Name: Coronoid-Temporalis Pedicled Flap for Orbital Floor Defect Reconstruction (Video) | JoVE Journal
Uploaded: 2025-12-05T14:25:00.000+00:00
Duration: 6 min 32 s
Description: Learn the coronoid-temporalis pedicled flap technique for orbital floor defect reconstruction using the coronoid process and temporalis muscle. This method reduces microvascular risks while maintaining biomechanical stability and facial symmetry.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

This research is supported by the Health Commission of Sichuan Province Medical Science and Technology Program (Grant number: 24LCYJZD10), Crosswise Project of Sichuan University (Grant Number 22H1378).

This research is approved by the institutional Ethics Board of West China Hospital of Stomatology (protocol approval number: WCHSIRB-D-2022-343), with informed consent obtained.
1. Dissection of the coronoid process
<ol>
	<li>Anatomical identification and initial exposure
	<ol>
		<li>Palpate the anterior border of the mandibular ramus intraorally using the index finger.</li>
		<li>Use a monopolar electrocautery tip (set to 25-30 watts coagulation mode) to incise the posterior buccal mucosa and the overlying masseter muscle along the anterior ramus border.</li>
		<li>Continue the dissection until the lateral surface of the mandibular ramus is exposed. Confirm visualization of the anterior ramus border and coronoid outline.</li>
	</ol>
	</li>
	<li>Muscular dissection and lateral exposure
	<ol>
		<li>Detach the masseter muscle from its bony attachment on the lateral surface of the mandibular ramus and elevate it subperiosteally.</li>
		<li>Stop dissection once the coronoid process and its lateral surface are fully exposed. 
		NOTE: Checkpoint: Ensure that the temporalis muscle remains firmly attached to the coronoid process.</li>
	</ol>
	</li>
	<li>Osteotomy and neurovascular management
	<ol>
		<li>Identify the base of the coronoid process where it joins the mandibular ramus.</li>
		<li>Use a reciprocating saw with a fine-toothed blade (0.5 mm thickness) to perform a horizontal osteotomy at the coronoid base.</li>
		<li>Maintain shallow blade depth (&#8804;8 mm) to avoid injury to the maxillary artery located posterior to the sigmoid notch. If the maxillary artery or its branches are inadvertently injured, immediately clamp the bleeding end with hemostatic forceps and ligate to achieve hemostasis.</li>
		<li>Preserve the continuity of the temporalis muscle attachment during osteotomy.</li>
		<li>Identify the inferior alveolar neurovascular bundle at the osteotomy margin and clamp proximally using curved hemostatic forceps to prevent bleeding.</li>
	</ol>
	</li>
</ol>
2. Coronoid process flap transfer and fixation
<ol>
	<li>Flap positioning and orientation
	<ol>
		<li>Grasp the harvested coronoid segment using Kocher or bone-holding forceps.</li>
		<li>Gently transpose the flap superiorly to the orbital floor defect site through the created tunnel.</li>
		<li>Rotate the segment in three dimensions to achieve optimal anatomical contouring relative to the defect. 
		&#8203;NOTE: Checkpoint: Confirm that the coronoid process conforms closely to the curvature of the anterior orbital floor.</li>
	</ol>
	</li>
	<li>Osseous contouring
	<ol>
		<li>If the coronoid segment exceeds the dimensions of the orbital floor defect, use a high-speed diamond burr (5 mm tip) to trim the protruding bone edges for better adaptation.</li>
		<li>Smooth the residual edges of the maxillary bone or bone graft surrounding the defect to ensure flush contact between the graft and maxillary bone.</li>
		<li>Irrigate the area thoroughly to remove bone debris.</li>
	</ol>
	</li>
	<li>Rigid internal fixation
	<ol>
		<li>Elevate the paranasal soft tissue flap via the existing extraoral incision to expose the residual anterior maxillary wall.</li>
		<li>Select a 1.0 mm titanium mini-plate and manually contour it to conform closely to the surface of the bone at the fixation site.</li>
		<li>Fix the plate using 5 mm length self-tapping screws (pilot holes drilled with a 1.6 mm bit).</li>
		<li>Laterally, use a 1.0 mm extended-interval L-shaped plate to bridge the coronoid graft and the zygomatic body.</li>
		<li>Confirm that the fixation provides firm immobilization of the flap. 
		NOTE: Checkpoint: Ensure that the orbital contents are adequately supported by the graft, and gently palpate the globe to confirm that intraocular pressure is approximately symmetrical between both sides.</li>
	</ol>
	</li>
</ol>
3. Soft tissue reconstruction
<ol>
	<li>Free flap transferring
	<ol>
		<li>Elevate and harvest the latissimus dorsi muscle free flap using the standard technique.</li>
		<li>Perform microvascular anastomosis between the flap vessels and recipient vessels in the neck region (e.g., facial artery and vein) under microscope magnification.</li>
		<li>Insert the flap to fill the soft tissue defect in the maxillary region, ensuring full coverage of the coronoid graft and titanium hardware.</li>
		<li>Suture the distal edge of the flap to surrounding soft tissue along the inferior orbital rim using interrupted 3-0 polypropylene sutures, ensuring stable coverage of the hardware and eliminating dead space. Suture the intraoral margin of the flap to the remaining oral mucosal edge using interrupted 3-0 absorbable sutures. 
		NOTE: Checkpoint: Verify that the flap fully covers the reconstructed orbital floor and internal fixation material, and that microvascular flow is intact (confirmed by vascular patency test).</li>
	</ol>
	</li>
	<li>Alternative soft tissue management
	<ol>
		<li>Place an iodoform gauze dressing over the intraoral soft tissue defect to serve as a temporary spacer and infection barrier.</li>
		<li>Secure the gauze in place using a tie-over dressing to prevent displacement.</li>
		<li>Reposition the labial-buccal flap over the defect area.</li>
		<li>Perform layered closure by suturing the infraorbital orbicularis oculi muscle, subcutaneous tissue, and skin sequentially with absorbable and non-absorbable sutures as appropriate. 
		NOTE: Checkpoint: Confirm that the iodoform gauze is fully covered, with no exposed graft or implant, and that tension-free closure is achieved across all layers.</li>
	</ol>
	</li>
</ol>

<ol><li>Morton, W. R., Turnbull, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Blowout+fractures+of+the+floor+of+the+orbit%5BTitle%5D)+AND+%22Can+Med+Assoc+J%22%5BJournal%5D)">Blowout fractures of the floor of the orbit.</a> Can Med Assoc J. 90 (2), 58-61 (1964).</li>
<li>Guillaume, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Orbital+floor+repair+using+patient+specific+osteoinductive+implant+made+by+stereolithography%5BTitle%5D)+AND+%22Biomaterials%22%5BJournal%5D)">Orbital floor repair using patient specific osteoinductive implant made by stereolithography.</a> Biomaterials. 233, 119721(2020).</li>
<li>Fu, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Reconstruction+of+maxillary+and+orbital+floor+defect+with+free+fibula+flap+and+whole+individualized+titanium+mesh+assisted+by+computer+techniques%5BTitle%5D)+AND+%22J+Oral+Maxillofac+Surg%22%5BJournal%5D)">Reconstruction of maxillary and orbital floor defect with free fibula flap and whole individualized titanium mesh assisted by computer techniques.</a> J Oral Maxillofac Surg. 75 (8), 1791.e1-1791.e9 (2017).</li>
<li>Morrison, E. J., Matros, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Modern+oncologic+maxillary+reconstruction%5BTitle%5D)+AND+%22Plast+Reconstr+Surg%22%5BJournal%5D)">Modern oncologic maxillary reconstruction.</a> Plast Reconstr Surg. 154 (3), 601e-618e (2024).</li>
<li>Chattopadhyay, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Reconstruction+of+orbital+floor+fractures+with+titanium+micromesh%3A+our+experience%5BTitle%5D)+AND+%22J+Maxillofac+Oral+Surg%22%5BJournal%5D)">Reconstruction of orbital floor fractures with titanium micromesh: our experience.</a> J Maxillofac Oral Surg. 21 (2), 369-378 (2022).</li>
<li>Ou, Q., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Complication+of+osteo+reconstruction+by+utilizing+free+vascularized+fibular+bone+graft%5BTitle%5D)+AND+%22BMC+Surg%22%5BJournal%5D)">Complication of osteo reconstruction by utilizing free vascularized fibular bone graft.</a> BMC Surg. 20 (1), 216(2020).</li>
<li>Abou-Foul, A. K., Borumandi, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anatomical+variants+of+lower+limb+vasculature+and+implications+for+free+fibula+flap%3A+systematic+review+and+critical+analysis%5BTitle%5D)+AND+%22Microsurgery%22%5BJournal%5D)">Anatomical variants of lower limb vasculature and implications for free fibula flap: systematic review and critical analysis.</a> Microsurgery. 36 (2), 165-172 (2016).</li>
<li>Curioni, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Reconstruction+of+the+orbital+floor+with+the+muscle-bone+flap+%28temporal+muscle+with+coronoid+process%29%5BTitle%5D)+AND+%22J+Maxillofac+Surg%22%5BJournal%5D)">Reconstruction of the orbital floor with the muscle-bone flap (temporal muscle with coronoid process).</a> J Maxillofac Surg. 11 (6), 263-268 (1983).</li>
<li>Wang, W. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Maxillary+reconstruction+using+submental+artery+island+flap+and+sagittal+mandibular+ramus%2Fcoronoid+process+graft+pedicled+with+temporalis+muscle%5BTitle%5D)+AND+%22J+Oral+Maxillofac+Surg%22%5BJournal%5D)">Maxillary reconstruction using submental artery island flap and sagittal mandibular ramus/coronoid process graft pedicled with temporalis muscle.</a> J Oral Maxillofac Surg. 75 (10), 2271.e1-2271.e6 (2017).</li>
<li>Liu, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Reconstruction+of+total+maxillectomy+defects+using+coronoid-temporalis+pedicled+flap%2C+titanium+mesh%2C+and+free+flap%5BTitle%5D)+AND+%22Otolaryngol+Head+Neck+Surg%22%5BJournal%5D)">Reconstruction of total maxillectomy defects using coronoid-temporalis pedicled flap, titanium mesh, and free flap.</a> Otolaryngol Head Neck Surg. 170 (4), 1200-1203 (2024).</li>
</ol>

The authors have no conflicts of interest to disclose.

This article demonstrated the surgical steps of the CTPF reconstruction of the orbital floor defect. The results showed that the CTPF could be used to reconstruct medium to small defects of the orbital floor, ensuring approximate symmetry of bilateral eyeballs. Unfortunately, due to limited bone volume, the CTPF could not be used to reconstruct large defects of the orbital floor. For such patients, titanium mesh or free bone flap grafting may be better choices.
Meanwhile, because the volume an...

The orbital floor, anatomically formed by the orbital plates of the maxilla, zygomatic bone, and palatine bone, serves as the principal scaffold for orbital soft tissue support. Defects in this region, commonly resulting from tumor resection or trauma, often lead to enophthalmos and diplopia due to loss of structural continuity1. Current reconstructive approaches primarily rely on two strategies: alloplastic materials (e.g., titanium mesh) or autologous free bone flaps (e.g., fibula or iliac crest grafts)2,3,4. Titanium mesh, despite its intraoperative malleability, carries risks of long-term complications including material fatigue, displacement, and foreign body reactions5. Structural fatigue fractures may traumatize intraorbital soft tissues, precipitating enophthalmos and diplopia, while chronic inflammatory responses to the implant can lead to titanium plate exposure due to progressive tissue necrosis. Free bone flaps, though avoiding synthetic material-related issues, require microvascular anastomosis with inherent risks of thrombosis, donor-site morbidity, and prolonged operative time6,7.
To address these limitations, we developed a novel technique: the coronoid-temporalis pedicled flap (CTPF). This method utilizes the coronoid process&#39;s spatial proximity to the orbital floor and its intrinsic biomechanical strength as a load-bearing bone. Figure 1 demonstrates the surgical steps of harvesting and transposing the CTPF to the orbital floor. By preserving the natural vascular supply through intact temporalis muscle attachments, the CTPF eliminates dependence on microsurgical anastomosis while maintaining osteogenic viability.
The technique is most applicable to isolated, small-to-medium anterior orbital floor defects that do not involve the medial orbital wall or posterior floor. It is not recommended for large, complex defects requiring significant volume or multi-wall reconstruction due to anatomic limitations of flap reach and size.
Our representative clinical case demonstrates that this pedicled flap enables anatomically sound orbital reconstruction with minimal donor-site morbidity. While this approach offers a promising alternative to traditional grafting or alloplastic materials, quantitative outcome data are not yet available, and further studies are warranted to validate long-term effectiveness.

<table><tbody><tr><td>3-0 antibaterial vicryl absorbable suture</td><td>Johnson (Suzhou) Medical Devices Co., Ltd.</td><td>VCP1772D</td><td>For tissue suturing</td></tr><tr><td>DSRobot 4K-Station</td><td>Digital Vision</td><td>-</td><td>Surgery video recording</td></tr><tr><td>High-Frequency Electrosurgical Unit</td><td>Guangdong Baisheng Medical Equipment Co., Ltd.</td><td>OBS-350A</td><td>Precise tissue cutting and coagulation</td></tr><tr><td>Operating microscope</td><td>Zumax</td><td>OMS3200Pro</td><td>For microvascular anastomosis</td></tr><tr><td>POWERED MAXILLOFACIAL SURGERY SYSTEM</td><td>CROWN EAGLE</td><td>DSQ-3L ZD3</td><td>For osteotomy</td></tr><tr><td>Ultrasonic cutting and hemostasis system</td><td>Tianjin Ruiqi Surgical Instrument Company</td><td>CSUS6000</td><td>For cutting and hemostasis</td></tr></tbody></table>

coronoid-temporalis pedicled flap for orbital floor defect reconstruction

Coronoid-Temporalis Pedicled Flap for Orbital Floor Defect Reconstruction

Orbital floor defects may result from maxillary trauma or tumor resection. Traditional reconstruction techniques often rely on vascularized or non-vascularized free bone grafts, which carry risks of graft failure due to thrombosis, infection, or poor integration. This protocol introduces a novel technique using a coronoid-temporalis pedicled flap (CTPF) for repairing small-to-medium orbital floor defects. The protocol involves harvesting the coronoid process with its attached temporalis muscle pedicle, transposing the flap to the orbital floor, contouring the bone to fit the defect, and achieving rigid fixation. When soft tissue coverage is insufficient, additional options such as local advancement or free flaps can be employed. The CTPF technique offers a biomechanically stable, vascularized solution that avoids the complications associated with microvascular anastomosis. It is particularly suitable for moderate defects, though it may not provide sufficient volume for large or complex orbital reconstructions. A representative clinical case illustrates the technical feasibility of this approach and demonstrates anatomic restoration with preservation of facial contour. While quantitative outcomes are not reported, the procedure shows potential as a viable alternative to conventional bone grafts or alloplastic implants.

A representative case was selected to demonstrate the clinical application of the CTPF combined with the latissimus dorsi free flap for orbital floor and maxillary reconstruction. Figure 2 shows the preoperative contrast-enhanced computed tomography evaluation of the patient. The patient presented with maxillary gingival squamous cell carcinoma invading the maxillary sinus, necessitating tumor resection that resulted in hemimaxillary and partial orbital floor...

This protocol presents a novel coronoid-temporalis pedicled flap (CTPF) technique for reconstructing small-to-medium orbital floor defects. CTPF avoids microvascular risks while maintaining biomechanical stability. Clinical cases demonstrate effective structural restoration, reduced complications, and preserved facial symmetry, offering a viable alternative to traditional grafts or alloplastic materials.

Orbital floor defects may result from maxillary trauma or tumor resection. Traditional reconstruction techniques often rely on vascularized or ...

This protocol introduces a novel technique using a coronoid-temporalis pedicled flap for repairing small to medium orbital flow defects. The protocol involves harvesting the coronoid process with its attached temporalis muscle pedicle, transposing the flap to the orbital floor, contouring the bone to fit the defect, and achieving rigid fixation. Use a monopolar electrocautery tip to incites the posterior buccal mucosa and the overlying masseter muscle along the anterior ramus border.Continue the dissection until the lateral surface of the mandibular ramus is exposed. Confirm visualization of the anterior ramus border and coronoid outline. Detach the masseter muscle from its bony attachment on the lateral surface of their mandibular ramus and elevate it subperiosteally.Stop dissection once the coronoid process and its lateral surface are fully exposed. Use a reciprocating saw with a fine-toothed blade to perform a horizontal osteotomy at the coronoid base. Maintain shallow blade depth to avoid injury to the maxillary artery, located posterior to the sigmoid notch.If the maxillary artery or its branches are inadvertently injured, immediately clamp the bleeding end with the hemostatic forceps and ligate to achieve hemostasis. Preserve the continuity of the temporalis muscle attachment during osteotomy. Identify the inferior alveolar neurovascular bundle at the osteotomy margin and clamp proximally using curved hemostatic forceps to prevent bleeding.Grasp the harvested coronoid segment using Kocher or bone-holding forceps. Gently pose the flap superiorly to the orbital floor defect site. Rotate the segment in three dimensions to achieve optimal anatomy contouring related to the defect.Elevate the perinasal soft tissue flap via the existing extraoral incision to expose the residual anterior maxillary wall. Smooth the residue edges of the maxillary bone or bone graft surrounding the defect to ensure flush contact with the coronoid graft. Select a one millimeter titanium mini-plate and manually contour it to conform closely to the surface of the bone at the fixation site.Fix the plate using five millimeter length self-tapping screws with pilot holes drilled with 1.6 millimeter bit. Laterally, use a one millimeter extended-interval plate to bridge the coronoid graft and the zygomatic body. Confirm that the fixation provides firm immobilization of the flap.Ensure that the orbital contents are adequately supported by the graft. Given the patient's combined hemi maxillectomy defect and planned postoperative radiotherapy, the latissiumus dorsi myocutaneous flap was selected to achieve three critical objectives, reconstructing maxillary volume, restoring facial contour, and providing vascularized soft tissue coverage over the titanium implants to prevent post-radiation exposure. Elevate and harvest the latissimus dorsi muscle free flap using standard technique.Perform microvascular anastomosis between the flap vessels and the recipient vessels in the neck region under microscope magnification. Insert the flap to fill the defect in the maxillary region, ensuring full coverage of the coronoid graft and titanium hardware. Suture the distal edge of the flap to the surrounding soft tissue along the inferior optical rim using interrupted 3-0 polypropylene sutures, ensuring stable coverage of the hardware and eliminating dead space.Suture the intraoral margin of the flap to the remaining oral mucosal edge using interrupted 3-0 absorbable sutures. We demonstrated the representative results of the protocol. The patient declared no diplopia or enopthalmos after surgery.The facial symmetry was also basically maintained. The intraoral images showed that the soft tissue flap established an anatomical barrier between oral and nasal cavities to prevent oronasal communication. 3D reconstruction of post-operation CT scan displayed well fixes of the bone flap three months after surgery.This article demonstrated the surgical steps of the CTPF reconstructing orbital floor defect. The results show that the CTPF could reconstruct medium to small defect of orbital floor, ensuring approximate symmetry of bilateral eyeballs. Unfortunately, due to limited bone volume, the CTPF could not reconstruct large defect of orbital floor.For such patients, titanium mesh or free bone flap grafting may be better choices.

coronoid-temporalis-pedicled-flap-for-orbital-floor-defect

Research

JoVE Journal

Medicine

The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

This protocol describes a new method for effectively reconstructing donor atrial cuff anterior wall defects during lung transplantation through the rotation of the donor posterior atrial flap.

Donor Posterior Atrial Flap Rotation for Left Atrial Cuff Reconstruction in Lung Transplantation

Personalized medicine for orbital reconstruction is developing rapidly. Due to the delicate nature of the orbit, small discrepancies following fracture reconstruction may cause impairment in visual perception. Here, we describe three methods for virtual 3D reconstruction of orbital defects and their indications and potential pitfalls for correct reconstruction.

Three-Dimensional Reconstruction of Orbital Fractures

Here, we present a protocol for surgical correction for pediatric epiblepharon and trichiasis.

Surgical Correction for Pediatric Epiblepharon and Trichiasis

This protocol details the surgical technique used to harvest and prepare a full-face allograft for transplantation in patients with severe facial disfigurements, focusing primarily on soft tissue procurement with limited bony harvest restricted to the nasal framework.

Surgical Approach to Full Soft Tissue Face Allograft Procurement for Vascularized Composite Allotransplantation

One constraint of preclinical research in the field of bone repair is the lack of experimental control over the local mechanical environment within a healing bone lesion. We report the design and use of an external fixator for bone repair with the ability to change fixator stiffness in vivo.

Adjustable Stiffness, External Fixator for the Rat Femur Osteotomy and Segmental Bone Defect Models

Animal models are frequently employed to mimic serious bone injury in biomedical research. Due to their small size, establishment of stabilized bone lesions in mice are beyond the capabilities of most research groups. Herein, we describe a simple method for establishing and analyzing experimental femoral defects in mice.

A Simple Critical-sized Femoral Defect Model in Mice

This protocol describes mesh implantation in the ovine rectovaginal septum using a single vaginal incision technique, with and without the trocar-guided insertion of anchoring arms.

Transvaginal Mesh Insertion in the Ovine Model

Here we present a protocol for the use of the pig superior epigastric artery perforator flap as a learning module for head and neck microvascular reconstruction.

Porcine As a Training Module for Head and Neck Microvascular Reconstruction

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Learn the coronoid-temporalis pedicled flap technique for orbital floor defect reconstruction using the coronoid process and temporalis muscle. This method reduces microvascular risks while maintaining biomechanical stability and facial symmetry.

Coronoid-Temporalis Pedicled Flap for Orbital Floor Defect Reconstruction

Explore More Videos