J Neurosurg 118:309–314, 2013

©AANS, 2013

Technical nuances of temporal muscle dissection and

reconstruction for the pterional keyhole craniotomy

Technical note
Nancy McLaughlin, M.D., Ph.D., Aaron Cutler, M.D., and Neil A. Martin, M.D.
Department of Neurosurgery, David Geffen School of Medicine, University of California
at Los Angeles, California

The supraorbital keyhole approach offers a limited access for aneurysms located at the middle cerebral artery
(MCA) bifurcation with long M1 segments or proximal M2 aneurysms. Alternative minimally invasive routes cen-
tered on the pterion have been developed to address these aneurysms. Appropriate dissection and reconstruction of
the temporal muscle are important for optimal exposure and best cosmetic results with the pterional keyhole crani-
otomy. The authors describe the technical nuances of temporal muscle dissection and reconstruction adapted to the
pterional keyhole craniotomy.
After incising the scalp in a curvilinear fashion behind the hairline, an interfascial dissection is performed, al-
lowing anterior reflection of the superficial temporal fat pat and superficial temporal fascia. The temporal muscle is
incised 7–10 mm below its insertion at the superior temporal line. The deep temporal fascia and temporal muscle are
incised vertically, completing a T-shaped incision. Subperiosteal dissection of both muscle flaps preserves the deep
temporal arteries and nerves. A craniotomy measuring 2.5–3 cm in diameter, based anteriorly at the pterion, is made
over the sylvian fissure. Dissection of the sylvian fissure and of MCA aneurysms can proceed without the use of
retractors. The bone flap and associated hardware is entirely covered by the temporal muscle, which is reconstructed
in 2 layers: the temporal muscle/deep temporal fascia and the superficial temporal fascia.
This dissection technique prevents damage to branches of the facial nerve and minimizes temporal muscle dam-
age. Dividing the temporal muscle vertically and reflecting both parts anteriorly and posteriorly prevents suboptimal
illumination and visualization under the microscope. Covering the bone flap and related hardware with a multilayer
anatomical reconstruction optimizes cosmetic results.
(http://thejns.org/doi/abs/10.3171/2012.10.JNS12161)

Key Words    •      pterion    •      keyhole approach      •      minipterional craniotomy      •

temporal muscle      •      facial nerve      •      cerebral aneurysm      •      surgical technique

O
ver the past 2 decades, the neurosurgical com-
munity has progressively moved toward less in-
vasive surgery. Keyhole approaches have been
increasingly used to address many different neurosur-
gically treated pathological entities, including cerebral
aneurysms. Among the keyhole approaches, the supraor-
bital eyebrow procedure has been used to treat aneurysms
located on the anterior circulation and on the PCA.4,10
However, for aneurysms located at the MCA bifurcation
Abbreviations used in this paper: ATA = anterior temporal artery;
MCA = middle cerebral artery; PCA = posterior cerebral artery;
STA = superficial temporal artery.
with long M1 segments, or for distal MCA aneurysms, the
supraorbital approach offers limited access.
Many surgical modifications have been added to the
traditional pterional craniotomy initially described by
Yaşargil and coworkers.12 Keeping the craniotomy cen-
tered on the pterion but decreasing its size may result in
restricted maneuverability, narrowing of the visual field,
and overall suboptimal appreciation of the potential of
pterional keyhole craniotomies.4 To optimize surgical ef-
ficacy of pterional keyhole craniotomies and assure best
functional and cosmetic outcome, some modifications
in the soft tissue and bone dissection as well as tempo-
ral muscle reconstruction are essential. We describe the

J Neurosurg / Volume 118 / February 2013 309

 N. McLaughlin, A. Cutler, and N. A. Martin

technical nuances related to temporal muscle dissection
and reconstruction adapted to the pterional keyhole cra-
niotomy.
Operative Technique
An incision is designed beginning 1 cm above the
base of the zygomatic arch and within 1 cm of the exter-
nal acoustic meatus. The incision curves toward the fron-
tal region and ends in the midline at the normal hairline.
Care is taken not to extend the scalp incision too deeply,
preventing injury to the superficial temporal artery (STA)
and facial nerve branches. The scalp flap is elevated and
reflected anteriorly with the superficial fat pad (Fig. 1A).
To prevent injury to the frontotemporal branches of the
facial nerve, an interfascial dissection is performed as
described by Yaşargil and colleagues.5,12 The superficial
temporal fascia is dissected with a scalpel, taking care
to maintain the dissection plane underneath the deep
lamina of the superficial temporal fascia. The dissection
should extend inferiorly, to the insertion of both superior
and deep laminae of the superficial temporal fascia on the
superior border of the zygomatic arch. This fascial flap is
reflected anterolaterally with the scalp flap (Fig. 1B).

Fig. 1.  Schematic drawings illustrating the operative procedure.  A: Scalp incision and reflection of the scalp flap anteriorly
with the superficial fat pad. The white arrow indicates that the scalp flap is reflected anteriorly, the blue arrows indicate that the
fascial flap is reflected anterolaterally, and the dashed line represents the incision performed in the superficial temporal fas-
cia.  B: Dissection of the superficial temporal fascia.  C: The T-fashion incision (dashed lines) in the temporal muscle.  D:
Retraction of both triangular flaps to expose the pterional region for the craniotomy (circular dashed lines; the small circle outlines
the bur hole and the larger ellipse shows the limit of the bone flap). Artwork by Tim Hengst.

310 J Neurosurg / Volume 118 / February 2013

Temporal muscle dissection and reconstruction

A curved incision paralleling and just below the su-

perior temporal line is made, leaving a 7- to 10-mm myo-
fascial cuff along the superior temporal line for muscle
reapproximation at the end of the procedure (Fig. 1C). For
the pterional keyhole craniotomy, this incision measures
approximately 7 cm and does not need to extend anteri-
orly to the frontal zygomatic process, nor does it need to
extend along the temporal muscle’s posterior aspect. The
deep temporal fascia is sharply cut exactly above the cen-
ter of the planned pterional craniotomy. The bulk of the
muscle is then cut along the same line, allowing retraction
of an anterior temporal muscle triangular flap forward
and retraction of a posterior temporal muscle triangular
flap backward, exposing the pterion for the craniotomy.
The temporal muscle is not completely dissected from
the temporal fossa; its most anterior and posterior compo-
nents remain in their anatomical position. Subperiosteal
dissection of both triangular flaps preserves deep tem-
poral arteries and nerves, thus avoiding temporal muscle
atrophy.8
A craniotomy is based anteriorly on the pterion, giv-
ing access intradurally to the anterior ascending ramus
of the sylvian fissure. The craniotomy measures approxi-
mately 2.5–3 cm in diameter, and does not extend up to
or above the superior temporal line (Figs. 1D and 2A).
Given the T-fashion incision in the temporal muscle, the
muscle mass is divided in half and no bulk obscures vi-
sualization or hinders maneuverability from any specific
angle of approach (anteriorly, inferiorly, or posteriorly).
Once the dura mater is opened, the inferolateral part of
the frontal lobe, the sylvian fissure, and the superior tem-
poral gyrus are exposed. Specifically for aneurysms of
the distal MCA bifurcation with long M1 segments, or M2
aneurysms, the sylvian fissure is opened along its anterior
ascendant ramus and the MCA and aneurysm dissection
proceeds as usual.
The bone flap is secured in place with plates and
screws (Fig. 2A). Given the location and size of the cra-
niotomy, the temporal muscle covers all of these devices.
The temporal muscle and deep temporal fascia are direct-
ly reattached with sutures along the vertical incision, and
to the myofascial cuff along the superior temporal line
(Fig. 2B). The superficial temporal fascia is also reap-
proximated with its fascial cuff (Fig. 2C). This results in a
2-layer reconstruction completely covering the bone flap.

Discussion
The pterional craniotomy is the workhorse of neuro-
surgical approaches because it offers access to a variety
of lesions in the anterior and middle cranial fossae, and
to the incisural region. Its design centered on the pterion
gives maximum basal exposure with the goal of minimiz-
ing brain retraction.12 To maximize exposure, the tempo-
ral muscle is usually completely dissected from the tem-
poral fossa. This has resulted in suboptimal functional
and cosmetic results—with temporomandibular junction
dysfunction; atrophy of the temporal muscle; bulging of
the temporal muscle in the zygoma region; and paraly-
sis of the frontalis, obicularis oculi, and corrugator mus-
cles.3,12
Surgeons have developed alternative approaches to
Fig. 2. Photographs showing intraoperative views of reconstruc-
tion.  A: Small bone flap obtained at craniotomy, with one bur hole
covered with appropriate plating.  B: Reattachment of the temporal
muscle and deep temporal fascia along the vertical incision and to the
myofascial cuff along the superior temporal line.  C: Suturing of the
superficial temporal fascia to its fascial cuff.
decrease soft-tissue and bone dissection as well as to
minimize brain tissue exposure and retraction. The key-
hole concept advocated by Perneczky and Fries implies
tailoring of the opening to create a surgical field that wid-
ens as the distance from the craniotomy increases.4,9,10

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 N. McLaughlin, A. Cutler, and N. A. Martin

The supraorbital eyebrow approach has been recognized
as a safe alternative route for the treatment of many an-
terior circulation aneurysms as well as selected PCA and
basilar tip aneurysms.4,10 However, it may not be suitable
for all aneurysms, such as MCA bifurcation aneurysms
with a long M1 segment, or distal MCA aneurysms.
Modified pterional approaches aiming to minimize
soft-tissue and bone dissection and brain exposure have
been described.1–3,6,7,11 In comparison with other reported
techniques, the surgical nuance presented here minimizes
temporal muscle dissection by performing a T-incision
centered on the region of the pterion and reflecting both
triangular muscle components only far enough to ex-
pose the bony area of interest. The temporal muscle is
therefore not completely dissected from the temporal
fossa. In addition to minimizing soft-tissue and muscle
manipulation, we perform a small craniotomy, which
prevents unnecessary brain exposure and unintentional
cortical injury.2,3 This approach affords enough working
space that dissection of the sylvian fissure and an MCA
aneurysm located as proximally as the M1 segment can
proceed without the use of retractors, thereby minimiz-
ing brain retraction (Figs. 3 and 4). During the closure,
the bone flap is entirely covered by an anatomical 2-layer
myofascial reconstruction. This minimizes any potential
cosmetic problems caused by bur hole covers, plates, and
screws, especially in bald patients or in those with a thin
scalp. Complete covering of the bone flap by temporal
muscle also hides any bone flap depression that can occur
with bone resorption over time.6
Success of pterional keyhole surgery relies on a se-
ries of small surgical details that in the end optimize
functional and cosmetic results, promote rapid healing,
decrease postoperative pain, and potentially shorten hos-
pital stay.2,3
Conclusions
The dissection technique described here prevents

Fig. 3.  Illustrative Case 1. This 63-year-old woman presented with a history highly suggestive of a sentinel hemorrhage oc-
curring 2 weeks prior to referral.  A and B: Angiographic studies revealing a left M1 aneurysm at the origin of the ATA and a
left MCA bifurcation aneurysm. The pterional keyhole approach was chosen because it offered the shortest route to treat both
aneurysms.  C: Intraoperative photograph showing the initial exposure after opening the dura.  D and E: Dissection (D) and
clipping (E) of the MCA bifurcation aneurysm.  F: Clip occluding the more proximal M1 aneurysm located at the origin of the
ATA.  G and H: Views of the sylvian fissure after aneurysm clipping.  I: Early postoperative head CT scan showing the keyhole
approach.

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Temporal muscle dissection and reconstruction
Fig. 4.  Illustrative Case 2. This 47-year-old man had a diagnosis of unruptured left M1 aneurysm measuring 7–8 mm and
presenting with a wide neck (A). The pterional keyhole approach allowed excellent exposure (B and C) and clip occlusion (D)
of this midportion M1 aneurysm. The early postoperative head CT scan (E) shows the keyhole approach, and the angiogram (F)
documents the complete exclusion of the aneurysm.
damage to the frontotemporal branches of the facial
nerve, minimizes temporal muscle damage, and elimi-
nates or reduces temporal atrophy. Because the verti-
cal incision of the temporal muscle is centered on the
planned area of craniotomy, illumination and visualiza-
tion are maximized through the pterional keyhole crani-
otomy. The multilayer anatomical reconstruction favors
excellent cosmetic results. Prospective collection of the
patient satisfaction score regarding cosmesis following
the temporal muscle dissection for the keyhole pterional
approach may enable objective documentation of its ben-
efits in comparison with the temporal muscle dissection
used in the standard pterional craniotomy.
Disclosure
This work has been supported in part from unrestricted educa-
tional funds obtained from Casa Colina Centers for Rehabilitation.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Martin, McLaughlin.
Acquisition of data: McLaughlin, Cutler. Analysis and interpreta-
J Neurosurg / Volume 118 / February 2013
tion of data: Martin, McLaughlin. Drafting the article: all authors.
Critically revising the article: all authors. Reviewed submitted ver-
sion of manuscript: all authors. Approved the final version of the
manuscript on behalf of all authors: Martin.
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Manuscript submitted January 22, 2012.
Accepted October 3, 2012.
Please include this information when citing this paper: published
online November 9, 2012; DOI: 10.3171/2012.10.JNS12161.
Address correspondence to: Neil A. Martin, M.D., Department of
Neurosurgery, David Geffen School of Medicine at UCLA, Ronald
Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 6236,
Los Angeles, California 90095-7436. email: neilmartin@mednet.
ucla.edu.
J Neurosurg / Volume 118 / February 2013