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Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1391-1395

Antegrade Subperiosteal Temporalis Muscle Elevation and Posterior Retraction Technique Avoiding Muscle Incision for Pterional Craniotomy: A Technical Note


1 Department of Neurosurgery, King Edward Memorial Hospital, Seth Gordhandas Memorial Hospital, Acharya Donde Marg, Parel, Mumbai, India
2 Department of Neurosurgery, I.R.C.C.S. NEUROMED, Pozzilli (IS), Italy
3 Department of Forensic Medicine, King Edward Memorial Hospital, Seth Gordhandas Memorial Hospital

Date of Submission26-May-2020
Date of Decision16-Aug-2020
Date of Acceptance11-Oct-2020
Date of Web Publication30-Aug-2022

Correspondence Address:
Survendra Kumar R Rai
Department of Neurosurgery, K. E. M. Hospital & Seth G. S. M, C., Acharya Donde Marg, Parel, Mumbai, Pin-400 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.355156

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 » Abstract 


Background: The current technique of pterional craniotomy involves temporalis muscle incision followed by retrograde elevation. Feasibility of antegrade temporalis muscle elevation without any direct incision over its bulk is evaluated.
Objective: Incisionless “antegrade, subgaleal, subfascial, and subperiosteal elevation” of temporalis muscle preserves vascularity and muscle bulk. Posterior maneuvering of “bare” temporalis muscle bulk either above (out rolling) or under (in rolling) the scalp for pterional craniotomy is discussed.
Material and Methods: Technique of antegrade, subfascial, subperiosteal elevation, and posterior rotation of temporalis muscle without incising in its bulk by “out rolling” or “in rolling” along the posterior aspect of the scalp incision was carried out in 15 cadavers and later in 50 surgical cases undergoing pterional craniotomy. Postoperatively, patients were evaluated for subgaleal collection and periorbital edema. Operated side cosmesis and temporalis muscle bulk was compared with nonoperated temporalis muscle at 6 months interval.
Results: Antegrade subperiosteal dissection of temporalis muscle was possible in all cases. “In-rolling” or “out rolling” technique provided adequate surgical exposure during pterional craniotomy. Postoperative subgaleal collection and periorbital edema was prevented. Facial nerve paresis or temporalis muscle-related complications were avoided.
Conclusion: Antegrade, subgaleal, subfascial, and subperiosteal dissection techniques of temporalis muscle elevation without any direct incision in its bulk enables neurovascular and muscle volume preservation. Posterior maneuvering of elevated temporalis muscle with “out rolling” or “in-rolling” technique is easy, quick, and provides adequate exposure during pterional craniotomy. Opening and closing of scalp layers without violating subgaleal space prevent postoperative subgaleal hematoma and periorbital edema.


Keywords: Facial nerve, pterional craniotomy, superior temporal line, temporalis fascia, temporalis muscle
Key Message: Antegrade subperiosteal dissection without any incision over the temporalis muscle preserves its vascularity. “Out rolling” or “in-rolling” of temporalis muscle provides adequate pterional craniotomy exposure. Scalp incision and closure without violating subgaleal space prevents postoperative subgaleal collection and periorbital edema.


How to cite this article:
R Rai SK, Dandpat SK, Ranjan S, Shah A, Sudarshan N, Mancarella C, Pathak HM, Goel AH. Antegrade Subperiosteal Temporalis Muscle Elevation and Posterior Retraction Technique Avoiding Muscle Incision for Pterional Craniotomy: A Technical Note. Neurol India 2022;70:1391-5

How to cite this URL:
R Rai SK, Dandpat SK, Ranjan S, Shah A, Sudarshan N, Mancarella C, Pathak HM, Goel AH. Antegrade Subperiosteal Temporalis Muscle Elevation and Posterior Retraction Technique Avoiding Muscle Incision for Pterional Craniotomy: A Technical Note. Neurol India [serial online] 2022 [cited 2022 Oct 7];70:1391-5. Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1391/355156




Pterional craniotomy is a work horse of skull base surgery. The surgical strategy and nuances of the approach have been elaborately described. Subgaleal collection and periorbital edema in immediate postoperative period are common issues associated with this approach. Temporalis muscle atrophy and its related consequence is another issue in late postoperative period. A number of techniques of handling and elevating the temporalis muscle have been described. The technique of elevation of the muscle should be such that it is quick and easy and should provide optimal exposure. Majority of described techniques discuss a retrograde technique of temporalis muscle dissection, wherein the muscle is cut at the posterior limit of dissection and is elevated anteriorly [Figure 1]a.[1],[2] Facial nerve preservation is a key component and can be accomplished by either interfascial or subfascial dissection. This risk is minimized by elevating temporalis muscle together with the scalp but the muscle bulk reduces the exposure of the surgical field.[3],[4] Retrograde dissection technique is described in the literature which involves incising temporalis muscle then separating muscle subperiosteally and then elevating it from posterior to anterior.[5] We report antegrade, subfascial, subperiosteal temporalis muscle dissection technique involving muscle elevation off temporal squama from anterior to posterior direction. We termed the technique as “antegrade” considering the existing terminology of the “retrograde” dissection technique. This technique preserves the vascularity of the muscle and minimizes muscle atrophy. The integrity of facial nerve branches is preserved by subfascial subperiosteal dissection over the zygomatic arch.
Figure 1: (a) Diagrammatic representation of the retrograde dissection technique which proceeds from posterior to anterior after incising temporalis muscle (light brown) exposing underlying bone (light yellow). Skin and subcutaneous tissue is shown in dark yellow color, while temporalis fascia in gray color. (b) Antegrade subperiosteal dissection of temporalis muscle from anterior to posterior direction is shown in black arrows. Autopsy specimen shows a preserved subperiosteal membrane seen as a shiny structure covering the reflected part of the muscle

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 » Methods Top


An antegrade subperiosteal elevation of the temporalis muscle was performed in 15 autopsy cases (30 temporalis muscles). Intactness of the subperiosteal membrane on the undersurface of the temporalis muscle was considered as the objective evidence of the neurovasculature preservation [Figure 1]b. This technique was implemented successfully in 50 patients undergoing pterional craniotomy for aneurysm surgery.

Surgical technique

Incision over the scalp and fascial layers covering the temporalis muscle were taken using standard described techniques. The aim was to preserve the vascularity of the scalp and save the frontalis branch of the facial nerve. The scalp and its fascial layers are elevated anteriorly without entering into the subgaleal space. The zygomatic arch is exposed subperiosteally. The temporalis muscle is elevated from the temporalis fossa in a posterior direction in subperiosteal plane without taking any direct surgical incision in its bulk. The muscle is then rotated posteriorly. Posterior rotation of the temporalis muscle beyond the line of scalp incision is carried out either by “in-rolling” or “out rolling” techniques. Posterior “in-rolling” technique involves infolding of the muscle under the edge of the scalp incision. Subperiosteal dissection is carried out beneath and beyond the posterior margin of the scalp incision to provide space for in-rolling of the temporalis muscle (double breasting). The posteriorly rotated muscle is then secured by using the muscle hitch stitches and bringing the needle out from the scalp posterior to the incision [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e. Another more frequently used method was “out rolling” technique in which temporalis muscle is rolled above the posterior margin of the scalp incision and is retracted posteriorly by hitch sutures [Figure 3]a and [Figure 3]b.
Figure 2: (a) Pericranium and temporalis fascia is incised along with the skin and subcutaneous tissue without entering into the subgaleal space exposing the frontal bone and temporalis muscle, respectively. (b) Temporalis fascia and pericranium is reflected down along with the skin and subcutaneous tissue as a single unit without entering in to subgaleal space exposing the temporalis muscle. The transition zone of the pericranium and temporalis fascia densely adherent along the superior temporal line is separated by sharp dissection with scalpel. (c) The “In rolling” technique temporalis muscle is dissected subperiosteally far beyond the scalp incision site to create space between temporalis muscle and bone for accommodating in-rolled muscle for posterior retraction with multiple hitch sutures. The blue arrow shows curved suture needle being brought out through the scalp by passing it underneath the temporalis muscle far beyond the site of scalp incision. (d) Pterional craniotomy by the “in rolling” technique provides a very low anterior basal temporal exposure. Hitch sutures are seen coming out of the scalp far beyond the site of scalp incision and are shown with the blue arrows. (e) Diagrammatic representation of the “in rolling” technique with “in rolled” temporalis muscle (light brown) being retracted by multiple hitch sutures passing underneath the scalp and being brought out far beyond the scalp incision site exposing underlying bone (light yellow color). Skin and subcutaneous tissue is shown in dark yellow, while reflected temporalis fascia and pericranium as one unit is shown in gray color

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Figure 3: (a) The “Out rolling” technique shows a very low anterior basal temporal exposure obtained during pterional craniotomy. The blue arrows are retracting sutures of the temporalis muscle, while the thin transparent membrane is shown by the blue arrow in the lower portion of figure indicating the intact subperiosteal membrane. (b) Diagrammatic representation of the “out rolling” technique with temporalis muscle (light brown) reflected outward over scalp incision site held in place with multiple hitch sutures exposing underlying bone (light yellow). The skin and subcutaneous tissue is shown in dark yellow color, while temporalis fascia and pericranium is shown in grey color

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In all the surgical cases, temporalis fascia was incised along with scalp incision and was elevated by avoiding subgaleal space opening [Figure 2]a. The adhesion at the transition zone of temporalis fascia and pericranium along superior temporal line was separated with sharp dissection [Figure 2]b. Use of diathermy was avoided. Subgaleal and subfascial dissection of temporalis fascia was performed as described above [Figure 2]a and [Figure 2]b. Thin strip of muscle was left attached along superior temporal line and was used for reattaching temporalis muscle [Figure 4]a, [Figure 4]b, [Figure 4]c. Temporalis fascia and pericranium was approximated, and layered closure of scalp was performed [Figure 4]d, [Figure 4]e.
Figure 4: (a) Fixation of free bone flap at the anterior end is done by sutures passing through anterior most portion of thin strip of muscle left along the superior temporal line, temporalis muscle, and temporalis/pericranial fascia, which is indicated by the blue arrow. (b) Fixation of free bone flap posteriorly is done by anchoring sutures passing through posterior most portion of thin strip of muscle left along the superior temporal line, temporalis muscle, and temporalis/pericranial fascia shown by the blue arrows. (c) The thin strips of muscle left along the superior temporal line are used for reattaching temporalis muscle, which are shown with the blue arrows. (d) Temporalis fascia and pericraniun is closely approximated covering craniotomy site completely as shown by the blue arrow. No subgaleal space violation as seen during closure restoring normal anatomy. (e) Patient postoperatively with no subgaleal collection or periorbital swelling

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All patients were evaluated for immediate postoperative issues like subgaleal hematoma and periorbital edema. Late complication like temporalis muscle atrophy was evaluated by comparing it with the contralateral normal side of the same patient. On follow-up, all patients were enquired regarding chewing difficulty. Temporalis muscle bulk and strength was evaluated by palpating it during teeth clenching and objectively assessing by spatula test. The bulk was compared with the contralateral side temporalis muscle. Magnetic resonance imaging could have been another objective assessment of temporalis bulk but was not done due to cost consideration.


 » Results Top


Antegrade subperiosteal elevation of the temporalis muscle was performed in 15 autopsy cases. Preservation of the subperiosteal membrane during muscle elevation was considered to be an objective evidence of intactness of its entire vascularity. Pterional craniotomy was performed with this technique in 50 cases for anterior circulation aneurysm. There was anterior communicating artery aneurysm in 27 cases, middle cerebral artery aneurysm in 11 cases, posterior communicating artery aneurysm in 6 cases, and supraclinoid internal carotid artery aneurysm in 6 cases. There were 21 females and 29 males with ages ranging from 26 to 81 years, and the mean age was 46 years. Out of 50 cases, the muscle elevation was done using the “in-rolling” technique in seven patients and with the “out-rolling” technique in 43 cases. Decision to use the “in-rolling” or “out rolling” technique was based on temporalis muscle thickness. Pterional exposure with this technique provided adequate exposure for aneurysmal surgery. Immediate postoperative subgaleal collection and periorbital edema was not encountered in any case. None of the cases had facial nerve injury or noticeable temporalis muscle-related complications with excellent cosmesis at 6 months of follow-up.


 » Discussion Top


Temporalis muscle is embryologically related to the first branchial arch.[6],[7] Intraoperatively, this muscle is seen as one unit/structure, but it has three muscle bundles anteromedial, anterolateral, and middle lateral.[8] Temporalis muscle lies between the temporalis fascia on the surface and the “subperiosteum” in the depth in approximation to the skull. Preserving these layers is important for its integrity, neural function, and vascularity.[5] Loss of functional integrity and muscle atrophy leads to asymmetry and temporal hollowing. The three deep temporal nerves that are the branches of mandibular division of trigeminal nerve are located superficial to the subperiosteum indicating the need for subperiosteal dissection as well as avoiding diathermy for its preservation.[9] Temporalis muscle has extensive anastomotic vascularity vertically and horizontally fed by MTA, anterior and posterior DTAs, and their connections.

DTAs and MTA form a plexus 1.8 cm below superior temporal line anastomosing with STA.[7] The anterior DTA anastomoses with small branches of lacrimal artery, perforating the zygomatic bone and the greater wing of the sphenoid bone.[10],[11] The MMA has anastomosis with the DTAs in the temporal bone and with the STA through the temporal muscle, while the MTA anastomoses with the anterior and posterior DTAs.[12],[13] The vascularity of mobilized temporalis muscle is dependent on the DTAs and the STA, which emphasizes its need for preservation. Excessive retraction of the temporal muscle compromises blood flow through temporal arteries leading to ischemic changes starting within 15 min of retraction. Prolonged and excessive retraction leads to irreversible changes 6 to 8 h after ischemia.[14],[15]

For basal exposure that requires excessive muscle retraction, zygomatic osteotomy is recommended to avoid tourniquet effect. Temporalis muscle can be damaged due to cutting, dissection, and retraction.[5],[8] Following the surgical procedure, reinsertion of the muscle at the original detachment site helps to retain muscle tension for optimal functioning and thereby preventing disuse atrophy.[16],[17]

Insertion of muscle at the site of its attachment is done by screw fixation or directly attaching muscle to bone by drilling holes along the superior temporal line, which helps in maintaining adequate muscle tension, thereby preserving its functional integrity.[16],[17] Subfascial, subperiosteal dissection reflecting intact temporalis muscle inferoposteriorly avoids injury to the frontotemporal branch of the facial nerve especially the anterior and middle branch of the facial nerve.[2] The orbicularis oculi and corrugator (anterior) and frontalis (middle) muscles are important for cosmesis. However, if incision is made up till the level of the tragus, the posterior branch of the tragus nerve, innervating the anterior and superior auricular muscles, is transected which does not cause any apparent deficit.[9]

Retrograde dissection in subperiosteal plane has been described in the literature for preservation of the neuro-vasculature of the temporalis muscle [Figure 1]a.[5] However, the antegrade dissection technique has not been reported in literature. Antegrade dissection proceeds from anterior to posterior. Temporalis muscle dissection in subperiosteal plane is continued posteriorly under direct vision till desired exposure is achieved. Dissection study carried out on 15 autopsy specimens assisted in assessing the feasibility of implementing this technique during pterional craniotomy. This provided evidence that antegrade dissection is safe if done maintaining the subperiosteal plane [Figure 1]b.

Adequate exposure for pterional craniotomy requires maneuvering of muscle bulk away from the surgical site. The technique of posterior retraction of the temporalis muscle is a better alternative for exposing the temporal bone in a pterional craniotomy. Although the technique of posterior retraction of temporalis muscle without incision is described in literature, however, the technique and its merits have not been detailed.[1] We have advocated two methods of posterior retraction of temporalis muscle. First is the “in rolling” technique wherein temporalis muscle is rolled under itself on the posterior aspect of the temporal bone [Figure 2]c, [Figure 2]b, [Figure 2]e. Second method is the “out rolling” technique wherein temporalis muscle is rolled outward over scalp incision site [Figure 3]a and [Figure 3]b. The anterior part of temporalis muscle is securely positioned with multiple anchoring sutures during both “in rolling” and “out rolling” techniques.

The anchoring sutures are utilized in retracting temporalis muscle posteriorly. Stretching of the temporalis muscle with anteriorly placed hitch suture leads to thinning of muscle where it is bulkiest. Posterior retraction of the muscle bulk should avoid undue stretch. In the “out rolling” technique, temporalis muscle is rotated outwards with muscle traversing over the scalp incision site providing adequate pterional exposure [Figure 3]a and [Figure 3]b. In the “in-rolling” technique, hitch sutures are made to pass underneath the scalp far beyond the site of scalp incision [Figure 2]c, [Figure 2]d, [Figure 2]e. Hence, accommodation of muscle bulk in the “in rolling” technique necessitates subperiosteal dissection posterior and beyond the scalp incision site to create space for in rolled and retracted muscle. Choice of using the “in rolling” or “out rolling” technique is decided by the thickness (bulk) of temporalis muscle. The “In rolling” technique is usually preferred in cases with thick temporalis muscle; however, this technique can be used in all cases irrespective of the temporalis muscle thickness (bulk). For normal or thin temporalis muscle, the “out rolling” technique is recommended as it is simple and quick. The “In rolling” technique requires subperiosteal temporalis muscle elevation more than that required for the “out rolling” technique. This has potential of damaging neurovascular structures. Hence, we preferred to use the “out rolling” technique as far possible unless compelled by excessive muscle bulk to use the “in rolling” technique.

During closure, muscle can be sutured by drilling pin holes along superior temporal line. We preferred to incise the muscle and leave a thin strip of temporalis muscle attached along the superior temporal line for temporalis muscle reattachment and for securing bone flap. The anterior as well as the posterior end of the muscle left along superior temporal line is anchored at both the ends by sutures passing through this muscle, temporalis muscle and the temporalis fascia [Figure 4]a and [Figure 4]b. The temporalis muscle is reattached in its entire length along the superior temporal line [Figure 4]c.

The thickest component of the temporalis muscle lies underneath the zygomatic arch. Pterional craniotomy by the conventional technique involves temporalis muscle incision and retraction inferiorly obstructing the basal temporal bone exposure, particularly in the region of base of the sphenoid wing. Posterior retraction of the temporalis muscle as discussed creates muscle free space underneath the anterior portion of the zygomatic arch and provides for basal pterional exposure than that offered by the conventional technique. Excessive retraction of the temporalis muscle over the zygomatic arch can results in compromise of its vascular supply, which eventually heals by fibrosis. This technique is suitable for cases requiring pterional craniotomy and intended for the frontotemporal craniotomy requiring exposure of anterior portion of the temporal lobe and anterolateral skull base. However, this technique is not suitable for cases requiring extensive exposure like fronto-temporo-orbital zygomatic craniotomy, which requires exposure of the posterior most portion of the temporal lobe.

Temporalis fascia and pericranium is incised along with skin and subcutaneous tissue. Temporalis fascia and masseteric fascia is in continuity with periosteum at the bony attachment over zygomatic arch.[18] Opening of subgaleal space is avoided from beginning and subfascial dissection is carried out to prevent facial nerve injury [Figure 2]a and [Figure 2]b. Temporalis fascia is separated from superior temporal line by sharp dissection. The use of diathermy is avoided to prevent thermal injury to the muscle and to the fascial layers. Temporalis fascia and frontal pericranium are closely approximated at the time of scalp closure restoring normal anatomy, which creates tense template for subcutaneous tissues of scalp thereby avoiding sinking of scalp along bony defect of the craniotomy edges, especially in the frontal region [Figure 4]d. Temporal region defect is covered by intact temporalis muscle and approximating temporalis fascia. Free bone flap is anchored with hitch sutures to the temporalis fascia/pericranium avoiding requirement of metal implants for bone fixation. This technique provides excellent cosmetic results and is devoid of any temporalis muscle related complications. Avoidance of developing subgaleal space and approximation of temporalis fascia and pericranium is a critical step in preventing subgaleal collection and periorbital edema in immediate postoperative period [Figure 4]e. Follow-up at 6-month interval showed excellent functional preservation of temporalis muscle without any complications, viz. atrophy, chewing difficulty, trismus or any facial deformity.


 » Conclusions Top


Antegrade, subgaleal, subfascial, and subperiosteal dissection techniques of temporalis muscle elevation without any direct incision in its bulk enable neurovascular and muscle bulk preservation. Posterior maneuvering of elevated temporalis muscle with the “out rolling” or “in-rolling” technique is easy, quick, and provides adequate exposure during pterional craniotomy. Opening and closing of scalp layers without violating subgaleal space prevents subgaleal hematoma and periorbital edema in the postoperative period. Dissection in precise anatomical planes as described enables facial nerve and temporalis muscle bulk preservation avoiding delayed complications in long run with excellent cosmesis.

Acknowledgments

We would like to thank Dr. Antony Thomas, Department of Neurosurgery, RMSH, Kimberley, South Africa for the excellent illustrative figures. The authors would like to thank following faculty members from the Department of Forensic medicine: Dr. Ravindra B. Deokar, Associate Professor. Assistant professors Dr. Shahank Tyagi, Dr. Sachin Sudarshan Patil, Dr. Girish Vijay Tasgaonkar, Dr. Mahendra Namdeo Wankhede, Dr. Vikas Premlal Meshram, Dr. Manoj Bhausaheb Parchake, and Dr. Harshwardhan Khartade. The authors would also like to thank Dr. Ravikumar Kamble and Dr. Abhijeet Hosmani for their wholehearted support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Miyazawa T. Less invasive reconstruction of the temporalis muscle for pterional craniotomy: Modified procedures. Surg Neurol 1998;50:347-51; discussion 351.  Back to cited text no. 1
    
2.
Horimoto C, Toba T, Yamaga S, Tsujimura M. Subfascial temporalis dissection preserving the facial nerve in pterional craniotomy —Technical Note. Neurol Med Chir (Tokyo) 1992;32:36-37.  Back to cited text no. 2
    
3.
Ammirati M, Spallone A, Ma J, Cheatham M, Becker D. An anatomicosurgical study of the temporal branch of the facial nerve. Neurosurgery 1993;33:1038-44.  Back to cited text no. 3
    
4.
Ammirati M, Spallone A, Ma J, Cheatham M, Becker D. Preservation of the temporal branch of the facial nerve in pterional-transzygomatic craniotomy. Acta Neurochir (Wien) 1994;128:163-5.  Back to cited text no. 4
    
5.
Oikawa S, Mizuno M, Muraoka S, Kobayashi S. Retrograde dissection of the temporalis muscle preventing muscle atrophy for pterional craniotomy. J Neurosurg 1996;84:297-9.  Back to cited text no. 5
    
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Standring S. Gray's Anatomy e-Book: The Anatomical Basis of Clinical Practice. Elsevier Health Sciences; 2015. 2256p  Back to cited text no. 6
    
7.
Yaşargil MG, Reichman MV, Kubik S. Preservation of the frontotemporal branch of the facial nerve using the interfascial temporalis flap for pterional craniotomy. J Neurosurg 1987;67:463-6.  Back to cited text no. 7
    
8.
Shimokawa T, Akita K, Soma K, Sato T. Innervation analysis of the small muscle bundles attached to the temporalis: Truly new muscles or merely derivatives of the temporalis? Surg Radiol Anat 1999;20:329-34.  Back to cited text no. 8
    
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Wang H, Gu Y, Xu J, Shen L, Li J. Comparative study of different surgical procedures using sensory nerves or neurons for delaying atrophy of denervated skeletal muscle. J Hand Surg Am 2001;26:326-31.  Back to cited text no. 9
    
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Chen CT, Robinson JB, Rohrich RJ, Ansari M. The blood supply of the reverse temporalis muscle flap: Anatomic study and clinical implications. Plast Reconstr Surg 1999;103:1181-8.  Back to cited text no. 10
    
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Cheung LK. The blood supply of the human temporalis muscle: A vascular corrosion cast study. J Anat 1996;189(Pt 2):431-8.  Back to cited text no. 11
    
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al-Mefty O, Anand VK. Zygomatic approach to skull-base lesions. J Neurosurg 1990;73:668-73.  Back to cited text no. 12
    
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Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper craniofacial skeleton: The search for composite calvarial bone flaps. Plast Reconstr Surg 1984;74:603-10.  Back to cited text no. 13
    
14.
Appell H-J, Gloser S, Duarte JAR, Zellner A, Soares JMC. Skeletal muscle damage during tourniquet-induced ischaemia. The initial step towards atrophy after orthopaedic surgery? Eur J Appl Physiol Occup Physiol 1993;67:342-7.  Back to cited text no. 14
    
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Blaisdell FW, Steele M, Allen RE. Management of acute lower extremity arterial ischemia due to embolism and thrombosis. Surgery 1978;84:822-34.  Back to cited text no. 15
    
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Adams RD, Kakulas BA. Diseases of Muscle: Pathological Foundations of Clinical Myology. Harpercollins College Division; 1985.  Back to cited text no. 16
    
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Zager EL, Del Vecchio DA, Bartlett SP. Temporal muscle microfixation in pterional craniotomies. J Neurosurg 1993;79:946-7.  Back to cited text no. 17
    
18.
de Vasconcellos JA, Britto JA, Henin D, Vacher C. The fascial planes of the temple and face: An en-bloc anatomical study and a plea for consistency. Br J Plast Surg 2003;56:623-9.  Back to cited text no. 18
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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