Temporoparietal Fascia Research Articles

Microtia repair.

Management of microtia can be one of the most rewarding yet humbling challenges faced by the reconstructive surgeon. The preferred method of total auricular reconstruction is with autologous cartilage and skin, based on modifications of the methods of Tanzer and Brent. Our goals in auricular reconstruction of microtia are: (1) a satisfied patient; (2) proper positioning; and (3) a pleasing size and contour. The reconstructive process in classic microtia reconstruction can be divided into four stages. The first stage is the creation and placement of the underlying framework derived from the autologous rib cartilage of the sixth to eighth ribs. The second stage is rotation of the lobule from the microtia remnant into position inferiorly on the helical rim. The third stage is elevation by creation of an auriculocephalic angle with a skin graft. The final stage is formation of the tragus from a composite graft from the opposite ear. Atypical microtia presents distinct challenges to the reconstructive surgeon. Complete framework insertion may not be necessary with the presence of some recognizable structure. Other circumstances arise that make each reconstruction unique, such as low-lying hairline or skin shortage. The extreme situations of skin shortage will benefit from the use of a temporoparietal fascia flap. However, adherence to the well-established principles of total auricular reconstruction will lead to satisfaction of the patient, the patient's family, and the surgeon.

Endoscopically assisted biplanar forehead lift.

The standard subgaleal coronal incision used for brow lifting is limited to patients with low foreheads. The subcutaneous hairline brow lift used for patients with high foreheads has a high rate of vascular complications. However, the main advantage of the subcutaneous approach is preservation of sensation posterior to the incision line. The subperiosteal approach, on the other hand, allows a better periorbital remodeling. I have combined the subperiosteal and the subcutaneous approach to take advantage of and minimize the disadvantages of each individual approach. The advent of the endoscopic technique has allowed more accurate and controlled periorbital dissection and brow depressor muscle modification. The operation is indicated in every patient in whom the anterior hairline incision is indicated. It is a good method for decreasing the height of the forehead. The dissection is done initially in the subcutaneous plane, and about halfway on the forehead slit incisions through the galea-periosteal layer and through the temporoparietal fascia are made to continue the dissection in the deep plane. The periosteal dissection and release at the arcus marginalis is done under endoscopic control. Likewise, the brow depressor muscle modification is done under endoscopic magnification. Deep anchoring sutures fix the brow in the elevated position. Trimming and closure of the cutaneous layer are done with minimal tension. The biplanar subperiosteal-subcutaneous forehead lift has been used in 24 patients with very satisfactory results. Complications have been of a minor nature. Patients have maintained sensation posterior to the hairline incision. The height of the forehead has been decreased in every case. Frontalis muscle function has been preserved.

Soft Tissue Reconstructive Choices for Craniofacial Reconstruction

The extensive blood supply to the scalp enables the use of local flaps based mainly on the superficial temporal artery: these include skin, temporoparietal fascia, subgaleal fascia, and temporal fascia. Also, the temporalis muscle provides flaps based upon the temporal branches of the internal maxillary artery. On top of the skull, scalp flaps, galeal flaps, and pericranial flaps can be used as random flaps or as axial flaps based on the problems or anatomic reasons that would preclude microvascular reconstruction. The pectoralis, latissimus, splenius capitis, and trapezius muscle flaps can dependably reach the base of the skull. The increasing reliability and versatility of microvascular reconstruction render their use standard for craniofacial reconstruction.

Facial Reconstruction with Prefabricated Induced Expanded (PIE) Supraclavicular Skin Flaps

The prefabricated induced expanded (PIE) supraclavicular flap refers to the staged transfer of an expanded supraclavicular skin with a fascia flap used as the carrier. In three patients, we utilized PIE supraclavicular flaps to successfully reconstruct a total forehead and two major nasal defects. Our first PIE flap confirmed the feasibility of the method but necessitated two microvascular free flaps. In the ensuing two patients, we reduced the need for microvascular anastomoses by using simple pedicled flap transfers in either or both stages. Whenever feasible, the preferred method consists of transferring a temporoparietal fascia flap to a subcutaneous pocket in the ipsilateral supraclavicular fossa and simultaneously placing a skin expander under both the fascia flap and the supraclavicular skin. After adequate expansion, the fascia becomes incorporated within the capsule of the expander, and the composite capsulofasciocutaneous flap can be safely transferred to the facial defect as the PIE flap. These patients show that supraclavicular PIE flaps can provide ample amounts of vascularized cutaneous tissue for the reconstruction of major facial defects. The necessary tissue is generated by expanding the most desirable tissue type available, and a selected vascular pedicle is induced to perfuse and carry that generated tissue. Compared with conventional expansion and adjacent flap transfers, PIE flaps allow the transfer of expanded skin to distant sites as island or free flaps perfused by the induced vascular pedicles.

Free temporoparietal fascia flap in reconstruction of the lower extremity.

Twenty-one patients with open wounds of the non-weight-bearing foot or the ankle underwent coverage with a free temporoparietal fascia flap and split-thickness skin graft. Our indications for this thin, well-vascularized flap included osteomyelitis and exposed tendon, bone, or fixation hardware. The pliability of the flap allowed superior restoration of natural anatomical contours. Only one flap was completely lost (95.2% overall success). There were four cases (20%) of partial flap loss, none of which required flap revision or a new flap. Four patients (19%) experienced transient donor-site alopecia, and one patient suffered transient palsy of the temporal branch of the facial nerve. One patient (4.7%) had an area of persistent scar alopecia in the temporal scalp after a donor-site hematoma that required revision under local anesthesia. Follow-up was available on 95% of the patients and averaged 20 months (range, 1-54 months). All patients resumed weight-bearing ambulation within 1 month from operation using unmodified footwear. The free TPF flap is a reliable coverage option, with long-term durability and minimal donor-site morbidity, for relatively superficial wounds of the distal lower extremity.

A Clinical and Histologic Comparison Between Free Temporoparietal and Scapular Fascial Flaps

It is universally accepted that the fascial flap is one of the best reconstructive strategies for contour and tendon-gliding function. In this study we compare the free temporoparietal fascial flap (n = 20) and the free scapular fascial flap (n = 6) mainly for these reconstructions and discuss their characteristics, including different clinical applications and histologic examination. Our histologic analysis reveals that the free temporoparietal fascial flap has a potential like a muscle flap; moreover, it is very thin. The free scapular fascial flap is very rich in adipose tissues to prevent adhesion between the flap and underlying tissues. Both flaps in our experience can bring satisfaction to the recipient site, but the donor site of the free temporoparietal fascial flap sometimes suffers from conspicuous widened scars in short-haired patients, and the scapular fascia has a tendency to be thicker in obese patients. Therefore, we recommend using the free temporoparietal fascial flap for women, who tend to have more fat and longer hair, and the free scapular fascial flap for men, who tend to be lean and shorten their side hair.

Nasal Reconstruction Using Free Temporoparietal Fascial Flap Transfer (Uptonʼs Method)

Reconstructive surgery for severe nasal deformity after radical operation of the maxillary antrum was performed by free temporoparietal fascia transfer to the nasal membrane, followed by secondary-rib cartilage grafting. Correction of nasal deformity caused by severe scar contracture and tissue defect in the nasal cavity has been considered difficult. However, skin grafting with temporoparietal fascia transfer to the nasal membrane can make it possible to perform cartilage grafting without exposure. This method should be nominated as a useful procedure for correction of severe nasal deformity caused by nasal membranous scar contracture.

후이부 피하조직-측두두정근막피판을 이용한 유양동절제술후 생긴 이후부 피부결손의 복구

Severe postmastoidectomy wound infection infrequently leaves large skin and soft tissue defects over postauricular area, which is ususlly quite difficult to repair by primary closure. Using “Retroauricular subcutaneous tissue-temporoparietal fascia flap” whose main vessel of blood supply is posterior auricular artery, such defects could be successfully repaired in two patients who underwent revision mastoidectomy. In this axial pattern local scalp flap, distal semilunar potion of the flap had only subcutaneous tissue and temporoparietal fascia, which was slid into the postauricular defect area. This new flap approach can be useful in repairing postauricular skin and soft tissue defects following radical mastoidectomy.

Use of the double-layered free temporal fascia flap for upper extremity coverage

Two layers of fascia exist in the temporal region, the temporoparietal fascia and the deep temporal fascia. Both can be elevated on a single vascular pedicle based on the superficial temporal artery, the double-layered temporal fascia flap. In our study, six patients who underwent upper limb coverage using the double-layered temporal fascia flap are reviewed, and the versatility of this thin flap is discussed.

Secondary Reconstruction for Unfavorable Microtia Results Utilizing Temporoparietal and Innominate Fascia Flaps

Unfavorable results in reconstruction of the auricle for microtia can be encountered from time to time, in which secondary reconstruction of the auricle is usually performed. One must note that secondary reconstruction is much more difficult than primary reconstruction for the following reasons: (1) all necrotic skin and scar tissue from the primary reconstruction must be removed, thus limiting the surface area of the skin for the secondary reconstruction; (2) the presence of scar tissue and loss of tensility in the subdermal layer makes it difficult to construct a subcutaneous pocket for grafting of the three-dimensional costal cartilage framework; and (3) in patients with full-thickness skin grafts in the conchal and postauricular regions, contraction of the grafted skin was noted. In order to resolve these problems, the temporoparietal fascia flap was used in the first-stage three-dimensional frame grafting operation, and the innominate fascia flap, obtained from the same site as the temporoparietal fascia in the first-stage operation, was used for the second-stage operation. The retroauricular full-thickness skin graft was utilized for color match on the anterior surface of the auricle where it is visible, and substitute skin from the groin was used to cover the donor site. The procedures and results for secondary reconstruction for unfavorable microtia are presented in this article.

Reconstruction of the wide palate defects with temporal osteocutaneous island flaps

The temporal osteocutaneous island (TOCI) flap was first performed in reconstruction of palatal defects by Furnas [8]. It consists of temporoparietal fascia, galea, pericranium and the cortical layer of parietal bone covered with pericranium. In this study, we present five patients with wide palatal defects treated by TOCI flaps. The causation of the wide palatal defects were gun-shot wounds in two patients and unsuccessful reconstruction of congenital cleft palate during early childhood in three patients. All patients were adult. TOCI flaps were performed in two stages. At first, the TOCI flap was elevated and covered with a split thickness skin graft. In the second stage (approximately 1.5 months later), the flap was elevated based on the superficial temporal artery as an island flap. It was then transferred to the palatal defect via a cheek tunnel and sutured to the edges of the defect. There was no need for bone fixation. The length of the pedicle of the flap was sufficient in size to easily reach the anterior part of the palate. No serious complications were seen. One minor oronasal fistula occurred; this was repaired by local flaps. The TOCI flaps improved speech only partially. In conclusion, we believe this procedure is a good method for reconstruction in wide palatal defects which need three layer closure. This procedure is not a satisfactory solution for complete correction of speech defects.

Microsurgical Vascularized Free Temporoparietal Fascia Transfer for Peyronie's Disease: An Experimental Study

This experimental study on 24 male rats evaluated the advantages of vascularized vs. nonvascularized temporoparietal free fascia transfer as an improved form of penile tunica albuginea replacement. The paper describes in detail steps in these techniques and offers functional, anatomic, and histologic follow-up after 3 months. All 24 rats developed straight corpora cavernosa in erection. The flap was successful in each case, providing satisfactory morphologic appearance with minimal bulk. The only differences were histologically provided. Secondary degenerative changes were identified in all penises with nonvascularized fascial transfer, and one-third of penises with vascularized temporoparietal fascia free transfer. These results encourage vascularized free-tissue transfer application as an optimal solution in human penile reconstructive surgery.

Reconstruction of the burned external ear using a Medpor porous polyethylene pivoting helix framework.

This paper describes a new technique using a Medpor porous polyethylene pivoting helix framework for reconstruction of the burned auricle. The polyethylene framework is composed of two distinct components, a curved shape that represents the helical rim which pivots around a base component. This framework is covered with a temporoparietal fascia flap and a skin graft that is chosen to match the adjacent resurfaced facial burn. The porous framework then becomes rapidly vascularized with soft-tissue ingrowth and collagen deposition. The pivoting helix design can be used to create an auricle of almost any size or projection. The helix can move independently and can be compressed against the head in the event of external pressure on the ear. The resultant ear reconstruction is extremely durable and remains flexible over time. Twenty-six consecutive ear reconstructions were performed using this method over a 2-year period. Two exposures occurred which were managed without removal of the implant. All reconstructions successfully restored an ear that was both aesthetically pleasing and functional so as to provide support for a pair of eyeglasses. The Medpor porous polyethylene pivoting helix framework offers an excellent solution for a difficult reconstructive problem.

The temporoparietal fascia flap

The temporoparietal fascia flap has a wide variety of applications for reconstruction of defects of the cheek, ear, and orbit. Extended versions that include galea can reach to the upper lip and into the oral cavity. The most common use of this flap is as a carrier of a skin graft; however, it can also transfer scalp and cranial bone. This article will describe experience with the flap in five representative cases.

Sinus obliteration for chronic oro-antral fistula: a case report

This report describes a patient with chronic oro-antral fistula resulting from tooth extraction. Several local flap procedures failed to close the fistula, which was complicated by chronic sinusitis. Ultimately, cure was achieved via antral obliteration using vascularised temporoparietal fascia, sparing remaining maxillary alveolar bone. Total, trans-buccal maxillary sinus obliteration with fascia should be considered for the treatment of oro-antral communications refractory to treatment with intraoral tissues.

Double-Layered Free Temporal Fascia Flap as a Two-Layered Tendon-Gliding Surface

We report the use of a two-layered free fascial flap consisting of temporoparietal and deep temporal fascia based on a single vascular pedicle, the superficial temporal artery and vein. The flap was used to reconstruct an extensive degloving injury of the dorsum of the hand, in which multiple intact extensor tendons lay fully exposed on all sides, with exposed bone beneath them. By sandwiching the tendons between the layers of vascularized fascia, gliding surfaces were provided, both superficial and deep to the exposed tendons. The single-stage reconstruction was completed with a split-thickness skin graft. The patient returned to heavy manual work within 12 weeks of injury. He obtained an excellent range of movement without the need for tenolysis.

Mastoid obliteration with the temporoparietal fascia flap

Obliteration of persistently discharging open mastoid cavities is one surgical option to achieve a dry ear. All the currently described techniques involve the use of random pattern local tissue flaps or free grafts. Ten patients have undergone obliteration procedures using the vascularized temporoparietal fascia flap. This resulted in rapid epithelialization by six weeks in seven out of 10 cases. The remaining three patients have persistent non healed areas over the medial attic wall, but are not troubled by otorrhoea. The indications, technique and complications of mastoid obliteration by this axial pattern flap are described.

Clinical Applications of the Subgaleal Fascia

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.

Injuries of the External Ear

Ear injuries occur in people of all ages but predominate in active people such as wrestlers, boxers, and bike riders. The types and extent of injury are a function of the force causing the injury. Shearing forces of moderate intensity cause hematoma formation, whereas greater force causes lacerations or even amputation. Sharp objects cause lacerations determined by the force, direction, and point of impact. The high ratio of surface area to mass makes the auricle vulnerable to extremes of temperature. People participating in high-risk activities should wear protective headgear. The goal of treatment is to restore the normal contours while preventing infection. Hematoma results in disfigurement by organization or chondritis. Evacuation and pressure dressings using sterile technique correct the condition. Second-degree burns are treated by regular cleansing and application of topical antimicrobials. Deeper burns require debridement, biologic dressings, or burying the cartilage subcutaneously for later reconstruction. Simple lacerations are closed under aseptic technique using either skin-to-skin sutures only or sutures of the skin combined with intercartilage sutures. Extensive and complex lacerations require meticulous care to match all fragments and prevent infection or loss of tissue. Bare cartilage must be covered with vascularized tissue. The treatment of total amputation is controversial. Some advocate reattachment as a composite graft using intravenous low molecular weight dextrans and heparin as adjuvants. Mladick dermabrades the amputated pinna, reattaches it with sutures, and then slips it into a pocket of elevated postauricular skin for 2 weeks. Others urge microvascular reanastomosis of the small nutrient vessels. Brent and Byrd separate the cartilage from its overlying skin and envelope it first with vascularized temporoparietal fascia and then a split-thickness skin graft. Chondritis is the most feared complication of injury or surgery of the pinna. It is an aggressive process, and prompt removal of pus and necrotic cartilage is required. Exteriorization and removal of all cartilage is effective but disfiguring. Removal of only affected cartilage and constant irrigation with antibiotic solutions is effective but requires prolonged hospitalization. Iontophoresis of antibiotics into the auricle may be effective and conserve tissue. Traumatic deformities are corrected with composite grafts from the opposite ear, costal cartilage, and local pedicled flaps.(ABSTRACT TRUNCATED AT 400 WORDS)

An anatomical study on the distribution of the temporal branch of the facial nerve

In an attempt to define the distribution of the temporal branch of the facial nerve, 30 facial halves of 15 Japanese cadavers were dissected. The tissue plane in which the temporal branch ran was investigated and the relationship between this nerve and the surrounding tissues observed. To quantify the distribution, the distance from the bony lateral canthus (LC) to the points where the temporal branches crossed two standard lines, (L1 and L2) were measured. These latter were determined according to the skeletal landmarks. The temporal branch consistently lay along the undersurface of the temporoparietal fascia. But its depth below the skin was not constant because the amount of overlying adipose tissue varied and it was localized within a limited area. The temporal branch generally branched into 3 or 4 rami and its trajectory was either straight or curved, depending on the relationship between the middle and the posterior ramus. The distances from LC to each point were relatively constant and there was no difference between the right and the left side. It is important for surgeons to know the quantified course of the temporal branches based on the skeletal landmarks. As a consequence of the quantification, it was possible to establish new guidelines for protection of the entire temporal branch from surgical injury.