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Temporoparietal Fascia Flap A Chapter Temporoparietal Fascia Flap A. Samandar Dowlatshahi, MD 31 Joseph Upton, MD ince the original description by Monks in the Boston is desired, palmar sensation can be restored by joining the Medical and Surgical Journal in 1898, the vascularized auriculotemporal nerve found within this flap to the palmar Ssuperficial temporal fascia (STF) flap has increased in cutaneous branch of the median nerve (Fig. 31-3). popularity and utility. The tissue that makes up this flap has Finally, the TPF flap offers the advantage of an inconspic- had many names over time, including the superficial layer of uous donor site without functional morbidity. The flap’s lo- the temporal fascia, the superficial cephalic fascia, the pari- cation—away from the upper extremity—allows one team etotemporal fascia and temporoparietal fascia (TPF)—yet all to harvest the flap while the other team prepares the recip- these terms designate the same fascial layer. The flap is based ient site; this two-team approach can considerably reduce on the superficial temporal arterial (STA) system. In hand procedure time. reconstruction, it is commonly used as a thin fascial flap. It is particularly effective for the coverage of digits and the thumb because the flap is thin, mobile and can be precisely RELEVANT ANATOMY fashioned to the shape of the defect (Fig. 31-1). The TPF flap has minimal bulk so late debulking procedures are unnec- Most anatomical textbooks and atlases improperly depict essary. In addition, there is no concern about post-transfer the subtleties of this anatomic region, and this lack of detail volume fluctuations with weight loss and weight gain, as has led to some confusion about flap elevation. Tissue layers can be seen in adipofascial and fasciocutaneous flaps. For have been given many names at various levels. Here we at- digital and web space reconstruction, the flap may be split tempt to clarify the anatomy (Fig. 31-4, Fig. 31-5). longitudinally based on the arborization of the frontal and parietal branches to allow for a more refined reconstruction Fascial Layers (Fig. 31-2). The mechanical stoutness of the fascia can also be harnessed in the reconstruction of pulleys and the exten- • The STF lies immediately deep to the hair follicles and sor retinaculum; the loose areolar plane on the undersurface is continuous with the superficial musculoaponeurotic of the flap provides an ideal gliding surface for reconstruc- system (SMAS) caudal and with the galea aponeurot- tion over tendons. The arterial branching pattern can also be ica cephalic. Fibrous attachments between this fascia utilized for flow-through flap reconstructions that require and skin are looser in the zygomatic region and denser simultaneous soft tissue augmentation. when approaching the vertex of the scalp. In elderly pa- Typically, the TPF flap requires coverage with either a tients, these septa are lax and attenuated, and dissection split-thickness graft or a full-thickness graft. For palmar is easier. The accepted safe flap dimensions are 8 cm × coverage, we prefer to use glabrous skin from the hypothe- 15 cm. Extension in an occipital direction will provide nar eminence or the instep of the foot. Glabrous skin offers a additional tissue (Fig. 31-3, top). Flap reliability is related more durable reconstruction with a lower propensity for hy- to the branching of the STA and distance from the axial perpigmentation. In cases where optimal sensory recovery vessels within the flap. 225 02_ASSH_02_Flap reconstruction_CH30-CH39.indd 225 02/08/18 4:58 PM Flap Reconstruction of the Upper Extremity • The deep temporal fascia invests the outer surface of the temporalis muscle, which partially originates from this dense fascial layer. The deep temporal fascia is separated from the STF by a loose, and largely avascular, areolar tis- sue plane that is often called the innominate (“no name”) layer. The deep temporal fascia is strictly limited to the temporal fusion line where it is continuous with the peric- ranium, unlike the STF that extends beyond this area and is continuous with the galea. At the level of the temporal fusion line, there can be more dense attachments between these two fascial layers that need to be sharply divided. Vascular Supply • The STA is one of the terminal branches of the external carotid artery. It passes through the parotid gland, travels beneath the facial nerve branches and hereby aids in ana- tomically separating the parotid into superficial and deep lobes. The artery gradually ascends through the sub- FIGURE 31-1 stance of the superficial lobe of the parotid and emerges Precise fashioning of the flap to meet the needs of the recipient at the level of tragus, immediately superficial to the tem- site. In this patient with Dupuytren diathesis, radical fasciectomy poromandibular joint. From this point onward, the ar- and extensive neurolysis were performed, with subsequent tery can be palpated and measures 1.8 mm to 2.7 mm in microvascular transfer of temporoparietal fascia and resurfacing external diameter. The pedicle length when harvested at with a split-thickness skin graft. The 1-year postoperative result is this level is approximately 2.0 cm to 4.0 cm and obviates shown. the need for an intraparotid dissection. Deep dissection is sometimes needed to obtain a vein of adequate caliber. FIGURE 31-2 Technique of splitting the flap along the arborization of the superficial temporal artery for palmar coverage of 2 adjacent fingers. A precise template and mapping of the superficial temporal system by means of a hand-held Doppler are critical. Digits were separated in a subsequent procedure. 226 American Society for Surgery of the Hand 02_ASSH_02_Flap reconstruction_CH30-CH39.indd 226 02/08/18 4:58 PM Chapter 31 • Temporoparietal Fascia Flap FIGURE 31-3 Transfer as a thin, sensory flap for palmar coverage. This patient sustained a roller press injury to the palm. The auriculotemporal nerve was raised with the superficial temporal vessels and was joined with the palmar cutaneous branch of the median nerve. The donor site is demonstrated 25 years following surgery. The preauricular incision is inconspicuous; localized alopecia along the scalp closure can occur. FIGURE 31-4 Fascial layers and relationships in the temporal region. American Society for Surgery of the Hand 227 02_ASSH_02_Flap reconstruction_CH30-CH39.indd 227 02/08/18 4:58 PM Flap Reconstruction of the Upper Extremity Temporal branch of facial n. Supercial temporal a. and v. 5% 5% Auriculotemporal n. Parotid gland FIGURE 31-5 Anatomy of the preauricular region relevant to pedicle dissection. 80% • The STA bifurcates into a frontal (anterior) branch and 5% 5% a parietal (posterior) branch, above the zygoma, and there are many variations in the level of branching: FIGURE 31-6 variation may become pertinent to ultimate fl ap design Variable branching pattern of the superfi cial temporal artery. (Fig. 31-6). • Just proximal to or at the zygomatic arch, the STA gives off a branch named the middle temporal artery. This nerve lies along a line drawn from an arbitrary point vessel passes between the zygomatic arch and the su- (nonanatomic) 0.5 cm below the tragus to a point 1.5 perfi cial temporal fascia and eventually reaches the deep cm above the lateral eyebrow. At the level of the arch, temporal fascia, supplying this fascial layer, as well as the fascial planes are thinned and more adherent. This sending branches into the substance of the temporalis makes the nerve vulnerable to injury, especially in a muscle. The dominant blood supply of the temporalis blood-stained fi eld. muscle originates from the deep temporal arteries aris- • The important anatomical pearl to remember during ing from the internal maxillary system. dissection of the fl ap is that the vessels (STA, STV) are • The superficial temporal vein (STV) is usually located superfi cial and nerve VII is deep to the TPF. within 8.0 mm of the artery but can be up to 3.0 cm dis- tant. This vein is anterior and superfi cial to the artery, just beneath the dermis, and can easily be cut while INDICATIONS making a preauricular incision. Above the zygoma, it has an external diameter of 2.1 mm to 3.3 mm. • Being thin and pliable, the TPF fl ap can be used in diffi cult anatomic regions such as the digit, web space, and palm. • For the reconstruction of a gliding surface for tendons, Neural Anatomy such as the dorsum of the hand. • The auriculotemporal nerve (from the V3 mandibu- • In situations where one needs to reconstruct or create lar branch of the trigeminal nerve) is a predominantly tendon pulleys. The entire extensor retinaculum at the sensory nerve that supplies the anterior auricle, the wrist can be reconstructed if necessary. outer surface of the tympanic membrane, the external • Cases where one needs to restore vascularity to a scarred auditory meatus, the temporomandibular joint and the wound bed, or one aff ected by chronic radiation injury. temporal scalp. Over a short distance, it also carries • In burn reconstruction, dorsal defects that are not parasympathetic fibers from the otic ganglion to the amenable to direct grafting (exposed tendons devoid of parotid gland. The auriculotemporal nerve is located be- paratenon) are preferentially treated with a fascial fl ap hind the STA and can be included in the fl ap if sensibil- due to its thinness. This allows for the silhouette of dor- ity is desired. sal veins, metacarpals and tendons to be visible, once • The nerve of greatest concern during TPF flap harvest the reconstructive sequence has been completed, lead- is the temporal branch of the facial nerve. It is a motor ing to a more aesthetic and natural appearance. nerve that innervates the frontalis muscle.
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