of facial nerve injuries and 2 cases of salivary fistulae. One case of temporary facial nerve injury occurred in the experimental group, with complete recovery within 1 month. The scars were less visible in the experimental group than in the control group. These results suggest that a modified tragus edge and transmasseteric anteroparotid approach reduced the incidences of facial nerve injuries, minimized the scar visibility, improved exposure of the operative site and fixation of titanium screws or plates, and did not increase the frequency of other complications.

Does the Deep Layer of the Deep Temporalis Fascia Really Exist?

PURPOSE

It has been widely accepted that a split of the deep temporal fascia occurs approximately 2 to 3 cm above the zygomatic arch and extends into the superficial and deep layers. The deep layer of the deep temporal fascia is between the superficial temporal fat pad and the temporal muscle. However, during procedures, the authors noted the absence of the deep layer of the deep temporal fascia between the superficial temporal fat pad and the temporal muscle. This prospective study was conducted to clarify the presence or absence of a deep layer of the deep temporal fascia.

MATERIALS AND METHODS

Anatomic layers of the soft tissues of the temporal region, with reference to the deep temporal fascia, were investigated in 130 cases operated on for zygomaticofacial fractures using the supratemporal approach from June 2013 to June 2017.

RESULTS

Of 130 surgeries, the authors found the absence of a thick, obviously identifiable, fascial layer between the superficial temporal fat pad and the temporal muscle. In fact, the authors found nothing above the temporal muscle in most cases. In a few cases, the authors observed only a small amount of scattered loose connective tissue between the superficial temporal fat pad and the temporal muscle.

CONCLUSIONS

This clinical study showed the absence of a thick, obviously identifiable, fascial layer between the superficial temporal fat pad and the temporal muscle, which suggests that a "deep layer of the deep temporal fascia" might not exist.

[Application of modified coronal approach in treatment of craniomaxillofacial fractures]

OBJECTIVE

This study aimed to investigate clinical efficacy of a modified coronal approach in treatment of craniomaxillofacial fractures.

METHODS

Thirty-seven cases of craniomaxillofacial fractures underwent open reduction and rigid internal fixation through modified coronal approach. Clinical follow-up visits were conducted to evaluate facial nerve functional status, temporal shape, appearance restoration, and reduction of fracture and surgical area scars.

RESULTS

During follow-up period of 6-36 months, appearance and function of all 37 patients recovered well without facial nerve injury and temporal depression deformity. All cases presented hidden scars, except for one case with hypertrophic scar.

CONCLUSIONS

Applying modified coronal approach to craniomaxillofacial surgery effectively reduces incidence of temporal depression and facial nerve injury compared with traditional approach. The modified coronal approach produced more subtle scars compared with traditional approach and should be applied to treatment of craniomaxillofacial fractures.

[Complications of supratemporalis approach with scalp coronal incision for orbital-zygomatic fracture]

OBJECTIVE

This study aimed to examine the complications of supratemporalis approach with scalp coronal incision for the treatment of orbital-zygomatic fractures.

METHODS

A total of 206 patients with orbital-zygomatic fractures were treated with scalp coronal incision through the supratemporalis approach. The effects and complications of the treatment were analyzed.

RESULTS

The degree of fracture of the 206 patients was successfully reduced. The facial morphologies and functions were improved. No facial nerve injury was observed in all of the cases. However, the following complications were noted: fossa introcession in 1 case, forehead scalp pain or paresthesia in 11 cases, incision infection in 1 case, subcutaneous hematoma in 1 case, incision scar in 5 cases, and alopecia in 3 cases.

CONCLUSIONS

The supratemporalis approach prevents facial nerve injury and does not increase the frequency of other complications. Therefore, this approach can be applied as a routine and safe procedure in clinical settings. 
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Postoperative temporal hollowing: Is there a surgical approach that prevents this complication? A systematic review and anatomic illustration

BACKGROUND

Temporal hollowing is a common complication following surgical dissection in the temporal region. Our objectives were to: (1) review and clarify the temporal soft tissue relationships - supplemented by cadaveric dissection - to better understand surgical approach variations and elucidate potential etiologies of postoperative hollowing; (2) identify if there is any evidence to support a surgical approach that prevents hollowing through a systematic review.

METHODS

Cadaveric dissection was performed on six hemi-heads. A systematic review of the literature was undertaken to identify surgical approaches with a decreased risk of postoperative hollowing.

RESULTS

A total of 1212 articles were reviewed; 19 of these met final inclusion criteria. Level I and II evidence supports against the use of a dissection plane beneath the superficial layer of the deep temporal fascia or through the intermediate temporal fat pad. Level II evidence supports preservation of the temporalis muscle origin - no evidence is available to support other temporalis resuspension techniques. For intracranial exposure, refraining from temporal fat pad dissection (Level I Evidence) and use of decreased access approaches such as the minipterional craniotomy (Level I Evidence) appear to minimize temporal soft tissue atrophy.

CONCLUSIONS

This study highlights the significance of preservation of the temporal soft tissue components to prevent hollowing. Preserving the temporalis origin and avoiding dissection between the leaflets of the deep temporal fascia or through the intermediate temporal fat pad appear to minimize this complication.

A Modified Preauricular Approach for Treating Intracapsular Condylar Fractures to Prevent Facial Nerve Injury: The Supratemporalis Approach

PURPOSE

The facial nerve remains at risk of injury with the preauricular approach; thus, preservation of the functional integrity of the facial nerve is considered an important factor in the success of temporomandibular joint surgery. The aim of this study was to prevent facial nerve injury using the supratemporalis approach in the treatment of intracapsular condylar fractures.

MATERIALS AND METHODS

In this prospective cohort study, the population consisted of patients diagnosed with intracapsular condylar fractures who received surgical treatment from July 2005 to May 2014. Patients in the experimental group were treated with the supratemporalis approach, and patients in the control group were treated with the traditional preauricular surgical technique. The primary outcome variable was facial never injury. The continuity correction χ(2) and test Student t test were used.

RESULTS

Eighty-four patients (112 sides) with intracapsular condylar fractures were treated surgically (56 men, 28 women; mean age, 29.85 yr; range, 4 to 70 yr); 44 patients (64 sides) were treated with the supratemporalis approach and 40 patients (48 sides) were treated with the traditional preauricular approach. Facial contours and functions recovered well postoperatively in all 84 patients. Seven cases of facial nerve injury, 2 of which were permanent, were observed in the group treated with the traditional preauricular approach, and no facial nerve injuries were observed in the group treated with the supratemporalis approach. None of the patients sustained auriculotemporal syndrome or wound infection complications.

CONCLUSIONS

The supratemporalis approach prevented facial nerve injury and did not increase the frequency of other complications.

Minimizing complications associated with coronal approach by application of various modifications in surgical technique for treating facial trauma: A prospective study

Background:

Coronal incision is a popular and versatile surgical approach to the anterior cranial vault and upper and middle third facial skeleton. The flap itself permits widespread exposure of the fractures in this region. The bicoronal flap was first described by Hartley and Kenyon (neurosurgeons) to gain access to the anterior cranium in 1907. It extension as an access flap to the upper and lateral aspect of the face was pioneered by Tessier (1971). Esthetically, it is pleasing as the surgical scar is hidden within the hair.

Aims:

To evaluate the versatility of coronal incision using various modifications advocated in incision, exposure to fractured site, and closure of flap in treating the upper and middle third facial fractures.

Materials and Methods:

A total of ten patients diagnosed with upper and middle third facial fractures requiring open reduction and internal fixation/correction of contour defect were selected after preoperative clinical and radiographic (computed tomography scan) evaluation. All the cases were operated by coronal approach to gain the access to the fracture/defect site for reduction/correction of the defect. Advantages and complication are evaluated.

Results:

Excellent access and anatomical reduction by this approach with least number of complications; if it is performed with healthy knowledge of anatomy of the scalp and temporal region. Certain minimal complications have also been noted using various modifications used in the procedure.

Conclusion:

Despite of prolonged surgical time for the exposure, it is very advantages in treating upper and middle third facial fractures due to wide access and discreet scar (minimal).

Temporal Approach to Removal of a Large Orbital Foreign Body

Accidents with firearms can result in extensive orbital trauma. Moreover, gun parts can come loose and impale the maxillofacial region. These injuries can cause the loss of visual acuity and impair eye movements. Multidisciplinary treatment is required for injuries associated with this type of trauma. Computed tomography with three-dimensional reconstruction is useful for determining the precise location and size of the object lodged in the facial skeleton, thereby facilitating the planning of the correct surgical approach. The temporal approach is a fast, simple technique with few complications that is indicated for access to the infratemporal fossa. This article describes the use of the temporal approach on a firearm victim in whom the breech of a rifle had impaled orbital region, with the extremity lodged in the infratemporal fossa.

Traditional and contemporary surgical approaches to the orbit

Traditional orbital approaches are nearly a century old and still comprise the foundation of techniques used today. Computer-assisted planning and intraoperative navigation have recently been reported with more prevalence in the literature. The purpose of this article was to review commonly used approaches to the orbit: old and new.