Technique for Harvesting Deep Temporal Fascia

The Problem

Dorsal nasal augmentation as recommended by Jack Sheen is needed in primary operations for patients with a deep nasofrontal angle or in secondary overresected cases. To achieve a balanced nose as described by Sheen, material for augmentation is needed. The most common material used is autologous cartilage block harvested from the septum, ear concha, and rib. Although these materials give a durable and permanent augmentation, the visibility of the edges of these cartilages under the skin results in an unsatisfactory aesthetic appearance, and multiple operations may be needed to correct it. One solution to solve this unwanted effect is to dice all large and small pieces of available cartilage or cartilages harvested from different anatomical sites such as septum, concha, or rib.

The Background

Dicing cartilage has been used since the 1940s, but Erol popularized this technique in 2000 by wrapping it in Surgicel in over 2000 cases. Further investigation showed that this material may produce a foreign-body reaction (surgical inflammatory effect), which reduces the graft viability and increases resorption. To decrease the surgical inflammatory effect, using deep temporal fascia to wrap graft material has been advocated by several authors. Some authors reported less volume change in the amount of dorsal augmentation when deep temporal fascia (DTF) was used to wrap diced cartilage grafts. Alternatively, the fascia can be used without cartilage when minimal augmentation is needed. It can be folded 2 to 3 times on itself and used to correct minimal depressions or defects.

The thickness of superficial temporal fascia in humans is 0.8 to 1 mm, whereas DTF thickness is 0.5 to 0.7 mm. Although the thickness of DTF does not prevent diffusion of nutrient materials to diced cartilages, allowing them to stay alive, some researchers who performed the same procedures in animal models showed that resorption is inevitable.

Anatomy

The temporal region consists of multiple layers of muscle and fascia, but unfortunately, the nomenclature is inconsistent. This anatomic misnomer is confusing for surgeons when choosing the appropriate layer of this important region for different purposes. To simplify the anatomy and nomenclature, we divided the temporal region into three layers of fascia. The most superficial one that snugly attaches to the skin is called ­temporoparietal fascia and contains temporal arteries and veins ­( Fig. 17.1 ). Removing the temporoparietal fascia is time-consuming and needs precise dissection to avoid harming the hair follicles. This layer is usually used as a vascularized flap to cover the reconstructed helical cartilages or when transferring a piece of scalp for eyebrow reconstruction. Under this layer are two more layers of fascia that we call deep temporal fascia (DTF) and investing temporal fascia ( Fig. 17.2 ). There is a potential space between these two layers, but they superiorly fuse together and continue on parietal bone as the pericranium. The deep investing fascia has a whitish glistening appearance and is attached to temporal muscle. Harvesting this layer may cause bleeding and invade the temporal muscle ( Fig. 17.2 ). The so-called DTF is between the other two layers. This layer is much easier to remove because fibrofatty tissue surrounds this layer both superficially and deeply, making a potential space that allows for an easier dissection and bloodless field.