Temporoparietal Fascia Research Articles

Soft-Tissue Manipulation Contributes to Craniofacial Symmetry as Importantly as Does Implant Reconstruction in Cranioplasty for Skull Defects

Soft-Tissue Manipulation Contributes to Craniofacial Symmetry as Importantly as Does Implant Reconstruction in Cranioplasty for Skull Defects

The Use of the Temporoparietal Fascial Flap in Preventing CSF Leak after Lateral Skull Base Surgery

Objective Determine the effectiveness of the temporoparietal fascia flap (TPFF) with adipose tissue in preventing cerebrospinal fluid (CSF) leaks for lateral skull base tumor reconstruction. Design A retrospective chart review from 2005 to 2010 was conducted of patients undergoing skull base tumor resection. Patients with TPFF reconstruction were compared with those with adipose packing alone based on lumbar drain placement, tumor size, extent of dissection, and incidence of CSF leak. Data was analyzed with a Fisher exact test at p < 0.05. Setting Tertiary care institution. Main Outcome Measures Incidence of CSF leak. Results A total of 16 patients had a TPFF reconstruction; 20 had adipose only. Four TPFF patients had lumbar drain placement, as did six in the adipose-only group. Six patients had a CSF leak, all in the adipose-only group (p = 0.02). Patients with a lumbar drain were more likely to have larger tumors (p = 0.01) and to have a CSF leak if they had adipose-only reconstruction (p = 0.07). Conclusions Lateral skull base reconstruction using TPFF with adipose tissue is easily performed and has a low operative morbidity. Early results show a significant decrease in the rate of CSF leak using TPFF, particularly in high-risk patients.

Parry-Romberg Syndrome: Severity of the Deformity Does not Correlate with Quality of Life

The aims of this study were to (1) describe the main clinical findings of Parry-Romberg syndrome (PRS), (2) evaluate surgical strategies and outcomes, and (3) investigate the quality of life of patients according to their disease severity. This retrospective observational study involved 14 patients treated between 2005 and 2011. The surgical treatment strategies were based on the proposed system for grading severity, and postoperative outcomes were assessed. The patients answered two questionnaires that covered the clinical manifestations of the syndrome and their quality of life in the postoperative period. A comparative analysis between the severity of the deformity and the quality of life was performed using the Kruskal-Wallis and Mann-Whitney tests. The most prevalent clinical manifestation of PRS was progressive hemifacial atrophy (85.71%). The surgical strategy was individualized based on the severity of disease of each patient. Surgical strategies included free-fat grafts, dermal fat grafts, and bone grafts associated with a temporoparietal fascia flap. Regardless of approach, all patients had an overall improvement in their facial appearance and were free of complications during the follow-up period. Our data showed no association between the severity of the deformity and the quality of life of these patients (all p>0.05). In this series, there was a predominance of clinical features of PRS that had been previously reported. Satisfactory outcomes were obtained using different surgical strategies that varied according to the severity of the deformity. The severity of the deformity did not impose a reduced quality of life on PRS patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Scars after total ear reconstruction with porous polyethylene: the patients’ perspective

Total ear reconstruction with porous polyethylene implants leads to three typical skin scars: a scalp scar from harvesting the temporoparietal fascia flap as well as a groin scar and a contralateral postauricular scar from harvesting full-thickness skin grafts. This study evaluates the annoyance of these scars from the patients’ perspective. Fifteen patients received structured questionnaires covering the aesthetical outcome and daily impairment by the three scar types, as well as validated questionnaires measuring health-related quality of life. The ear reconstruction had raised the health-related quality of life in 14 patients. The scalp and groin scars were rated “satisfactory,” and the postauricular scar was “good” on an average. In contrast to the postauricular scar, the annoyance by scalp and groin scars was substantial: Half of the patients had sensation disorders on the scalp or groin. The scalp scar impaired a third of the patients wearing a desired hairstyle and the groin scar a third of the patients wearing swimsuits. A fifth of the patients experienced feelings of shame in the public due to the scalp and groin scars. While not preventing the beneficial effect of ear reconstruction on patients’ health-related quality of life, scalp and groin scars are annoying for a relevant percentage of the patients. Therefore, the temporoparietal fascia flap should be harvested with the smallest incision possible, full-thickness skin grafts from the groin should be harvested as small as possible, and harvesting areas for full-thickness skin grafts other than the groin should be evaluated. Level of Evidence: III.

Endoscopic endonasal transpterygoid approaches: Anatomical landmarks for planning the surgical corridor

Endoscopic endonasal transpterygoid approaches (EETA) use the pneumatization of the sinonasal corridor to control lesions of the middle and posterior skull base. These surgical areas are complex and the required surgical corridors are difficult to predict. Define anatomical landmarks for the preoperative planning of EETAs. Anatomical study. We reviewed images from high-resolution maxillofacial CT scans with (0.6-mm axial slice acquisition). Cephalometric measurements were obtained using Kodak Carestream Image Software (Rochester, NY). Average distance from midline to the vidian canal was 12.78 mm (range 9.4-15.8 mm). Average horizontal distance from the vidian canal to the foramen rotundum was 5.6 mm (range 2.8-11.5 mm). Average vertical distance from the vidian canal to the foramen rotundum was 6.22 mm (range 4.3-9.3 mm). These landmarks are consequential during the preoperative planning of the surgical corridor. To facilitate communication, we classified EETAs as: A) Partial removal of the pterygoid plates (transposition of temporo-parietal fascia); B) removal of anteromedial aspect of the pterygoid process (lesions involving the lateral recess of the sphenoid sinus); C) involves dissecting the vidian nerve to control the petrous ICA and removing the pterygoid plates base to reach the petrous apex, Meckel's cave, or cavernous sinus; D) variable removal of the pterygoid plates to access the infratemporal fossa; and E) removal of pterygoid process and medial third of the Eustachian tube to expose the nasopharynx. Our novel classification and landmarks system helps to understand the anatomy of this complex area and to accurately plan the EETA.

Feasibility of 4-Point Fixation Using the Preauricular Approach in a Zygomaticomaxillary Complex Fracture

A zygomaticomaxillary complex fracture is a facial bone fracture that commonly occurs as a centrally and laterally protruding zygomatic area. The exact reduction of the displaced fracture is the most important task in the treatment of a zygomatic fracture, from the aesthetic point of view. In some types of zygomaticomaxillary complex fracture, however, it is somewhat difficult to maintain the reduction after the surgery using 3-point fixation. In addition, surgery using 3-point fixation may cause malunion or nonunion. Thus, 4-point fixation using the coronal approach is alternatively considered. The authors performed 4-point fixation using the preauricular approach to counter the disadvantages of the coronal approach. The results and usefulness of 4-point fixation using the preauricular approach are reported in this study. This study was conducted on 172 patients who had a zygomaticomaxillary complex fracture and an isolated zygomatic arch fracture from March 2010 to September 2011. Open reduction and internal fixation were performed on the patients with a zygomaticomaxillary fracture, and closed reduction using the Gilles technique was performed on the patients with an isolated zygomatic arch fracture, among whom reduction using the preauricular approach was further performed on 17 patients who had insufficient intraoperative reduction or who had unsatisfactory intraoperative radiologic outcomes. An approximately 1.8-cm preauricular incision was made from 1.5 cm anterior to the helical root of the ear to 1 cm anterior to the tragus in a curved shape. After the incision, the temporoparietal fascia was dissected to confirm that the incision had reached the zygomatic arch behind the facture line. The reduction was performed, whereas the displaced fractured bone was being observed with the eyes, followed by the internal fixation. Plane x-ray and 3-dimensional head computed tomography were performed before the surgery, after the surgery, and 6 months after the surgery to examine the reduction status and outcomes of the displaced fracture. The mean follow-up period was 5.5 (range, 5-6) months. Reduction using the preauricular approach was further performed on 17 patients who showed unsatisfactory reduction among 172 patients with a zygomaticomaxillary complex fracture and an isolated zygomatic arch fracture. Reduction using the preauricular approach was further performed on the displaced fractured site that remained unrepaired in an intraoperative radiologic examination. In the postoperative 3-dimensional head computed tomography and plane x-ray, satisfactory reduction that showed exact correction was observed. In an outpatient follow-up, no complication such as nonunion or malunion was found, and facial symmetry was also shown. In addition, the preauricular scar was hardly observed. Exact reduction and internal fixation of a fracture site are required to restore the appearance and functions of the normal face and to reduce complications such as malunion or nonunion in patients with a zygomaticomaxillary complex fracture. If a complex fracture of the zygomatic body or facture of the zygomaticomaxillary buttress is accompanied by a fracture of the inferior orbital rim, and thus, if incomplete reduction or malunion is anticipated, 4-point fixation using the easier-to-manipulate preauricular approach would be more useful than the conventional method that uses the coronal approach.

Description and variability of temporal venous vascularization: clinical relevance in temporoparietal free flap technique

The few studies on the venous vascularization of the temporal area indicate a high variability among individuals. The preoperative knowledge of the venous vascularization of the temporal area is critical for microsurgical reconstruction, such as temporoparietal fascia free flap, and especially in understanding the anatomy of the veins for flap survival. Therefore, we conducted an anatomic study to confirm the classification of Legre et al. and a radiologic study to examine the venous network of the temporal area. We found three frequent patterns of the temporal venous network: (1) Type I (the most common), with a predominant temporal vein; (2) Type II, with a predominant posterior auricular vein; (3) Type III, when both veins were equally important. Because of this great variability, the use of a temporal flap for reconstruction of the head and neck should be restricted, and the examination of venous vascularization appears to be necessary before surgery. Here, we report a three-dimensional description of the venous temporal vascularization by computer tomography, which is particularly useful before temporoparietal flaps.

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.

Patient benefit from ear reconstruction with porous polyethylene in severe cases of hemifacial microsomia

Ear reconstructions in patients with severe hemifacial microsomia belong to the most challenging cases. When deciding about the best position for the reconstructed ear, the surgeon has to make a compromise out of different given factors, it being impossible to achieve symmetry to the contralateral side. The present study was initiated to analyze if this difficult patient collective with naturally imperfect esthetical results benefits from the operation by an increase in health-related quality of life. For ear reconstruction, the authors used frameworks of porous polyethylene (PPE) covered by a temporoparietal fascia flap. Six patients with microtia and hemifacial microsomia type 3 (three adults and three children) received validated questionnaires determining the effects of the ear reconstruction on the patients’ health-related quality of life (Glasgow Benefit Inventory, GBI, or Glasgow Children’s Benefit Inventory, GCBI, respectively). Scores can range from −100 (maximal negative effect of the intervention) through 0 (no effect) to +100 (maximal positive effect). All patients achieved positive GBI or GCBI scores suggesting a benefit from the ear reconstruction. For the adults, the mean GBI total score was 27.8. For the children, the mean GCBI total score was 40.3. Scores were higher compared to a control group of microtia patients without additional facial asymmetries. In severe cases of hemifacial microsomia, ear reconstruction with PPE can significantly increase patients’ health-related quality of life. Furthermore, PPE frameworks offer different surgical advantages compared to autologous cartilage especially in severe hemifacial microsomia. Level of Evidence: Level III, therapeutic study.

Relationship of the Temporofrontal Rami of the Facial Nerve to the Fascial Layers of the Temporal Region

Historically, dissection of the temporoparietal fascia immediately above the zygomatic arch has been avoided due to the risk of transection of the temporofrontal rami of the facial nerve. A total of 8 fresh cadaveric hemi-faces have been dissected to investigate the relationship of the temporofrontal rami of the facial nerve to the fascial layers in the temporal region. The relationship of the temporofrontal rami of the facial nerve to the fascial layers in the temporal region is variable, with some deep rami coursing below the parotid-temporal fascia and other superficial rami reaching the temporoparietal fascia before entering the lateral edge of the orbicularis oculi. Dissection of the temporoparietal fascia immediately above the zygomatic arch may place superficial branches of the temporofrontal rami at risk.

Reconstruction of a contracted eye socket using an anterofrontal superficial temporal artery island flap and scapha composite grafting in an elderly patient

There are numerous methods for reconstruction of the eye socket. However, the use of an island flap on the forehead based on the anterofrontal branch of the superficial temporal artery has not been reported upon. This article describes an experience of eye-socket reconstruction in a 90-year-old woman with an anterofrontal superficial temporal artery island flap, a temporoparietal fascia flap and scapha composite grafting in a one-step procedure. Deep fornices were obtained and the convex eye socket was stably and easily fitted with the ocular prosthesis, which the patient started to wear 4 weeks after the operation. The socket and eyelids are without any deficits and in good condition with a 1-year follow-up.

Lower eyelid reconstruction in a paediatric face: A one-stage aesthetic approach using the versatile temporoparietal fascia flap

There are many different lower eyelid reconstruction techniques defined in the literature. Almost all of the published techniques have been described on elderly patients and use upper eyelid, periorbital or facial tissues as donor sites. However, in case of a paediatric patient or a young adult who has a crease-free and scarless face, camouflage of the facial donor-site scar is usually impossible. In order to avoid possible facial donor-site scars and upper eyelid deformities, a technique which uses the temporoparietal fascia (TPF) flap as the framework of a new eyelid was used for the reconstruction of an adolescent patient's postoncologic defect. The inner side of the flap was covered with nasal septal chondromucosal graft and the external side was covered with a retroauricular full-thickness skin graft. Eighteen months of unproblematic follow-up of this overlooked usage of the versatile TPF flap indicates that our technique has proved successful in terms of good functional and cosmetic outcome that is obtained at one stage.

Reconstruction of Periparotid Defects Using Temporoparietal Fascia Flap with Layered Acellular Human Dermal Allograft

Excision of lesions in the periparotid area can leave a sizable concavity of the preauricular area with skeletonization of the mandible. To achieve the bulk necessary to fill this defect, we propose using a composite graft. Acellular human dermal allograft provides the thickness of the graft, and the temporoparietal fascia flap provides blood supply to the dermal graft. Our hypothesis is that vascularization of the graft will promote greater ingrowth of native tissue and prevent breakdown and absorption of the graft. Four representative patients are described.

Application of both over-expanded cutaneous flap and temporal superficial fascia flap in ear reconstruc- tion with Medpor

Objective To investigate the feasibility and results of the application of both ex panded cutaneous flap and temporoparietal fascia flap in total ear reconstruction with Medpor frame- work. Methods The main procedures consisted of three stages： stage Ⅰ-skin expansion, stage Ⅱ-auri cle formation that consisted of orientation of Medpor implant and creation of coverage for the implant by both expaned skin flap and temporoparietal fascia flap, and stage Ⅲ-treatment of residual ear and reeontruction of aurieular lobule. Results Twenty-two ears in 22 unilateral microtia patients were constructed using Medpor implants covered with both expanded cutaneous flap and temporoparietal fascia flap over the last three years, and they were accepted as pleasing by the patients. Conclusions Application of both expanded cutaneous flap and temporoparietal fascia flap can assure no extrusion of Medpor implant in ear reconstruction. Further more, the two layers of transferred tissues will not af fect the profile details of the reconstructed ear. And because the skin covering the framework and fas- cia is derived from frommastoid region, the appearance and profile of the reconstructed auricle is true to nature and close to that of the opposite one. Key words: Over-expanded; Fascia flap; Medpor; Ear reconstruction

Superficial temporoparietal fascia flap in diabetic ketoacidosis patient

Oral submucous fibrosis (OSF) is a collagen disorder commonly seen in the Indian sub-continent. Here, we present a case report of a diabetic male with a history of diabetic ketoacidosis suffering from OSF, treated with superficial temporoparietal fascia flap with good post-surgical outcome.

Reconstruction of a distal extremity defect using a temporoparietal fascia flap covered with a split-thickness skin graft harvested from the scalp: a cosmetic consideration in donor site selection

In reconstructive surgery, the ultimate goal in rebuilding a structure is to provide the most similar substitute from both the functional and structural points of view. At the same time, the reconstructive surgeon should focus on minimizing donor area complications. In this report, we present our experiences with the reconstruction of distal extremity defects using a free temporoparietal fascia flap in five patients. The flap was subsequently covered with a split-thickness skin graft harvested from the same region of the scalp as the flap donor site. By procuring the skin graft from the scalp, the donor sites of both the flap and the skin graft were concealed by hair. The transferred flaps and skin grafts healed uneventfully in all patients without any complications at the donor or recipient site. We conclude that this combination of harvesting a temporoparietal fascia flap, which has many advantages in reconstructing distal extremity defects, along with a skin graft from the same region as the flap, both hidden by hair, can limit donor site morbidity and achieve optimal reconstructive outcomes.

Reconstruction of Total Lower Eyelid Defects with the Temporoparietal Fascial Flap

Purpose. To describe the use of the temporoparietal fascial flap (TPF) in the reconstruction of extensive lower eyelid defects in a functioning eye. Methods. We present a surgical case report of a 73-year-old female with melanoma of the left lower eyelid. The lower eyelid was resected, and a composite nasal cartilage-mucosa graft, a skin graft, and a TPF were used to reconstruct the lower eyelid. Results. This achieved reconstruction of the lower eyelid with the protection of the eye and preservation of the visual system function. Conclusion. The TPF serves as a good option for reconstruction of the lower eyelid in a viable functioning globe.

Der temporoparietale Faszienlappen zur Rekonstruktion von Weichteildefekten

Soft tissue reconstruction with a temporoparietal fascial flap (TPFF). Defect coverage with thin, pliable, and well-vascularized tissue. A bilayered TPFF provides a gliding surface in tendon reconstruction. Further options include TPFF harvest with overlying skin or subjacent bone for composite tissue reconstruction or the application as a sensate local fascial flap. Maximum defect dimensions: 17 × 14cm. Absolute: prior injury to the flap or flap pedicle, temporal arteritis, Moyamoya syndrome, defects with volume deficit. Relative: alopecia along the planned incision. Pedicle location is outlined using Doppler ultrasound. Injection of the incision line with diluted epinephrine solution. Skin incision with subsequent visualization of the temporoparietal fascia and supplying vessels. Skin flaps are raised carefully paying special attention to the hair follicles (CAVE: postoperative alopecia). Primary closure of the donor site. Defect coverage with pedicled or free TPFF with subsequent full or split-thickness skin grafting. Dressing: Bolster or V.A.C. Immobilization/elevation in the setting of extremity reconstruction. Removal of bolster dressing or V.A.C. on postoperative day5. Dangling protocol instituted on postoperative day7. Removal of sutures/staples at the donor site on postoperative day5-7 and at the recipient site on postoperative day12-14. The TPFF was utilized for soft tissue reconstruction in 8patients. A pedicled TPFF was used in 2patients. Mean time to healing was 16.3days. Mean follow-up was 13.4months. Successful reconstructive results with satisfactory functional and aesthetic appearance were obtained in all patients. Complications were encountered in 3patients and included alopecia at the donor site and iatrogenic injury to the frontal branch of the facial nerve. Vascular compromise was observed in the early postoperative period in a third patient. However, operative revision resulted in successful flap salvage.

Temporoparietal fascia free flap for pharyngeal coverage after salvage total laryngectomy

The aim of this study was to assess whether the use of the temporoparietal fascia as a free flap for pharyngeal closure reinforcement reduced the incidence of pharyngocutaneous fistula (PCF) in the salvage setting. Consecutive case series. After research ethics board approval, 12 patients who required salvage laryngectomy, including reinforcement coverage of the primarily closed pharyngeal defect with temporoparietal fascia as a free tissue transfer, were analyzed. One (8%) out of 12 patients experienced pharyngocutaneous fistula that responded with conservative wound packing. The PCF rate of 8% is significantly better than in similar salvage cases without flap coverage. Moreover, our PCF rate is comparable to the results shown for the pectoralis major muscle flap. The most obvious benefit of the temporoparietal fascia free flap for pharyngeal coverage in salvage laryngectomy is a reduced PCF rate with diminished donor-site morbidity, including cosmetic outcome, shoulder girdle function, and chest deformity.

Acellular human dermis, a good option for correcting the free border deficiency in secondary cleft lip deformity

Free border deficiency is often seen after repairing the primary cleft lip. Mild deficiency of this area can be corrected by rearranging available local tissue, but, in severe cases, the absolute shortage of tissue requires recruitment of other tissues for a satisfying result. Although many types of materials have been used, filling materials alone have not provided favourable results. We have therefore attempted to overcome these limitations by combining V-Y advancement of the labial mucosa, with providing additional tissue to the deficient area with acellular human dermis or temporoparietal fascia. From September 2001 to January 2009, a combination of acellular human dermis or temporoparietal fascia graft with mucosal V-Y advancement was performed on 20 patients with free border deficiency of secondary cleft lip. Ten patients received temporoparietal fascia graft, and the others received acellular human dermis grafts. Results were evaluated by the surgeon based on the aesthetic appearance and consistency of the free border of the upper lip. All 20 patients were satisfied with the results. There were no significant differences in absorption rate, texture and volume between the acellular human dermis and temporoparietal fascia group. There were no complications such as infection, graft exposure and epidermal cysts in both groups. The use of acellular human dermis is a simple and effective method for managing severe cases of free border deficiency. Combined with V-Y advancement of the labial mucosa, it is as effective as temporoparietal fascia, offering long-lasting results without major complications in managing this difficult problem.