Hair-Bearing Temporoparietal Fascial Flap Reconstruction of Upper Lip and Scalp Defects

ORIGINAL ARTICLE Hair-Bearing Temporoparietal Fascial Flap Reconstruction of Upper Lip and Scalp Defects

Jennifer C. Kim, MD; Tessa Hadlock, MD; Mark A.Varvares, MD; Mack L. Cheney, MD

Background: The temporoparietal fascial flap has proven Results: All reconstructive results were satisfactory. Oral to be a versatile flap for a broad spectrum of reconstruc- competence, measured by both speech and mastication tive problems in the head and neck. The temporoparietal performance, was achieved in patients with upper lip de- fascial flap is a thin, pliable layer of richly vascularized tis- fects. Healthy scalp coverage was obtained in patients with sue that may be transferred either pedicled or free and alone local defects. The cosmetic appearance was satisfactory or as a carrier of subjacent bone or overlying skin and scalp. to all patients.

Objective: To report our experience using a hair- Conclusions: Ideal reconstruction of large upper lip and bearing temporoparietal fascial flap for reconstruction in scalp defects is achieved with local tissue that best mim- 6 male patients with extensive upper lip and scalp de- ics the normal face color, texture, and hair-bearing quali- fects, including a discussion of the surgical anatomy and ties. Hair-bearing temporoparietal fascial flaps possess technique. these characteristics and are an excellent choice for the restoration of function and aesthetics. Methods: Temporoparietal fascial flaps with overlying scalp were used as pedicled and free flaps for the reconstruction of upper lip and scalp defects. Arch Facial Plast Surg. 2001;3:170-177

HE USE of scalp tissue in fa- ricle, orbit, cheek, and oral cavity.5-11 The cial reconstruction has been temporoparietal fascial flap (TPFF) has also appreciated for thousands been used to address Frey syndrome,12 os- of years. Gillies1 was one of teoradionecrosis,6 nasal septal perfora- the first to describe the use tions,13 and temporal bone pathology.14,15 Tof the pedicled scalp flap based on the su- Many treatment options are avail- perficial temporal artery for reconstruc- able for large upper lip and scalp defects, tion of lip and eyebrow defects. The ad- including skin grafts, local flaps, regional vent of microvascular surgery renewed compound flaps, and free flaps.16-19 Lip and interest in the vascular supply of the tem- scalp tissues have specific intrinsic quali- poral region as a potential free flap donor ties, along with functional and aesthetic site. Numerous anatomical studies that de- requirements, which limit optimal recon- scribed the layers and blood supply of the structive choices. For example, scalp tis- scalp followed.2-4 Since then, there has been sue lacks elasticity by nature, and its lay- a greater appreciation of the anatomy, with out is dictated by hair follicle orientation. a succession of advances and refine- Hair-bearing TPFFs provide an ideal ments in the use of this tissue. reconstructive option for significant up- The skin of the scalp can survive as a per lip and scalp defects given their high random local flap, or it can be carried with vascularity, anatomical proximity, mini- some or all of the underlying tissue layers. mal associated donor site morbidity, and Similarly, the temporoparietal fascia can be overlying hair. used as a random local fascial flap or as an axial flap based on the superficial tempo- REPORT OF CASES ral vessels. Its rich vascularity, proximity, and similar texture offer distinct advan- CASE 1 From the Department of tages in the reconstruction of complex head Otolaryngology, Massachusetts and neck defects. This versatile flap has been A 64-year-old man underwent resection of Eye and Ear Infirmary, used as a pedicled, free, or composite flap a squamous cell carcinoma of the left na- Harvard Medical School, with calvarium or hair-bearing skin to re- sal alar–nasolabial region. This resulted in Boston. construct defects of the extremities, au- a complex midfacial soft tissue defect in-

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 PATIENTS AND METHODS preserved by staying at least 5 mm from the pedicle during inferior flap elevation.2

We describe a series of 5 male patients in whom a hair- SURGICAL TECHNIQUE bearing TPFF was used for reconstruction of large upper lip and scalp defects. One patient with alopecia had a A Doppler ultrasound is used to mark out the course of the non–hair-bearing TPFF covered with a split-thickness anterior and posterior branches of the superficial tempo- skin graft. ral vessels. The hair-bearing skin is most often based on the posterior branch, well posterior to the hairline and dan- ANATOMICAL FEATURES ger zone of the frontal branch. A template of the defect is outlined on the scalp. The distance from the point of ro- Various nomenclature has been used interchangeably with tation at the level of the tragus to the proximal extent of temporoparietal fascia, including superficial temporal fas- the defect is measured. Then, if needed, the flap can cross cia, epicranial aponeurosis, and galeal extension.2 These all the midline for 2 to 3 cm without vascular compromise. accurately reflect the anatomy of the tissue (Figure 1). A For our pedicled flaps, a 2-cm strip of scalp along TPFF is a thin, highly vascularized connective tissue layer the course of the vessels is preserved. Flap dissection is just deep to the hair follicles and subdermal layer of fibro- started along the superior cutaneous margin of the flap fatty tissue in which they lie. The temporoparietal fascial and elevated in the loose areolar layer between the galea layer becomes increasingly adherent to this overlying layer and pericranium The pedicle is elevated inferiorly as far as more fibrous septae and blood vessels traverse the lay- as is practical, most often up to the zygomatic arch. For ers toward the vertex. Above the temporal line, the tem- the bipedicled flaps, the same concepts are upheld, but poroparietal fascia becomes galea aponeurotica. In con- we maintain a continuous strip of scalp extending over trast, the temporoparietal fascial layer glides over its medial the vertex, analogous to a bucket handle. The donor site or deep surface, where it is separated from the deep tem- is closed in 2 layers over a suction drain. poralis fascia by a loose areolar tissue layer.20,21 The pedicled flap is sutured into the defect where it A temporoparietal fascia is continuous with the galea remains for a minimum of 3 weeks. In the bipedicled flaps, above, the frontalis muscle in front, the occipitalis be- the release of the pedicles is staged at least 1 week apart, hind, and the subcutaneous musculoaponeurotic layer of and challenged with a tourniquet prior to transection. The the face. The flap ranges from 2 to 4 mm in thickness and pedicles are transected proximally at their bases. can be harvested with dimensions up to 17ϫ14 cm.2,20,21 For our free hair-bearing grafts, the axial vessels are The superficial temporal artery and vein nourish the isolated via a preauricular incision. Once the pedicle is temporoparietal fascial layer. Coursing through this layer, identified, the anterior and posterior scalp flaps are the artery arborizes approximately 2 cm above the zygo- elevated just deep to the hair follicles; this is best initiated matic arch into anterior and posterior branches. Each of just above the ear where it is looser and easier to enter the main branches then sends perforators to the overlying the correct subcutaneous plane. As previously mentioned, subdermal layer. The superficial temporal vein runs more the TPFF is densely adherent to the subcutaneous layer of superficially and less predictably in this layer, increasing the scalp. The lateral aspect of the flap dissection seems to its risk of injury during harvest. The artery averages 2.0 mm be in an unnatural plane requiring attention to preserve in diameter as it exits the parotid salivary gland; the vein the hair follicles and the vascular pedicle. is slightly larger.2,20,21 Bipolar cautery for hemostasis helps avoid damage to Two nerves lie in close proximity to the temporopa- hair follicles and vessels. Pedicle lengths up to 6 cm may rietal fascia. The frontal branch of the facial nerve runs just be obtained. Additional length may be gained inferiorly, deep to the temporoparietal fascia. It traverses the zygo- but may require mobilization of the parotid salivary gland matic arch obliquely one finger breadth behind the poste- to identify and preserve the facial nerve branches. rior edge of the zygomatic process of the frontal bone. The If used as a free flap, the vascular pedicle is divided auriculotemporal nerve is within 5 mm of the superficial anterior to the root of the helix. Saphenous veins are har- temporal artery until 1.5 cm above the helix and may be vested for use as interposition grafts.

cluding full-thickness loss of the lateral ala, oronasal fis- dures, including a scapula osteocutaneous free flap. He tula, and scarred upper lip sparing the vermilion also underwent radiotherapy. Recurrent wound break- (Figure 2A). down resulted in a complex midfacial soft tissue defect A pedicled hair-bearing TPFF to repair a 3.5ϫ2-cm involving near-total upper lip and wound dehiscence of upper lip defect was harvested and inset as the first stage the lower lip (Figure 3A). (Figure 2B-C). The lateral alar defect was repaired con- A bipedicled hair-bearing TPFF prefabricated with full- currently using a midline forehead flap. The pedicle was thickness skin graft was used for reconstruction in 3 stages. divided after 4 weeks (Figure 2D). The wound healed well In the first stage, the midportion of the scalp flap was de- with excellent cosmetic and functional results. signed in the shape of the defect and prefabricated with a skin graft. The scalp flap was elevated like a bucket handle, CASE 2 pedicled bilaterally on both superficial temporal vessels, and stapled in place for delayed release (Figure 3B-C). A 48-year-old man underwent multiple resections of a In the second stage, the bipedicled prefabricated flap basal cell carcinoma and multiple reconstructive proce- was released and sutured into the defect (Figure 3D). Six

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 weeks later, 1 pedicle was divided followed by the second pedicle the next week (Figure 3E). Postoperatively, he had moderate wound dehiscence of the left commis- D sure requiring revision. C E F G CASE 3 A B H A 38-year-old man underwent total maxillectomy for os- I teosarcoma followed by reconstruction with rectus free flap and a conventional iliac bone graft. The patient sub- sequently experienced upper lip necrosis leaving only 0.5 cm of upper lip at each commissure (Figure 4A). A bipedicled bitemporal hair-bearing TPFF was designed and inset into the defect (Figure 4B-C). The pedicles were divided in a staged fashion 21⁄2 and 31⁄2 weeks postoperatively (Figure 4D). The wound healed well and the patient was able to wear his dentures, eat, and speak normally. Additionally, he experienced some return of sensation in the neoupper lip.

CASE 4 A 40-year-old man had severe scarring and alopecia of Figure 1. The layers of the scalp are follows: A, hair bearing; B, subcutaneous tissue; C, frontalis muscle and galea aponeurotica; D, periosteum; E, cranium; the right superior temporoparietal scalp as a result of bat- F, temporalis muscle; G, deep temporalis fascia; H, loose areolar tissue; tery acid burns (Figure 5A). For 2 months tissue ex- and I, temporoparietal fascia with superficial temporal vessels. panders were placed adjacent to the expected defect site

A B

C D

Figure 2. A, Left upper lip defect; B and C, left pedicled temporoparietal fascial flap; and D, final postoperative result.

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D E F

Figure 3. A, Complex upper lip defect; B, superficial temporal vessels traced using Doppler ultrasonography; C, flap design for upper lip defect; D, prefabrication of deep surface with skin graft; E, bipedicled temporoparietal fascial flap inset; and F, final postoperative result.

A B

C D

Figure 4. A, Upper lip defect; B and C, bipedicled temporoparietal fascial flap inset; and D, final postoperative result.

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D E F

G H

Figure 5. A and B, Right temporoparietal alopecia-scar and tissue expanders; C, marking of pedicle; D, elevated island of hair-bearing temporoparietal fascial flap; E and F, insetting of flap island; and G and H, final postoperative result.

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D E F

Figure 6. A, Recurrent scalp melanoma; B, 9ϫ7-cm parietal scalp defect; C, temporoparietal fascial flap with interpositional vein grafts; D, hair-bearing skin island transposed in V- to Y-fashion; E, flap inset with skin graft closure of defect superior to pinna; and F, final postoperative result.

(Figure 5B). The incisions for expander insertion were remained in an area over which a split-thickness skin graft incorporated into the final flap design. Skin incisions were was placed. designed to restore the natural hairline and hair-bearing skin to the scarred temporoparietal region. An island of CASE 6 hair-bearing TPFF was elevated on its pedicle and used to fill the defect following scar-alopecia excision (Fig- A 76-year-old man underwent resection of a basal cell ure 5C-E). The previous tissue expansion allowed for pri- carcinoma of the scalp leaving a 6ϫ8-cm, full- mary closure of the scalp (Figure 5F-H). thickness defect including the periosteum (Figure 7A). Similar to patient 5, he underwent reconstruction with CASE 5 TPFF with saphenous vein interposition. However, ow- ing to his natural state of alopecia, a split-thickness skin A 48-year-old man with recurrent scalp melanoma had graft was used to cover the graft. The wound healed with- previously undergone a wide local excision with preser- out event and with excellent cosmesis. vation of the pericranium and immediate split- thickness skin graft for coverage. Five months after ini- RESULTS tial resection, he had a recurrence at the margins. He underwent a radical resection with removal of the outer All flaps (N=6) survived. No major perioperative com- calvarium in conjunction with a posterior neck dissec- plications occurred. One patient (case 2) had moderate tion. This resulted in a 9ϫ7-cm defect in the parietal scalp dehiscence in the previously irradiated wound bed, re- anda3ϫ3-cm subjacent defect of the calvarium quiring a secondary revision. One patient (case 3) had (Figure 6A-B). Mobilization of the adjacent hair- some return of sensation in the upper lip. In long-term bearing TPFF using a V- to Y-technique was performed follow-up (minimum of 2 years), adequate functional and for reconstruction. The vascular pedicle was extended us- aesthetic outcomes were obtained in all cases. All 3 pa- ing an interposition vein graft (Figure 6C-E). Postop- tients with upper lip reconstruction were able to eat and eratively, the patient did well with complete coverage of speak satisfactorily. All 6 patients were satisfied with the the cranial defect. A persistent proximal area of alopecia improvement in their appearance.

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C D

E F

Figure 7. A and B, Basal cell carcinoma of scalp; C, outline of superficial temporal vessels; D, temporoparietal fascial flap with interpositional vein grafts; and E and F, inset of flap with skin graft coverage.

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 COMMENT These cases illustrate not only one of many potential reconstructive options for large upper lip and scalp Optimal reconstruction of extensive upper lip and scalp defects in males but the advantages of using the hair- defects is achieved with local tissue that best mimics the bearing TPFF. The reliable vascular supply, inconspicu- normal face color, texture, and hair-bearing qualities. For ous donor site, match in tissue characteristics, and prox- upper lip defects, functional considerations, including the imity to the reconstructive site make it an optimal choice. ability to articulate and maintain oral competence during mastication, are important. This require reconstruc- Accepted for publication January 25, 2001. tion with tissue of adequate bulk, volume, texture, pli- Presented in part at the fall meeting of the American ability, and color, as well as maximizing the preservation Academy of Facial Plastic and Reconstructive Surgery, Wash- of motion and sensation. Unfortunately, the complex func- ington, DC, September 21, 2000. tion and contour of the lip make the dual goals of restor- Corresponding author and reprints: Mack L. Cheney, MD, ing form and function difficult to achieve. Department of Otolaryngology, Massachusetts Eye and Ear When lip defects exceed more than 60% of lip width, Infirmary, Harvard Medical School, 243 Charles St, Boston, the conventional methods of local flaps (ie, Gillies fan MA 02114 (e-mail: [email protected]). flap,22 or Bernard-Burow flap23) are less satisfactory aes- thetically and functionally due to displacement of the modiolus and invariable microstomia. When skin grafts or REFERENCES distant flaps are used, bulk, color, and texture are fre- quently compromised and the orbicularis sphincter is not 1. Gillies HD. Plastic Surgery of the Face. New York, NY: Gower Medical Publish- ing Ltd; 1983. restored. There is also increased donor site morbidity and 2. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood surgical time with distant flaps. supply of the fascial layers of the temporal region. Plast Reconstr Surg. 1986; For males, the scalp most closely approximates the hair 77:17-23. 3. David SK, Cheney ML. An anatomic study of the temporoparietal fascial flap. Arch density and quality of the upper lip. Our 3 cases demonstrate Otolaryngol Head Neck Surg. 1995;121:1153-1156. acceptable cosmetic outcomes in patients with near-total up- 4. Tellioglu AT, Tekdemir I, Erdemli EA, Tuccar E, Ulusoy G. Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical appli- per lip defects by simulating the lip contour, thickness, tex- cations. Plast Reconstr Surg. 2000;105:40-45. ture, and height. The growth of a mustache may camouflage 5. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial scars and reestablish facial character with consequent im- free flap. Plast Reconstr Surg. 1985;76:177-188. 6. Cheney ML, Varvares MA, Nadol JB Jr. The temporoparietal fascial flap in head provement in cosmetic as well as psychological results. and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1993;119:618-623. Furthermore, the modiolus is undisturbed and the 7. Rose EH, Norris MS. The versatile temporoparietal fascial flap: adaptability to a orbicularis sphincter is bridged to each side of the graft. variety of composite defects. Plast Reconstr Surg. 1990;85:224-232. 8. Upton J, Ferraro N, Healy G, Khouri R, Merrell C. The use of prefabricated fascial Although the oral sphincter is not restored, continuity flaps for lining of the oral and nasal cavities. Plast Reconstr Surg. 1994;94:573-579. is reestablished. The patients achieve good functional re- 9. Ellis DS, Toth BA, Stewart WB. Temporoparietal fascial flap for orbital and eyelid reconstruction. Plast Reconstr Surg. 1992;89:606-611. sults for speech and mastication. There is also potential 10. Panje WR, Morris MR. The temporoparietal fascia flap in head and neck recon- sensory return in the neo–upper lip with preservation of struction. Ear Nose Throat J. 1991;70:311-317. the auriculotemporal nerve acting as a scaffold.3 11. Cheney ML, McKenna MJ, Megerian CA, Ojemann, RG. Early temporalis muscle transposition for the management of facial paralysis. Laryngoscope. 1995;105: Disadvantages include the multistaged procedure. The 993-1000. alternative would be to perform a single-staged free tissue 12. Sultan MR, Wider TM, Hugo NE. Frey’s syndrome: prevention with temporopa- transfer for upper lip reconstruction or tunnel a hair-bearing rietal fascial flap interposition. Ann Plast Surg. 1995; 34:292-296. 13. Delaere PR, Guelinckx PJ, Ostyn F. Vascularized temporoparietal fascial flap for island of skin. These options come with their own atten- closure of a nasal septal perforation: report of a case. Acta Otorhinolaryngol Belg. dant risks, including increased risk of injury to the facial 1990;44:47-49. 14. Cheney ML, Megerian CA, Brown MT, McKenna, MJ, Nadol JB. The use of the nerve. There is limited applicability to female patients. temporoparietal fascial flap in temporal bone reconstruction. Am J Otol. 1996; An examination of reconstructive option in scalp de- 17:137-142. fects highlights shortcomings. Skin grafts, while quick 15. Cheney ML, Megerian CA, Brown MT, McKenna MJ. Mastoid obliteration and lining using the temporoparietal fascial flap. Laryngoscope. 1995;105:1010-1013. and easy, have poor tissue texture and thickness, and are 16. Lesavoy MA, Dubrow TJ, Schwartz RJ, Wackym PA, Eisenhauer DM, McGuire non–hair-bearing. They rely on intact subjacent perios- M. Management of large scalp defects with local pedicle flaps. Plast Reconstr teum and are, therefore, subject to more frequent loss. Surg. 1993;91:783-790. 17. Potparic Z, Starovic B. Reconstruction of extensive defects of the cranium using Local advancement, transposition, and rotational flaps free-tissue transfer. Head Neck. 1990;15:97-104. as emphasized by Orticochea24 are ideal, but limited to 18. Williams EF III, Setzen G, Mulvaney MJ. Modified Bernard-Burow cheek advancement and cross-lip flap for total lip reconstruction. Arch Otolaryngol Head Neck small to medium-sized defects. Myofascial or musculo- Surg. 1996;122:1253-1258. cutaneous flaps have good vascular supply, but can be 19. Yih WY, Howerton DW. A regional approach to reconstruction of the upper lip. too bulky, time-consuming, non–hair-bearing, and have J Oral Maxillofac Surg. 1997;55:383-389. 20. Marty F, Montandon D, Gumener R, Zbrodowski A. Subcutaneous tissue in the more significant donor site morbidity. scalp: anatomical, physiological, and clinical study. Ann Plast Surg. 1986;16: Reconstruction using hair-bearing TPFF as local ad- 368-376. vancement flaps were made possible by the use of tissue 21. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ. The surgical anatomy of the scalp. Plast Reconstr Surg. 1991;87:603-626. expanders and interpositional vein grafts. Tissue expand- 22. Gillies HD, Millard DR Jr. Principles and Practice of Plastic Surgery. Boston, Mass: ers are indicated when there is a shortage of suitable do- Little Brown & Co Inc; 1957. 23. Bernard C. Cander de la levre infericure opere par un procede nouveau. Bull Mem nor tissue. The neovascularization of the expanded skin al- Soc Hir (Paris). 1853;3:357. lows the flap to behave like a delayed flap, permitting a larger 24. Orticochea M. New three-flap scalp reconstruction technique. Br J Plast Surg. viable donor length than random advancement or rota- 1971;24:184-188. 25 25. Cherry GW, Austed ED, Pasyk K, McClatchey K, Rohrich RJ. Increased survival tion flaps. Further benefits include a single, inconspicu- and vascularity of random-pattern skin flaps elevated in controlled, expanded ous operative site with minimal to no morbidity. skin. Plast Reconstr Surg. 1983;72:680.

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