Temporal Approach and Variants

Cristian Gragnaniello, Nicholas J. Erickson, Filippo Gagliardi, Marzia Medone, Pietro Mortini, and Anthony J. Caputy

19.1 Indications

• Temporal lobectomy for epilepsy (amygdalo-hippocampectomy).

• Tumors and vascular malformations of the lateral and middle temporal lobe.

• Temporal lobe open brain biopsy.

19.2 Patient Positioning

• Position: The patient is positioned supine with the head fixed with a Mayfield head holder.

• Body: The body is kept in neutral position slightly rotated toward the contralateral side and a roll is placed under the ipsilateral shoulder.

• Head: The head is rotated of about 60° toward the contralateral side and tilted up to 30° toward the floor.

• The zygoma should be kept as the highest point of the surgical field.

• The frontotemporal region has to be kept on a horizontal plane, parallel to the floor.

19.3 Skin Incision

• Question-mark shaped unilateral incision (Fig. 19.1)

◦ Starting point: The incision starts just above the zygomatic arch, 1 cm in front of the tragus, in order to preserve the frontal branches of the facial nerve and it makes a small “V” in front of the tragus itself to allow for a more cosmetic closure result.

◦ Run: Incision line curves first posteriorly around the top of the pinna for 6 to 9 cm, then turns superiorly along the superior temporal line, turning anteriorly toward the forehead.

◦ Ending point: The surgical incision ends at the hairline.

• Linear unilateral incision

Linear incision is mostly used for minimally invasive keyhole temporal approaches.

◦ Starting point: The linear incision does begin in the same position as the question-mark-shaped one, 1 cm above the zygomatic arch and 1 cm anterior to the tragus.

◦ Run: It runs superiorly for about 6 cm at the level of the temporal muscle.

◦ Ending point: Incision line ends at the superior temporal line.

19.3.1 Critical Structures

• Frontal branch of the facial nerve.

• Superficial temporal artery.

19.4 Soft Tissues Dissection

• Myofascial level (Fig. 19.2, 19.3)

◦ Interfascial dissection of the temporal muscle is carried out according to the technique described in Chapters 6 and 8.

◦ The masseter muscle is carefully detached from the inferior margin of the zygomatic arch.

◦ The superficial temporal fascia is incised according to the skin incision.

Fig. 19.1 Skin incision. Starting just above the zygomatic arch and anterior to the tragus, the incision curves posteriorly around the top of the pinna and continues superiorly and anteriorly along the superior temporal line towards the forehead.