Temporoparietal Fascial Flap

Introduction

In general, the temporoparietal fascia is a poorly recognized, but highly useful, layer of tissue that invests the lateral scalp overlying and extending beyond the surface area of the underlying temporalis muscle. Skill in recognizing and elevating the temporoparietal fascia is important in both skull base exposures such as the infratemporal fossa approach and in reconstructive procedures that use the temporoparietal fascia as a pedicled flap based upon the superficial temporal artery and vein. Its successful preservation helps to ensure the continuity of the frontal branches of the facial nerve, and its elevation as a pedicled flap is valuable in the reconstruction of a wide array of defects. With a rich vascular supply, large area, thinness, pliability, and mobility, it allows for reconstruction of soft tissue, orbital, anterior or middle cranial fossa, nasopharyngeal, oropharyngeal, oral, maxillary, and palatal defects with ease. The ability to accept a skin graft makes it an excellent choice for facial, auricular, scalp, or orbital defects. In the oral cavity or pharynx, rapid mucosalization of the graft eliminates the need for further grafting over it. As a hardy graft it has utility in buttressing cranial defects with cerebrospinal fluid (CSF) leaks, permitting watertight exclusion of the intracranial contents from the upper aerodigestive tract. Bilateral flaps that remain connected across the sagittal suture may be harvested to reconstruct larger midline defects, that is, a “visor” flap. We have found temporoparietal fascial (TPF) flaps to be particularly useful in the management of palate defects, obviating the need for an obturator or free flap reconstruction in some cases. In pituitary or extended pituitary approaches, a flap can be tunneled through the maxillary sinus into the sphenoid sinus and draped along the dural defect. This permits vascularized closure in situations where a nasoseptal flap is unavailable or inadequate for closure.

Key Operative Learning Points

The TPF flap is a robust vascularized tissue flap with myriad utility used in cranial base, facial, oral and pharyngeal reconstruction.
The pedicle must be meticulously protected during the tedious dissection.

Preoperative Period

History

A thorough history is important to identify inappropriate candidates for this flap. Examples include patients who have had embolization or ligation of the external carotid artery and those in which previous surgery or trauma has transected the flap or its vascular supply.
Previous parotidectomy is not necessarily a contraindication unless the superficial temporal vessels were sacrificed.

Physical Examination

Thorough examination of the head and neck should be completed to gauge the extent of the tumor and anticipate the size of the defect.
Examine the neck and scalp for evidence of previous surgery that could have compromised blood supply to the flap.
The superficial temporal artery is generally 2 mm at the pretragal region and can be identified by Doppler to confirm adequate blood supply prior to deciding upon its use.

Imaging

Careful preoperative review of computed tomography (CT) and magnetic resonance (MR) imaging is necessary to ensure that vasculature to the flap will not be compromised during the resection of the tumor.

Indications

The TPF flap’s area, thinness, pliability, and mobility make it a good choice for reconstruction of soft tissue, orbital, anterior or middle cranial fossa, nasopharyngeal, oropharyngeal, oral, maxillary, and palatal defects.

Contraindications

The flap cannot be used if there has been previous disruption to its blood supply or when anticipated resection would disrupt the blood supply.
Previous radiation therapy is a relative contraindication as it may result in poor wound healing and increased risk of flap necrosis.

Preoperative Preparation

Patients should be counseled that there is a hemi-coronal incision with increased risk of alopecia along the donor area.
A particular advantage to this flap is that there is no significant donor site defect since the flap is so thin.

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