Temporal Pedicle Research Articles

Usefulness of using the superficial temporal pedicle as the recipient site for microvascular anastomosis in facial reconstruction: A retrospective study of 94 cases

In cranio-cervico-facial reconstructive surgery, it is accepted that the use of free flaps is the treatment of choice. The multiple antecedents can place the surgeon in situations of vascular deserts. The aim of our study is to report and analyse our experience of the use of temporal vessels in primary and secondary reconstructive surgery. A retrospective study was conducted between 01/01/2010 and 31/03/2023. Patients who underwent cranio-cervico-facial reconstruction using free flaps, with use of the superficial temporal pedicle as the recipient site for the vascular anastomosis were included. Early and late complication and failure rates were analysed according to type of reconstruction, location and risk factors for free flap failure. A total of 94 patients underwent craniocervical-facial reconstruction using a free flap anastomosed to the superficial temporal pedicle (in primary or secondary situations). Ten patients underwent reconstruction of the upper third, 58 the middle third and 26 the lower third. With an overall complication rate of 28.7% (21.3% minor complications and 7.4% major complications). Our study proves the reliability of the superficial temporal pedicle, both in the primary situation (with a success rate of 93.9%) and in the secondary situation (with a success rate of 89.3%), as well as its versatility whatever the cranio-cervico-facial level to be reconstructed. This study demonstrates the value of preserving the superficial temporal pedicle in craniofacial reconstruction surgery. This is because it is a preferred recipient site for reconstructions of the upper and middle thirds in the primary situation or in the event of recourse.

Superficial temporal artery capillary perforator-based island flap for conchal bowl and external auditory canal reconstruction

Reconstruction of the auricle is challenging to surgeons as a result of its complex anatomy. Defects including the conchal bowl and the external auditory canal (EAC) do not accept imperfection as functional consequences may add to aesthetic ones. Local flaps that are relying mainly on posteriorly based auricle flaps do not represent ideal solutions. This study aims to report the perforator modification of an anteriorly based pre-auricular flap that matches all requires goals of reconstruction. From 2015 to 2019, three capillary perforator-based island flaps (c-PBIF), with the Superficial Temporal Artery (STA) as source pedicle, were performed to reconstruct a combined Conchal Bowl-External Auditory Canal (CB-EAC) defect, secondary to basal cell carcinoma resection. Free margins were obtained via the Tubigen micrographic approach. All three flaps were raised on the perforator originating from the superficial temporal pedicle. In 2 of the cases, the perforator was found at the level of the tragus while in the last case, it was found 1cm more distal. Capillary perforators were isolated and dissected down to their origin from the STA thereby increasing their arc of rotation and pliability. The median follow-up time was 4 years. All flaps survived. Aesthetic results were excellent leaving no distortion of the external ear and the hollow aspect of the conchal was well supported. The tragus mount was preserved, EAC lining was secured, and good audition was restored with no bulging of the flap into the canal in all the cases. Harvesting pre-auricular flaps as c-PBIFs are safe and acts as an excellent solution for the reconstruction of the challenging combined CB-EAC defect. It allows a one-stage reconstruction that does not need a secondary revision, it also gives excellent correction and functional results. We would recommend it as a useful option for the reconstruction of the conchal-EAC defects.

Split Lateral Forehead Flap for Reconstruction of Upper and Lower Eyelids

Background: Eyelids reconstruction after tumor resection has be one of the most challenging procedures in reconstructive plastic surgery. Small defects may be closed by primary suture or covered by small local flaps or skin graft. But in large eyelids defects, we need to find a bigger source of color and texture matching tissue that will ensure functional and aesthetical outcomes. Many techniques have been described, but in this case, the author suggest a split lateral forehead flap designed to cover upper and lower eyelids. Patient and Operation Techniques: A Male 51 years-old-patient, presented himself in our clinic with a basal cell carcinoma involving the right upper and lower eyelids. The tumor had a history of 7 years, without any pain or vision disorders involved. Tumor was widely excised, leaving a full thickness on upper and lower eyelids. The inner lining palpebral was replaced by composite auricular graft following by lateral cantophexy. A lateral forehead flap raised with a right temporal pedicle, and the distal part of flap was split in half, and inset into the upper and lower eyelids defect. The donor region was closed with an STSG from Femur Dextra. After 14 days the flap was divided, the functional result was excellent. Discussion: At first, surgeons were worried of raising forehead flaps beyond the midline, fearing that by splitting the distal flap would cause its compropmise. However, rich anastomostic plexus exists between the major forehead angiosomes lined by the smaller calibre “choke” vessels. Conclusions: Periorbital Basal cell carcinoma resection may leave great defect to the underlying tissue. The need to provide adequate support to this structure requires complex techniques with minimum two flaps. In our case, we performed a split lateral forehead flap with a good functional and cosmetic outcome.

Facial reconstruction with temporalis muscle flap after orbital exenteration

Orbital exenteration and maxillectomy result in functional and aesthetic loss, representing a challenge for reconstructive surgeons. The temporalis muscle flap is a versatile and safe option for plastic surgery. It was first described by Lentz in 1895. In 1898 Golovine described this flap for the reconstruction of the defect after exenteration of the orbit. In 1948 Campbell described its use for the reconstruction of a defect after a maxillectomy6. Our objective was to report the use of pedicle temporalis flap for post-maxillectomy reconstruction and associated orbital exenteration due to squamous cell carcinoma. We report on two cases of giant tumors due to squamous cell carcinomas of the skin with orbital, periorbital and malar involvement. Reconstruction was done with a temporalis flap associated with a skin graft.The study included two female patients, aged 71 and 58 years, respectively, affected by a tumor in- volving he orbital, periorbital and malar regions. Histology confirmed squamous cell carcinoma. Re- construction was done with a temporal pedicle and a skin graft. No morbidity or mortality occurred. The first patient underwent radiotherapy postoperatively, as the resection was R1. Resection for the second patient was R0.Pediculated temporal muscle flap plus a skin graft is a valid option for post-maxillectomy reconstruction with associated orbital exenteration. It allows covering and filling of the area, with acceptable aesthetic and repair results, posing an alternative to the use of free flaps with a lower lear- ning curve and a lower complication rate.

Reconstruction of large unilateral hemi-facial scar contractures with supercharged expanded forehead flaps based on the anterofrontal superficial temporal vessels

The expanded forehead flap, using temporal pedicles, has been employed extensively in facial reconstruction. To overcome the disadvantages of the traditional dual temporal pedicles, such as the limited transfer range and the short length of the flap, the distal supercharging technique can be applied to lengthen the flap and extend the transfer range, especially in the cases with a past temporal burn injury. This article aims to present an application of the distal supercharged expanded forehead flap procedure for hemi-facial reconstruction and discuss the haemodynamics of the expanded forehead flap. The tissue expander implantation and the following forehead tissue expansion were performed regularly. When the forehead skin expansion was completed, an expanded forehead flap was created and transferred to the damaged facial area with one distal temporal vessel pedicle that was anastomosed with facial vessels in a supercharged way. All patients were analysed retrospectively. From September 2009 to September 2011, eight male patients and one female patient were treated using this method. Their flaps size ranged from 20 cm × 8 cm to 30 cm × 11 cm and no flap loss occurred. Patients came in for follow-ups 9-16 months after the procedures. All the patients were satisfied with the results. The supercharging expanded forehead flap procedure can provide reliable flap vascularity due to its elastic transferring abilities. By using a distal supercharging technique, we can lengthen and widen the flap to tailor it to the defect, while also minimising the donor defect in the patients with a past temporal injury.

Le lambeau de muscle temporal dédoublé vascularisé par le pédicule temporal superficiel

The temporalis muscle has been used for more than a century for facial reconstruction. But this flap cannot fill defects beyond the midline. Splitting the temporalis muscle in the plane of the tendon insertion allows lengthening the flap and crossing the midline. The scalp incision is followed by a subcutaneous dissection, taking care to spare hair follicles and superficial temporal vessels. Then the temporalis muscle is detached by a strictly subperiosteal dissection and deep temporal pedicles are dissected and ligated. The flap is split in the plane of the insertion tendon up to its distal end. This technique allows reconstructing cranio-facial defect beyond the midline with well-vascularized tissue.

Split temporalis muscle flap anatomy, vascularization and clinical applications

For more than a century, the temporalis muscle has been used for facial reconstructions. More recently, a split temporalis muscle flap elevated on the superficial temporal pedicle has been described, for which the resulting gain of length makes crossing of the midline possible, as well as reconstruction of substance losses exceeding the midline. Fourteen fresh cadaveric dissections were performed to study the different techniques for splitting the temporalis muscle. Dissections with catheterization and injection of radio-opaque contrasting agent in the external carotid artery were then performed to specify the vascularization of the flap split on the superficial temporal pedicle. The duplication of the superficial temporal pedicle grants greater length compared to that of the deep pedicles, 57 mm versus 40 (p = 0.036). The middle temporal artery is capable of ensuring the vascularization, and therefore the viability, of the split flap. From these results, we spoke about the limitations of this study and we have inferred the main indications.

Couverture d’une exposition cérébrale post-traumatique par un lambeau temporal total : à propos d’un cas

Major defect of the scalp associated with penetrating brain injury is one of the most challenging issues in acute craniofacial trauma. Depressed skull fractures associated with injuries of the skin and periosteal tissue can be easily covered using various locoregional scalp flap techniques. However, if the skin is damaged around the wound, the surgical possibilities are reduced, allowing only local transposition flap or free flap coverage with many disadvantages for the latter such as vascular micro-anastomosis issues, unsuitable underlying vascular status, and a “patch” effect which is often unsightly. The authors describe, using a clinical case, the steps to provide a total temporal flap to cover a defect of both skin and bone. This can be performed in three separated stages: the first is the empowerment of both middle temporal pedicles; the second stage, 15 days later, is the section, transposition and coverage of the wound; the third stage, 30 days later, is the flap separation.

Carcinome adénoïde kystique du cuir chevelu

Few cases of adenoid cystic carcinoma of the scalp have been described in the literature. Herein, we report a new case illustrating the difficulties of diagnosis and treatment of this rare form of tumour. A 49-year-old man consulted for a large ulcerated scalp tumour. The biopsy sample exhibited an aspect of cystic adenoid carcinoma. Bone invasion had occurred. Extremely wide surgical excision was carried out, extending down to the dura mater, with covering by means of a frontal flap with left temporal pedicle. Since the edges of the resection were also tumoural, postoperative radiotherapy at 56Gy was given. Twelve months later, the patient was still in remission. The standard treatment for adenoid cystic carcinoma is complete surgical excision but this approach may be complicated by difficulties relating to the degree of tumour spread or to the anatomical site. Postoperative radiotherapy appears to improve local control, as illustrated by our case.

Lambeaux locaux pour pertes de substance transfixiantes du scalp sur tumeurs évoluées. À propos d'une série de 21 patients

Subject The advanced tumors of the scalp can involve the calvarium, the dura and the cerebral tissue. The medium sized full thickness scalp defects secondary to the excision of such cutaneous malignancy can be successfully treated with local flaps coming from the remaining scalp if these flaps are large and including at least one major pedicle of the scalp. The cranioplasty can be done immediately or secondarily. Patients and methods From May 2001 to July 2006, 21 patients aged between 52 and 78 years old, suffering from advanced basal and squamous cell carcinomas with invasion of the calvarium in all cases, the dura in 1 case and the cerebral tissue in 2 cases have benefited from an excision of the scalp and calvarium with a margin between 1 and 3 cm. The secondary defects measured between 9 and 15 cm for the scalp and between 6 and 9 cm for the calvarium. In 1 case, the dura was resected and reconstructed with a fascia lata graft. The flaps used were: a single pedicled transposition flap based on one or two occipital pedicles in 10 cases — a bipedicled transposition flap based on the superficial temporal pedicles in 3 cases and on the frontal and occipital pedicles in 4 cases — a large rotation flap in 4 cases. These flaps were undermined under the galea without any galeotomies. Their donor sites were immediately grafted. The calvarium was reconstructed by a methylmetacrylate implant in 9 cases, simultaneously with these flaps in 4 cases and secondarily in 5 cases. Results There were no vascular problems in all these flaps — 3 cases of infection in the simultaneous reconstruction of the scalp and calvarium are reported. The two patients with cerebral invasion are deceased 1 year after the surgery. The other patients are still alive without any recurrence or metastasis with a mean follow-up of 36 months. Conclusion Such complex defects of the tumoral scalp can be reconstructed with large and axial local flaps of the remaining scalp with safety. The cranioplasty has to be delayed.

Reconstruction étendue des téguments du nez à l’aide d’un lambeau libre rétroauriculaire levé sur le pédicule temporal superficiel

The microsurgical coverage of large nasal skin avulsion was performed in a 40 years old patient after a human bite. Widely exposing the columelle, the alar cartilages and the distal part of the septum, the defect was covered with a retroauricular free flap harvested on the superficial temporal pedicle and transferred on the upper labial vessels in the nasogenian area. Thanks to its excellent colour and texture match with the nose integuments, this flap enjoyed of an optimal integration in the centrofacial area. Its potential indications, advantages, drawbacks and technical variants are discussed in the present paper.

Nasal reconstruction using the Washio retroauricular temporal flap

Reconstruction of an external nasal defect presents a challenge to the reconstructive surgeon. Transferring retroauricular tissue on a temporal pedicle was first described by Washio as a means to repair the central portion of the face. This paper describes our experience with the Washio retroauricular temporal flap for nasal reconstruction in twelve patients, together with our modifications to simplify the planning and raising of the flap. There was one patient with a stitch abscess, one case of hair loss from the pedicle which recovered within one month and one elderly patient who developed thromboembolic complications. There was no instance of flap necrosis. Our results confirm that the Washio retroauricular flap is an excellent technique for difficult nasal reconstruction in young patients.

Face lift postoperative recovery.

The purpose of this paper is to describe what I have studied and experienced, mainly regarding the control and prediction of the postoperative edema; how to achieve an agreeable recovery and give positive support to the patient, who in turn will receive pleasant sensations that neutralize the negative consequences of the surgery.After the skin is lifted, the drainage flow to the flaps is reversed abruptly toward the medial part of the face, where the flap bases are located. The thickness and extension of the flap determines the magnitude of the post-op edema, which is also augmented by medial surgeries (blepharo, rhino) whose trauma obstruct their natural drainage, increasing the congestion and edema. To study the lymphatic drainage, the day before an extended face lift (FL) a woman was infiltrated in the cheek skin with lynfofast (solution of tecmesio) and the absorption was observed by gamma camera. Seven days after the FL she underwent the same study; we observed no absorption by the lymphatic, concluding that a week after surgery, the lymphatic network was still damaged. To study the venous return during surgery, a fine catheter was introduced into the external jugular vein up to the mandibular border to measure the peripheral pressure. Following platysma plication the pressure rose, and again after a simple bandage, but with an elastic bandage it increased even further, diminishing considerably when it was released. Hence, platysma plication and the elastic bandage on the neck augment the venous congestion of the face. There are diseases that produce and can prolong the surgical edema: cardiac, hepatic, and renal insufficiencies, hypothyroidism, malnutrition, etc. According to these factors, the post-op edema can be predicted, the surgeon can choose between a wide dissection or a medial surgery, depending on the social or employment compromises the patient has, or the patient must accept a prolonged recovery if a complex surgery is necessary. Operative measures which prevent extensive edemas are: avoiding transection of the temporal pedicle, or to realizing platysma plication too tight by using strong aspirative drainage instead of elastic bandages. In the post-op, the manual lymphatic drainage is initiated on the third or fifth day, but must be done by a trained professional, in a method contrary to that specified in the books for non-operated individuals. An aesthetician washes the hair and applies decongestive cold tea on the face the second day, and on the fifth, moisturizes the skin and cosmetically conceals any signs of bruising. The psychological support provided by the staff keeps the patient calm and relaxed. Five years experience with this protocol has enabled us to minimize post-op pain. The edema can be predicted with certain consistency (in which surgery there will be more or less edema) and the proper technique can be selected, permitting the patient to choose the best moment for a FL while the surgeon can avoid intra and postoperative measures that increase the edema. After surgery, the patient receives the daily assistance of the staff, which rapidly and efficiently improves this condition. We can predict and control the post-op recovery and the patient feels fine, unlike the past when recovery was abandoned to its natural evolution. If the patient perceived an intensive, positive support on behalf of the entire staff that kept him or her content, then we have succeeded in doing an excellent marketing. This may encourage others to undergo aesthetic surgery, especially those who are convinced that after surgery they might have to endure considerable suffering.

Lengthening Temporalis Myoplasty and Lip Reanimation

The authors report a new surgical technique of myoplasty of the temporalis muscle applied to the treatment of permanent peripheral facial paralysis. It consists of a muscle lengthening, using the totality of the temporalis muscle and the transfer of its tendon attached to the coronoid process directly to the lips, therefore modifying the temporal fixed point and respecting the deep temporal pedicles. Ten cadaver dissections were performed for a better understanding of the muscle fiber redistribution during surgery to measure the distance between coronoid process and lip commissure and to measure the width of the temporal tendon. The results in 10 patients have been very encouraging. This technique was performed on ten cases of permanent facial paralysis of various etiologies, by the same surgeon, with a 4-year follow-up.

Technique of functional disc repositioning in internal derangements of the temporomandibular joint

Internal derangements of the temporomandibular joint (TMJ) are composed of several pathophysiologic entities: anterior dislocation of the disc, with or without reduction, alone or in association with degenerative changes in the condyle. In situations where the internal derangement involves a structurally intact, but chronically locked or reducible disc, treatment consists of surgical repositioning and stabilization. Several techniques have been developed to restore a proper disc-condyle relationship.1-5 One of the earlier procedures, advocated by Toiler,’ was that of “capsular rearrangement.” This consisted of releasing the lateral disc attachments to allow freedom of disc movement in association with a temporal pedicle to strengthen the lateral ligament and capsule. In 1979, McCarty and Farrar2 recommended that a small amount of tissue from the bilaminar zone be removed. The amount of resected tissue corresponded to the degree of displacement of the disc. The disc was then repositioned over the condyle and sutured to the distal and collateral ligaments. This was sometimes accomplished in conjunction with a 2-3 mm condylar resection. A modification of this technique consists of a true plication or folding over and sewing of the redundant bilaminar zone. Leopard3 has described a relatively simple operation in which the lateral border of the disc is anchored to the lateral margin of the glenoid fossa. Weinberg“ accomplished disc repositioning in conjunction with some form of arthroplasty. This involved direct plication of the fibrous disc to the ar-

Reconstruction of the lower lid.

As the lower eyelid is frequently the site of malignant disease, lower lid replacement is a common task in oculoplastic surgery. As a rule the reconstruction of larger defects (more than one-third) can be accomplished with free grafts or with flaps. Different forms of pedicle flaps (full thickness, tarsoconjunctival, combined) from the upper lid provide better results than free grafts. A convenient method of lower lid replacement is the use of a medial pedicle rotation flap of the cheek. This has advantages over the temporal pedicle cheek flap or the frontal flap.

Monopedicled Transposition Flap for the Treatment of Traumatic Scalp Alopecias

We present some variations of the monopedicled flap with temporal pedicle, used for treatment of traumatic scalp alopecias of different origin. Emphasis is on the frontal region--the most important area aesthetically.