Naming the Soft Tissue Layers of the Temporoparietal Region: Unifying Anatomic Terminology Across Surgical Disciplines

ons120 | VOLUME 67 | OPERATIVE NEUROSURGERY 1 | SEPTEMBER 2010 www.neurosurgery-online.com

Kristen M. Davidge, MDDivision of Plastic Surgery,University of Toronto,Toronto, Canada

Wouter R. van Furth, MDDepartment of Neurosurgery,Academic Medical Center,University of Amsterdam,Amsterdam, The Netherlands

Anne Agur, PhDDivision of Anatomy,Department of Surgery,University of Toronto,Toronto, Canada

Michael Cusimano, MD,MHPE, PhDDivision of Neurosurgery,St. Michael’s Hospital,University of Toronto,Toronto, Canada

Reprint requests:Kristen Davidge, MD,Division of Plastic Surgery,University of Toronto,Medical Sciences Building, Room 1158,1 King’s College Circle,Toronto, Ontario M5S 1A8, Canada.E-mail: [email protected]

Received, May 11, 2009.

Accepted, January 11, 2010.

Copyright © 2010 by theCongress of Neurological Surgeons

An understanding of the anatomy of the tem-poroparietal region is critical to a multi-tude of surgical subspecialties, including

plastic surgery, neurosurgery, otolaryngology, oph-thalmology, and oral and maxillofacial surgery. Agood grasp of this anatomy is hindered by theoften confusing and contradictory nomenclatureutilized in the literature. This variability existsboth in the naming of the temporoparietal fasciallayers, as well as in the description of the vascularand neural architecture of the temporal region.

Several recent reports have sought to further clar-ify the anatomy of the temporoparietal area.1-6

However, these efforts have largely focused onstandardizing nomenclature within a surgicaldiscipline, and inconsistencies persist across dis-ciplines. With the increasing overlap of casesperformed by subspecialty surgeons, and theinterdisciplinary collaboration required in com-plex cases, it is imperative to establish a com-mon language when describing surgical planesand dissection techniques within the temporalregion. A more uniform understanding of thecomplex temporoparietal anatomy should helpfacilitate intersurgeon communication, teach-ing of resident physicians, and success in theoperating room.

The purpose of this article is to review the lit-erature on temporoparietal anatomy, highlightthe existing incongruities, and propose a stan-

Naming the Soft Tissue Layers of theTemporoparietal Region: Unifying AnatomicTerminology Across Surgical Disciplines

BACKGROUND: The complexity of temporoparietal anatomy is compounded by incon-sistent nomenclature.OBJECTIVE: To provide a comprehensive review of the variations in terminology andanatomic descriptions of the temporoparietal soft tissue layers, with the aim of improv-ing learning and communication across surgical disciplines.METHODS: MEDLINE (1950-2009) searches were conducted for anatomic studies of thetemporoparietal region, and for studies describing temporoparietal anatomy in the con-text of surgical techniques.RESULTS: Sixty-nine articles were included in the review. Naming of the soft tissue layersof the temporoparietal region was inconsistent both within and across surgical disciplines,with several terms utilized for the same layer and occasionally the same term applied to dif-ferent layers. Studies also varied in their description of the vascular, neural, and soft tissuearchitecture of the temporoparietal region.CONCLUSION: A uniform, descriptive nomenclature is paramount to facilitating surgicaleducation and interpreting future studies. A naming system based on the TerminologicaAnatomica is proposed in this review. From superficial to deep, the proposed terms forthe soft tissue layers of the temporoparietal region include: temporoparietal fascia, looseareolar tissue plane, superficial leaflet of temporal fascia, fat pad of temporal fascia, deepleaflet of temporal fascia, fat pad deep to temporal fascia, temporalis or temporal muscle,and pericranium.

KEY WORDS: Facial nerve, Medical terminology, Temporal fascia, Temporal fat pad, Temporal muscle, Temporalis,Temporoparietal fascia

Neurosurgery 67[ONS Suppl 1]:ons120-ons130, 2010 DOI: 10.1227/01.NEU.0000383132.34056.61

SURGICAL ANATOMY Review

ABBREVIATIONS: SMAS, superficial muscu-loaponeurotic system; STA, superficial temporalartery; TPF, temporoparietal fascia

NE UROSURGERY VOLUME 67 | OPERATIVE NEUROSURGERY 1 | SEPTEMBER 2010 | ons121

ANATOMIC TERMINOLOGY FOR TEMPOROPARIETAL REGION

dardized nomenclature for the anatomic structures of the tem-poroparietal region.

PATIENTS AND METHODSMEDLINE (1950-2009) searches were conducted using the MeSH

terms “Anatomy” and “Fascia” combined with the keywords “tempo-ral,” “temporalis,” and/or “temporoparietal.” A second search was per-formed using the MeSH term “Facial Nerve” combined with the keyword“temporal branch.” Both searches were then limited to English-language studies in humans, and yielded a total of 35 and 23 articles,respectively. Of these, studies focusing on the anatomy of the fasciallayers of the temporoparietal region and of the temporal branch of thefacial nerve were selected.

To capture terminology used in descriptions of various surgical tech-niques, further MEDLINE searches were conducted using the MeSHterms “Surgical Flaps” and “Pterional Craniotomy” with the keywords“temporal,” “temporalis,” and “temporoparietal.” After limiting to English-language studies in humans, these searches yielded 124 and 26 articles,respectively. Articles that did not name or discuss the soft tissue layers ofthe temporoparietal region were excluded. Of the remaining studies, rep-resentative articles from each surgical subspecialty were chosen for inclu-sion in our review. Furthermore, the reference list of each article wasscanned for any key anatomic studies or nomenclature systems that mayhave been missed in our initial MEDLINE searches.

Each reference was reviewed for its nomenclature and anatomic descrip-tion of the fascial layers of the temporoparietal region, as well as the rela-tionship of these layers to the temporal branch of the facial nerve.

For the purpose of illustration, an adult cadaveric head was dissectedand photographed (Division of Anatomy, Department of Surgery, Universityof Toronto). Exposure to the temporoparietal soft tissue layers was gainedthrough a preauricular incision beginning at the tragus and extendingsuperiorly to a point approximately midway between the midsagittalplane and the superior temporal line. A parasagittal incision was thenmade from the lateral brow to just posterior to the mastoid process,thereby creating a T-type incision. The fascial layers were sequentiallydissected, including exposure of the superficial temporal vessels and thetemporal branches of the facial nerve. Each layer of serial dissection wasphotographed (Figure 1).

RESULTS

In total, 69 articles were included in this review. From super-ficial to deep, the temporoparietal soft tissue layers consist of skinand subcutaneous tissue, temporoparietal fascia, loose areolar tis-sue plane, temporal fascia and temporal fat pads, temporalis, andpericranium. The Table illustrates the range of terminology uti-lized for each layer by surgical specialty. Figures 1 and 2 demon-strate the temporoparietal layers in photographic and illustrationformat, respectively.

Temporoparietal FasciaImmediately subjacent to the skin and subcutaneous tissue is the

first fascial layer of the temporoparietal region, most commonlyreferred to as the temporoparietal fascia (TPF) or superficial tem-poral fascia (Table). Most authors describe the temporoparietalfascia as a single unit of highly vascular connective tissue that,

while thin, can be raised as a distinct layer.2,4,7-15 Only one studyfound this fascia to have a bilaminar structure, with the laminaenclosing the superficial temporal vessels.6 Hata16 hypothesizedthat this outer lamina was the true TPF, whereas the inner laminawas a likely component of the underlying loose areolar tissue. Todate, there has been little evidence to support the idea of a bilam-inar structure.

On its deep aspect, the temporoparietal fascia is bordered byloose areolar tissue, whereas, superficially, it is intimately relatedto the subcutaneous tissue. Its attachment to the subdermis islooser in the vicinity of the zygomatic arch, but becomes progres-sively more firm as these layers approach the vertex.7,15 Sharp dis-section in a plane just deep to the hair follicles is required toseparate the TPF from the overlying skin and subcutaneous tis-sue when raising this layer as a flap.8,12,14

The transverse boundaries of the TPF are less distinct, as itblends with adjacent musculofascial structures. Anteriorly, it iscontinuous with the frontalis and orbicularis oculi muscles, whereasposteriorly, it blends with the occipitalis and posterior auricularmuscles.1,6,7,15,17 Superiorly, the TPF merges with the galea aponeu-rotica, a dense fibrous sheet that unites the paired occipitofrontalisand auricular muscles.1,3,5-8,11,13-15,18-24 Although somewhatdebated, most reports also agree that the temporoparietal fasciais continuous inferiorly with the superficial musculoaponeuroticsystem (SMAS).1,5,21,22 The SMAS is an organized fibrous net-work that lies below the zygomatic arch and connects the facialmimetic muscles to the overlying dermis.25-27 The continuitybetween the TPF, galea, and SMAS has generated additional ter-minology for describing the TPF, including “galeal extension” or“extension of epicranial aponeurosis,”3,20,23,28 and “suprazygo-matic/temporal extension of the SMAS.”2,17,27

Other, less intuitive, terms have also been applied to the TPF,such as “mesotemporalis”29,30 and “temporoparietalis.”16 The lat-ter was proposed by Hata16 in 2001 to reflect his belief in the truemuscular nature of the temporoparietal fascia, albeit noting thatthese muscle fibers cannot be seen macroscopically. In support ofthis nomenclature, Tellioglu et al6 found a thin muscle layer withinthe temporoparietal fascia in their histological study. No otheranatomic study supports this finding, however.

It is well accepted that the superficial temporal vessels providethe dominant vascular supply to the temporoparietal fascia, withthe zygomatico-orbital, zygomaticotemporal, zygomaticofacial, andtransverse facial arteries providing minor contributions.31 Whileall studies agree that the superficial temporal artery (STA) lies inclose association with the temporoparietal fascia, the exact plane inwhich the respective superficial temporal artery and vein run differsbetween reports. In most descriptions, the vein lies on the surfaceof the temporoparietal fascia, slightly superficial to the artery, whichitself lies within the temporoparietal fascia.4,6-8,13,15,19,24,32,33 Thereare others, however, who depict both the superficial artery and veinas lying in the same plane: either superficial to the temporoparietalfascia,2,14,23,28,31 within this fascia,17 or deep to this fascia within theoutermost aspect of the loose areolar layer.3,10


DAVIDGE ET AL

Loose Areolar Tissue PlaneA loose areolar tissue plane lies deep

to the temporoparietal fascia andextends beneath the entire superficialfascial system of the scalp, includingthe galea aponeurotica and the frontalisand occipitalis muscles.2,5,10,13,14,34,35

The gliding nature and extensive spanof the loose areolar tissue plane con-tribute to scalp mobility by allowingthe skin and TPF to move in relationto the temporalis fascia and perios-teum.7,34,36

Anteriorly, the loose areolar tissueplane courses deep to the orbicularisoculi muscles14 and contributes to theformation of the retro- and suborbic-ularis oculi fat pads.2 Inferior to thetemporoparietal region, the loose are-olar layer becomes discontinuous,being separated by dense attachmentsbetween the superficial and deep fas-cial systems in 3 regions: the zygo-matic arch, the parotid gland, and theanterior border of the masseter mus-cle.35 The areolar tissue plane exists,however, between the SMAS and theparotideomasseteric fascia in the cheek,and between the platysma and theunderlying strap muscles in the neck.35

As with the TPF, the continuityof the loose areolar tissue planes inthe temporal, scalp, and facial regionshas led to alternate terms for thislayer, including “subgaleal fas-cia,”2,3,8,10,14,16,20,28,36-38 “subaponeu-rotic plane,”7,10,13,19,21,35,37 “sub-SMASplane,”29,38 and “areolar temporalisfascia.”39 In addition, the term “innom-inate fascia” has been applied to theloose areolar tissue plane.1,6,40,41

Confusingly, this term has also beenused for the superficial leaflet of thetemporal fascia.13

Histologically, the loose areolar tis-sue plane was shown to be trilami-nate, consisting of a central layer ofwell-defined collagen, flanked by looseareolar tissue and microscopic branchesof blood vessels and nerves.14 The vas-cularity of the loose areolar tissue planehas been discussed controversially inthe literature. It has been alternatelydescribed as avascular 8,11,13,21,39 and

FIGURE 1. Soft tissue layers of the temporoparietal region. A, temporoparietal fascia; underneath this layer liesthe loose areolar layer (not shown). B, temporal fascia investing temporalis; the temporal fascia splits at the levelof the superior orbital margin into superficial and deep leaflets encompassing a fat pad. C, removal of the super-ficial leaflet of temporal fascia reveals the fat pad of temporal fascia. D, deep leaflet of temporal fascia. E, removalof the temporal fascia reveals temporalis and the fat pad deep to temporal fascia. F, temporalis (temporal muscle).G, pericranium. H, temporal branches of the facial nerve.

A B

CD

E F

G H



of fusion with the periosteumoccurs at the superior temporalline.4,5,7,11,14,28,33 The temporalfascia terminates inferiorly byattaching to the zygomaticarch.1,28

Several authors describe a splitin the temporal fascia at the levelof the superior orbital mar-gin.2,3,10,13,14,21,28,35,46,47 Thesuperficial and deep leaflets ofthe temporal fascia then divergeto encompass a fat pad. Con -troversy exists as to whetherthese lamina at tach inde -pendently to the zygomaticarch,3,13,14,46 or whether theyfuse superior to the arch.47,48

Campiglio and Candiani2 sug-gested that fusion occurs ante-riorly and posteriorly, but thatthe leaflets remain separated inthe middle by adipose tissue.After 10 cadaveric dissections,Accioli de Vasconcellos et al1proposed that only the superfi-

cial leaflet attaches to the zygomatic arch, while the deep leafletremains in intimate connection with the temporalis.

Below the zygomatic arch, the superficial leaflet of the tem-poral fascia is continuous with the parotideomasseteric fas-cia.1,3,13,28,35 Similarly, the deep leaflet of the temporal fasciablends with the posterior masseteric fascia.13,21 Some studies haveconfusingly reported that the temporoparietal fascia8,22 and looseareolar tissue plane16,41 are also in continuity with the parotideo-masseteric fascia. However, most authors would agree that theTPF and loose areolar tissue plane in the temporoparietal regionare continuous with the SMAS and loose areolar tissue of themidface, respectfully.5

Both the superficial2,7,10,15,24,33,42,49 and deep2,24 lamina ofthe temporal fascia are supplied by the middle temporal artery, abranch of the superficial temporal artery that arises below the pos-terior edge of the zygomatic arch.31 The blood supply of the tem-poral fascia may also be supplemented by the zygomaticotemporal,zygomaticofacial, and transverse facial arteries.31

Among those who describe the temporal fascia as bilaminar,the naming of the superficial and deep leaflets is inconsistent.Most commonly, the terms “superficial and deep layers of the tem-poral fascia” are utilized.10,13,14,24,30,38,41,46,50 However, they havealso been described as the “superficial and deep temporalis fas-cia,”3,10 the “superficial and deep layers of the deep temporal fas-cia,”11 the “intermediate and deep temporal fascia,”2 and the“superior and inferior layers of the superficial temporalis fascia.”23

In addition, Stuzin et al13 offered the synonym “innominate fas-cia” for the superficial leaflet of the temporalis fascia.

richly vascularized.1,10,14,36,37,40 Detailed anatomic studies of thetemporal vasculature have suggested that above the superior tem-poral line, the loose areolar tissue receives a dual blood supplyfrom descending branches of the superficial temporal artery thatperforate the TPF, and from branches of the middle meningealartery that penetrate upward through the calvarium.31,42-44 Betweenthe superior temporal line and the zygomatic arch, oblique descend-ing branches of the superficial temporal and zygomatico-orbital arter-ies penetrate the TPF to arborize within the loose areolar plane,particularly within its superficial aspect.31,42-44

The potential clinical applications of the loose areolar tissuehave been recently delineated. Carstens et al34 noted 6 propertiesthat permit the loose areolar tissue to be successfully utilized forreconstructive surgery: delicacy, elastic strength, a gliding surface,vascularity, minimal donor site morbidity, and multiple potentialpedicles. Indeed, this layer has been raised as both an independ-ent flap, as well as a composite flap with the TPF or superficialleaflet of the temporal fascia.1,34,36,45

Temporal FasciaThe temporal fascia is the dense fascia that invests the tempo-

ralis (temporal muscle).5,7,13,14 The terminology utilized for thetemporal fascia is confusing, ranging from “superficial temporalfascia” (a name also used for the TPF), “deep temporal fascia,”and “true temporalis fascia” (Table). The boundaries of the tem-poral fascia are demarcated by the subjacent temporalis muscle.Beyond the muscle, the temporal fascia fuses with the periosteumof the temporal, parietal, and frontal bones; superiorly, the point

FIGURE 2. A schematic of the anatomic layers of the temporoparietal region.


DAVIDGE ET AL

Temporalis (Temporal Muscle)Compared with the fascial structures that overlie it, the naming

of the temporalis is unambiguous and includes “temporalis” or “tem-poral muscle” in English, and “musculus temporalis” in Latin.51

The fan-shaped temporal muscle arises from both the deep sur-face of the temporalis fascia and the temporal fossa. It may alsotake origin from the greater wing of the sphenoid bone, or thetemporal surface of the zygomatic bone.52 It extends superiorlyto the superior temporal line and inferiorly it passes deep to thezygomatic arch to attach to the coronoid process and the anteriorramus of the mandible.5,10 The anterior surface of temporalis is cov-ered by the deep lamina of the temporal fascia above the zygo-matic arch; below the arch, its surface is exposed. By most accounts,its posterior surface lies directly on pericranium. In an early work,Yaşargil23 described a thin layer of fascia deep to temporalis, whichhe called “deep temporalis fascia.” Subsequent research by thesame author did not substantiate this finding, however.5 Interestingly,Ziccardi et al24 also found an intramuscular fascial layer, whichthey used as the inferior plane of dissection in their elevation ofa temporalis muscle flap for temporomandibular joint reconstruc-tion. To date, this finding has not been replicated.

Both the middle temporal artery and the anterior and poste-rior deep temporal arteries supply the temporalis,24,31,33,49,52,53

although a few reports mention only the deep temporal arterialsupply.10,20 The temporal muscle is innervated by the anteriorand posterior deep temporal nerves (branches of the mandibulardivision of the trigeminal nerve), which run on its inferior sur-face.18 Burggasser et al53 also noted innervation from temporalbranches of the buccal and masseteric nerves.

PericraniumThe pericranium is the deepest layer of the temporoparietal

region, and comprises the periosteum of the cranial bones.5Although most authors utilize the terms “pericranium” and “perios-teum” interchangeably, the concept of “pericranial flaps” may dif-fer between surgical studies. Indeed, some authors have utilized theterm “pericranial flap” to denote a periosteal flap,54-56 whereasothers have used it as a synonym for galeal-periosteal flaps.57-61

Readers should be aware of this distinction and of the variabledefinitions in the literature.

Temporal Fat PadsReports differ as to whether 2 or 3 fat pads exist within the

temporoparietal region. Four studies describe a fat pad between theTPF and the superficial leaflet of the temporal fascia.1-3,14 Campiglioand Candiani,2 Tollhurst et al,14 and Accioli de Vasconcellos et al1named this the “superficial fat pad,” whereas Coscarella et al3applied the term “suprafascial fat pad.” However, many othershave not identified a fat pad superficial to the temporal fascia.The presence or absence of this fat pad may be variable and dependon individual characteristics, such as obesity.

Another fat pad lies between the superficial and deep leafletsof the temporal fascia, and is more universally present. This was

TABL

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Reg

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1984

46

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n,19

903

3

Wor

mal

d &

Alu

n-Jo

nes,

1991

15

Dav

id &

Chen

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1995

4

Zicc

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l,19

972

4

Bozz

etti

etal

,19

996

9

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993

9

Schm

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,20

012

2

Ols

onet

al,

2002

10

Falla

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al20

03,8

Lope

zet

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2003

19

Man

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nda,

2003

49

Prad

eset

al,

2003

67

Tem

poro

parie

tal

fasc

iaST

FTP

F/ST

F/G

E/EA

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TPF

TPF

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TsF

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called the “intermediate” fat pad by Campiglioand Candiani2 and Accioli de Vasconcellos et al,1the “interfascial” fat pad by Coscarella et al,3and the “intrafascial” fat pad by Ammirati et al.28

However, for the many authors who have failedto identify a fat pad superficial to the temporalfascia, the fad pad lying between the lamina ofthe temporal fascia is accordingly termed the“superficial fat pad”10,13,30,38,50 or is left name-less.23,46,51 In a detailed anatomic study, Kimand Matic38 characterized this fat pad as a quad-rangular, fan-shaped structure suspended to thesuperficial leaflet of the temporalis fascia byfibrous septations. It was limited inferiorly bythe zygomatic arch, anteriorly by the lateralorbital wall, and extended superiorly to justabove the zygomatico-frontal suture.38 In con-trast to the findings of Kim and Matic38 andStuzin et al,13 Ziccardi et al24 found the fat padof temporal fascia to be continuous inferiorlywith the buccal fat pad.

The middle temporal artery2,10,38 and zygo-maticotemporal nerve3,38,62 have been found totravel through the substance of the fat pad oftemporal fascia. Kim and Matic38 found thatits blood supply originated from both the mid-dle and deep temporal arteries, but in an earlierreport, Stuzin et al13 felt that it was suppliedsolely by the middle temporal artery.

The final well-described fat pad of the tem-poroparietal region is located between the deepleaflet of the temporal fascia and the temporalis.In most reports, this fat pad is named the “deeptemporal fat pad,”1,2,13,14,28,30,38,50 although“subfascial fat pad” has also been utilized.3 Thefat pad deep to temporal fascia begins just supe-rior to the zygomatic arch and extends inferi-orly below the arch to become continuous withthe buccal fat pad.2,13,14,30,38,63 The functions ofthe fat pad deep to temporal fascia and the buc-cal fat are therefore likely similar: to line andprotect the masticatory space,13 and to allowthe temporalis muscle to glide smoothly overbony prominences.2

Temporal Branch of the Facial NerveThe temporal branch of the facial nerve, also

called the frontal or temporofrontal branch of thefacial nerve, emerges at the anterosuperior aspectof the parotid gland, just caudad to the zygo-matic arch.7,13 As it crosses the zygomatic arch,the temporal branch divides into multiple ramithat remain highly interconnected throughouttheir trajectory.32,41,64 The point at which the

TABL

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Mit

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762

7

Abd

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Has

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67

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1989

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1990

17

Tolh

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911

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al,

1992

35

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1994

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981

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DAVIDGE ET AL

temporal branch crosses the zygomatic arch is under somedebate, and can be difficult to compare between studiesowing to the use of different superficial landmarks fromwhich the location of the nerve is measured. Abdul-Hassanet al7 found that the temporal branch crossed the arch onefingerbreadth behind the posterior margin of the zygo-matic process of the frontal bone. Quirke et al11 andCampiglio and Candiani2 depicted the temporal branchas crossing the midpoint of the arch between the lateralcanthus and the crus of the helix. Lei et al32 had similarfindings, whereby the temporal branch crossed the zygomaticarch between the anterior side of the tragus and the lateralside of the orbicularis oculi muscle, at the junction of themiddle and lateral thirds of the arch.

Other authors have described the temporal branch ofthe facial nerve as having multiple rami that span acrossthe arch and cannot be localized to a specific point.3,41,64,65

Al-Kayat et al65 found the most posterior branch of thefacial nerve to cross the arch at 2.0 ± 0.5 cm from the mostanterior concavity of the bony external auditory canal.Gosain et al41 divided the temporal branch into anterior,middle, and posterior rami, which diverge as they proceedcranially so that they span 29 mm at the inferior border ofthe arch and 36 mm at the superior border. Based on theirstudy of 12 cadaveric facial halves, they found the safestpoints for dissection along the zygomatic arch to be within10 mm anterior to the external acoustic meatus or up to19 mm posterior to a vertical line through the lateral orbitalrim.41 Coscarella et al3 also separated the temporal branchof the facial nerve into 3 distinct rami, but named themdifferently: rami auricularis, rami frontalis, and rami orbic-ularis. The authors only specify where rami frontalis crossesthe zygomatic arch, which is approximately 2 cm anteriorto the tragus.3

The superficial temporal artery lies in close proximityto the temporal branch of the facial nerve, and has longbeen suggested as a landmark for localizing the nerve.66

Coscarella et al3 found the rami frontalis to lie within 1cm of the frontal branch of the STA. Several authors agreethat the temporal branch of the facial nerve runs parallel andanteroinferior to the frontal branch of the STA.6,7,11,13,19,28

However, Gosain et al41 found that the more anterior divi-sions of the nerve do remain anteroinferior to the frontalbranch of the STA, but the more posterior divisions lie inintimate connection with the STA throughout its course.In a recent anatomic study of the relationship between theSTA and the temporal branch of the facial nerve, Lei et al32

found that this relationship varied according to the pointof STA bifurcation. If the STA bifurcated above the hori-zontal line of the superior orbital rim, the temporal branchwas consistently anteroinferior to the STA. On the otherhand, if STA bifurcation occurred below this line, one ormore branches of the nerve could be located superior to, orinterweaving with, the STA.32

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Superior to the zygomatic arch, the temporal branch of thefacial nerve travels in an oblique line toward the frontalis mus-cle. In 1989, Stuzin et al13 commented that the temporal branchinnervates frontalis above the level of the superior orbital rim.Later studies have sought to measure the trajectory of the tem-poral branch more precisely. Quirke et al11 determined the tem-poral branch to pass from a point 0.5 cm below the tragus to apoint 3 cm lateral to the orbital rim. Fallah et al8 found thesuperior point of the temporal branch at 3 cm above and 2 cmlateral to the supraorbital rim, whereas Schmidt et al22 locatedit at approximately 2.5 cm lateral and 2.8 cm superior to thelateral canthus.

Rather than depicting a single trajectory, Seckel30 delineated atriangular area within which the temporal branch can be found.He named this area “facial danger zone 2,” and it is outlined by draw-ing a line from 0.5 cm below the tragus to a point 2 cm above thelateral eyebrow, drawing a second line on the zygoma to the lat-eral orbital rim, and then connecting these 2 lines with a thirdline.30 Lei et al32 similarly defined a triangular area housing the tem-poral branch of the facial nerve, formed by the “lower aspect of thezygomatic arch, the vertical line crossing the highest point of thefrontal eminence of the frontal bone, and the course of the frontalbranch” of the STA.

Understanding the anatomic relationship between the tempo-ral branch of the facial nerve and the soft tissue layers of the tem-poroparietal region can be confusing owing to the variable namingof these layers. Between the parotid gland and the zygomatic arch,the temporal branch lies deep to SMAS.2,14,22,27 The nerve thencourses more superficially and has been described as lying on theundersurface of both the TPF13 and the loose areolar tissue1 atthe level of the zygomatic arch. Above the zygomatic arch, thereis general agreement that the temporal branch of the facial nervelies in a plane between the temporoparietal fascia and the super-ficial leaflet of the temporalis fascia.3,6-8,10,15,22,24,25,28,30,33,49,67 Stuzinet al13 and Hwang et al48 have described the temporal branch aslying within the TPF itself; although, in a later article, Stuzinet al35 agreed that the nerve runs on the underside of the TPF,only becoming invested within the TPF peripherally. Earlier stud-ies have also depicted the temporal branch of the facial nerve as run-ning in a slightly deeper plane, such as deep to the loose areolarlayer2 or within the superficial lamina of the deep temporal fascia.23

By most accounts, the temporal branch of the facial nerve trav-els in a constant plane, but becomes more superficial and hori-zontal as it nears its target muscles.2,13,21,22 The temporal branchprimarily innervates the frontalis, corrugator, and orbicularis oculimuscles, yet also supplies more posterior mimetic muscles suchas the anterior auricular muscle.21,22,28,32 Although both Gosainet al41 and Coscarella et al3 subdivided the temporal branch intorami, Gosain et al found that they could not differentiate whichrami innervate which facial muscles. According to Coscarella et al,however, the most posterior rami (rami auricularis) innervate thetemporoparietal, auricular, and tragal muscles, the most anteriorrami (rami orbicularis) innervate the orbicularis oculi muscle, andthe central rami (rami frontalis) innervate the frontalis muscle.3



DISCUSSION

There is no doubt that the anatomy of the temporoparietalregion is complex. Although researchers have sought to clarify thesoft tissue layers of the temporoparietal area, most studies arebased on small numbers of cadaveric dissections or on personalsurgical experience. Together with interindividual anatomic vari-ability, it is not surprising that findings differ between studies.Furthermore, the complexity of the anatomy is compounded bythe conflicting and variable names used for each temporoparietallayer both within and between surgical subspecialties. This incon-sistent nomenclature renders it easy to misinterpret and confuseterms used in the literature.

Temporoparietal anatomy also has major clinical implica-tions. Protection of the temporal branch of the facial nerve is crit-ical to a wide range of surgical procedures, from raising atemporoparietal fascial flap to performing a pterional or orbitocra-nial craniotomy, or reconstructing the temporomandibularjoint. A detailed understanding of this anatomy is also vitallyimportant for safe surgical dissection in modern proceduresusing limited-access incisions, such as endoscopic brow lifts.Our experience indicates that localizing the temporal branchof the facial nerve by its relation to defined anatomic landmarksprovides the best method for ensuring safe surgical dissection.Distance- and fingerbreadth-based localizations of the nerveare subject to both measurement error and error due to indi-vidual variability in cranial anatomy. The fallacy of this approachis highlighted in this review by the inconsistent distance meas-urements across studies.

Techniques for protecting the temporal branch of the facial nerveduring surgical dissection depend on the goal of surgery and there-fore vary somewhat between studies. Transition points, such as thezygomatic arch and lateral brow (medial limit of temporal fascia),68

present the highest risk for nerve injury. Most authors agree that dis-secting in the loose areolar tissue plane is safe superiorly, but thatcloser to the zygomatic arch, the plane of dissection should becomedeep to the superficial leaflet of the temporal fascia (ie, within thefat pad of the temporal fascia) so as to protect the temporal branchof the facial nerve.5,32 The point at which this transition shouldtake place has been variably defined, using both landmarks, suchas the inferior temporal septum,5 and distances, such as 2 cm abovethe zygomatic arch.13,24 At the zygomatic arch, the condensed fas-cial layers necessitate a subperiosteal dissection for facial nerve pro-tection.1,5,32 Variations of this approach do exist, however. Telliogluet al6 believe that dissecting in a subcutaneous plane, superficialto the TPF, carries less risk to the temporal branch of the facialnerve than dissecting in a sub-TPF plane. Based on their observa-tion that the superficial and deep leaflets of the temporal fasciafuse above the zygomatic arch, Ramirez et al47 and Hwang et al48

suggested that caudal dissection deep to the deep leaflet of the tem-poral fascia is required to adequately protect the nerve. When rais-ing a temporoparietal-galeal flap, Fallah et al8 dissect caudally in theloose areolar tissue all the way to the zygomatic arch, with no tran-sition to a deeper plane.


DAVIDGE ET AL

Considering the significant risks associated with temporopari-etal surgery, foremost including facial nerve injury, it is imperativeto understand and teach effective and safe dissection techniqueswithin all surgical subspecialties. This is best facilitated by a uni-versal, clear, and consistent description of the anatomy of the tem-poroparietal region. For this reason, the goals of this study were3-fold. First, by performing a comprehensive review of the anatomyof the temporoparietal region, we hoped to make readers awareof the breadth of terminology in use for the soft tissue layers ofthe temporoparietal region, and thus provide a tool for the accu-rate interpretation of the existing literature. Second, by drawingattention to the controversies among studies, we hoped to high-light areas requiring further anatomic study. Finally, we wantedto recommend a naming system for the soft tissue layers of thetemporoparietal region, to be utilized across all surgical disci-plines. The terminology we propose is based on the TerminologicaAnatomica51 and is simple, but descriptive. From superficial todeep, the proposed terms for the temporoparietal layers are: (1) tem-poroparietal fascia, (2) loose areolar tissue plane, (3) superficialleaflet of temporal fascia, (4) fat pad of temporal fascia, (5) deepleaflet of temporal fascia, (6) fat pad deep to temporal fascia, (7)temporalis or temporal muscle (musculus temporalis), and (8)pericranium (periosteum externum cranii).

It is our hope that applied uniformly and consistently, a com-mon language for anatomic descriptions of the temporoparietalregion will improve learning and communication within andbetween surgical disciplines, and will ultimately benefit patientoutcomes following temporoparietal surgery.

DisclosureThe authors have no personal financial or institutional interest in any of the

drugs, materials, or devices described in this article.

REFERENCES1. Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C. The fascial planes of the

temple and face: an en-bloc anatomical study and plea for consistency. Br J PlastSurg. 2003;56(7):623-629.

2. Campiglio GL, Candiani P. Anatomical study on the temporal fascial layers andtheir relationship with the facial nerve. Aesth Plast Surg. 1997;21(2):69-74.

3. Coscarella E, Vishteh AG, Spetzler RF, Seoane E, Zabramski JM. Subfascial and sub-muscular methods of temporal muscle dissection and their relationship to thefrontal branch of the facial nerve. J Neurosurg. 2000;92(5):877-880.

4. David SK, Cheney ML. An anatomic study of the temporoparietal fascial flap.Arch Otolaryngol Head Neck Surg. 1995;121(10):1153-1156.

5. Krayenbuhl N, Isolan GR, Hafez A, Yaşargil MG. The relationship of the fronto-temporal branches of the facial nerve to the fascias of the temporal region: a liter-ature review applied to practical anatomical dissection. Neurosurg Rev. 2007;30(1):8-15.

6. Tellioglu AT, Tekdemir I, Erdemli EA, Tuccar E, Ulusoy G. Temporoparietal fas-cia: an anatomic and histologic reinvestigation with new potential clinical applica-tions. Plast Reconstr Surg. 2000;105(1):40-45.

7. Abdul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and bloodsupply of the fascial layers of the temporal region. Plast Reconstr Surg. 1986;77(1):17-28.

8. Fallah DM, Baur DA, Ferguson HW, Helman JI. Clinical application of the tem-poroparietal-galeal flap in closure of a chronic oronasal fistula: review of the anatomy,surgical technique, and report of a case. J Oral Maxillofac Surg. 2003;61(10):1228-1230.

9. Mokal NJ, Raje RS, Ranade SV, Prasad JS, Thatte RL. Release of oral submucousfibrosis and reconstruction using superficial temporal fascia flap and split thick-ness skin graft-a new technique. Br J Plast Surg. 2005;58(8):1055-1060.

10. Olson KL, Manolidis S. The pedicled superficial temporalis fascial flap: a newmethod for reconstruction in otologic surgery. Otolaryngol Head Neck Surg.2002;126(5):538-547.

11. Quirke T, Fiorillo M, Sharma P. The reverse temporoparietal fascia flap. PlastReconstr Surg. 1998;101(5):1338-1341.

12. Raffaini M, Costa P. The temporoparietal fascia flap in reconstruction of the cranio-maxillofacial area. J Craniomaxillofac Surg. 1994;22(5):261-267.

13. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branchof the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg.1989;83(2):265-275.

14. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ. The surgical anatomy of thescalp. Plast Reconstr Surg. 1991;87(4):603-612.

15. Wormald PJ, Alun-Jones T. Anatomy of the temporalis fascia. J Laryngol Otol.1991;105(7):522-524.

16. Hata Y. Is it true that the temporoparietal fascia has two layered structures? PlastReconstr Surg. 2001;107(5):1309-1310.

17. Thaller SR, Kim S, Patterson H, Wildman M, Daniller A. The submuscular aponeu-rotic system (SMAS): a histologic and comparative anatomy evaluation. PlastReconstr Surg. 1990;86(4):690-696.

18. Hu Z-Q, Ogawa R, Aoki R, Gao JH, Hyakusoku H. Temporalis muscle-galea pedi-cled flap for reconstruction of longstanding facial paralysis. J Nippon Med Sch.2005;72(2):105-112.

19. Lopez R, Dekeister C, Sleiman Z, Paoli JR. The temporal fasciocutaneous islandflap for oncologic oral and facial reconstruction. J Oral Maxillofac Surg. 2003;61(10):1150-1155.

20. Miyazawa T. Less invasive reconstruction of the temporalis muscle for pterionalcraniotomy: modified procedures. Surg Neurol. 1998;50(4):347-351.

21. Salas E, Ziyal IM, Bejjani GK, Sekhar LN. Anatomy of the frontotemporal branchof the facial nerve and indications for interfascial dissection. Neurosurgery.1998;43(3):563-568; discussion 568-569.

22. Schmidt BL, Pogrel MA, Hakim-Faal Z. The course of the temporal branch of thefacial nerve in the periorbital region. J Oral Maxillofac Surg. 2001;59(2):178-184.

23. Yaşargil MG. Interfascial temporalis flap. In: Microneurosurgery. Vol 1. Stuttgart,Germany: Georg Thieme Verlag; 1984.

24. Ziccardi VB, Schneider RE, Braun TW. Intramuscular temporalis fascia: a guide toprocurement of temporalis myofascial flaps. J Craniofac Surg. 1997;8(1):23-28.

25. Ghassemi A, Prescher A, Riediger D, Axer H. Anatomy of the SMAS revisited.Aesthetic Plast Surg. 2003;27(4):258-264.

26. Gosain AK, Yousif NJ, Madiedo G, Larson DL, Matloub HS, Sanger JR. Surgicalanatomy of the SMAS: a reinvestigation. Plast Reconstr Surg. 1993;92(7):1254-1263.

27. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in theparotid and cheek area. Plast Reconstr Surg. 1976;58(1):80-88.

28. Ammirati M, Spallone A, Jianya M, Cheatham M, Becker D. An anatomicosurgi-cal study of the temporal branch of the facial nerve. Neurosurgery. 1993;33(6):1038-1044.

29. de la Fuente A, Honig JF. Video-assisted endoscopic transtemporal multilayer uppermidface lift (MUM-Lift). J Craniofac Surg. 2005;16(2):267-276.

30. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery. St.Louis, MO: Quality Medical Publishing, Inc.; 1994.

31. Nakajima H, Imanishi N, Minabe T. The arterial anatomy of the temporal regionand the vascular basis of various temporal flaps. Br J Plast Surg. 1995;48(7):439-450.

32. Lei T, Xu DC, Gao JH, et al. Using the frontal branch of the superficial temporalartery as a landmark for locating the course of the temporal branch of the facialnerve during rhytidectomy: an anatomical study. Plast Reconstr Surg. 2005;116(2):623-629.

33. Pogrel MA, Kaban LB. The role of a temporalis muscle flap in temporomandibu-lar joint surgery. J Oral Maxillofac Surg. 1990;48(1):14-19.

34. Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE. Clinical applications of thesubgaleal fascia. Plast Reconstr Surg. 1991;87(4):615-626.

35. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deepfacial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441-449; discussion 450-451.



36. Tremolada C, Candiani P, Signorini M, Vigano M, Donati L. The surgical anatomyof the subcutaneous fascial system of the scalp. Ann Plast Surg. 1994;32(1):8-14.

37. Copcu E, Sivrioglu N. The new reconstruction technique in the treatment of theskin cancers located on the eyelid: posterior temporalis fascia composite graft. IntSemin Surg Oncol. 2004;1(1):5-13.

38. Kim S, Matic D. The anatomy of temporal hollowing: the superficial temporal fatpad. J Craniofac Surg. 2005;16(4):651-654.

39. Cueva RA. Areolar temporalis fascia: a reliable graft for tympanoplasty. Am J Otol.1999;20(6):709-711.

40. Casanova R, Cavalcante D, Grotting JC, Vasconez LO, Psillakis JM. Anatomicbasis for vascularized outer table calvarial bone flaps. Plast Reconstr Surg.1986;78(3):300-308.

41. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial nerve: how reli-ably can we predict its path? Plast Reconstr Surg. 1997;99(5):1224-1233; discus-sion 1234-1236.

42. Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper craniofacialskeleton: the search for composite calvarial bone grafts. Plast Reconstr Surg.1984;74(5):603-610.

43. Horowitz JH, Persing JA, Nichter LS, Morgan RF, Edgerton MT. Galeal-pericra-nial flaps in head and neck reconstruction: anatomy and application. Am J Surg.1984;148(4):489-497.

44. McCarthy JG, Zide BM. The spectrum of calvarial bone grafting: introduction ofthe vascularized calvarial bone flap. Plast Reconstr Surg. 1984;74(1):10-18.

45. Park C, Lew DH, Yoo WM. An analysis of 123 temporoparietal fascial flaps:anatomic and clinical considerations in total auricular reconstruction. Plast ReconstrSurg. 1999;104(5):1295-1306.

46. Kreutziger KL. Surgery of the temporomandibular joint. I. Surgical anatomy andsurgical incisions. Oral Surg. 1984;58(6):637-646.

47. Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal face lift: a defin-itive soft tissue remodeling for facial rejuvenation. Plast Reconstr Surg. 1991;88(2):227-238.

48. Hwang K, Kim DJ. Attachment of the deep temporal fascia to the zygomatic arch:an anatomic study. J Craniofac Surg. 1999;10(4):342-345.

49. Mani V, Panda AK. Versatility of temporalis myofascial flap in maxillofacial recon-struction-analysis of 30 cases. Int J Oral Maxillofac Surg. 2003;32(4):368-372.

50. Hwang K, Lee DK, Kim HJ, Shin YH, Chung IH. Zygomaticomandibularis mus-cle. J Craniofac Surg. 2005;16(4):655-657.

51. Federal Committee on Anatomical Terminology (FCAT). Terminologica Anatomica:International Anatomical Terminology. Stuttgart, Germany: Thieme; 1998.

52. Elazab EEB, Abdel-Hameed FAH. The arterial supply of the temporalis muscle. SurgRadiol Anat. 2006;28(3);241-247.

53. Burggasser G, Happak W, Gruber H, Freilinger G. The temporalis: blood supplyand innervation. Plast Reconstr Surg. 2002;109(6):1862-1869.

54. Abe T, Goda M, Kamida T, et al. Overlapping free bone graft with galea-pericra-nium in reconstruction of the anterior skull base to prevent CSF leak and sequestrumformation. Acta Neurochir (Wien). 2007;149(8):771-775.

55. Autelitano L, Rabbiosi D, Poggio A, Biglioli F. Pericranium graft in reconstructivesurgery of atrophied maxillary bones. Minerva Stomatol. 2008;57(5):265-274.

56. Mohanty A, Suman R. Role of galeal-pericranial flap in reducing postoperativeCSF leak in patients with intracranial endoscopic procedures. Childs Nerv Sys.2008;24(8):961-964.

57. Donath A, Sindwani R. Frontal sinus cranialization using the pericranial flap: andadded layer of protection. Laryngoscope. 2006;116(9):1585-1588.

58. Leatherbarrow B, Watson A, Wilcsek G. Use of the pericranial flap in medial can-thal reconstruction: another application for this versatile flap. Ophthal Plast ReconstrSurg. 2006;22(6):414-419.

59. Moshaver A, Harris JR, Seikaly H. Use of anteriorly based pericranial flap in frontalsinus obliteration. Otalaryngol Head Neck Surg. 2006;135(3):413-416.

60. Yung M, Smith P. Mid-temporal pericranial and inferiorly based periosteal flapsin mastoid obliteration. Otolaryngol Head Neck Surg. 2007;137(6):906-912.

61. Zanation AM, Snyderman CH, Carrau RL, Kassam AB, Gardner PA, PrevedelloDM. Minimally invasive endoscopic pericranial flap: a new method for endonasalskull base reconstruction. Laryngoscope. 2009;119(1):13-18.

62. Hwang K, Suh MS, Lee SI, Chung IH. Zygomaticotemporal nerve passage in theorbit and temporal area. J Craniofac Surg. 2004;15(2):209-214.

63. Dubin B, Jackson IT, Halim A, Triplett WW, Ferreira M. Anatomy of the buccalfat pad and its clinical significance. Plast Reconstr Surg. 1989;83(2):257-262.

64. Sabini P, Wayne I, Quatela VC. Anatomical studies to precisely localize the frontalbranch of the facial nerve. Arch Facial Plast Surg. 2003;5(2):150-152.

65. Al-Kayat A, Bramley P. A modified pre-auricular approach to the temporomandibu-lar joint and malar arch. Br J Oral Surg. 1979;17(2):91-103.

66. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of itsvariations in face lifting. Plast Reconstr Surg. 1966;38(4):352-356.

67. Prades J-M, Timoshenko A, Merzougui N, Martin C. A cadaveric study of a com-bined trans-mandibular and trans-zygomatic approach to the infratemporal fossa.Surg Radiol Anat. 2003;25(3-4):180-187.

68. Lettieri S. Frontal branch of the facial nerve: galeal temporal relationship. AesthetSurg J. 2008;28(2):143-146.

69. Bozzetti A, Biglioli F, Salvato G, Brusati R. Technical refinements in surgical treat-ment of benign parotid tumours. J Craniomaxillofac Surg. 1999;27(5):289-293.

COMMENTS

Parallel to current training possibilities and technological surgical tools,the development of surgery is ultimately based in a more detailed

anatomical knowledge of its battle fields. Because of its practical aim,knowledge in surgical anatomy applies mostly in the description of theanatomical structures with an emphasis on their relationships and limits(sometimes very difficult to determine as in this topic), but should applyalso in establishing a common anatomical nomenclature, and, in bothof these directions, this article by Davidge et al is very opportune for allsurgical specialties that deal with the superficial cranial layers. Thesestructures are well described within the text, their namings are appropri-ately mentioned along the results, with the discussion left more to theirrelated surgical issues. As the authors propose, because of its official char-acter, the surgical anatomical nomenclature should be ultimately basedon the Terminologia Anatomica1 that replaced the previous NominaAntomica.2 Nevertheless, the common use of classic anatomical terms isdifficult to be avoided in the surgical practice, and, in our opinion, thesetraditional terms should be also properly defined and progressively incor-porated in the Terminologia Anatomica grounded in this type of study.The Federative Committee on Anatomical Terminology that edits theTerminologia Anatomica, or International Anatomical Terminology,1welcomes the proposal of anatomical terms, which can be done througha card for this aim that comes enclosed in this publication. Davidge etal should now forward them their proposals based in this article, and sur-geons, clinicians, radiologists, and clinical anatomists should be moti-vated by this type of study and by the real necessity of unifying anatomicterminology.

Dov C. GoldenbergGuilherme Carvalhal RibasSão Paulo, Brazil

1. Federative Committee on Anatomical Terminology. International AnatomicalTerminology. Stuttgart, Germany: Thieme; 1998.

2. Excerpta Medica Foundation. Nomina Anatomica. 6th ed. Amsterdam; 1980.

Although neurosurgeons are in awe of the remarkable neurovascularanatomy of the human skull base and although we thirst to assimi-

late every bit of it, reading this manuscript that deals with a less thanglamorous anatomy of the temporoparietal extracranial soft tissues wasnevertheless enjoyable and refreshing. Indeed, the authors are correct tohighlight the inconsistencies in the nomenclature of various temporopari-etal soft tissue layers, leading to confusion across surgical disciplines at bestand injuries to the frontotemporal branch of the facial nerve at worst. Iwas pleased to see that the authors referred in their literature review toProfessor Yaşargil’s classic work (references 5 and 23) on the subject ofthe anatomic relationship of the frontotemporal branch of the facial nerve


DAVIDGE ET AL

to the fascial planes and fat pads in the temporal region. For decades thiswork has served as the blueprint for navigation in conjunction with fron-totemporal approaches. It would appear to me that the authors’ studyshould also be a recommended reading for both novice and experiencedneurosurgeons alike.

Ivan CiricEvanston, Illinois

This is a well executed study. The authors’ goal of standardizing nomen-clature in this area is a laudable one. However, in pursuing this goal

one must not lose track of practical implications and of the ability tocommunicate with the selected audience. The practical implication hereis that of protecting the temporal branch/branches of the facial nerveand the function of the muscles innervated by this nerve. There is gen-eral agreement that this branch originates in the parotid gland and itsterminal twigs are located in the subcutaneous tissue to innervate the tar-get muscles frontalis, corrugator supercilii, and orbicularis oculi. At somepoint between its origin and its termination this branch and/or its twigsbecome more and more superficial piercing the different layers of thisregion, no matter what name one gives to these layers. As the authorsclearly indicate consensus is lacking regarding at which point this pierc-ing takes place and it may very well be that there is significant anatomic

variation. Consequently, if one dissects in a plane that is deep to the fas-cial layers of the temporal region—again no matter what they are called—one should be rather safe with respect to anatomical integrity of thetemporal branch of the facial nerve. That is why we proposed a dissectionflash with the temporal muscle and deep to the fascial plane1; this anatom-ical concept/proposal was followed by a subsequent clinical paper2 thatvalidated the anatomical one demonstrating good functional preserva-tion of the temporal branch of the facial nerve following this subfascialdissection. Regarding the goal of communicating with the selected audi-ence, neurosurgeons are familiar with the term galea; consequently, considering that obviously the author agree that what they call the tem-poroparietal fascia is indeed continuous with the galea, we prefer the useof the term galea to that of temporoparietal fascia.

Mario AmmiratiColumbus, Ohio

1. Ammirati M, Spallone A, Jianya M, Cheatham M, Becker D. An anatomicosurgi-cal study of the temporal branch of the facial nerve. Neurosurgery. 1993;33(6):1038–1044.

2. Ammirati M, Spallone A, Ma J, Cheatham M, Becker D. Preservation of the tempo-ral branch of the facial nerve in pterional-transzygomatic craniotomy. Acta Neurochir(Wien). 1994;128(1-4):163–165.

CALL FOR CLINICAL TRIALS CONTRIBUTIONSClinical trials are an increasingly important part of daily neurosurgical practice that can change man-agement paradigms and influence decision-making. NEUROSURGERY has a new Clinical Trials sec-tion that focuses on clinical trial design and comprehensive reviews of trials treating neurosurgicallyrelevant disease processes. Submissions describing results of single or multi-center clinical trials arealso encouraged. An online offering to this section allows neurosurgeons to list their own clinical tri-als as part of NEUROSURGERY-Online. We look forward to better informing our readers about clini-cal trials so that the most recent, validated results can be integrated into daily practice.

Please contact Andrew T. Parsa M.D., Ph.D. directly regarding any questions attendant to this expand-ing area of NEUROSURGERY’S content and focus at: [email protected]

Documents

Naming the Soft Tissue Layers of the Temporoparietal Region: Unifying Anatomic Terminology Across Surgical Disciplines