Maxillary defects are a complex problem owing to many factors, such as anatomical specific aspects in the maxillary area, multiple pathological conditions, variability of the aetiologies, the large number of surgical techniques, and the poor knowledge about their effective functional results. Whether caused by tumours or trauma, maxillary defects may cause facial disfigurement, compromised oral functions and psychological problems. Obturation has been the traditional method of rehabilitation for maxillectomy, but the variety of reconstructive options that are now available challenge the traditional view.

Conventional obturators ideally require access to a restorative dental service and are often associated with problems of poor fit and oronasal reflux that requires frequent adjustment. They can be bulky and difficult to insert in the presence of trismus or poor manual dexterity, and require daily cleaning to remove crusting. The temporalis muscle is thin and pliable and because its vascular pedicle is close and superior to the surgical defect the problems caused by the defects are overcome. The temporalis muscle flap (TMF) was first described by Lentz in 1895 who used it after resection of the condylar neck for temporomandibular joint ankylosis. Golovine used the flap to repair an orbital exenteration defect. In the oral cavity, the TMF has been used specifically for reconstructing the palate, floor of the mouth, tongue, retromolar trigone, and oropharynx.

The objectives of this study were: to evaluate the advantages of the TMF in the immediate reconstruction of maxillary defects after maxillectomy and analyse the complications; to correlate the relationship between defect tissue classification and postoperative results; to recommend some suggestions about these indications (some topics such as relation between age, gender and outcomes, or age and outcomes, will not be discussed here).

Materials and methods

The study protocol was reviewed and approved by the Medical Ethical Committee of the Academic Medical Centre, Wuhan University, China. All patients gave informed consent for use of their clinical data.

The authors retrospectively reviewed 39 consecutive patients who had undergone subtotal maxillectomy and immediate reconstruction with TMF from April 1989 to February 2009. All surgical operations were carried out by the same clinician. Demographic data, features of the disease, follow-up, outcome and complications were analysed. Patients were eligible if they had a maxillary defect and reconstruction was performed using TMF tissue transfer. There were 39 cases in the study, 21 males and 18 females, with an average age of 43.9 years (range 17–72 years). No eligible patients declined enrolment in the study. To characterize the extent of the bony and tissues defect(s), the classification introduced by Brown et al ³ was used. Classes 1–4 define the vertical component of the defect: Class 1 involves maxillectomy without an oro-antral fistula; Class 2 is low maxillectomy not including orbital floor or contents; Class 3 includes high maxillectomy involving orbital contents; and Class 4 encompasses radical maxillectomy including orbital exenteration. Classes 2–4 are also qualified by adding the letters a, b, or c. The horizontal or palatal component is classified as follows: (a) unilateral alveolar maxillectomy; (b) bilateral alveolar maxillectomy; (c) total alveolar maxillary resection. Patients were classified into three groups (Class 1, Class 2 and Class 3) according to the defect classification of Brown et al., to ascertain the influence between defect classification and functional results, aesthetic outcomes and complications in each group.

The coronal approach is the best surgical approach for this area because it provides excellent access. The patient should be shaved in the area of the surgical incision. The patient should be placed in a supine position. Routine disinfection of the operative field is required. The patient is draped with good access to the operative field. A coronal incision is made through the skin, subcutaneous tissue and temporalis myofascia. After elevation of the anterior and posterior wound margins, haemostatic clips are applied or bleeding vessels are isolated and cauterised. A malleable retractor may be used to avoid damage to the vascular structures that lie posteromedially. Anteriorly, the superficial layer of the temporalis fascia is included with the skin flap to protect the temporal branch of the facial nerve, which crosses the midpoint of the zygomatic arch. The muscle is then separated from the temporal fossa with an elevator. Care must be taken to remain in the subperiosteal plane in order to avoid injury to the deep temporal vessels. When less bulk is required, especially for mid-adult patients, the TMF can be sectioned coronally whilst maintaining adequate blood supply to both anterior and posterior halves. After rotating the anterior part, the posterior part can be brought forward, thus avoiding a temporal depression. The fascia attachment to the zygomatic arch is incised and elevated. A tunnel through the infratemporal fossa into the oral cavity is created by blunt dissection and the muscle is guided into the oral cavity. In some cases the authors performed coronoidectomy to increase the access for moving the muscle, especially when tissue defects require the full length and width of the temporalis muscle for reconstruction. If further length is required for reconstructing contralateral or anterior defects, the coronoid process may be osteotomized transorally, gaining a further centimetre of pedicle length. Once transposed into the oral cavity, the muscle flap is sutured into the defect. The temporal fascia faces into the mouth and undergoes epithelialisation after 2–3 weeks. Finally, the donor site is irrigated with physiological saline and sutured; a suction drain is inserted and bandaged with moderate compression ( Figs. 1–7 ).

39-Year-old male with alveolus and palatal squamous cell carcinomas.

The donor site was prepared and outlined for hemicoronal incision with preauricular extension.

Elevation of the entire temporalis muscle from the temporal fossa.

Clinical photograph showing resection of a squamous cell carcinoma of the right maxillary alveolus and palate.

Temporalis muscle flap used to reconstruct a surgical defect following ablation of squamous cell carcinoma, 10 days after surgery.

Six-month postoperative, showing a total closure of the palate and the flap surface colour and texture tends to be the same with oral mucosa.

Six-month postoperative photo, showing the cosmetic result and view of the donor site for the entire temporal muscle flap.