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A Post Operative Case Presentation On Temporalis
Myofascial Flap To Reconstruct Cheek Defect.

Dr Mahbub Hussain
MS Phase B Resident
Oral And Maxillofacial Surgery Department
BSMMU
Temporalis flap
• History
• Lentz in 1895

• Golovine 1898
 Different Flap In Temporal Region

Fasciocutaneous flap
Myocutaneous flap
TPF flap
Myofascial flap
Surgical anatomy
• It is a bipennate fan shaped muscle:

• Origin, insertion:
Blood Supply And Innervation:
Temporalis myofascial flap contd.

Advantage Disadvantage
• Simplicity to raise. • Not bringing skin into the mouth
• Ease of access to the muscle
• Minimum donor site morbidity
• Minimum donor site aesthetic problem.
• Moderate quantity of muscle that can
be harvested approx. 10x20 cm(sq).
• Ability to transfer the muscle to the
oral cavity.
• Rapid epithelialization.
Flap harvest
• A decision to shave a strip of the
hair along the path of the
incision or to shave the entire
head will often depend on the
gender of the patient. In males,
the head is more commonly
shaven while in females only a
strip of the hair along the path
of the planned incision is shaven
Flap Harvest
• The patient is positioned with
the head rotated to expose the
donor side towards the surgeon.
• The incision for the harvest of
the temporalis muscle is
designed from the pre-auricular
area and extends as Popowich
modification or hemicoronal
incision.
Flap Harvest Contd.
• Incision is made along the
marked incision line and carried
deep to the dermis in the pre-
auricular area and deep to the
temporoparietal fascia along the
scalp.
Flap Harvest Contd.
• The scalp flap is then elevated
superficial to the temporalis
muscle fascia. This fascia is easily
identified by its very white
appearance.
Flap Harvest Contd.
• An anterior incision is then made
in the muscle and carried down
to the bone .The muscle is
elevated from its temporal crest
and the posterior incision is
made based on the desired
width needed to repair the
defect.
Flap Harvest Contd.
• The dissection is directed
inferiorly towards the pre-
auricular area, medial and down
to zygomatic arch. Care should
be taken as dissection is carried
deep not to traumatize the
muscle and injure the deep
temporal vessels. The temporal
fascia is freed from its insertion
on the upper border of the
zygomatic arch
Flap Harvest Contd.
• Two long silk sutures (anterior
and posterior) are secured to the
myofascial flap at its thickest
portion that is just above the
zygomatic arch.
• A 1-inch width malleable
retractor is inserted from above,
lateral to the temporais fascia
and medial to the zygomatic
arch, to reach the intraoral
region.
• Antero-posterior sweeping of
the malleable retractor creates a
tunnel medial to the zygomatic
arch. Two long and narrow beak
hemostats are then clamped to
the oral end of the malleable
retractor, and the temporal end
of the malleable retractor is then
pulled out gently, bringing the
hemostats along with it.
• Once the beaks of hemostats
exit through the temporal
region, the anterior and
posterior silk sutures are
clamped to the hemostats .
Then, both the hemostats are
pulled simultaneously intraorally.
Gentle traction applied to the
sutures that bring the thickest
portion of the myofascial flap
intraorally.
• Now, rest of the portion of the
flap can easily be transposed
intraorally with the help of the
traction sutures.
• In this way, whole of the flap can
easily be transposed intraorally
through a tunnel created medial
to the intact zygomatic arch and
sutured to fill the defect.
Particulars of the patient
• Name: Azida
• Age: 60 years
• Sex : female
• Address: Shatarkul, Badda.
Chief complaints
• Ulceration on right cheek for 1 and half month
• Pain in the same region for 15 days.
 Salient feature
• Mrs Azida 60 years old female normotensive non diabetic, presented in OMFS
Department BSMMU, with the complaints of ulceration on right side of buccal
mucosa for 1 and half month and pain in the same region for 15 days. She
states that she was reasonably well 1 and a half month back then developed an
ulceration on right side of cheek which was increasing in size day by day, she
has also complaints of pain for 15 days. She has given history of same ulceration
10 month back which was diagnosed as squamous cell carcinoma grade –I .
Then she admitted here and wide excision with SOND was done. On Frozen
section anterior inferior margin was found to be involved then excision margin
was extended. Wound was closed locally with buccal fat pad. 1 and half month
later she took 30 cycle radiotherapy. On local examination there is an
ulceration on right side of buccal mucosa measuring 2.5x3 cm, extending from
upper GBS to lower GBS. 3cm distal from angle of mouth to retromolar area.
Which is irregular in shape, everted margin, floor is sloughy, base indurated.
Investigation
• All investigation for G/A fittnes was done and found within normal
limit.

• Incisional biopsy revealed

Squamous cell Carcinoma Grade II
Treatment Plan
• Wide excision with 1 cm healthy margin followed by Temporalis
myofascial flap reconstruction.
4th POD
9th POD
11th POD
Thank you &
Eid
Mubarak
In Advance