O’Brien, Justin X. B.M.B.S., P.G.Dip.Surg.Anat.; Ashton, Mark W. F.R.A.C.S.; Rozen, Warren M. M.D.B.S., Ph.D.; Ross, Richard B.M.B.S., P.G.Dip.Surg.Anat.; Mendelson, Bryan C. F.R.C.S.E., F.R.A.C.S., F.A.C.S.
G. I. Taylor Laboratory, Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Victoria, Australia
Correspondence to Dr. O’Brien, G. I. Taylor Laboratory, Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Victoria, Australia 3010, firstname.lastname@example.org
It is a privilege to have Dr Knize1 contribute to our work,2 as his original articles and textbook have made him one of the foremost authorities on the anatomy of the temporal region. His committed review of this article for the Journal has contributed to the precision and accuracy of the work. Our initial submission to this Journal was reviewed by six surgeons, all of whom provided significant insight and suggestions on the nomenclature for the anatomy of the region. As such, we believe this has become a collaborative effort of contemporary authorities facilitated by the Journal, Plastic and Reconstructive Surgery.
An important distinction is that between the terms “layer” and “plane.” Unfortunately, due to word limits, this distinction does not appear in the article itself but was agreed on with Dr. Knize as a reviewer. To clarify for the readers, we state the following:
The terms “layer” and “plane” have been used interchangeably in the literature, and this causes ongoing confusion. A tissue layer is a three-dimensional structure of substance. A plane is a flat, two-dimensional, theoretical entity. For example, there is a dissection plane between bone and periosteum, but it has no substance; it is just a description of the potential space between two structures. On the other hand, the periosteum itself is a three-dimensional structure of substance and hence a tissue layer. This occurs in the upper temporal compartment, where the usual dissection plane used by surgeons is between laminae of tissue layer 4, although it is not usually recognized that a tissue layer actually exists. It is assumed by many that this is merely a plane between the superficial temporal fascia and the deep temporal fascia (Figs. 1 and 2).
It was pointed out in the review process by Dr. Knize that Figure 2 in our original article represents a dissection that might never be performed in surgery, so it was subsequently omitted from the article. Part of Dr. Knize’s reasoning was that we had infiltrated the tissue layer with normal saline prior to dissection, and so the layer appeared more substantial than it would intraoperatively. The purpose of this figure, however, is to show that this layer in the upper temporal compartment is a tissue layer of substance rather than merely a dissection plane. Injecting the loose areolar tissue of the scalp over the vertex does not result in a similar tissue layer.
Dr. Knize also comments that layer 4 in the upper temporal compartment does not warrant a specific name. We were careful not to rename any structure that had already been named in the literature, preferring to suggest an existing name that we felt to be the most appropriate. In the case of layer 4 in the upper temporal compartment, we believe that it does deserve a name. This layer is vascularized and can be used as a flap (Fig. 3). It was accurately described by de la Plaza et al.3
Our dissections were performed on fresh cadavers, which conferred the advantage of dissection that cannot be performed during an operation. Dr. Knize makes the observation that some of our dissections may not accurately reflect the structures as they are seen intraoperatively. The point of these dissections was to show the true nature of the structures anatomically, and hence to improve understanding of the limited anatomy seen when operating on patients. Dr. Knize is concerned that the appearance of certain structures had been altered, “stretched and elongated,” to demonstrate our anatomic concepts. We agree that these structures have been displayed in such a way as to demonstrate our concepts, but we would also like to add that no structures were altered in any way other than to separate tissue layers in order to display the true and “unseen in surgery” nature of the septa.
The question of “surgical relevance” of certain structures in this region has been raised by Dr. Knize. We believe that any anatomical structures that can be consistently identified during dissection add to our knowledge of the region and provide landmarks for orientation of the surgeon. The sentinel vein is a good example of this point, having little surgical importance to the surgeon other than orientation. Naming such structures confers the advantage of both brevity and clarity when discussing dissection technique.
In attempting to standardize the terminology used, it was recognized that parts of the anatomy needed to be clarified, and once that was achieved, a consensus needed to be reached. We have suggested a nomenclature system that we believe is comprehensive and based on anatomical principles and contemporary use. We believe that “favoritism” would be a poor foundation for such a system, and we remain open to further collaboration.
The authors have no financial interest to declare in relation to the content of this communication or of the associated article.
Justin X. O’Brien, B.M.B.S., P.G.Dip.Surg.Anat.
Mark W. Ashton, F.R.A.C.S.
Warren M. Rozen, M.D.B.S., Ph.D.
Richard Ross, B.M.B.S., P.G.Dip.Surg.Anat.
Bryan C. Mendelson, F.R.C.S.E., F.R.A.C.S., F.A.C.S.
G. I. Taylor Laboratory
Department of Anatomy and Neuroscience
University of Melbourne
Parkville, Victoria, Australia
1. Knize DM. Discussion: New perspectives on the surgical anatomy and nomenclature of the temporal region: Literature review and dissection study Plast Reconstr Surg. 2013;131:523–525
2. O’Brien J, Ashton MW, Rozen WM, Ross R, Mendelson BC. New perspectives on the surgical anatomy and nomenclature of the temporal region: Literature review and dissection study Plast Reconstr Surg. 2013;131:510–522
3. de la Plaza R, Valiente E, Arroyo JM. Supraperiosteal lifting of the upper two-thirds of the face. Br J Plast Surg. 1991;44:325–332
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