Preservation of the nerves to the frontalis muscle during pterional craniotomy

There continues to be confusion over how best to preserve the branches of the facial nerve to the frontalis muscle when elevating a frontotemporal (pterional) scalp flap. The object of this study was to examine the full course of the branches of the facial nerve that must be preserved to maintain innervation of the frontalis muscle during elevation of a frontotemporal scalp flap.

Dissection was performed to follow the temporal branches of facial nerves along their course in 5 adult, cadaveric heads (n = 10 extracranial facial nerves).

Preserving the nerves to the frontalis muscle requires an understanding of the course of the nerves in 3 areas. The first area is on the outer surface of the temporalis muscle lateral to the superior temporal line (STL) where the interfascial or subfascial approaches are applied, the second is in the area medial to the STL where subpericranial dissection is needed, and the third is along the STL. Preserving the nerves crossing the STL requires an understanding of the complex fascial relationships at this line. It is important to preserve the nerves crossing the lateral and medial parts of the exposure, and the continuity of the nerves as they pass across the STL. Prior descriptions have focused largely on the area superficial to the temporalis muscle lateral to the STL.

Using the interfascial-subpericranial flap and the subfascial-subpericranial flap avoids opening the layer of loose areolar tissue between the temporal fascia and galea in the area lateral to the STL and between the galea and frontal pericranium in the area medial to the STL. It also preserves the continuity of the nerve crossing the STL. This technique allows for the preservation of the nerves to the frontalis muscle along their entire trajectory, from the uppermost part of the parotid gland to the frontalis muscle.