Temporoparietal Fascial Flap Research Articles

Reconstruction of composite oral cavity defects with temporalis flaps after prior treatment

BackgroundReconstruction of composite oral cavity defects in the setting of prior surgery and radiotherapy presents a significant challenge. Although free tissue transfer has shown success in such situations, it is not without considerable risk. Regional pedicled flaps may provide a more suitable alternative. In certain patients, however, severe soft tissue fibrosis makes more conventional regional flaps impractical or impossible. In these situations, temporalis flaps (temporalis muscle and temporoparietal fascia flaps) are versatile options for coverage of complex defects. ObjectiveTo report our experience using pedicled temporalis flaps for reconstruction of composite oral cavity defects in patients with significant co-morbidities and prior treatment. MethodsThree patients were identified and their medical records were reviewed. Their clinical courses and functional outcomes are described. We include a discussion of the operative technique and relevant literature. ResultsAll patients had previously undergone extensive treatment. One patient needed reconstruction after resection of a third head and neck malignancy and two patients presented for treatment of osteoradionecrosis. A temporalis muscle flap was used to reconstruct composite oral cavity defects in two patients and a combined temporalis muscle and temporoparietal fascia flap was used for independent defects in one patient. All flaps survived. Functional status and pain improved or stabilized in all patients. There were no major or minor complications. ConclusionIn previously treated fields, where more conventional flaps are impractical, temporalis flaps are a suitable alternative to achieve a stable healing wound and prevent worsening of functional status.

Reconstruction of Oromandibular Defects after Prior Irradiation Using a Temporalis Muscle and Temporoparietal Fascia Flap

Objectives: Reconstruction of oromandibular defects in the setting of previous treatment, or significant patient comorbidities, presents a significant challenge. Although free tissue transfer has shown success, it is not without considerable risk, especially in patients with poor baseline functional status. In these patients, regional pedicled flaps may provide a more suitable alternative. The combined temporalis muscle and temporoparietal fascia flap is a versatile option for oromandibular reconstruction in a previously treated field, or in patients with severe comorbidities and poor functional status. Our objective was to report our experience using a combined temporalis muscle and temporoparietal fascia flap for reconstruction of oromandibular defects in high-risk situations. Methods: Three patients were identified, medical records were reviewed, and their clinical courses were described. Functional outcomes were reviewed. We include a discussion of the relevant surgical anatomy and operative technique. All patients had previously undergone extensive treatment. They needed additional ablative surgery for different reasons: new malignancy, intractable trismus, and osteoradionecrosis. A combined temporalis muscle and temporoparietal fascia flap was used to reconstruct the oromandibular defects in each patient. Results: All flaps survived. Functional status improved in all patients. There were no significant operative or postoperative complications. Conclusions: The combined temporalis muscle and temporoparietal fascia flap provides a reliable option for reconstruction of complex oromandibular defects in high-risk situations. In previously treated fields, the transfer of a vascularized flap into the wound hastens healing and improves the quality of native oral cavity tissue.

The temporalis muscle flap and temporoparietal fascial flap.

The temporal arterial system provides reliable vascular anatomy for the temporalis muscle flap and temporoparietal fascial flap that can support multiple reconstructive needs of the oral and maxillofacial region. The minimal donor site morbidity and ease of development of these flaps result in their predictable and successful transfer for reconstructive surgery of the oral and maxillofacial region.

Reconstructive Techniques of the Parotid Region

The aim of our study was to evaluate and check (analyze and compare the results) the complications of patients with benign parotid disease reconstructed with the 3 reconstructive techniques used after the removal of benign tumors of the parotid gland treated at our institution. The reconstruction of this anatomical region may include the use of superficial musculoaponeurotic system (SMAS) flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap to prevent aesthetic and functional complications. We carried out a retrospective review of 224 patients operated on between February 2002 and March 2009 with benign primary parotid tumors. Extracapsular dissection or superficial parotidectomy was performed and then these patients were reconstructed with the 3 techniques that we used to apply at the Department of Maxillofacial Surgery in the University Federico 2 of Naples: the SMAS flap, flap of sternocleidomastoid muscle, and temporoparietal fascia flap. The statistical difference between the extracapsular dissection versus superficial parotidectomy and the statistical difference between the 3 types of flaps as concerns evaluated recurrence rate and complications were measured with the χ test. The chosen level of statistical significance was P less than 0.05. Out of the 224 enrolled patients, 103 were women and 121 men, with an average age of 54 years. After histopathological examination, 136 adenomas and 88 cystadenoma lymphomas were diagnosed. Enucleoresection was the surgical technique adopted in 169 cases while superficial parotidectomy was used in the remaining 55 cases. The reconstruction was performed with SMAS flap in 122 patients, with muscle flap SMC in 66 patients and temporoparietal fascia flap in 36 patients. Table 1 shows that no significant differences as concerns hematoma and wound infection were observed after extracapsular dissection and superficial parotidectomy(1.8% vs.1.8% [P > 0.05] and 1.8% vs. 5.5% [P > 0.05]). Transient facial nerve weakness, fistula, dip skin, Frey syndrome, spinal nerve injury, and facial paralysis were significantly more frequent after superficial parotidectomy than after extracapsular dissection (4.1% vs. 27.3% [P < 0.001], 1.8% vs. 10.9% [P < 0.001], 3% vs. 12.7% [P < 0.001], 0% vs. 5.5% [P < 0.001], 0% vs. 3.6% [P < 0.001], and 0% vs. 9.1% [P < 0.001], respectively). Table 3 shows that the presence of Frey syndrome is statistically significant in the first 2 comparisons, group I against group IV and group II against group V, respectively (P < 0.05 and P < 0.01). And in the first comparison between group I and IV, there was a statistically significant presence of transient facial nerve weakness (P < 0.001), fistula (P < 0.001), dip skin (P < 0.05), and facial paralysis (P < 0.001). In the second comparison between group II and group V besides the presence of Frey syndrome, there is also a statistically significant presence of transient facial nerve weakness (P < 0.05), skin depression (P < 0.05), accessory spinal nerve injury (P < 0. 01), and facial paralysis (P < 0.01). In the comparison between the third and the sixth group, there is a statistically significant presence of transient facial nerve weakness (P < 0.05), fistula (P < 0.01), and facial paralysis(P < 0.05). Extracapsular dissection showed similar effectiveness and fewer side effects than superficial parotidectomy, and the 3 reconstruction techniques used in this trial drastically reduce the occurrence of post-parotidectomy Frey syndrome and greatly reduce functional and aesthetic complications.

Management of Neglected Periorbital Squamous Cell Carcinoma Requiring Orbital Exenteration

With its perineural invasion capacity, periorbital squamous cell carcinoma (SCC) may easily invade orbital structures. When SCC invades the orbital musculature or the orbit itself, orbital exenteration, one of the most disfiguring operations on the face, is required. We reviewed elderly patients with periorbitally localized SCC requiring orbital exenteration to evaluate reconstructive options and survival. A chart review of patients' records was conducted to identify all patients older than 65 years with periorbital malignancy requiring orbital exenteration from 2006 to 2011. A total of 9 patients who met the criteria were included in the study. The mean age at surgery was 77 ± 6.7 years, and the mean defect size was 74.2 cm2. All patients had a similar history of late presentation to a doctor because of hesitation to undergo surgery. The temporoparietal fascia flap, galeal flap, free gracilis flap, and free vastus lateralis musculocutaneous flap were the treatment options for reconstruction of the defects. All patients died during follow-up, and the mean survival was 15.7 months (range, 6-36 months). Only 2 of them had relapse before the death. Our small series suggest that elderly patients with periorbital SCC requiring orbital exenteration may not have enough survival to relapse because of the death from different causes without relapse or any sign of spreading cancer. Also, prolonged surgery with free flap reconstruction may increase the risk of postoperative intensive care unit requirement. Because local flaps may work very well for reconstructing the orbital exenteration defects, free flap option should be kept for selected cases.

Treatment of Postburn Ear Defect With Expanded Upper Arm Flap and Consequent Expansion Without Skin Grafting

Total ear reconstruction in the postburn auricle is one of the most challenging procedures for plastic surgeons. Adverse factors associated with these procedures include reduced or damaged blood supply, poor elasticity of scar tissue, increased risk of infection, and the possible destruction of skin, temporoparietal fascia, or retroauricular fascia. In cases where patients are severely burned, free flaps, such as radial forearm flaps, contralateral temporoparietal fascial flaps, or omental flaps, can be used as framework envelopes. In this work, we introduced a novel method of expanded upper arm flap transfer, followed by an expansion method of total ear reconstruction without skin grafting.

Reconstruction of post-traumatic full-thickness defects of the upper one-third of the auricle

Background Reconstruction of partial ear defects represents a difficult challenge to the plastic surgeon due to the delicate and intricate architecture of the chondrocutaneous sandwich of the external ear. Methods Fourteen patients with acute or previous traumatic subtotal loss of the upper one-third of the auricle were treated with autologous contralateral conchal cartilage graft and superficial temporoparietal fascia flaps. Results The symmetry of the reconstructed ears was satisfactory and the cosmetic appearance was acceptable for 13 patients. Minor hematoma at the conchal cartilage graft donor site occurred in one (7.1%) patient and marginal loss of temporoparietal flap in another (7.1%). Revision surgery was required for widening of the scar and obscuring of the upper pole contour in one (7.1%) patient. No additional complications were encountered. Conclusion The authors recommend using this combined technique for reconstruction of full-thickness auricular defects.

Temporoparietal fascial flap for reconstruction of open wounds in patients previously treated for head and neck cancer

Wound-healing problems with subsequent plate exposure are frequent in patients who have undergone reconstructive surgery for head and neck cancer. Management of these wounds is difficult. The objective of this report is to present two head and neck cancer patients with chronic facial wounds and plate exposure after radiation therapy. A temporoparietal fascial flap was used to manage the wound in both cases. From January 2009 to January 2013, there were 37 patients with head and neck cancer who required reconstruction of composite mandibular defects in Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Plate exposure developed in 10 patients, and in two patients the chronic facial wound was treated with a temporoparietal fascial flap. Both the flaps survived, and at 6 months of follow-up the wounds were healed with minimal donor site morbidity. Neither patient experienced alopecia or injury to the facial nerve. The temporoparietal fascial flap is thin, pliable, and well vascularized with a long pedicle, and provides resistant coverage to the recipient site from infection. The temporoparietal fascial flap may be an alternative choice for the reconstruction of head and neck open wounds.

Beyond the nasoseptal flap: Outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction

Endoscopic endonasal skull base surgery defects require effective reconstruction. Although the nasoseptal flap (NSF) has become our institution's workhorse for large skull base defects with cerebrospinal fluid (CSF) leaks, situations where it is unavailable require secondary flaps. Clinical outcomes, pearls and pitfalls, and an algorithm will be presented for these secondary flaps. Clinical case series. Medical records of all endoscopic endonasal skull base surgeries at a tertiary care academic medical center were reviewed for skull base defect type, reconstruction method, CSF leak rate, and flap necrosis rate. Of 330 flaps for reconstructing endoscopic endonasal skull base defects, secondary flaps were used in 34 cases (10%). These included 16 endoscopic-assisted pericranial flaps, seven tunneled temporoparietal fascia flaps, three inferior turbinate flaps, two middle turbinate flaps, two anterior lateral nasal wall flaps, two palatal flaps, one occipital flap, and one facial artery buccinator flap. There were 19 anterior cranial fossa defects, 10 clival defects, three sellar defects, and one frontal and one lateral orbit/middle fossa defect. Twenty-five of the 34 cases (73.5%) had either prior or postoperative radiation therapy. The most common pathology was sinonasal cancer, with 16 cases (47.1%). The postoperative CSF leak rate was 3.6% due to one middle turbinate flap necrosis. Secondary flaps for skull base reconstruction can be harvested with minimally invasive techniques and demonstrate excellent success rates (97%) that are comparable to that of the NSF (>95%). Multiple flaps for complex skull base defects should be in the armamentarium of comprehensive skull base surgery centers. 4.

Reconstruction of post-traumatic full-thickness defects of the upper one-third of the auricle

Reconstruction of partial ear defects represents a difficult challenge to the plastic surgeon due to the delicate and intricate architecture of the chondrocutaneous sandwich of the external ear. Fourteen patients with acute or previous traumatic subtotal loss of the upper one-third of the auricle were treated with autologous contralateral conchal cartilage graft and superficial temporoparietal fascia flaps. The symmetry of the reconstructed ears was satisfactory and the cosmetic appearance was acceptable for 13 patients. Minor hematoma at the conchal cartilage graft donor site occurred in one (7.1%) patient and marginal loss of temporoparietal flap in another (7.1%). Revision surgery was required for widening of the scar and obscuring of the upper pole contour in one (7.1%) patient. No additional complications were encountered. The authors recommend using this combined technique for reconstruction of full-thickness auricular defects.

Evaluation of the sufficiency of pedicled temporoparietal fascial flap on rat head and neck defects: detailed anatomical study

The temporoparietal flap containing the temporal fascia has a wide spectrum of applications in head and neck surgery. The aim of this study is to demonstrate a temporoparietal fascial flap model that can be used in various head and neck defects in rats. Ten male Sprague-Dawley rats weighing 250-300 g were used in this study. Temporoparietal fascial flaps were elevated with the axial pedicle from the rats using microsurgical techniques. The arc rotations of the flaps on the pedicles were examined and the dimensions of the defects these flaps could cover were identified. The flaps were observed to be the right size for use with defects of the occipital, temporal and mastoid regions, ear, facial nerve and the mandible. The temporoparietal fascial flap is an experimental flap model, which can be useful in experimental studies related to complex head and neck defects.

Partial auricular reconstruction with porous polyethylene frameworks and superficial temporoparietal fascia flap

Untreated acquired auricular damage can be a psychological burden, especially for younger patients. The significance of auricular reconstruction in patients with microtia in terms of quality of life has already been demonstrated. In these patients the use of porous polyethylene combined with a temporoparietal fascia flap has proven to be a suitable method for achieving good cosmetic results. Here, we describe how to use porous polyethylene combined with an endoscopically harvested temporoparietal fascia flap and autologous skin grafts for the reconstruction of acquired partial auricle defects and present outcomes and patient benefit. Ten consecutive patients were asked to answer validated questionnaires [modified Glasgow Benefit Inventory (GBI)] determining the effects of partial ear reconstruction on their health-related quality of life. These patients were seen regularly in our outpatient clinic for documentation and postoperative counseling. All patients returned a valid questionnaire; 80% were satisfied with the esthetic result. In retrospect, all patients would again decide to undergo surgery. The mean total GBI score was 27.8 (median 29.2, p < 0.05) reflecting an improvement of the health-related quality of life due to the operation. Odd feeling, numbness and the formation of scar tissue were the main complaints. Partial auricular reconstruction using porous polyethylene combined with an endoscopically harvested temporoparietal fascia flap and autologous skin grafts yields good esthetic results and can significantly increase patient's health-related quality of life.

Indirect Cerebral Revascularization With a Temporoparietal Fascial Flap in Pediatric Moyamoya Patients

Moyamoya syndrome is a progressive occlusive disease of the cerebral vessels. There are a variety of surgical treatments directed at revascularizing the ischemic brain in pediatric moyamoya disease. Many reports of varying success with both direct and indirect type of procedures can be found in medical literature. We present a novel technique, encephalo-TPF-synangiosis (ETS) with a pedicled bone flap, for indirect moyamoya revascularization in pediatric patients. A three-quarters osteoplastic temporal craniotomy was created. A pedicled temporoparietal fascial flap was passed intracranially through the temporalis muscle and placed into contact with the pial surface. The bone flap was the reaffixed to the skull. We performed 8 ETS in 6 patients. This is a well-vascularized, highly reliable method that offers broad-based surface area for revascularization. We also offer a composite overview of current surgical indirect revascularization techniques.

Carcinoma adenoide quístico parotídeo: soluciones estéticas y funcionales

Adenoid cystic carcinoma represents 10-30% of all malignant neoplasms in the parotid gland. Treatment is a formal parotidectomy, which includes removing the tumour with an adequate margin and postoperative radiotherapy to improve the locoregional control of the disease. We report a case in order to present the management of the functional and aesthetic consequences obtained from its treatment. When the facial nerve is clinical affected or involved by the tumour, it requires resection and an immediate reconstruction. We suggest the sural nerve graft for the reconstruction of the affected facial branches and the temporo-parietal fascia flap to fill the volume left by the parotidectomy.

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 .

Facial artery myomucosal free flap for cheek mucosa reconstruction: A case report

Squamous cell carcinoma (SCC) of the buccal mucosa is an aggressive form of oral cancer. It tends to spread to adjacent tissues and often metastasizes to occult cervical node. There are multiple techniques for cheek reconstruction after tumor removal, including temporalis myocutaneous and temporoparietal fascial pedicled flaps and a forearm free flap. In this report, a case of a 76-year-old man with SCC of the left cheek mucosa and extending to the posterolateral superior alveolar ridge is presented. The patient underwent radical excision of the tumor, omolateral modified radical neck dissection (MRND-III), and contralateral selective neck dissection (levels I-III). Reconstruction was performed with a facial artery myomucosal free flap. The flap was transplanted successfully, and there were no donor or recipient site complications. This technique is a good reconstructive option because of its adherence to the plastic surgery principle of "replacing like with like" and its minimal donor-site morbidity.

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.

How can Frey's syndrome be prevented or treated following parotid surgery?

How can Frey's syndrome be prevented or treated following parotid surgery?

The Usage of Temporoparietal Fascial Flap for Severe Traumatic Auricle Laceration Repair

This report outlines the successful use of the temporoparietal fascial flap (TPFF) for primary reconstruction of a severely lacerated auricle. The TPFF was chosen in order to increase the vascularization and subsequent success of the procedure. For reconstruction of the head and neck region, particularly the auricular region, the TPFF presents a reliable and straightforward option with a high potential for success. We therefore suggest that Otolaryngologists and Head and Neck Surgeons keep this technique in mind when planning a surgical course of action.