The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases.

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.

INTRODUCTION

The 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 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 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.

Figure 1

Anatomy of TPFF

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].

Table 1

Use of the temporoparietal fascia flap (TPFF) in various scenarios

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.

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 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 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 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,[89] nonvascularized auricular cartilage,[10] costochondral grafts,[111213] dermis fat graft,[14] muscle or myofascial flaps,[15] and resected bony material[1617] 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.

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

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 post-traumatic and post-burn ear reconstruction each. With its location adjacent to the auricular reconstruction site, axial transfer of the TPFF is ideal.

Figure 3

(a) Right ear microtia, (b) Harvest of TPFF, (c) TPFF to cover cartilage framework in single stage, (d) Post op reconstructed ear

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 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 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]

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

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 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.[3031]

An expanded hair-bearing composite bilateral TPFF flap in a male patient was used for reconstruction of 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]

Figure 5

(a) Composite flap of TPFF with hair bearing scalp (b) Bilateral composite TPFF for cheek and beard recronstruction

The disadvantages of this procedure include multiple surgeries, temporary disfigurement due to the tissue expanders, and limited applicability in female patients.

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 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

In two patients lower lid ectropion due to scar adherent to the underlying bone was released and the resultant 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 full-thickness 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.[373839]

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.

Though there is minimum morbidity associated with this flap, complications like temporal branch of facial nerve 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.

Figure 7

Complication showing partial flap necrosis

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].

Figure 8

(a-c) Complication showing necrosis of one side composite flap which was reconstructed using occipatal flap, (d) Final post op appearance

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.

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.