Temporoparietal Fascia Flap Treatment & Management

Trauma, previous surgery, irradiation, or carotid occlusion may jeopardize the integrity of the temporoparietal fascia flap. Doppler ultrasonography should be used preoperatively to determine the reliability of the superficial temporal artery and to map the course of the main pedicle, frontal branch, and parietal branch.

The face and scalp are prepared and draped. The flap can usually be harvested without shaving hair if the hair is carefully prepped out of the field with ointment and tape or rubber bands.

The important topography of the temporoparietal flap to mark on the scalp includes the superior temporal line, the course of the superficial temporal artery trunk and the frontal and parietal branches, and the approximate course of the frontal branch of the facial nerve (see the image below). The incision is marked as a vertical incision from the root of the helix to the superior temporal line. This incision can be extended as a V superiorly to gain additional access to the galea. The preauricular portion of the incision is extended as a face-lift incision around the tragus as necessary.

Temporoparietal fascia flap. The important topography to mark on the scalp prior to incision includes the proximal trunk of the superficial temporal artery, the frontal and parietal arterial branches, the temporal line, and the approximate course of the frontal branch of the facial nerve.

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The anterior and posterior scalp flaps are elevated in the subcutaneous plane immediately deep to the hair follicles. The temporoparietal fascia adheres to this subcutaneous tissue, and meticulous sharp dissection is necessary to avoid injuring either the vascular supply of the flap or the hair follicles.

The frontal branch of the superficial temporal artery and the anterior edge of the flap are ligated. As with any frontal dissection in the superficial planes, care should be taken anterior to this point to avoid injury to the frontal branch of the facial nerve. If dissection becomes necessary anterior to this point, then the frontal branch should be identified and carefully preserved.

After elevation of the skin flaps, the superior, posterior, and anterior edges of the flap are divided (see the image below). A flap measuring up to 17 X 14 cm can be harvested without extensive scalp undermining. The dissection then proceeds from superior to inferior by dissecting the loose areolar tissue between the 2 layers of fascia. This plane is avascular and easily identified, and dissection can proceed quickly during this portion of the operation.

Temporoparietal fascia flap. After elevating the flaps, the superior, posterior, and anterior borders of the temporoparietal flap are incised.

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As the surgeon approaches the root of the helix, dissection must proceed carefully to avoid injury to the vascular pedicle. The pedicle is identified, and the flap base is narrowed to 2.0-2.5 cm, if necessary, to improve rotation. Dissection inferior to the root of the helix is limited by the parotid gland and the risk of injury to the main trunk of the facial nerve. As mentioned previously, 2 layers of vascularized fascia can be harvested by identifying and carefully dissecting the temporalis muscular fascia with its nutrient middle temporal artery. The artery can be followed to its origin from the superficial temporal artery in the region of the zygomatic arch.

The flap is draped carefully into the recipient site and fastened to the surrounding skin and soft tissue (see the image below). The pliability of the flap makes it uniquely suited to draping over irregular surfaces. A skin graft may be applied to the flap and held in place with sutures and suction drainage. The wound is dried carefully with cautery and then irrigated. Suction drainage is placed in the superior donor site away from the pedicle, and the wound is closed in layers. A pressure dressing is applied to the scalp for 12-24 hours.

Temporoparietal fascia flap. After careful elevation of the flap with protection of the superficial temporal artery pedicle, the flap is draped into the recipient bed. The pliability of the flap make it uniquely suited for draping over cartilage and bone.

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Alopecia

Alopecia is more common in the setting of scalp tissue previously compromised by trauma, irradiation, or surgery. The surgeon can reduce the incidence of this complication by meticulous elevation of the scalp flaps in the proper plane immediately deep to the hair follicles. Cauterization of the skin edges and hair follicles should be minimized.

Hematoma

Meticulous attention to hemostasis should occur prior to closure. Injury to the frontal branch of the facial nerve can occur if the dissection proceeds anterior to the frontal branch of the superficial temporal artery.

Flap necrosis

Complete failure of this flap is rare, even in the presence of poor wound vascularity and contamination.

The temporoparietal flap is a very hearty flap with excellent survivability and low incidence of necrosis and infection. The donor site normally heals well, and the incisions are usually camouflaged well by hair and rhytids. Even when skin grafts over the flap are unsuccessful, the flap has the vascularity to survive and re-epithelialize or remucosalize.

A study by Schrötzlmair et al, using a patient questionnaire, found that among adults and children who underwent auricular reconstruction with a porous polyethylene framework and temporoparietal fascia flap, approximately 80% expressed satisfaction with the surgery’s results. Complaints primarily concerned scars and shape. Compared with adults, children in the study reported that the reconstruction had greater benefit to their health-related quality of life. ^[11]

Even though microvascular reattachment of the severed auricle has been described many times in the literature, the difficulty in performing this technique reliably has led some authors to propose implantation of the de-epithelialized cartilaginous framework under a temporoparietal fascial flap as the standard therapy for this traumatic deformity.

Helal et al reported good results from reconstruction of full-thickness defects of the upper one third of the auricle using a combination of an autologous contralateral conchal cartilage graft and a superficial temporoparietal fascia flap. The procedure was performed on 14 patients, 13 of whom found the cosmetic appearance to be acceptable. ^[12]

In a report on ear reconstruction in young children, using a porous, high-density polyethylene implant, Reinisch and Tahiri stressed the importance of employing a meticulously harvested, well-vascularized, superficial temporoparietal fascia flap and appropriate color-matched skin grafts. ^{[13, 14]}

The versatility and reliability of the temporoparietal fascia flap will no doubt result in future descriptions as reconstructive surgeons imagine new ways to employ it in difficult wounds. ^[15]

For example, a retrospective study by Altındaş et al reported that in selected patients, a two-stage prelaminated temporoparietal fascia flap with skin graft can successfully be used to reconstruct partial facial defects, without the need for tissue expansion or microsurgery. ^[16]

A study by Lesta-Compagnucci et al suggested that in patients with microtia, random occipito-temporal fascia flaps in association with a dermal regeneration template can serve as an alternative to temporoparietal fascia flaps in ear construction surgery. Operations took an average of 177 minutes in the 46 temporoparietal fascia flap patients, compared with 84.5 minutes in the eight patients in whom the random occipito-temporal fascia flap/dermal regeneration template was employed. Moreover, the complication rate was similar in both groups. ^[17]