2026 Proffered Presentations
S013: TEMPORALIS SPARING MINI-PTERIONAL - TECHNICAL NUANCES AND OUTCOMES
Lydia Kaoutazani, MD; Fernando Vale-Enrique; David Baker, MD; Christopher Carr, MD; Shannon Derthick; Luca Debs; Fernando Vale, MD; M. Salman Ali, MD; Medical College of Georgia at Augusta University
Introduction: Pterional approach has been the workhorse for neurosurgeons for decades. Many variations of this approach have been adopted including mini-pterional (MPA). Here we describe our version of temporalis muscle (TM) sparing MPA, discuss outcomes and limitations.
Methods: Cases performed in past 18 months since the completion of fellowship were reviewed. Indications, imaging, and surgical technique were reviewed.
Results: Surgical Technique (Figure 1) – a slightly curvilinear incision is made at the anterior most extent of the hairline but nerve crossing half distance between lateral canthus and tragus to protect the frontalis branch of the facial nerve and avoid making incision beyond the hairline. The incision is tailored based on the location of the pathology, frontal, frontotemporal or temporal. Knife is used to making the incision down to the temporalis fascia. Sub-fascial blunt dissection is performed using the blunt end of a Penfield-1. Dissection is extended up to the keyhole. At this point, the curette end of the Penfield-1 is used to elevate the muscle postero-inferiorly and secured with hooks. No electrocautery is used at any stage. This exposes the lateral sphenoid wing. A single burrhole is made and bone flap is elevated using a craniotome, taking care not to try to extend the craniotomy into medial sphenoid wing which can increase the risk of dural tears. Lateral sphenoid wing is extensively drilled down to the peri-orbita and meningo-orbital band is cut to free the fronto-temporal dura. At this point, extradural dissection is continued to expose the anterior clinoid if a clinoidectomy is indicated. Dura is opened in the usual fashion and retracted anteriorly. Tumor is removed in the usual fashion. Primary closure of the dura is performed. Bone flap is replaced attached to kidney shaped titanium plate to cover the sphenoid wing bony defect. Temporalis muscle is replaced and pushed anteriorly. One or two tach-up sutures are applied to the superior TM to cover the plates and apply tension. Remaining closure is performed in the usual fashion.
Outcomes – Excellent cosmetic results were achieved in all patients without visual differences in temporal thickness (Fig. 4). No frontalis palsies were noted.
Figure 2 – 12 cases of this approach were identified. Indications and temporalis muscle thickness difference to contralateral side. No significant differences in temporal thickness were noted from contralateral side.
Limitations - a bulky TM can restrict the view. Patients with receding hairline prevents making the incision forward enough to minimize the amount of TM that needs to be dissected. For these patients, a traditional pterional may be a better option.
Conclusions: Our TM sparing MPA provides excellent cosmetic results with minimal to no noticeable temporal wasting as the TM is not cut or burnt and merely stripped and retracted. This approach is based on the keyhole concepts and requires familiarity with surgical anatomy and comfort in operating in narrow surgical corridor.
