temporoparietal flaps

temporoparietal fascial flap(galeal flap)

1. Temporoparietal Fascial Flap Dr Jameel Kifayatullah Senior lecturer Khyber College of dentistry Peshawar ,Pakistan

2. Relevant Anatomy of TPF The first layer consists of the skin and subcutaneous tissue . I mmediately deep and firmly bound to this layer is the temporoparietal (sometimes called superficial temporal) fascia The temporoparietal fascia (TPF) is an extension of the subcutaneous musculoaponeurotic system (SMAS) inferiorly and the galea aponeurotica superiorly. 

3. Relevant Anatomy of TPF Beneath the temporoparietal fascia lies a loose areolar and avascular tissue layer that separates the fascia from the temporalis muscular fascia (sometimes termed the deep temporal fascia ).  division of the temporalis muscular fascia as it splits into a superficial and deep layer (of the deep temporal fascia) surrounding a fatty tissue pad at the temporal line of fusion, approximately 2 cm above the zygomatic arch

4. Relevant Anatomy of TPF The temporalis muscular fascia is contiguous(touching) with the pericranium above the superior temporal line and is contiguous with the masseter muscle fascia below the arch . The superficial temporal artery supplies the temporoparietal fascia flap

5. Relevant Anatomy of TPF nerves The auriculotemporal nerve, a sensory branch of the mandibular nerve, lies posterior to the superficial temporal artery within the temporoparietal fascia. The frontal branch of the facial nerve traverses an oblique course over the zygomatic arch, which can be estimated by a line connecting a point 0.5 cm inferior to the tragus to a point 1.5 cm lateral to the superior brow. This nerve also lies within the temporoparietal fascia, and flap elevation anterior to the frontal branch of the superficial temporal artery should proceed with caution to avoid injuring this nerve

6. Temporalis fascia superficial and deep layers

7. Relevent anatomy tempoproparietal fascial flap

8. SMAS The Superficial Muscular Aponeurotic System (SMAS) is a fibrous network that invests the facial muscles and connects them with the dermis. It is continuous with the platysma inferiorly; superiorly it attaches to the zygomatic arch. In the lower face, the facial nerve courses deep to the SMAS and the platysma .

9. F ascia A  fascia  ( /ˈ fæʃ ( i )ə/ ; plural  fasciae   /ˈ fæʃii / ; adjective  fascial ; from  Latin : "band") is a band or sheet of  connective tissue , primarily  collagen , beneath the  skin  that attaches, stabilizes, encloses, and separates  muscles  and other internal  organs .  Fascia is classified by layer, as  superficial fascia ,  deep fascia , and  visceral  or  parietal  fascia, or by its function and anatomical location. fascia is made up of   fibrous connective tissue  containing closely packed bundles of collagen fibers oriented in a wavy pattern parallel to the direction of pull.

10. Landmarks The important topography of the temporoparietal flap to mark on the scalp includes the superior temporal line, the course of the superficial temporal artery trunk and the frontal and parietal branches , approximate course of the frontal branch of the facial nerve

11. TOPOGRAPHY

12. The proposed scalp incision has been marked. Note dotted line over lateral brow marking the course of the temporal branch of the facial nerve A

13. incision The TPF is initially exposed at the level of the ear through a pre-auricular facelift incision which is carried into the hairline. This may be extended through the scalp in a T or Y pattern; a zigzag pattern has also been described

14. Identification of superficial temporal vessels The TPF lies immediately deep to the hair follicles in the pre-auricular area. The superficial temporal vessels are identified and the surgeon verifies that the caliber of the vessels is adequate for flap elevation.

15. I dentification of the Superficial temporal artery and vein C

16. Epinephrine infiltration A 1:200,000 epinephrine solution is now infiltrated into the area of the scalp to control bleeding from the scalp flaps

17. Elevation of the scalp flap Elevation of the scalp flap begins inferiorly where the plane between the dermis and superficial temporal fascia is more easily identified As dissection proceeds cephalad (cranially), separation becomes increasingly difficult secondary to the fibrous connections and the perforating vessels from the superficial temporal artery to the overlying scalp. Meticulous hemostasis is required. Countertraction of the scalp by an assistant significantly facilitates dissection

18. Flap size estimation After the scalp flaps have been elevated, a template may be made of the recipient site defect, and the template may be applied to the TPFF

19. Extent of dissection Anterior dissection is not carried below the level of the anterior branch of the superficial temporal artery. Care is also taken to stay far enough posterior to avoid injuring the branches of the temporal nerve.

20. Once the overlying skin has been freed from the tpF , the tpF is incised at its superior margin and elevated along with its pedicle in retrograde fashion. the loose areolar plane deep to the tpFF is raised along with the flap rather expediently with visualization of the deep temporal fascia below.   D

21. Raising of TPFF

22. Flap elevation The TPF is then incised and elevated along with its pedicle in retrograde fashion. The loose areolar plane deep to the TPFF is raised along with the flap rather expediently with visualization of the deep temporal fascia below

23. D issection Dissection then proceeds to the major pedicle. Dissection is usually stopped at the base of the tragus. Further dissection into the parotid gland is not recommended as injury to the facial nerve may occur. Flap splitting may be carried out between the major vascular branches of the STA, usually between the central and posterior branch or anterior and posterior branch if two smaller areas require coverage

24. Dissection then proceeds to the major pedicle. harvest of the deep temporal fascia requires preservation of the perforat - ing vessel which is identified just inferior to the superior auricular margin. Once the vascular pedicle of the deep temporal fascia has been identified, the fascia surrounding the muscle is elevated. Dissection of the main pedicle then proceeds to the base of the tragus.   Superficial temporal fascia flap Flap can be split here Deep temporal fascia Temporal branch of facial nerve

25. Indications for TPF The temporoparietal galea flap is used for 1. Obliteration of oral defects 2. Cranial base reconstruction 3. Obliteration of orbital defects after enucleation 4. Malar augmentation and maxillary and mandibular reconstruction with vascularized osseous cranial bone 5. Reconstruction of the hair-bearing upper lip or brow (flap with skin island) 6. Obliteration of a postparotidectomy defect with preventive treatment for Frey’s syndrome

26. I ndications As a pedicled flap: – Ear ( microtia , anotia ) and scalp reconstruction. Orbital , maxillary, palatal, and cheek coverage. Facial reanimation and lip reconstruction. Skull base defects

27. Advantages Easy and quick harvesting. A very thin flap with a reliable vascular pedicle. Low donor side morbidity with no functional loss. Can be used as a pedicled or free flap. A two-team approach is possible.

28. Disadvantages • Short vascular pedicle (The short pedicle length of 4 cm may be a challenge in free flap reconstruction) • Risk of scarring in the visible area. • Alopecia along the incision line. • Limited flap size.