Original Article The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases Nitin J Mokal, Amol N Ghalme1, Deepak S Kothari, Mahinoor Desai2 Deparments of Plastic Surgery, G.T Hospital, 1J.J Hospital, 2Shusrusha Hospital, Mumbai, Maharashtra, India Address for correspondence: Dr. Amol Ghalme, Department of Plastic surgery, J.J Hospital, Balaram Building, Mumbai, Maharashtra, India. E-mail: [email protected]
ABSTRACT Objective: This report details our experience with the use of the temporoparietal fascia flap in different scenarios of reconstruction and to discuss our technique of harvest, clinical applications, and review of literature of this versatile flap. Materials and Methods: A retrospective study of 82 cases of temporoparietal fascia flap in 71 patients, operated over a period of 10 years was conducted. Patients were grouped based on various clinical indications. The follow up period ranged from a minimum of 1 to a maximum of 10 years (Mean-four and a half years). All patients were analyzed for functional and aesthetic outcome using preoperative and postoperative photographs. Results: No significant complications were seen in our series. Only 2 out of 82 flaps had partial necrosis of flap (2.44%). Two patients who were operated for release of submucous fibrosis developed recurrence due to continued use of tobacco. The final outcome in one patient of ear reconstruction was unsatisfactory due to flap failure. The remaining patients had satisfactory functional and aesthetic outcomes (95.77%). None had other complications like temporal branch of facial nerve injury or alopecia along the scar line. Conclusion: The TPFF is one of the most reliable and versatile flap in the head and neck region. It can also be reliably used as free fascial flap. When its advantages are combined with the surgeon’s resourcefulness, various defects can be successfully reconstructed using the temporoparietal facia flap with satisfactory aesthetic and functional outcome.
KEY WORDS Head and neck reconstruction; temporoparietal fascia flap; TPFF
INTRODUCTION
T
he temporoparietal facial flap (TPFF) is a versatile tool which has been widely used in the management of a variety of defects in the head and Access this article online
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Website: www.ijps.org DOI: 10.4103/0970-0358.121988
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neck region as a pedicled flap and also as a free flap to reconstruct hand and forearm defects. Its thin and pliable quality, reliable vascular supply and minimal donor site morbidity are unparalleled when compared with other regional flaps such as forehead or scalp flaps.[1] It was first described in 1898 nearly simultaneously for reconstruction of the external ear (after a horse bite)[2] and for reconstruction of the lower eyelid.[3] In 1983, Gillies described the use of the pedicled scalp flap based on the superficial temporal artery for reconstruction of lip and eyebrow defects.[4] In the same year Brent et al., reported the successful use of the flap as an axial-pattern fascial
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
flap, a random-pattern fascial flap, and a free fascial flap for secondary ear reconstruction.[5] The advent of microvascular surgery has renewed interest in the vascular supply of the temporal region as a potential free flap donor site. There are numerous anatomical studies that describe the layers and blood supply of the scalp.[6]Although temporoparietal fascia is called by numerous names such as superficial temporal fascia, epicranial aponeurosis, or galeal extension by different authors; temporoparietal fascia is the most preferred term for this anatomically identified fascial layer.[6] It is a thin, highly vascular layer which lies immediately deep to the hair follicles and the subdermal layer of fibrofatty tissue in which they lie [Figure 1]. This layer is continuous with the superficial musculoaponeurotic system (SMAS) as it passes over the zygomatic arch into the mid face, the galea aponeurotica above, the frontalis muscle in front, and the occipitalis muscle behind.
MATERIALS AND METHODS We present our experience with the versatility of the temporoparietal fascia flap (TPFF) and its application in a series of patients [Table 1]. A total of 82 TPFFs were raised in 71 patients. Bilateral TPFF was harvested in 11 patients and unilateral TPFF in
60 patients. In ten patients, bilateral pedicled TPFF was used to cover the intraoral defect following the release of submucous fibrosis. In five patients, split thickness graft (STSG) was used along with TPFF. In the rest of the five patients, the intraoral defect was covered with TPFF without skin graft. Bilateral expanded hair-bearing galeopericranial composite TPFF was used in one patient for the correction of post-burn deformity of cheek and chin. The major group included 25 paediatric patients who were operated for temporomandibular joint (TMJ) ankylosis release followed by interposition arthroplasty using a costal cartilage graft covered with pedicled TPFF. Folded TPFF was used without the costal cartilage graft for interposition arthroplasty in four adult patients of TMJ ankylosis. It was used for ear reconstruction in 17 patients to cover the cartilage framework. The other indications for pedicled TPFF were lining of the orbital socket (three patients), lower eyelid reconstruction (five patients), after excision of mastoid fistula (one patient), and soft tissue augmentation of cheek (four patients). Composite TP fascia flap with vascularized conchal cartilage graft was used in one patient who presented with pain on chewing secondary to condylar hyperplasia. All patients were followed up for functional and aesthetic outcome in the postoperative period. Surgical technique Trauma, previous surgery, irradiation, or carotid occlusion may jeopardize the integrity of the TPFF. Therefore, Doppler examination with a hand held device is used preoperatively to determine the reliability of the superficial temporal artery and to map the course of the main pedicle, frontal branch, and parietal branch.
Figure 1: Anatomy of TPFF
An informed consent explaining the details and possible complications of the procedure is obtained preoperatively. We do not prefer to shave a wide area of scalp but only the hair along the incision line. Rest of the hair is held out of the field with the use of the ointment and rubber bands. We use an infiltration solution containing one ampoule of hyalase in 1:100000 adrenaline in Ringers lactate, which is injected in the subfollicular plane. Several incisions such as lazy S, inverted T, Y-shaped, or
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
Indications TMJ ankylosis
Temporo-mandibular joint Ear reconstruction
Oral submucous fibrosis
Orbital reconstruction
Lower eyelid reconstruction
Soft tissue augmentation
Cheek and chin reconstruction Mastoid fistula
Table 1: Use of the temporoparietal fascia flap (TPFF) in various scenarios Method of use No. Of patients Children Interposition arthroplasty with costal 25 cartilage covered with TPPF Adults Interposition arthroplasty with ball of TPFF 04 Condylar hyperplasia in Composite TPPF with vascularised conchal 1 adults cartilage graft Complete microtia associated with hemifacial microsomia Incomplete Microtia
None None
Single stage total ear reconstruction with cartilage framework covered with TPFF and STSG cartilage framework covered with TPFF and STSG Second stage of Microtia Reconstructed auricle with wedge of banked costal cartilage graft with TPFF and STSG Post traumatic ear cartilage framework covered with TPFF deformity and STSG Post burn ear deformity cartilage framework covered with TPFF and STSG Oral submucous fibrosis TPFF with STSG
02
One partial necrosis of flap
1
None
10
None
2
None
2
None
5
Recurrence in one patient
Oral submucous fibrosis TPFF only
5
Recurrence in one patient
Langerhans cell histiocytosis
Composite galeopericranial TPFF flap with Temporalis muscle and free rib graft
1
None
Retinoblastoma Post-tumor resection defect
Lining of socket with TPFF and STSG Bi-lamellar lower eyelid reconstruction with island superficial temporal artery flap with hard palate muco-periosteal free graft
2 3
None None
Ectropion with scar adherent to bone Post tuberculosis deformity of cheek
Pedicled TPFF with STSG
2
None
Soft tissue augmentation
1
None
Post traumatic deformity Soft tissue augmentation of cheek
2
None
Post infective deformity of lip
Soft tissue augmentation
1
None
Post burn scar
Expanded hair bearing composite flap
1
Partial loss of flap
Post-auricular mastoid fistula
Pedicled TPFF with STSG
1
None
zigzag incision have been described. We commonly use a zigzag incision. The incision is made starting from the preauricular region extending to the superior temporal line. The anterior and posterior scalp flaps are elevated in the subfollicular plane immediately deep to the hair follicles using loupe magnification in order to avoid inadvertent damage to the hair follicles. After obtaining adequate exposure, a flap of appropriate size is marked. The flap may be up to 14 to 17 cm in height and 10 cm in width. The conventional fascial flap can be extended up to 3-4 cm superior to the origin of the temporal muscle. The temporoparietal fascial flap is then raised from superior to inferior by dissecting in the loose areolar tissue plane between the two layers of fascia. The pedicle containing 495
Complications None
superficial temporal artery and vein is identified, and the flap base is narrowed to 2.0-2.5 cm for ease of transfer. The flap is transferred into the recipient site. Its pliability makes it uniquely suited to draping over irregular surfaces. A fine-tipped bipolar electrocautery is used to achieve hemostasis, thus avoiding damage to the hair follicles. After the temporoparietal fascia is transferred to the recipient site, suction drains are inserted and the donor site is closed in two layers.
RESULTS The ages of the patients ranged from 18 months to
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
62 years. The follow up period ranged from a minimum of 1 to a maximum of 10 years (Mean- four and a half years). Of the 29 patients operated for TMJ ankylosis all achieved adequate mouth opening (mean of 3.9 cm) and we did not encounter any complication or reankylosis over a follow up period of 2 years. In ten patients operated for submucous fibrosis release, inter incisor distance of 45 mm was achieved intraoperatively. The average mouth opening in this group was 4.1 cm over a follow up period of 2 years. Two patients developed recurrence due to continued use of tobacco/gutkha. In our series all but two patients had complete survival of the flap (2.44%) and an uneventful post-operative course. There was partial flap loss due to hematoma below the flap in one patient of ear reconstruction. This leads to the unsatisfactory final outcome. One patient who was operated for cheek and chin reconstruction following post-burn scarring using bilateral expanded hair bearing composite TPF flaps showed partial necrosis of the flap on the left side. This was managed by using a local tube pedicle flap from the occipital hair bearing skin. A satisfactory aesthetic and functional outcome was achieved. Two patients who were operated for the release of submucous fibrosis developed recurrence due to continued use of tobacco. The final outcome in one patient of ear reconstruction was unsatisfactory due to flap failure. The remaining patients had satisfactory functional and aesthetic outcomes (95.77%). There have been no complications such as alopecia along the incision line or injury to the temporal branch of facial nerve in our series of patients.
DISCUSSION The TPFF is one of the most reliable and versatile flaps in the head and neck region. It can be used both as a pedicled and as a free flap. In our series of 71 patients, we used TPFF as a pedicled flap, as a composite TP fascia with conchal cartilage graft, as a composite galeopericranial TPFF flap with temporalis muscle flap, as an expanded hair bearing composite flap.
Gap arthroplasty in the treatment of TMJ ankylosis is shown to be associated with poorly organized residual fibrous tissue in the gap with deposition of bone within it even after 3 months.[7] Therefore, various methods of interposition arthroplasty using acrylic,[8,9] nonvascularized auricular cartilage,[10] costochondral grafts,[11-13] dermis fat graft,[14] muscle or myofascial flaps,[15] and resected bony material[16,17] have been described with varying degrees of success. The alloplastic materials have problems such as displacement and extrusion. Smith and co-workers (1993) have reported implant erosion into the middle cranial fossa.[18] Of all the autologous materials TPFF has the advantage that it is readily available in the immediate vicinity, is extremely pliable so can be molded easily to fit the defect, and is well vascularized, hence less likely to resorb with lesser chances of recurrence of ankylosis. Jagannathan et al., have suggested a modification which includes the use of a vascularized cartilage graft from the helix of the ear along with the TPFF. This provides not only a cartilage lining for the condylar remnant or the graft but also augments the vertical height of the ramus.[19] We used pedicled TPFF in 29 patients for interposition arthroplasty following TMJ ankylosis release. It was used to cover the costal cartilage graft in 25 children. Folded TPFF without the costal cartilage graft was used in four adult patients of TMJ ankylosis [Figure 2a-f]. The TPFF flap covers the cartilage graft or the cut end of the mandibular condyle and serves as a pseudocapsule and provides a cushioning effect. This prevents contact between the bony/cartilaginous surfaces, organization of fibrous tissue in the gap and hence reankylosis. In one adult patient of condylar hyperplasia we used Jagannathan’s modification of the TPFF.[19] This vascularized flap shows fewer chances of subsequent absorption and hence reankylosis. We used pedicled TPFF in a total of 17 patients for ear reconstruction [Figure 3a-d]. Of these the majority i.e. ten patients were undergoing the second stage of microtia reconstruction, three were undergoing a single stage ear reconstruction for microtia and two were for posttraumatic and post-burn ear reconstruction each. With its location adjacent to the auricular reconstruction site, axial transfer of the TPFF is ideal. In the second stage of ear reconstruction, greater projection of the auricle can be obtained by placing a wedge of costal cartilage behind the elevated ear, but this must be covered with a tissue flap for a skin graft
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
a
c
b
a
b
c
d
e
d
f
Figure 2: (a) OPG of patient showing ankylosis, (b, c) Pre and post op mouth opening, (d) Tpff used as spacer between recreated zygoma and ramus, (e) Costochondral graft used to make zygoma and ramus, (f) Post op OPG showing well maintained ramus height
to take over the cartilage. Nagata used TPFF for this purpose.[20] In our series ten patients of micotia were operated for second stage of ear reconstruction using Nagata’s technique. The reconstructed auricle was raised with a wedge of banked costal cartilage graft which was covered pedicled TPFF and split skin graft. In two patients of complete microtia associated with hemifacial microsomia, one patient of incomplete microtia and two patients of post-burn ear deformity, we performed single stage total ear reconstruction with cartilage framework covered with TPFF and split thickness skin graft (STSG). The TPFF was used to cover the cartilage framework due to skin paucity due to low hairline in microtia group and scarring in post-burn group. Brent and Byrd stated that the use of primary fascial flap may be considered if one predicts a tight cutaneous pocket and a hairline that will cover only one-half of the new ear.[20] In an effort to resolve the problem of skin paucity, they implemented the use of TPFF and skin graft to cover cartilage framework for secondary ear reconstruction.[21] In two patients, we used TPFF to cover the exposed cartilage framework following trauma. Reattaching the total or subtotal amputated ear as a composite graft is unreliable. Use of the retro auricular pocket to enhance survival of the reattached ear entails multistage procedures with somewhat poor results due to the associated fibrosis.[22] Microsurgical replantation can be performed but its applicability is limited due to difficulty with venous drainage.[23] Pedicled TPFF with skin graft 497
Figure 3: (a) Right ear microtia, (b) Harvest of TPFF, (c) TPFF to cover cartilage framework in single stage, (d) Post op reconstructed ear
can be used as an alternative to the pocket technique and microvascular reattachment for complete ear avulsion.[24] This technique is simple, single stage and the thinness and pliability of the flap allow it to maintain the delicate details of the auricular cartilage[25] while its rich vascularity nurtures excellent skin graft survival rates. In this series, pedicled TPFF covered with split skin graft was used to line the intraoral defect following the release of submucous fibrosis in five patients. In the other five patients, pedicled TPFF without skin graft used to cover intraoral defect [Figure 4a-f]. Mokal et al., concluded that well vascularized TPFF brings good blood supply to the fibrosed muscles and mucosa. The flap is raised bilaterally and turned over the zygomatic arch and brought intraorally to fill the mucomuscular defect. This provides a healthy and vascularized bed for the skin graft.[26] We used pedicled TPFF covered with split skin graft for orbital socket reconstruction in three patients. It is favorable for managing various orbital socket defects due to its reliable and rich vascularity, pliable form and proximity to the orbit. It is useful even in irradiated or chronically infected tissue beds.[27] Its use has also been described by Lai et al.,[28] for orbital cavity or periorbital soft tissue or bony defects. In chronically inflamed wounds such as with osteoradionecrosis and orbitoantral fistula, TPFF successfully restored vascularity, obliterated the defects, and enabled the placement of osteointegrated implants. We used a composite galeopericranial TPFF flap with temporalis muscle and free rib graft for reconstruction of lateral wall of orbit in a 7-year-old child who underwent
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resection for Langerhans Cell Histiocytosis. Mokal et al., have previously described the successful use of this composite flap in lateral orbital wall reconstruction.[29] It can also be used as composite flap with calvarial bone particularly in extended exenteration defects with loss of orbital wall or maxillary defects.[30,31]
post-burn hypertrophic scarring of the cheek and chin [Figure 5a, b]. The reliable vascular supply, inconspicuous donor site match in tissue characteristics and proximity to the reconstructive site make TPFF an optimal choice. This hair-bearing TPFF can also be used in eyebrow, moustache, or scalp restoration.[33] Kim et al., concluded that hair-bearing TPFF is an excellent choice for the restoration of function and aesthetics in full thickness upper lip defects.[34]
An expanded hair-bearing composite bilateral TPFF flap in a male patient was used for reconstruction of
The disadvantages of this procedure include multiple surgeries, temporary disfigurement due to the tissue expanders, and limited applicability in female patients.
a
b
c
d
e
f
Five patients were operated on for full thickness lower eye lid reconstruction [Figure 6a-e]. Bilamellar lower eyelid reconstruction with island superficial temporal artery flap and hard palate mucoperiosteal free graft was done in three patients for post-oncological resection reconstruction of lower eyelid. This has been previously reported by Jacob et al., and all five patients had good aesthetic and functional results.[32]
Figure 4: (a) mouth opening of patient with submucous fibrosis (b,c) TPFF harvested, (d,e) Intraoral tunneling of TPFF bilaterally, (f) Post op mouth opening
In two patients lower lid ectropion due to scar adherent to the underlying bone was released and the resultant
a
b Figure 5: (a) Composite flap of TPFF with hair bearing scalp (b) Bilateral composite TPFF for cheek and beard recronstruction
a
b
c
d
e
Figure 6: (a) Flap marked over forehead, (b) Flap elevated along with temporoparietal fascia, (c) To be insetted for complete lower lid defect, (d,e) Pre and post op appearance for total lower eyelid reconstruction
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
defect was covered with TPFF and skin graft. There are no published reports of TPFF being used for this indication in the current literature. We believe TPFF to be a good option to cover bare bone in the periorbital region due to its thinness and pliability. In comparison, a skin flap would be bulky while a skin graft alone might not survive on an avascular and scarred bed. The TPFF was used for soft tissue augmentation in three patients. One patient had upper lip augmentation and two patients had cheek augmentation to correct the contour deformity. The flap’s thin texture and rich vascularity produces desirable and consistent results. Local flaps (i.e., Gillies fan flap,[35] or Bernard-Burow flap)[36] are less satisfactory aesthetically and functionally for fullthickness defects of the upper lip due to displacement of the modiolus and invariable microstomia, while distant flaps are bulky and associated with donor site morbidity and increased surgical time. Use of TPFF and its variations like prefabrication with dermal fat graft have been described in soft tissue augmentation and to correct contour deformities in conditions like facial palsy or congenital dysplasia.[37-39] Post-auricular cutaneous mastoid fistula is an uncommon complication of chronic suppurative otitis media. The fistula tracts are typically difficult to manage because of the surrounding necrotic skin edges.[40] The TPFF has desirable properties for otologic surgery: High malleability, distinct vascularity, and close proximity to the temporal bone.[41] We have successfully managed a case of post-infective mastoid fistula using TPFF.
injury, scar alopecia, and bleeding have been described. We have not observed nerve injury or scar alopecia in any of our series of 82 flaps in 71 patients. This could be attributed to our meticulous dissection technique using hydrodissection in the subfollicular plane along with loupe magnification for flap elevation and minimal use of electrocautery in the vicinity of the follicles. Also elevation of fascia above the loose areolar plane avoids injury to the frontal branch of facial nerve. Partial loss of flap was seen in 2 out of 82 flaps (2.44%). In one patient of total ear reconstruction, partial necrosis was due to hematoma under the flap [Figure 7a,b]. The final outcome was aesthetically unsatisfactory. Hence, careful attention to hemostasis must be paid following elevation of the flap. Use of a fine bipolar cautery is advised for this purpose in order to minimize the damage to the hair follicles, thus preventing alopecia. Partial loss of the flap in the other patient, who was operated for post-burn cheek and chin resurfacing by expanded hair bearing composite flap was managed by fabricating a local tube-pedicled flap from occipital hair bearing skin [Figure 8a-d].
CONCLUSION The TPFF is a thin, pliable, well vascularized, and readily available flap in the head and neck region. Meticulous surgical dissection in the appropriate plane, judicious use of electrocautery and the use of loupe magnification allow excellent flap elevation without much risk of complications.
Though there is minimum morbidity associated with this flap, complications like temporal branch of facial nerve
a
b Figure 7: Complication showing partial flap necrosis
499
a
b
c
d
Figure 8: (a-c) Complication showing necrosis of one side composite flap which was reconstructed using occipatal flap, (d) Final post op appearance
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When its advantages are combined with the surgeon’s resourcefulness, various defects secondary to trauma, tumor resection, congenital deformities, and radiation injury can be successfully reconstructed with satisfactory aesthetic and functional outcome.
REFERENCES 1. Mathes SJ, Nahai F. Regional Flaps: Anatomy and Basic techniques head and neck section. In: Reconstructive Surgery Principles, Anatomy, Technique Volume 1. Philadelphia: Churchill Living-Stone; 1997. p. 367-85. 2. Brown W. Extraordinary case of horse-bite; the external ear completely bitten off and successfully replaced. The Lancet1898;151(3901):1533-4. 3. Monks GH. The restoration of a lower lid by a new method. The Boston Medical and Surgical Journal 1898;139:385-7. 4. Gillies HD. Plastic surgery of the face. New York, NY: Gower Medical Publishing Ltd; 1983. 5. Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:141-52. 6. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77:17-23. 7. Matsuura H, Miyamoto H, Ogi N, Kurita K, Goss AN. The effect of gap arthroplasty on temporomandibular joint ankylosis: An experimental study. Int J Oral Maxillofac Surg 2001;30:431-7. 8. Sawhney CP. Bony ankylosis of temporomandibular joint: Followup of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 1986;77:29-40. 9. Erdem E, Alkan A. The use of acrylic marbles for interposition arthroplasty in the treatment of temporomandibular joint ankylosis: Follow-up of 47 cases. Int J Oral Maxillofac Surg 2001;30:32-6. 10. Lello GE. Surgical correction of temporomandibular joint ankylosis. J Craniomaxillofac Surg 1990;18:19-26. 11. Posnik JC, Goldstein JA. Surgical management of temporomandibular joint ankylosis in paediatric population. Plast Reconstr Surg 1993;91:791-8. 12. Güzel MZ, Arslan H, Saraη M. Mandibular condyle reconstruction with inlay application of autogenous costochondral graft after condylectomy: Cerrahpa?a’s technique. J Oral Maxillofac Surg 2007;65:615-20. 13. Donkor P, Acheampong AO. Intra-articular ramus ostectomy combined with costochondral grafting for the treatment of recurrent ankylosis of the mandible. Br J Oral Maxillofac Surg 2006;44:497500. 14. Dimitroulis G. The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 2004;33:755-60. 15. Turco M, Di Cosola M, Faccioni F, Cortelazzi R. Treatment of severe bilateral temporomandibular joint ankylosis in adults-our protocol. Minerva Stomatol 2007;56:181-90. 16. YongLong H, Xiaoming G, Xinhua F, Yilin W. Modified coronoid process grafts combined with sagittal split osteotomy for treatment of bilateral temporomandibular joint ankylosis. J Oral Maxillofac Surg 2002;60:11-8. 17. Gunaseelan R. Condylar reconstruction in extensive ankylosis of temporomandibular joint in adults using resected segment as autograft: A new technique. Int J Oral Maxillofac Surg 1997;26:4057. 18. Smith RM, Goldwasser MS, Sabol SR. Erosion of Teflon Proplast
implant into the middle cranial fossa. J Oral Maxillofac Surg 1993;51:1268-71. 19. Jagannathan M, Devale M, Kesari P, Karanth S. Use of vascularised cartilage as an additional interposition in temporomandibular ankylosis surgery: Rationale, advantages and potential benefits. Indian J Plast Surg 2008;41:110-5. 20. Nagata S. Modification of the stages in total reconstruction of the auricle: Part I. Grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg 1994;93:221-30. 21. Brent B, Byrd H. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:141-52. 22. Mladick RA, Horton CE, Adamson JE. The pocket principle: A new technique for the reattachment of a severed ear part. Plast Reconstr Surg 1971;48:219-23. 23. Steffen A, Katzbach R, Klaiber S. A comparison of ear reattachment methods: A review of 25 years since Pennington. Plast Reconstr Surg 2006;118:1358-64. 24. Anous MM, Hallock GG. Immediate reconstruction of the auricle using amputated cartilage and the temporoparietal fascia. Ann Plast Surg 1988;21:378-81. 25. Saad Ibrihim SM, Zidan A, Madani S. Totally avulsed ear: New technique of immediate ear reconstruction. J Plast Reconstr Aesthet Surg 2008;61 Suppl 1:S29-36. 26. Mokal N, Raje R, Ranade S, Prasad J, Thatte R. Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft — a new technique. Br J Plast Surg 2005;58:1055-60. 27. Hanasono MM, Lee JC, Tang JS. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg 2009; 123:98-105. 28. Lai A, Cheney ML. Temporoparietal fascial flap in orbital reconstruction. Arch Facial Plast Surg 2000;2:196-201. 29. Mokal NJ, Shetty KP, Arora R, Thatte MR. Langerhans Cell Histiocytosis: Orbital Involvement as an Unusual Location. Plast Reconstr Surg 2001;107:813-7. 30. Davison SP, Mesbahi AN, Clemens MW. Vascularized calvarial bone flaps and midface reconstruction. Plast Reconstr Surg 2008;122:10e-8e. 31. Parhiscar A, Har-El G, Turk JB. Temporoparietal osteofascial flap for head and neck reconstruction. J Oral Maxillofac Surg 2002;60:619-22. 32. Jacob V, Mokal NJ, Deshpande SN. Bi-lamellar lower eyelid reconstruction with superficial temporal artery island flap and hard palate muco-periosteal free graft. Indian J Plast Surg 2005;38:10597. 33. Navarro-Ceballos R, Bastarrachea RA. Clinical applications of temporoparietal hair-bearing flaps for male pattern baldness and mustache formation. Aesthetic Plast Surg 1991;15:343-8. 34. Kim JC, Hadlock T, Vavares MA, Cheney ML. Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects. Arch Facial Plast Surg 2001;3:170-7 35. Bernard C. Cander de la levre infericure opere par un procede nouveau. Bull Mem Soc Hir (Paris) 1853;3:357. 36. Gillies HD, Millard DR Jr. Principles and Practice of Plastic Surgery. Boston, Mass: Little Brown and Co Inc; 1957. 37. Zhang Y, Jin R, Sun B. Pedicaled superfcial temporal fascia sandwich flap for reconstruction of severe facial depression. J Craniofac Surg 2009;20:505-8. 38. Guven E, Kuvat SV, Aydin HU, Yazar M, Emekli U. Facial contour reconstruction with temporoparietal prelaminated dermal-adipose flaps. J Craniomaxillofac Surg 2010;38:374-8.
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How to cite this article: 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 J Plast Surg 2013;46:493-501.
Source of Support: Nil, Conflict of Interest: None declared.
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Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
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ABSTRACT Objective: This report details our experience with the use of the temporoparietal fascia flap in different scenarios of reconstruction and to discuss our technique of harvest, clinical applications, and review of literature of this versatile flap. Materials and Methods: A retrospective study of 82 cases of temporoparietal fascia flap in 71 patients, operated over a period of 10 years was conducted. Patients were grouped based on various clinical indications. The follow up period ranged from a minimum of 1 to a maximum of 10 years (Mean-four and a half years). All patients were analyzed for functional and aesthetic outcome using preoperative and postoperative photographs. Results: No significant complications were seen in our series. Only 2 out of 82 flaps had partial necrosis of flap (2.44%). Two patients who were operated for release of submucous fibrosis developed recurrence due to continued use of tobacco. The final outcome in one patient of ear reconstruction was unsatisfactory due to flap failure. The remaining patients had satisfactory functional and aesthetic outcomes (95.77%). None had other complications like temporal branch of facial nerve injury or alopecia along the scar line. Conclusion: The TPFF is one of the most reliable and versatile flap in the head and neck region. It can also be reliably used as free fascial flap. When its advantages are combined with the surgeon’s resourcefulness, various defects can be successfully reconstructed using the temporoparietal facia flap with satisfactory aesthetic and functional outcome.
KEY WORDS Head and neck reconstruction; temporoparietal fascia flap; TPFF
INTRODUCTION
T
he temporoparietal facial flap (TPFF) is a versatile tool which has been widely used in the management of a variety of defects in the head and Access this article online
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Website: www.ijps.org DOI: 10.4103/0970-0358.121988
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neck region as a pedicled flap and also as a free flap to reconstruct hand and forearm defects. Its thin and pliable quality, reliable vascular supply and minimal donor site morbidity are unparalleled when compared with other regional flaps such as forehead or scalp flaps.[1] It was first described in 1898 nearly simultaneously for reconstruction of the external ear (after a horse bite)[2] and for reconstruction of the lower eyelid.[3] In 1983, Gillies described the use of the pedicled scalp flap based on the superficial temporal artery for reconstruction of lip and eyebrow defects.[4] In the same year Brent et al., reported the successful use of the flap as an axial-pattern fascial
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
flap, a random-pattern fascial flap, and a free fascial flap for secondary ear reconstruction.[5] The advent of microvascular surgery has renewed interest in the vascular supply of the temporal region as a potential free flap donor site. There are numerous anatomical studies that describe the layers and blood supply of the scalp.[6]Although temporoparietal fascia is called by numerous names such as superficial temporal fascia, epicranial aponeurosis, or galeal extension by different authors; temporoparietal fascia is the most preferred term for this anatomically identified fascial layer.[6] It is a thin, highly vascular layer which lies immediately deep to the hair follicles and the subdermal layer of fibrofatty tissue in which they lie [Figure 1]. This layer is continuous with the superficial musculoaponeurotic system (SMAS) as it passes over the zygomatic arch into the mid face, the galea aponeurotica above, the frontalis muscle in front, and the occipitalis muscle behind.
MATERIALS AND METHODS We present our experience with the versatility of the temporoparietal fascia flap (TPFF) and its application in a series of patients [Table 1]. A total of 82 TPFFs were raised in 71 patients. Bilateral TPFF was harvested in 11 patients and unilateral TPFF in
60 patients. In ten patients, bilateral pedicled TPFF was used to cover the intraoral defect following the release of submucous fibrosis. In five patients, split thickness graft (STSG) was used along with TPFF. In the rest of the five patients, the intraoral defect was covered with TPFF without skin graft. Bilateral expanded hair-bearing galeopericranial composite TPFF was used in one patient for the correction of post-burn deformity of cheek and chin. The major group included 25 paediatric patients who were operated for temporomandibular joint (TMJ) ankylosis release followed by interposition arthroplasty using a costal cartilage graft covered with pedicled TPFF. Folded TPFF was used without the costal cartilage graft for interposition arthroplasty in four adult patients of TMJ ankylosis. It was used for ear reconstruction in 17 patients to cover the cartilage framework. The other indications for pedicled TPFF were lining of the orbital socket (three patients), lower eyelid reconstruction (five patients), after excision of mastoid fistula (one patient), and soft tissue augmentation of cheek (four patients). Composite TP fascia flap with vascularized conchal cartilage graft was used in one patient who presented with pain on chewing secondary to condylar hyperplasia. All patients were followed up for functional and aesthetic outcome in the postoperative period. Surgical technique Trauma, previous surgery, irradiation, or carotid occlusion may jeopardize the integrity of the TPFF. Therefore, Doppler examination with a hand held device is used preoperatively to determine the reliability of the superficial temporal artery and to map the course of the main pedicle, frontal branch, and parietal branch.
Figure 1: Anatomy of TPFF
An informed consent explaining the details and possible complications of the procedure is obtained preoperatively. We do not prefer to shave a wide area of scalp but only the hair along the incision line. Rest of the hair is held out of the field with the use of the ointment and rubber bands. We use an infiltration solution containing one ampoule of hyalase in 1:100000 adrenaline in Ringers lactate, which is injected in the subfollicular plane. Several incisions such as lazy S, inverted T, Y-shaped, or
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
Indications TMJ ankylosis
Temporo-mandibular joint Ear reconstruction
Oral submucous fibrosis
Orbital reconstruction
Lower eyelid reconstruction
Soft tissue augmentation
Cheek and chin reconstruction Mastoid fistula
Table 1: Use of the temporoparietal fascia flap (TPFF) in various scenarios Method of use No. Of patients Children Interposition arthroplasty with costal 25 cartilage covered with TPPF Adults Interposition arthroplasty with ball of TPFF 04 Condylar hyperplasia in Composite TPPF with vascularised conchal 1 adults cartilage graft Complete microtia associated with hemifacial microsomia Incomplete Microtia
None None
Single stage total ear reconstruction with cartilage framework covered with TPFF and STSG cartilage framework covered with TPFF and STSG Second stage of Microtia Reconstructed auricle with wedge of banked costal cartilage graft with TPFF and STSG Post traumatic ear cartilage framework covered with TPFF deformity and STSG Post burn ear deformity cartilage framework covered with TPFF and STSG Oral submucous fibrosis TPFF with STSG
02
One partial necrosis of flap
1
None
10
None
2
None
2
None
5
Recurrence in one patient
Oral submucous fibrosis TPFF only
5
Recurrence in one patient
Langerhans cell histiocytosis
Composite galeopericranial TPFF flap with Temporalis muscle and free rib graft
1
None
Retinoblastoma Post-tumor resection defect
Lining of socket with TPFF and STSG Bi-lamellar lower eyelid reconstruction with island superficial temporal artery flap with hard palate muco-periosteal free graft
2 3
None None
Ectropion with scar adherent to bone Post tuberculosis deformity of cheek
Pedicled TPFF with STSG
2
None
Soft tissue augmentation
1
None
Post traumatic deformity Soft tissue augmentation of cheek
2
None
Post infective deformity of lip
Soft tissue augmentation
1
None
Post burn scar
Expanded hair bearing composite flap
1
Partial loss of flap
Post-auricular mastoid fistula
Pedicled TPFF with STSG
1
None
zigzag incision have been described. We commonly use a zigzag incision. The incision is made starting from the preauricular region extending to the superior temporal line. The anterior and posterior scalp flaps are elevated in the subfollicular plane immediately deep to the hair follicles using loupe magnification in order to avoid inadvertent damage to the hair follicles. After obtaining adequate exposure, a flap of appropriate size is marked. The flap may be up to 14 to 17 cm in height and 10 cm in width. The conventional fascial flap can be extended up to 3-4 cm superior to the origin of the temporal muscle. The temporoparietal fascial flap is then raised from superior to inferior by dissecting in the loose areolar tissue plane between the two layers of fascia. The pedicle containing 495
Complications None
superficial temporal artery and vein is identified, and the flap base is narrowed to 2.0-2.5 cm for ease of transfer. The flap is transferred into the recipient site. Its pliability makes it uniquely suited to draping over irregular surfaces. A fine-tipped bipolar electrocautery is used to achieve hemostasis, thus avoiding damage to the hair follicles. After the temporoparietal fascia is transferred to the recipient site, suction drains are inserted and the donor site is closed in two layers.
RESULTS The ages of the patients ranged from 18 months to
Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
62 years. The follow up period ranged from a minimum of 1 to a maximum of 10 years (Mean- four and a half years). Of the 29 patients operated for TMJ ankylosis all achieved adequate mouth opening (mean of 3.9 cm) and we did not encounter any complication or reankylosis over a follow up period of 2 years. In ten patients operated for submucous fibrosis release, inter incisor distance of 45 mm was achieved intraoperatively. The average mouth opening in this group was 4.1 cm over a follow up period of 2 years. Two patients developed recurrence due to continued use of tobacco/gutkha. In our series all but two patients had complete survival of the flap (2.44%) and an uneventful post-operative course. There was partial flap loss due to hematoma below the flap in one patient of ear reconstruction. This leads to the unsatisfactory final outcome. One patient who was operated for cheek and chin reconstruction following post-burn scarring using bilateral expanded hair bearing composite TPF flaps showed partial necrosis of the flap on the left side. This was managed by using a local tube pedicle flap from the occipital hair bearing skin. A satisfactory aesthetic and functional outcome was achieved. Two patients who were operated for the release of submucous fibrosis developed recurrence due to continued use of tobacco. The final outcome in one patient of ear reconstruction was unsatisfactory due to flap failure. The remaining patients had satisfactory functional and aesthetic outcomes (95.77%). There have been no complications such as alopecia along the incision line or injury to the temporal branch of facial nerve in our series of patients.
DISCUSSION The TPFF is one of the most reliable and versatile flaps in the head and neck region. It can be used both as a pedicled and as a free flap. In our series of 71 patients, we used TPFF as a pedicled flap, as a composite TP fascia with conchal cartilage graft, as a composite galeopericranial TPFF flap with temporalis muscle flap, as an expanded hair bearing composite flap.
Gap arthroplasty in the treatment of TMJ ankylosis is shown to be associated with poorly organized residual fibrous tissue in the gap with deposition of bone within it even after 3 months.[7] Therefore, various methods of interposition arthroplasty using acrylic,[8,9] nonvascularized auricular cartilage,[10] costochondral grafts,[11-13] dermis fat graft,[14] muscle or myofascial flaps,[15] and resected bony material[16,17] have been described with varying degrees of success. The alloplastic materials have problems such as displacement and extrusion. Smith and co-workers (1993) have reported implant erosion into the middle cranial fossa.[18] Of all the autologous materials TPFF has the advantage that it is readily available in the immediate vicinity, is extremely pliable so can be molded easily to fit the defect, and is well vascularized, hence less likely to resorb with lesser chances of recurrence of ankylosis. Jagannathan et al., have suggested a modification which includes the use of a vascularized cartilage graft from the helix of the ear along with the TPFF. This provides not only a cartilage lining for the condylar remnant or the graft but also augments the vertical height of the ramus.[19] We used pedicled TPFF in 29 patients for interposition arthroplasty following TMJ ankylosis release. It was used to cover the costal cartilage graft in 25 children. Folded TPFF without the costal cartilage graft was used in four adult patients of TMJ ankylosis [Figure 2a-f]. The TPFF flap covers the cartilage graft or the cut end of the mandibular condyle and serves as a pseudocapsule and provides a cushioning effect. This prevents contact between the bony/cartilaginous surfaces, organization of fibrous tissue in the gap and hence reankylosis. In one adult patient of condylar hyperplasia we used Jagannathan’s modification of the TPFF.[19] This vascularized flap shows fewer chances of subsequent absorption and hence reankylosis. We used pedicled TPFF in a total of 17 patients for ear reconstruction [Figure 3a-d]. Of these the majority i.e. ten patients were undergoing the second stage of microtia reconstruction, three were undergoing a single stage ear reconstruction for microtia and two were for posttraumatic and post-burn ear reconstruction each. With its location adjacent to the auricular reconstruction site, axial transfer of the TPFF is ideal. In the second stage of ear reconstruction, greater projection of the auricle can be obtained by placing a wedge of costal cartilage behind the elevated ear, but this must be covered with a tissue flap for a skin graft
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
a
c
b
a
b
c
d
e
d
f
Figure 2: (a) OPG of patient showing ankylosis, (b, c) Pre and post op mouth opening, (d) Tpff used as spacer between recreated zygoma and ramus, (e) Costochondral graft used to make zygoma and ramus, (f) Post op OPG showing well maintained ramus height
to take over the cartilage. Nagata used TPFF for this purpose.[20] In our series ten patients of micotia were operated for second stage of ear reconstruction using Nagata’s technique. The reconstructed auricle was raised with a wedge of banked costal cartilage graft which was covered pedicled TPFF and split skin graft. In two patients of complete microtia associated with hemifacial microsomia, one patient of incomplete microtia and two patients of post-burn ear deformity, we performed single stage total ear reconstruction with cartilage framework covered with TPFF and split thickness skin graft (STSG). The TPFF was used to cover the cartilage framework due to skin paucity due to low hairline in microtia group and scarring in post-burn group. Brent and Byrd stated that the use of primary fascial flap may be considered if one predicts a tight cutaneous pocket and a hairline that will cover only one-half of the new ear.[20] In an effort to resolve the problem of skin paucity, they implemented the use of TPFF and skin graft to cover cartilage framework for secondary ear reconstruction.[21] In two patients, we used TPFF to cover the exposed cartilage framework following trauma. Reattaching the total or subtotal amputated ear as a composite graft is unreliable. Use of the retro auricular pocket to enhance survival of the reattached ear entails multistage procedures with somewhat poor results due to the associated fibrosis.[22] Microsurgical replantation can be performed but its applicability is limited due to difficulty with venous drainage.[23] Pedicled TPFF with skin graft 497
Figure 3: (a) Right ear microtia, (b) Harvest of TPFF, (c) TPFF to cover cartilage framework in single stage, (d) Post op reconstructed ear
can be used as an alternative to the pocket technique and microvascular reattachment for complete ear avulsion.[24] This technique is simple, single stage and the thinness and pliability of the flap allow it to maintain the delicate details of the auricular cartilage[25] while its rich vascularity nurtures excellent skin graft survival rates. In this series, pedicled TPFF covered with split skin graft was used to line the intraoral defect following the release of submucous fibrosis in five patients. In the other five patients, pedicled TPFF without skin graft used to cover intraoral defect [Figure 4a-f]. Mokal et al., concluded that well vascularized TPFF brings good blood supply to the fibrosed muscles and mucosa. The flap is raised bilaterally and turned over the zygomatic arch and brought intraorally to fill the mucomuscular defect. This provides a healthy and vascularized bed for the skin graft.[26] We used pedicled TPFF covered with split skin graft for orbital socket reconstruction in three patients. It is favorable for managing various orbital socket defects due to its reliable and rich vascularity, pliable form and proximity to the orbit. It is useful even in irradiated or chronically infected tissue beds.[27] Its use has also been described by Lai et al.,[28] for orbital cavity or periorbital soft tissue or bony defects. In chronically inflamed wounds such as with osteoradionecrosis and orbitoantral fistula, TPFF successfully restored vascularity, obliterated the defects, and enabled the placement of osteointegrated implants. We used a composite galeopericranial TPFF flap with temporalis muscle and free rib graft for reconstruction of lateral wall of orbit in a 7-year-old child who underwent
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
resection for Langerhans Cell Histiocytosis. Mokal et al., have previously described the successful use of this composite flap in lateral orbital wall reconstruction.[29] It can also be used as composite flap with calvarial bone particularly in extended exenteration defects with loss of orbital wall or maxillary defects.[30,31]
post-burn hypertrophic scarring of the cheek and chin [Figure 5a, b]. The reliable vascular supply, inconspicuous donor site match in tissue characteristics and proximity to the reconstructive site make TPFF an optimal choice. This hair-bearing TPFF can also be used in eyebrow, moustache, or scalp restoration.[33] Kim et al., concluded that hair-bearing TPFF is an excellent choice for the restoration of function and aesthetics in full thickness upper lip defects.[34]
An expanded hair-bearing composite bilateral TPFF flap in a male patient was used for reconstruction of
The disadvantages of this procedure include multiple surgeries, temporary disfigurement due to the tissue expanders, and limited applicability in female patients.
a
b
c
d
e
f
Five patients were operated on for full thickness lower eye lid reconstruction [Figure 6a-e]. Bilamellar lower eyelid reconstruction with island superficial temporal artery flap and hard palate mucoperiosteal free graft was done in three patients for post-oncological resection reconstruction of lower eyelid. This has been previously reported by Jacob et al., and all five patients had good aesthetic and functional results.[32]
Figure 4: (a) mouth opening of patient with submucous fibrosis (b,c) TPFF harvested, (d,e) Intraoral tunneling of TPFF bilaterally, (f) Post op mouth opening
In two patients lower lid ectropion due to scar adherent to the underlying bone was released and the resultant
a
b Figure 5: (a) Composite flap of TPFF with hair bearing scalp (b) Bilateral composite TPFF for cheek and beard recronstruction
a
b
c
d
e
Figure 6: (a) Flap marked over forehead, (b) Flap elevated along with temporoparietal fascia, (c) To be insetted for complete lower lid defect, (d,e) Pre and post op appearance for total lower eyelid reconstruction
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
defect was covered with TPFF and skin graft. There are no published reports of TPFF being used for this indication in the current literature. We believe TPFF to be a good option to cover bare bone in the periorbital region due to its thinness and pliability. In comparison, a skin flap would be bulky while a skin graft alone might not survive on an avascular and scarred bed. The TPFF was used for soft tissue augmentation in three patients. One patient had upper lip augmentation and two patients had cheek augmentation to correct the contour deformity. The flap’s thin texture and rich vascularity produces desirable and consistent results. Local flaps (i.e., Gillies fan flap,[35] or Bernard-Burow flap)[36] are less satisfactory aesthetically and functionally for fullthickness defects of the upper lip due to displacement of the modiolus and invariable microstomia, while distant flaps are bulky and associated with donor site morbidity and increased surgical time. Use of TPFF and its variations like prefabrication with dermal fat graft have been described in soft tissue augmentation and to correct contour deformities in conditions like facial palsy or congenital dysplasia.[37-39] Post-auricular cutaneous mastoid fistula is an uncommon complication of chronic suppurative otitis media. The fistula tracts are typically difficult to manage because of the surrounding necrotic skin edges.[40] The TPFF has desirable properties for otologic surgery: High malleability, distinct vascularity, and close proximity to the temporal bone.[41] We have successfully managed a case of post-infective mastoid fistula using TPFF.
injury, scar alopecia, and bleeding have been described. We have not observed nerve injury or scar alopecia in any of our series of 82 flaps in 71 patients. This could be attributed to our meticulous dissection technique using hydrodissection in the subfollicular plane along with loupe magnification for flap elevation and minimal use of electrocautery in the vicinity of the follicles. Also elevation of fascia above the loose areolar plane avoids injury to the frontal branch of facial nerve. Partial loss of flap was seen in 2 out of 82 flaps (2.44%). In one patient of total ear reconstruction, partial necrosis was due to hematoma under the flap [Figure 7a,b]. The final outcome was aesthetically unsatisfactory. Hence, careful attention to hemostasis must be paid following elevation of the flap. Use of a fine bipolar cautery is advised for this purpose in order to minimize the damage to the hair follicles, thus preventing alopecia. Partial loss of the flap in the other patient, who was operated for post-burn cheek and chin resurfacing by expanded hair bearing composite flap was managed by fabricating a local tube-pedicled flap from occipital hair bearing skin [Figure 8a-d].
CONCLUSION The TPFF is a thin, pliable, well vascularized, and readily available flap in the head and neck region. Meticulous surgical dissection in the appropriate plane, judicious use of electrocautery and the use of loupe magnification allow excellent flap elevation without much risk of complications.
Though there is minimum morbidity associated with this flap, complications like temporal branch of facial nerve
a
b Figure 7: Complication showing partial flap necrosis
499
a
b
c
d
Figure 8: (a-c) Complication showing necrosis of one side composite flap which was reconstructed using occipatal flap, (d) Final post op appearance
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Mokal, et al.: The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases
When its advantages are combined with the surgeon’s resourcefulness, various defects secondary to trauma, tumor resection, congenital deformities, and radiation injury can be successfully reconstructed with satisfactory aesthetic and functional outcome.
REFERENCES 1. Mathes SJ, Nahai F. Regional Flaps: Anatomy and Basic techniques head and neck section. In: Reconstructive Surgery Principles, Anatomy, Technique Volume 1. Philadelphia: Churchill Living-Stone; 1997. p. 367-85. 2. Brown W. Extraordinary case of horse-bite; the external ear completely bitten off and successfully replaced. The Lancet1898;151(3901):1533-4. 3. Monks GH. The restoration of a lower lid by a new method. The Boston Medical and Surgical Journal 1898;139:385-7. 4. Gillies HD. Plastic surgery of the face. New York, NY: Gower Medical Publishing Ltd; 1983. 5. Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:141-52. 6. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77:17-23. 7. Matsuura H, Miyamoto H, Ogi N, Kurita K, Goss AN. The effect of gap arthroplasty on temporomandibular joint ankylosis: An experimental study. Int J Oral Maxillofac Surg 2001;30:431-7. 8. Sawhney CP. Bony ankylosis of temporomandibular joint: Followup of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg 1986;77:29-40. 9. Erdem E, Alkan A. The use of acrylic marbles for interposition arthroplasty in the treatment of temporomandibular joint ankylosis: Follow-up of 47 cases. Int J Oral Maxillofac Surg 2001;30:32-6. 10. Lello GE. Surgical correction of temporomandibular joint ankylosis. J Craniomaxillofac Surg 1990;18:19-26. 11. Posnik JC, Goldstein JA. Surgical management of temporomandibular joint ankylosis in paediatric population. Plast Reconstr Surg 1993;91:791-8. 12. Güzel MZ, Arslan H, Saraη M. Mandibular condyle reconstruction with inlay application of autogenous costochondral graft after condylectomy: Cerrahpa?a’s technique. J Oral Maxillofac Surg 2007;65:615-20. 13. Donkor P, Acheampong AO. Intra-articular ramus ostectomy combined with costochondral grafting for the treatment of recurrent ankylosis of the mandible. Br J Oral Maxillofac Surg 2006;44:497500. 14. Dimitroulis G. The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis. Int J Oral Maxillofac Surg 2004;33:755-60. 15. Turco M, Di Cosola M, Faccioni F, Cortelazzi R. Treatment of severe bilateral temporomandibular joint ankylosis in adults-our protocol. Minerva Stomatol 2007;56:181-90. 16. YongLong H, Xiaoming G, Xinhua F, Yilin W. Modified coronoid process grafts combined with sagittal split osteotomy for treatment of bilateral temporomandibular joint ankylosis. J Oral Maxillofac Surg 2002;60:11-8. 17. Gunaseelan R. Condylar reconstruction in extensive ankylosis of temporomandibular joint in adults using resected segment as autograft: A new technique. Int J Oral Maxillofac Surg 1997;26:4057. 18. Smith RM, Goldwasser MS, Sabol SR. Erosion of Teflon Proplast
implant into the middle cranial fossa. J Oral Maxillofac Surg 1993;51:1268-71. 19. Jagannathan M, Devale M, Kesari P, Karanth S. Use of vascularised cartilage as an additional interposition in temporomandibular ankylosis surgery: Rationale, advantages and potential benefits. Indian J Plast Surg 2008;41:110-5. 20. Nagata S. Modification of the stages in total reconstruction of the auricle: Part I. Grafting the three-dimensional costal cartilage framework for lobule-type microtia. Plast Reconstr Surg 1994;93:221-30. 21. Brent B, Byrd H. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:141-52. 22. Mladick RA, Horton CE, Adamson JE. The pocket principle: A new technique for the reattachment of a severed ear part. Plast Reconstr Surg 1971;48:219-23. 23. Steffen A, Katzbach R, Klaiber S. A comparison of ear reattachment methods: A review of 25 years since Pennington. Plast Reconstr Surg 2006;118:1358-64. 24. Anous MM, Hallock GG. Immediate reconstruction of the auricle using amputated cartilage and the temporoparietal fascia. Ann Plast Surg 1988;21:378-81. 25. Saad Ibrihim SM, Zidan A, Madani S. Totally avulsed ear: New technique of immediate ear reconstruction. J Plast Reconstr Aesthet Surg 2008;61 Suppl 1:S29-36. 26. Mokal N, Raje R, Ranade S, Prasad J, Thatte R. Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft — a new technique. Br J Plast Surg 2005;58:1055-60. 27. Hanasono MM, Lee JC, Tang JS. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg 2009; 123:98-105. 28. Lai A, Cheney ML. Temporoparietal fascial flap in orbital reconstruction. Arch Facial Plast Surg 2000;2:196-201. 29. Mokal NJ, Shetty KP, Arora R, Thatte MR. Langerhans Cell Histiocytosis: Orbital Involvement as an Unusual Location. Plast Reconstr Surg 2001;107:813-7. 30. Davison SP, Mesbahi AN, Clemens MW. Vascularized calvarial bone flaps and midface reconstruction. Plast Reconstr Surg 2008;122:10e-8e. 31. Parhiscar A, Har-El G, Turk JB. Temporoparietal osteofascial flap for head and neck reconstruction. J Oral Maxillofac Surg 2002;60:619-22. 32. Jacob V, Mokal NJ, Deshpande SN. Bi-lamellar lower eyelid reconstruction with superficial temporal artery island flap and hard palate muco-periosteal free graft. Indian J Plast Surg 2005;38:10597. 33. Navarro-Ceballos R, Bastarrachea RA. Clinical applications of temporoparietal hair-bearing flaps for male pattern baldness and mustache formation. Aesthetic Plast Surg 1991;15:343-8. 34. Kim JC, Hadlock T, Vavares MA, Cheney ML. Hair-bearing temporoparietal fascial flap reconstruction of upper lip and scalp defects. Arch Facial Plast Surg 2001;3:170-7 35. Bernard C. Cander de la levre infericure opere par un procede nouveau. Bull Mem Soc Hir (Paris) 1853;3:357. 36. Gillies HD, Millard DR Jr. Principles and Practice of Plastic Surgery. Boston, Mass: Little Brown and Co Inc; 1957. 37. Zhang Y, Jin R, Sun B. Pedicaled superfcial temporal fascia sandwich flap for reconstruction of severe facial depression. J Craniofac Surg 2009;20:505-8. 38. Guven E, Kuvat SV, Aydin HU, Yazar M, Emekli U. Facial contour reconstruction with temporoparietal prelaminated dermal-adipose flaps. J Craniomaxillofac Surg 2010;38:374-8.
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How to cite this article: 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 J Plast Surg 2013;46:493-501.
Source of Support: Nil, Conflict of Interest: None declared.
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Indian Journal of Plastic Surgery September-December 2013 Vol 46 Issue 3
Copyright of Indian Journal of Plastic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
