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 recon- struction 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- (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 3, JULY-SEP 2001 WWW.ARCHFACIAL.COM 170 ©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 dur- ing 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 17314 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 3.532-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.