dentistry journal

Case Report Superficial Temporal Perforator Flap: Indications, Surgical Outcomes, and Donor Site Morbidity

Raffaele Rauso 1 , Giovanni Francesco Nicoletti 2, Enrico Sesenna 3, Carmelo Lo Faro 4,* , Fabrizio Chirico 4, Romolo Fragola 1, Giorgio Lo Giudice 4 and Gianpaolo Tartaro 1

1 Oral and Maxillofacial Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialities, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; raff[email protected] (R.R.); [email protected] (R.F.); [email protected] (G.T.) 2 Plastic Surgery Unit, Multidisciplinary Department of Medical and Dental Specialties, AOU University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; [email protected] 3 Head and Neck Department, Maxillo-Facial Surgery Division, University Hospital of Parma, 43126 Parma, Italy; [email protected] 4 Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80138 Naples, Italy; [email protected] (F.C.) [email protected] (G.L.G.) * Correspondence: [email protected]; Tel.: +39-3459707932

 Received: 12 August 2020; Accepted: 9 October 2020; Published: 12 October 2020 

Abstract: The aim of this retrospective case series was to discuss indications, surgical outcomes, and donor site morbidity in the use of superficial temporal artery perforator (STAP) flaps in intra-oral or extra-oral facial reconstruction. This study involved 9 patients treated with a STAP flap at the Maxillo-Facial Surgery Unit of the University of Campania “Luigi Vanvitelli”, Naples. A STAP flap was used alone or in combination with other local flaps, for the coverage of facial soft tissue defects, after the resection of craniofacial malignant tumors (n = 7) or as a salvage flap, in partial or total microvascular flap loss (n = 2). The STAP flap was proven to be a valuable surgical option despite it not being frequently used in facial soft tissue reconstruction nor was it chosen as the first surgical option in patients under 70 year’s old. Donor site morbidity is one of the major reasons why this flap is uncommon. Appropriate patient selection, surgical plan, and post-surgical touch-ups should be performed in order to reduce donor site scar morbidity.

Keywords: superficial temporal artery island flap; intraoral defect; free flap combination; reconstructive surgical procedures; donor site morbidity

1. Introduction The first goal in facial reconstruction is anatomical repair while respecting the aesthetic units [1]. Facial reconstructive procedures are extremely heterogenous and can be tailored on the basis of the location and the size of the defect [2]. Currently, several surgical techniques for intra-oral and extra- oral facial defects can be performed, including free flaps [3], local and rotational flaps [4], pedicle flaps [5], and skin grafts [6], although scar quality and donor site morbidity must be carefully evaluated in the pre-operative planning. Free flaps such as free radial forearm or anterolateral thigh perforator flap, when possible, always represent the first choice [7]. However, poor clinical condition, depleted vessels necks, previous radiotherapy, and elderly patients could represent relative contraindication to microsurgery [7].

Dent. J. 2020, 8, 117; doi:10.3390/dj8040117 www.mdpi.com/journal/dentistry Dent. J. 2020, 8, 117 2 of 9

The superficial temporal artery perforator (STAP) flap might represent a versatile surgical option in such clinical scenarios. The temporal region is an excellent donor site because of its rich vascular network and its multitude of tissues types, including skin, , muscle, and the calvarial bone. For this reason, single or composite flaps can be harvested from this site, which are based on the superficial temporal artery, and the path of its branches, and are chosen according to the defect site and nature [8]. Some papers describe the STAP flap as a good option in restoring several anatomic areas such as forehead, eyebrow, eyelid, , nose, and also for intra-oral reconstructions [9–14]. The anatomy of the pedicle is reliable and constant and the wide rotation angle of the pedicle (up to 180 degree), allows large defect reconstruction (4–15 cm) [12]. In our opinion, donor site morbidity, including any subsequent alopecia and scarring, is one of the major reasons why the use of the STAP flap is still uncommon in practice. Up to 3–4 cm of donor area defect can be closed primarily [15], although brow asymmetry can be detected postoperatively; moreover, bigger donor sites usually require a split thickness skin graft to resurface the area, resulting in poor aesthetic results secondary to skin color mismatch, and a thickness defect compared to the surrounding tissue or alopecia [16]. Surgical and non-surgical procedures can be further performed to reduce donor site morbidity. The aim of this study was to discuss indications, surgical outcomes, and donor site morbidity in the use of STAP flap in intra-oral and extra-oral facial reconstruction.

2. Materials and Methods This study was conducted retrospectively by evaluating the medical report of patients treated at the Maxillo-Facial Surgery Unit of the University of Campania “Luigi Vanvitelli”, Naples, between May 2018 and January 2020. A total of 9 patients (6M, 3F; 62–87 years) were recruited. A primary indication for STAP flap was given only in the case of defects involving the ear (Case 2), in an old patient with poor clinical conditions (Case 7), and in one case who had a small defect where a direct skin closure of the donor site was achievable without significant eyebrow asymmetry (Case 8). In 3 patients, this flap was used because of neck depleted vessels (Case 3, Case 6, and Case 9), in 2 patients it was used as a salvage procedure of partial microsurgical flap failure (Case 1 and Case 5), and in 1 patient it was used as a second flap, associated with a radial forearm free flap, following maxillary demolition (Case 4). The study followed the Declaration of Helsinki on medical protocol and ethics and due to the retrospective nature of this study, it was granted an exemption in writing by the University “Luigi Vanvitelli Naples Institutional Review Board.”

Surgical Technique Superficial temporal artery (STA) is the superficial branch of the system. The anatomical position of superficial temporal artery is relatively constant between patients and the pedicle is also easily exposed. STA usually has 2 main branches just above the ear, namely the posterior (parietal) and anterior (frontal). The anterior branch divides into 2 main terminal branches—frontal and parietal. Each of these branches allows the surgeon to harvest a different flap—the parietal branch is used when bearing is required for the reconstruction (eyebrow, mustache, etc.); the frontal one is preferred when hair is not required for the reconstruction. Usually, the main branch of the superficial temporal artery can be identified by digital palpation 1-cm in front of and 1-cm above the tragus, that said, it is also useful to identify and follow it along its main course, with a handle doppler. An explorative skin incision, of about 3 cm, is usually performed, as in face-lift procedures, hidden in the pre-auricular fold. Once the superficial temporal pedicle is identified, skin incision can be performed cranially across the hair line and the pedicle can be followed in a free style technique. When the parietal branch is not required for the flap, it has to be ligated as it emerges from the main pedicle, usually 1 cm above the ear. The vascular pedicle is followed up to the length required (a Dent. J. 2020, 8, 117 3 of 9 maximum of 15 cm) in order to have a wide arc of rotation, without tension or torsion of the pedicle itself, in order to close the defect. Since the superficial temporal artery and do not run closely together along the entire course of the pedicle, the STAP flap has a well-defined arterial blood supply but frequently no single venous outflow. Its venous outflow might run through the peri-arterial tissue and the temporal artery pedicle should not be skeletonized to its core. Consequently, the flap might be observed in a varying blue tone in the first post-operative days. Once the surgeon reaches the required pedicle length, a myo-cutaneous flap can be harvested, distally to proximally, sparing the periosteum layer, in order to have a good graft healing. The flap Dent. J. 2020, 8, x FOR PEER REVIEW 3 of 11 is usually designed leaving the pedicle at the center of it. Along the pedicle length, only a few collateral branches(a maximum can be of identified 15 cm) in order and to have ligated, a wide arc someof rotation, more without branches tension or torsion carrying of the pedicle blood to the ear and itself, in order to close the defect. to TMJ can be identifiedSince the at superficial the emerging temporal artery point and ofvein STA; do not run in closely case together some along more the pedicleentire course length is required, of the pedicle, the STAP flap has a well-defined arterial blood supply but frequently no single venous these branches haveoutflow. to be Its venous ligated. outflow A might wide run subcutaneous through the peri-arterial tunnel tissue and between the temporal the artery flap pedicle and the recipient site is then performedshould and not the be flap skeletonized is inset to its and core. adaptedConsequently, into the flap the might defect be observed site. in a varying blue tone in the first post-operative days. Once the surgeon reaches the required pedicle length, a myo-cutaneous flap can be harvested, 3. Results distally to proximally, sparing the periosteum layer, in order to have a good graft healing. The flap is usually designed leaving the pedicle at the center of it. Along the pedicle length, only a few In all cases, thecollateral flap branches healed can without be identified major and ligated, complication, some more branches although carrying blood one to patientthe ear and(Case 4) who was treated with a syntheticto TMJ can acellular be identified dermalat the emerging regeneration point of STA; in template case some more (Integra pedicle length Lifesciences, is required, Plainsboro, NJ, these branches have to be ligated. A wide subcutaneous tunnel between the flap and the recipient USA) before skinsite grafting, is then performed died and 3 the weeks flap is inset after andsurgery, adapted into duethe defect to site. cardiopulmonary distress, with the template still in site.3. Results Direct closure of the donor site was achieved in 2 patients (Case 5 and Case 8), in 6 patients (Case 1,In Caseall cases, 2, the Case flap healed 3, Casewithout 6,major Case complication, 7, and although Case one 9), patient the (Case donor 4) who site was was skin grafted, and in 1 more patienttreated (Case with a synthetic 4), a synthetic acellular dermal acellular regenerati dermalon template regeneration (Integra Lifesciences, template Plainsboro, (Integra NJ, Lifesciences, USA) before , died 3 weeks after surgery, due to cardiopulmonary distress, with the Plainsboro, NJ, USA)template was still temporarilyin site. Direct closure placed. of the donor site was achieved in 2 patients (Case 5 and Case 8), To reduce donorin 6 patients site scar (Case morbidity,1, Case 2, Case 3, in Case one 6, Case patient 7, and Case (Case 9), the 6) donor forehead site was liftskin wasgrafted, associated and with STAP in 1 more patient (Case 4), a synthetic acellular dermal regeneration template (Integra Lifesciences, flap harvesting (FigurePlainsboro,1), NJ, and USA) in was another temporarily patient placed. (Case 3) repeated hyaluronic acid injections were performed to reduceTo the reduce concave donor site appearance scar morbidity, ofin one grafted patient (Case site (Figure6) forehead2 lift). Thewas associated patients with were followed up STAP flap harvesting (Figure 1), and in another patient (Case 3) repeated hyaluronic acid injections for a minimum ofwere 6 months performed (range to reduce 6 the–18 concave months). appearance of grafted site (Figure 2). The patients were followed up for a minimum of 6 months (range 6–18 months).

Figure 1. Case 6. A 79-year old woman underwent surgical excision for a recurrent left tuber maxillae Figure 1. Case 6. Asquamous 79-year cell carcinoma. old woman The patient underwent had previous surgically undergone excision a homolateral for neck a recurrent dissection and left tuber maxillae squamous cell carcinoma.radiation therapy The resulting patient in a depleted had previously vessel neck. For undergone this reason, a pedicle a homolateral superficial temporal neck dissection and

radiation therapy resulting in a depleted vessel neck. For this reason, a pedicle superficial temporal artery flap (9 9 cm) was raised and used to reconstruct the oral defect. The flap donor site was × repaired with a skin graft and to reduce donor site scar morbidity, a forehead lift was implemented. (a) Pre-operative facial appearance of the patient. (b) Post-operative facial appearance of the patient. In order to reduce donor site morbidity and to achieve a symmetrical post-operative appearance of the forehead, a forehead lifting was performed. Dent. J. 2020, 8, x FOR PEER REVIEW 4 of 11 Dent. J. 2020, 8, x FOR PEER REVIEW 4 of 11 artery flap (9 × 9 cm) was raised and used to reconstruct the oral defect. The flap donor site was repairedartery flap with (9 a× skin9 cm) graft was and raised to reduce and used donor to sireconstructte scar morbidity, the oral adefect. forehead The lift flap was donor implemented. site was (arepaired) Pre-operative with a skin facial graft appearance and to reduce of the donor patient. site (b scar) Post-operative morbidity, a foreheadfacial appearance lift was implemented. of the patient. Dent. J.In(2020a )order Pre-operative, 8, 117to reduce facial donor appearance site morbidity of the and patient. to ac (hieveb) Post-operative a symmetrical facial post-operative appearance ofappearance the patient. of 4 of 9 theIn orderforehead, to reduce a forehead donor lifting site morbidity was performed. and to achieve a symmetrical post-operative appearance of the forehead, a forehead lifting was performed.

Figure 2. Case 3. A 74 -year old man underwent surgical excision for a recurrent left tuber maxillae FigureFigure 2. 2.Case Case 3.3. AA 7474 -year-year oldold manman underwentunderwent surgical excision for for a a recurrent recurrent left left tuber tuber maxillae maxillae squamous cell carcinoma. The patient previously underwent a homolateral neck dissection and squamoussquamous cellcell carcinoma.carcinoma. The patient previously underwent underwent a a homolateral homolateral neck neck dissection dissection and and radiation therapy, resulting in a depleted vessel neck. For these reasons, a pedicle superficial temporal radiationradiation therapy, therapy, resulting resulting in in a a depleteddepleted vesselvessel neck.neck. For these these reasons, reasons, a a pedi pediclecle superficial superficial temporal temporal artery flap (7 × 7 cm) was raised and used to reconstruct the oral defect. The flap donor site was arteryartery flap flap (7 (7 7× cm)7 cm) was was raised raised and and used used to reconstruct to reconstruct the oral the defect. oral defect. The flap The donor flap sitedonor was site repaired was repaired with× a skin graft. Five sessions of a 20 mg/mL cross-linked hyaluronic acid (HA) filler withrepaired a skin with graft. a Fiveskin sessionsgraft. Five of asessions 20 mg/mL of cross-linkeda 20 mg/mL hyaluronic cross-linked acid hyaluronic (HA) filler acid (Hyamira (HA) filler Basic, (Hyamira Basic, ®Nyuma pharma®, Arona, Italy) was injected into the grafted area. About 0.2 mL of Nyuma(Hyamira pharma Basic, Nyuma, Arona, pharma Italy) was®, Arona, injected Italy) into was the injected grafted into area. the About grafted 0.2 area. mL of About HA per 0.2 sessionmL of HA per session was injected over a total of 5 sessions, spaced 30 days apart. After the HA was injected wasHA injectedper session over was a total injected of 5 over sessions, a total spaced of 5 session 30 dayss, spaced apart. 30 After days the apart. HA After was injected the HA intowas injected the graft into the graft site, a better skin quality with a more elastic tissue, and a less depressed appearance of site,into a the better graft skin site, quality a better with skin a quality more elastic with a tissue, more andelastic a lesstissue, depressed and a less appearance depressed of appearance the area were of the area were noticed. (a) The concave appearance of the grafted site was improved, following several noticed.the area (werea) The noticed. concave (a) appearanceThe concave of appearance the grafted of site the wasgrafted improved, site was followingimproved, several following sessions several of sessions of cross-linked HA injections (b). cross-linkedsessions of cross-linked HA injections HA (b injections). (b). In every case, symmetry of the eyebrows was achieved (Figure 3). Patient’s demographic data, InIn every every case, case, symmetrysymmetry ofof thethe eyebrowseyebrows waswas achievedachieved (Figure 33).). Patient’sPatient’s demographic data, data, surgery motivation, donor site morbidity, and the size of the flap used are reported in Table 1. surgerysurgery motivation, motivation, donordonor sitesite morbidity,morbidity, andand thethe sizesize ofof thethe flapflap usedused are reported in Table1 1..

FigureFigure 3. 3. Case Case 2. 2. A A 76-year76-year oldold womanwoman underwent excisions forfor aa squamoussquamous cell cell carcinoma carcinoma involving involving Figure 3. Case 2. A 76-year old woman underwent excisions for a squamous cell carcinoma involving thethe external external ear ear and and mastoidmastoid areaarea AA pediclepedicle superficiall temporaltemporal arteryartery flapflap (9 (9 × × 7 7 cm) cm) was was raised raised and and the external ear and mastoid area A pedicle superficial temporal artery flap (9 7 cm) was raised usedused toto reconstructreconstruct thethe earear defect.defect. The flap donor site waswas repairedrepaired withwith aa skinskin× graftgraft and and a a local local and used to reconstruct the ear defect. The flap donor site was repaired with a skin graft and a local advancementadvancement flap flap was was harvestedharvested to reduce the skin graft size. AtAt 6-months6-months follow-up, follow-up, the the patient patient was was advancement flap was harvested to reduce the skin graft size. At 6-months follow-up, the patient pleasedpleased withwith thethe aestheticaesthetic resultresult and was free. ((aa)) Pre-operativePre-operative appearanceappearance ofof aa cancercancer was pleased with the aesthetic result and was disease free. (a) Pre-operative appearance of a cancer involving external ear and mastoid area. (b) The reconstruction performed with STAP flap; the donor site was skin grafted. (c) Post-operative symmetric appearance of the brows at rest. Dent. J. 2020, 8, 117 5 of 9

Table 1. Patient’s demographic data, motivation for surgery, donor site closure, and the size of STAP flap used. BCC = Basal Cell Carcinoma; HA = hyaluronic acid; RFFF = Radial Free Forearm Flap.

Surgical Procedure Surgical Procedure Further Clinical Condition Patient Demographics Motivation to Surgery Associated to Associated to Reduce Donor Site Closure Refinements Size of the Flap Associated Cover the Defect Donor Site Morbidity Procedure Local advancement flap Case 1 72 y.o. (M) Microsurgical flap failure Hypertension Skin graft 15 7 cm to reduce graft size × Local advancement flap Hypertension; Case 2 76 y.o. (F) Ear squamous carcinoma Skin graft 9 7 cm to reduce graft size × Neck depleted HA injection on the L tuber maxillae Local advancement flap Case 3 74 y.o. (M) vessel, previous RT; Skin graft grafted site; surgical 7 7 cm carcinoma to reduce graft size × hypertension eyebrow touch up Synthetic acellular RFFF for the Hypertension; Case 4 62 y.o. (M) L maxillary cancer dermal regeneration 7 7 cm internal lining diabetes × template Partial microsurgical flap Local advancement flap Case 5 78 y.o. (M) Diabetes Direct closure 5 5 cm failure to have direct closure × R tuber maxillae Neck depleted Case 6 79 y.o. (F) Forehead lift Skin graft 9 9 cm carcinoma vessel, previous RT × R Cheek/nasal side Glabellar flap and Local rotational flap to Case 7 87 y.o. (M) wall/eyelid (skin) Hypercolesterolemia Skin graft 5 5 cm upper eyelid flap reduce graft size × squamous cell carcinoma Local advancement flap Case 8 72 y.o. (M) R Cheek BCC Direct closure 4 4 cm to have direct closure × Local advancement flap Neck depleted Case 9 82 y.o. (M) R Cheek BCC Skin graft 5 4 cm to reduce graft size vessel, previous RT × Dent. J. 2020, 8, 117 6 of 9 Dent. J. 2020, 8, x FOR PEER REVIEW 8 of 11 Dent. J. 2020, 8, x FOR PEER REVIEW 8 of 11 4. Discussion4. Discussion 4. Discussion TheThe superficial superficial temporal temporal artery artery pedicled pedicled flap flap was was first first described described by by Dunhan Dunhan in in 1893 1893 and and was was used to repairused Theto various repair superficial facialvarious defectstemporal facial defects [16 artery]. [16]. pedicled flap was first described by Dunhan in 1893 and was usedScaglioni Scaglionito repair et al.variouset al. in in 2015 facial2015 [12 [12],defects], and and [16]. Elbanoby Elbanoby etet al. in in 2016 2016 [17], [17], in in anatomy-based anatomy-based clinical clinical papers, papers, describeddescribedScaglioni STAP STAP flap et flapal. harvesting in harvesting 2015 [12], with with and several severalElbanoby innovations inno etvations al. in 2016 compared [17], in to anatomy-based to the the conventional conventional clinical technique. technique. papers, describedTheThe parietal parietal STAP branch flap branch harvesting of the of STAthe with oSTAffers severaloffers a good ainno operativegoodvations operative choicecompared choice if hair to if isthe hair needed conventional is needed for a beard, technique.for a mustaches,beard, or eyelidmustaches,The reconstruction, parietal or eyelid branch andreconstruction, of usually the STA the offersdonorand usualla site good isy grafted operativethe donor and choice hiddensite is if graftedbyhair the is surrounding neededand hidden for a hair bybeard, the [15 ,18]. mustaches, or eyelid reconstruction, and usually the donor site is grafted and hidden by the surroundingIn the present hair study, [15,18]. we only used the frontal branch of STA because hairless flaps were needed surroundingIn the present hair [15,18]. study, we only used the frontal branch of STA because hairless flaps were needed for reconstruction. (Figures4 and5). for reconstruction.In the present study,(Figures we 4 onlyand 5).used the frontal branch of STA because hairless flaps were needed for reconstruction. (Figures 4 and 5).

Figure 4. Same patient as Figure 2 (Case 3) (a) Intra-oral aspect of the cancer involving left tuber Figure 4. Same patient as Figure2 (Case 3) ( a) Intra-oral aspect of the cancer involving left tuber Figuremaxillae 4. and Same cheek. patient The asreconstructi Figure 2 (Caseon performed 3) (a) Intra-oral with STAP aspect flap of(b ).the cancer involving left tuber maxillaemaxillae and and cheek. cheek. The The reconstruction reconstruction performed performed with STAP STAP flap flap (b (b).).

Figure 5. Same patient as Figure 1 (Case 6) (a) Intra-oral aspect of the cancer involving right tuber Figuremaxillae 5. and Same cheek. patient (b) asThe Figure reconstruction 1 (Case 6) performed (a) Intra-oral with aspect STAP offlap. the cancer involving right tuber Figure 5. Same patient as Figure1 (Case 6) ( a) Intra-oral aspect of the cancer involving right tuber maxillae and cheek. (b) The reconstruction performed with STAP flap. maxillae and cheek. (b) The reconstruction performed with STAP flap. Dent. J. 2020, 8, 117 7 of 9

Donor site morbidity, including alopecia, dysfunctional and unaesthetic scarring, are amongst the main reasons why the use of STAP flap is still uncommon in practice, despite several advantages like providing a thick and long pedicle with an average external diameter of the superficial temporal artery more than 2.8 mm, a consistent anatomical position, and ease of its harvest. Similarly, in our experience, a STAP flap is not the first choice in patients under 70 year’s old, especially considering the need for forehead sagging skin that is used to reduce donor site morbidity. Our youngest patient presented in this case series was a 62 year’ old and a STAP flap was performed to overcome a non-preoperatively planned excision of the skin during maxillary cancer removal. This case displayed the versatility and reliability of this flap “in case of need”. In this patient, we applied a synthetic acellular dermal regeneration template (Integra Lifesciences, Plainsboro, NJ, USA) onto the donor site, in order to achieve proliferation of the underlining tissue and had a three-dimensional reconstruction, only grafting the site few weeks later to the template application. Patients who were over 70-years-old usually had enough lax tissue above the forehead and the use of local advancements flaps allowed the surgeon to have a direct wound closure or reduction of the site to graft. A major concern regarding the STAP flap, when harvested above its frontal branch, was the asymmetry of the eyebrows occurring after direct closure of donor site [19], or the appearance and the size of donor site when the skin was grafted. Elbanoby et al. in 2018 [20] reported their experience with STAP flap and classified the application of superficial temporal artery flaps to reconstruct a wide range of facial defects, and organized these guidelines as an algorithmic approach. In their paper, Elbanoby et al. [20] underlined how the limitations of the use of the island superficial temporal artery flap could result in donor site morbidity, and the need for second-stage refinements of the flap. According to this algorithmic approach, we found this flap to be reliable in restoring both intra-oral and extra-oral defects and some considerations arose while reducing donor site morbidity. In cases where the pedicle length was between 5 and 7 cm and a maximum 5 5 cm sized flap was × needed, direct donor site closure could be achieved by performing a rotational advancement of the lower flap, moving it from central to lateral. When bigger flaps, or longer pedicles, are required, especially for intra-oral reconstructions, skin grafting is mandatory to avoid post-operative complications regarding asymmetry of the eyebrows. Once the flap is harvested, a rotational advancement of the lower flap, moving it from central to lateral, has to be performed, in order to reduce the size of the graft. In these cases, the area to be grafted should fall just above the hairline in the temporal region, easily hidden by the hair of the patient. A useful step to conduct once the flap is harvested, is to perform a frontal–temporal lift of the contralateral side when larger flaps are required (9 9 cm or more). We performed this × technique in Case 6, harvesting a 9 9 cm flap, grafting the donor site with a 3 1 cm skin graft, × × and achieving good eyebrows symmetry, post operatively. A STAP flap is also a reliable option after neck dissections, in the so-called vessels depleted necks. Local facial rotational/advancement flaps are mainly based on the facial artery pedicle, often ligated during neck dissection and, although a retrograde revascularization of the facial artery can be achieved, the superficial temporal artery seems to be a more reliable choice. Some authors consider post-operative eyebrow asymmetries to be a direct consequence of STAP flaps. Ozdemir et al. [21] argued that the STAP flap causes eyebrow asymmetry and for this reason Z-plasty, transposition flap, or sling procedures should be performed to the opposite side. We agree with these suggestions, although we prefer to overcome this issue with a careful preoperative plan and doing our best to reduce eyebrows asymmetry, while adjusting the technique intra-operatively. Another issue regarding skin grafting is the appearance of the grafted area. Placing a skin graft directly over the periosteum of the frontal area to allow it to achieve a convex appearance. To overcome this issue in one patient (Case 3), once surgical sites were completely healed, 3 months after surgery, we came up to the surgical sequela of the donor site with a non-surgical approach, performing sub and supra-periosteal injections of a 20mg/mL crosslinked HA filler (Hyamira Dent. J. 2020, 8, 117 8 of 9

BASIC, NYUMA PHARM s.r.l ®., Arona, Italy). About 0.2 mL of HA per session was injected for a total of 5 sessions, spaced 30 days each. Nine months after the last injection, the grafted site showed a better skin quality, a more elastic tissue, and a less depressed appearance (Figure2).

5. Conclusions STAP flaps were proven to be a valuable flap, despite its uncommon use in facial soft tissue reconstruction. We believe that it is also a good alternative for patients who have not considered free flaps. In some patients who have significant comorbidities or specific contraindications to free tissue transfer, a STAP flap provides an excellent alternative for reconstructing the defects of the oral cavity. Although a larger series of cases is needed, STAP flaps might represent a versatile surgical option, also allowing a wide range of reconstructions of different facial subunits. Donor site morbidity is one of the major motivations why this flap is uncommon. An appropriate patient selection, surgical plan, and post-surgical touch-ups could be performed in order to reduce donor site scar morbidity.

Author Contributions: Conceptualization, R.R. and C.L.F.; methodology, R.R. and G.F.N. and E.S.; validation, G.T., R.R. and G.F.N.; investigation, R.R. and E.S.; resources. C.L.F. and G.L.G.; data curation F.C.; writing—original draft preparation, R.R. and C.L.F.; writing—review and editing, R.R., C.L.F., G.L.G., and R.F.; supervision, G.T. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Conflicts of Interest: The authors declare no conflict of interest. Ethics Statement/Confirmation of Patients’ Permission: Due to the retrospective nature of this study, it was granted an exemption in writing by the University Ethics Committee. Patients’ consent was obtained and can be produced on request.

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