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Temporoparietal Fascia Flaps


Temporoparietal Fascia Flaps

Article Author:
Basit Jawad
Article Editor:
Blake Raggio
Updated:
10/15/2020 9:25:22 AM
For CME on this topic:
Temporoparietal Fascia Flaps CME
PubMed Link:
Temporoparietal Fascia Flaps

Introduction

The temporoparietal fascia flap (TPFF) is a versatile flap well recognized in the reconstruction of craniofacial defects.[1] Most commonly, the TPFF is utilized in a pedicled fashion for the reconstruction of the scalp, auricle, facial soft tissue, orbital, oral cavity, nasopharyngeal, and skull base defects.[2] Moreover, the flap may be harvested with the overlying scalp, making it particularly useful for defects of the hair-bearing regions.[3] Additionally, if more substantial reconstruction is required, the TPFF may be elevated in a combined or chimeric fashion with temporalis muscle and/or adjacent calvarial bone.[4][5] When harvested for free microvascular anastomosis, the TPFF can be useful for a wide array of distal extremity reconstructions, specifically the hand and feet.[6]

Anatomy and Physiology

In order to increase the success of harvesting the temporoparietal fascia flap, it remains paramount to understand the relevant anatomy.

Layers (from superficial to deep) potentially encountered during harvesting of the TPFF include:

  • Skin
  • Subcutaneous tissue
  • Temporoparietal fascia
  • Loose areolar tissue
  • Superficial temporalis fascia
  • Temporalis muscle
  • Deep temporalis fascia
  • Pericranium
  • Bone

The temporoparietal fascia represents a thin layer of connective tissue, which lies below the level of the subcutaneous adipose tissue.[7] The TPFF lies in continuity with the adjacent galea aponeurosis, which exists beyond the temporal line.

Blood Supply

  • The superficial temporal artery (STA) has a well-described course within the substance of the flap itself. The main STA vessel divides into multiple segments, roughly 3 centimeters above the level of the zygomatic arch. The terminal branches of the STA will arborize with the vessels supplying the pericranium. 
  • The STA gives rise to the middle temporal artery. When dissected in sync, the surgeon may harvest the deep temporal fascia and/or muscle concomitantly during the TPFF harvest.[4]

NOTE: Dissection along the anterior/frontal branch of the STA may put the frontotemporal branch of the facial nerve at risk. Various anatomic landmarks can be used to help identify the course and/or location of this nerve, including:

  • Pitanguy’s line - line drawn from 0.5 cm inferior to the tragus to a 1.5 cm superolateral to the lateral brow[8]
  • 2.85 cm superior and 2.54 cm lateral to the lateral canthus[9]
  • 6.4 mm cephalad to the sentinel vein (useful landmark for endoscopic brow lifts)[10]
  • 2.4 cm anterior to the zygomatic arch and helix junction[10]

Indications

The temporoparietal fascia flap is a well-recognized technique in head and neck, hand, and lower extremity reconstruction. It can be harvested as a pedicled flap, chimeric flap (alongside the deep temporal fascia with/without the inclusion of surrounding calvarial bone), or as a free tissue flap, depending on the size and thickness of the defect needing to be repaired.[11][12][13] Without a doubt, however, the thin nature of the TPFF renders it a great choice for reconstruction of a variety of defects involving the skull base, facial soft tissues, nasopharynx, oral cavity, orbit, ear, and scalp.

Contraindications

 There are few contraindications to consider when performing a temporoparietal fascia flap:

  • When used as a pedicled flap, the surgeon should first consider the anatomical reach limitations of the proposed TPFF.
  • The surgeon should be mindful that previous radiation therapy may have altered the microvascular anatomy of the flap and potentially can lead to decreased success.
  • Prior injury or manipulation of the superficial temporal vascular system (e.g., STA biopsy for temporal cell arteritis)

Equipment

Preoperatively

  • Surgical marker
  • Local anesthesia (per surgeon preference)
  • Topical antiseptic
  • Based on the clinical scenario, a corneal shield may be considered for eye protection
  • Facial nerve monitoring system (not routinely implemented)

Intraoperatively

  • Head and neck soft tissue surgical tray
  • Bipolar cautery
  • 15 blade scalpel
  • Multiprong retractors
  • Closed suction drain with bulb
  • Closure of scalp skin (suture vs. staple) per surgeon preference

Postoperatively

  • Antibiotic ointment
  • Wound dressing material (per surgeon preference)

Personnel

  • Surgeon
  • Surgical assistant
  • Surgical scrub technician
  • Operating room nurse (circulator)
  • The anesthesiologist and/or nurse anesthetist

Preparation

  • The patient should be risk-stratified and medically optimized for general anesthesia.
  • A thorough preoperative head and neck examination, including assessment of facial nerve function, should be performed.
  • Preoperative photography may be considered to document the shape and size and location of the defect.
  • The patient should be appropriately counseled regarding the risks, benefits, and alternatives to the procedure. Pertinent to this procedure, it is important to mention flap compromise, alopecia, paresthesias, and facial nerve injury, among the other more common risks associated with surgery (e.g., pain, bleeding, infection, scarring, etc.).
  • The surgeon should mark the skin incisions in the temporal scalp to ensure the maximal preservation of the hairline. The Y or T shaped incision is made parallel to the course of the STA. The arterial bifurcation is commonly found 3 centimeters above the helical root.
  • Important landmarks are identified, including the STA and trajectory of the frontotemporal branch of the facial nerve.
  • General anesthesia is recommended. Muscle paralytics are usually avoided to allow for intraoperative facial nerve monitoring. 
  • A single dose of intravenous antibiotics covering skin flora is given preoperatively.

Technique

It is not necessary to shave any hair during this procedure, though it may be helpful to shave the hair 1 to 2 cm beyond the anticipated incision line.

  1. A Y or T shaped incision is planned in the preauricular crease and extended several centimeters cranially. 
  2. The incision is made through the skin, dermis, and subcutaneous fat. The cranial and outward dissection from this point is in a subcutaneous plane just below the level of the hair follicles. This step is of utmost importance as it assists the surgeon in maintaining the appropriate depth of dissection and preserves robust temporoparietal fascia flap thickness. Sharp, cold dissection is preferred to avoid thermal injury to the hair follicles and decreased the risk of alopecia.
  3. Care should be taken to avoid injuring the underlying STA, which courses through the substance of the flap itself. Once the appropriate size of the required temporoparietal flap is exposed, the surgeon can incise the periphery of the temporoparietal fascia sharply with care to preserve the vascular pedicle. At this step, the distal branches of the superficial temporal artery are ligated. The surgeon may now rotate the flap into its desired defect. If hair-bearing skin is required, this flap may be harvested in the continuity of the overlying skin. NOTE: One should be mindful during anterior dissection as not to injury the frontotemporal branch of the facial nerve, which lies either within or just beneath the temporoparietal fascia. (See ANATOMY section above)
  4. The superficial temporal artery may be dissected further proximally until the middle temporal artery is identified. In certain situations, the surgeon may require dissection of parotid tissue to facilitate this step. At this point, the flap may be harvested as a chimeric flap to include the deep temporal fascia and/or temporalis muscle. If desired, the surgeon can extend the anatomic boundaries of this fascial layer beyond the temporal fossa to include pericranium and/or to harvest a vascularized strip of calvarium (outer cortex).
  5. The surgeon may either rotate or tunnel this flap into the desired defect or the vascular bundle may be ligated in anticipation of free microvascular reconstruction of distal defects.
  6. The surgeon may select to place a closed suction drain. This is optional.
  7. The skin flaps are then reapproximated with deep absorbable sutures, followed by staples or suture closure of skin.

Complications

Potential complications for a temporoparietal fascia flap may include[14]:

  • Alopecia
  • Flap necrosis
  • Incomplete eye closure following an injury to the frontal branch of the facial nerve
  • Venous congestion
  • Wound breakdown
  • Hematoma formation
  • Infection
  • Unfavorable scarring
  • Paresthesia

The majority of complications can be avoided with meticulous dissection and careful flap elevation respecting the local scalp anatomy. Rates of flap loss (partial vs. total) are roughly 2.44%.[12] Some degree of alopecia may be documented in up to 8% of patients.[15] Injury to the frontotemporal branch of the facial nerve resulting in transient weakness to paralysis may range from 1% to 20%.[16]

Clinical Significance

A temporoparietal fascia flap can act as a work-horse reconstructive option in the armamentarium of a reconstructive surgeon. It is a low-risk option for the reconstruction of local (craniofacial) and distal soft tissue defects. It has found notoriety in head and neck reconstruction as a pedicled flap but may be harvested as a free flap for extremity reconstruction. In the hands of an experienced and knowledgeable surgeon, the outcomes can be very satisfactory. 

Enhancing Healthcare Team Outcomes

It remains imperative to identify the risk factors and perform a thorough assessment before performing a temporoparietal fascial flap. The patient should have the following done:

  • Evaluation by a surgeon experienced in reconstructive surgery using a temporoparietal fascial flap.
  • Medical optimization in anticipation of general anesthesia
  • Monitoring by the preoperative, operative, and postoperative specialty nurse to assist with coordination of care and education. 

An interprofessional team of an experienced surgeon, anesthesiologist, surgical assistant, and operative nurse should perform the temporoparietal fascial flap for best outcomes. Close follow-up should monitor the patient for potential complications: flap necrosis, alopecia, wound breakdown, hematoma, and facial paralysis. Proper education should counsel the patient on appropriate wound care and activity level. 

This coordinated interprofessional care is essential to achieving the best results in reconstructive procedures utilizing a temporoparietal fascial flap. [Level 5]

Nursing, Allied Health, and Interprofessional Team Interventions

Recovery following a temporoparietal fascia flap depends on the complexity of the original problem for which the reconstruction was performed. Local wound care is paramount to ensure a healthy and clean surgical environment.   Suction drains (if placed) can be removed when output has appropriately decreased (e.g., output less than 30 mL over 24 hours). The patient should avoid rigorous activity for the next 10 days following surgery to allow adequate wound healing. Following discharge, the patient is typically followed regularly for several weeks to months to ensure proper healing. 

Nursing, Allied Health, and Interprofessional Team Monitoring

Close follow-up should monitor for potential possible complications: flap necrosis, alopecia, wound breakdown, hematoma, and facial paralysis. The ancillary staff should assist in patient education, monitoring, and follow-up coordination.


References

[1] Garfein E,Doscher M,Tepper O,Gill J,Gorlick R,Smith RV, Reconstruction of the pediatric midface following oncologic resection. Journal of reconstructive microsurgery. 2015 Jun;     [PubMed PMID: 25803408]
[2] Li D,Xu F,Zhang R,Zhang Q,Xu Z,Li Y,Wang C,Li T, Surgical Reconstruction of Traumatic Partial Ear Defects Based on a Novel Classification of Defect Sizes and Surrounding Skin Conditions. Plastic and reconstructive surgery. 2016 Aug     [PubMed PMID: 27465192]
[3] Marks MW,Friedman RJ,Thornton JW,Argenta LC, The temporal island scalp flap for management of facial burn scars. Plastic and reconstructive surgery. 1988 Aug     [PubMed PMID: 3399556]
[4] Jose A,Nagori SA,Arya S,Roy ID, Chimeric temporopareital osteofascial and temporalis muscle flap; a novel method for the reconstruction of composite orbito-maxillary defects. Journal of stomatology, oral and maxillofacial surgery. 2019 Jun;     [PubMed PMID: 30763779]
[5] Denadai R,Raposo-Amaral CE,Marques FF,Raposo-Amaral CA, Posttraumatic eyebrow reconstruction with hair-bearing temporoparietal fascia flap. Einstein (Sao Paulo, Brazil). 2015 Jan-Mar;     [PubMed PMID: 25993077]
[6] Schreiber M,Dragu A, Free temporal fascia flap to cover soft tissue defects of the foot: a case report. GMS Interdisciplinary plastic and reconstructive surgery DGPW. 2015;     [PubMed PMID: 26504730]
[7] Olcott CM,Simon PE,Romo T 3rd,Louie W, Anatomy of the superficial temporal artery in patients with unilateral microtia. Journal of plastic, reconstructive     [PubMed PMID: 30528867]
[8] Pitanguy I,Ramos AS, The frontal branch of the facial nerve: the importance of its variations in face lifting. Plastic and reconstructive surgery. 1966 Oct     [PubMed PMID: 5926990]
[9] Schmidt BL,Pogrel MA,Hakim-Faal Z, The course of the temporal branch of the facial nerve in the periorbital region. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2001 Feb     [PubMed PMID: 11213986]
[10] Trinei FA,Januszkiewicz J,Nahai F, The sentinel vein: an important reference point for surgery in the temporal region. Plastic and reconstructive surgery. 1998 Jan     [PubMed PMID: 9427913]
[11] Safavi-Abbasi S,Komune N,Archer JB,Sun H,Theodore N,James J,Little AS,Nakaji P,Sughrue ME,Rhoton AL,Spetzler RF, Surgical anatomy and utility of pedicled vascularized tissue flaps for multilayered repair of skull base defects. Journal of neurosurgery. 2016 Aug     [PubMed PMID: 26613175]
[12] Mokal NJ,Ghalme AN,Kothari DS,Desai M, The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India. 2013 Sep;     [PubMed PMID: 24459337]
[13] Jaquet Y,Higgins KM,Enepekides DJ, The temporoparietal fascia flap: a versatile tool in head and neck reconstruction. Current opinion in otolaryngology & head and neck surgery. 2011 Aug     [PubMed PMID: 21593668]
[14] Mavropoulos JC,Bordeaux JS, The temporoparietal fascia flap: a versatile tool for the dermatologic surgeon. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2014 Sep     [PubMed PMID: 25158871]
[15] Hing DN,Buncke HJ,Alpert BS, Use of the temporoparietal free fascial flap in the upper extremity. Plastic and reconstructive surgery. 1988 Apr;     [PubMed PMID: 3347663]
[16] Yano H,Fukui M,Yamada K,Nishimura G, Endoscopic harvest of free temporoparietal fascial flap to improve donor-site morbidity. Plastic and reconstructive surgery. 2001 Apr 1;     [PubMed PMID: 11252096]