Temporoparietal fascial flap

Considerations

• 1996: The use of the temporoparietal fascial flap in temporal bone reconstruction

• 2000: Temporoparietal Fascial Flap in Orbital Reconstruction

• 2010: Technique of temporoparietal fascia flap in ear and lateral skull base surgery

• 2011: The Versatile Use of Temporoparietal Fascial Flap

• 2014: Auricular reconstruction for microtia: A review of available methods

  • Anatomy 

    • Layers

    • 2010: Naming the soft tissue layers of the temporoparietal region: unifying anatomic terminology across surgical disciplines

      • From superficial to deep, the proposed terms for the soft tissue layers of the temporoparietal region include:

        • temporoparietal fascia (TPF)

        • loose areolar tissue plane

        • superficial leaflet of temporal fascia

        • fat pad of temporal fascia

        • deep leaflet of temporal fascia

        • fat pad deep to temporal fascia

        • temporalis or temporal muscle, and

        • pericranium

    • 2013: New perspectives on the surgical anatomy and nomenclature of the temporal region: literature review and dissection study

    • Facial nerve

    • 1995: Surgical anatomy of the facial nerve

      • The temporal branch of the facial nerve emerges within the parotid gland to cross the zygomatic arch at the deep surface of the temporoparietal fascia. The nerve is separated from the deep temporal fascia immediately above the zygomatic arch by a loose areolar plane; this plane may be obliterated when previous surgical procedures have been performed in this region.

      • The temporal branch can be found within a trajectory that has been described relating the lower portion of the auricle to the lateral aspect of the eyebrow. However, one must be aware that these surface landmarks may vary with respect to the underlying skeleton and from one individual to the next.

      • Recent studies indicate that the temporal branch consists of not one, but multiple rami that cross the zygomatic arch. Because there are multiple rami to the temporal branch of the facial nerve, any single trajectory can describe only a portion and not the entirety of the temporal branch.

    • 2007: The relationship of the fronto-temporal branches of the facial nerve to the fascias of the temporal region: a literature review applied to practical anatomical dissection

    • 2015: Anatomical considerations to prevent facial nerve injury

Image source: Essential facial anatomy for petit surgery

Image source: Essential facial anatomy for petit surgery

Preparation

Procedure

• • Depending on the site that will be covered or reconstructed, different surgical approaches may be used. When a conventional fascial flap operation is planned, superficial temporal vessels in the pretragal region are palpated and the course of vessels is marked prior to incision. In order to locate the pedicle, hand-held Doppler device is also helpful. Entire scalp and the face are prepared with antiseptic solution. Some surgeons may prefer to shave the scalp's hair however we have only shaved the incision line.

• Several incisions, such as lazy S, inverted T, Y-shaped, or zigzag incisions can be used. The incision is made starting from the preauricular region extending to the superior temporal line. This incision should be made carefully just over the temporal vessels. The superficial temporal fascia is dissected sharply with scalpel just beneath the hair follicles. Since there is no avascular plane between the skin and the fascia, a meticulous dissection should be carried out.

• When the incision is completed, anterior and posterior scalp skin should be dissected. When adequate exposure is obtained, a proper flap and its axis of rotation are marked. At least 2-3 cm of tissue should be preserved around the pedicle at the pretragal level. The flap may be up to 14 to 17 cm in height and 10 cm in width11 The conventional fascial flap can be extended up to 3-4 cm superior to the origin of the temporal muscle. Then, the TPF is elevated from the deep temporal fascia by blunt dissection. If lengthening of the pedicle is needed, proximally superficial temporal vessels should be dissected cautiously in the pretragal region. Loupe magnification can be used during this procedure.

• A fine-tipped bipolar electrocautery should be used carefully in hemostasis to avoid damaging hair follicles. After the TPF is transferred to the recipient site, hemovac drains are inserted and the donor site is sutured using 3/0 polypropylene. Depending on the amount of drainage, the drain is usually removed on the first or second postoperative day. An informed consent explaining all the details and possible complications should be obtained from all patients preoperatively.

• Alopecia is the most common complication of this flap. Hematoma formation may occur if meticulous attention has not made for hemostasis. Partial or total flap loss may also be seen depending on inappropriate technique or previous surgery, irradiation, or carotid occlusion. When elevating anterior scalp flap, a particular care must be given to preserve the frontal branch of the facial nerve, otherwise, partial or total nerve injury may be seen.

Sample operative report

Post-op

Pearls & Pitfalls

High-Yield

Links

• YouTube (2:52) - Temporoparietal Fascial Flap

• YouTube (4:35) - Temporoparietal Flap Procedure

• YouTube (8:44) - 2nd stage ear reconstruction by superficial temporal artery fascia flap

• YouTube (8:49) - TEMPROPARIETAL FASCIA by MICROSURGERY MADE EASY !!

• Vimeo (2:04) - Tunneled temporoparietal fascia (TPF) flap by JNS

• Microsurgeon.org - The Superficial Temporal Fascia Flap

• eMedicine - Temporoparietal Fascia Flap

• Iowa Head and Neck Protocols - Temporoparietal Fascia Flap

• Local and Regional Flaps in Head & Neck Reconstruction - The Temporoparietal Fascia Flap

• Pocket Dentistry - The temporoparietal fascia flap

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - THE TEMPORALIS MUSCLE FLAP