The Prefabricated Temporalis Fascio-Cutaneous Free Flap

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J Oral Maxillofac Surg67:683-688, 2009

The Prefabricated TemporalisFascio-Cutaneous Free Flap

Corrado Toro, MD,* Massimo Robiony, MD, FEBOMS,†

Roberto Cian, MD,‡ Fabio Costa, MD,§ and

Massimo Politi, MD, DMD¶

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overage of moderately sized oral and facial defectsas always been a difficult problem because of the

imited availability of local tissue and excessive bulkf common free flaps.Free tissue transfers have been rapidly replacing

ocal and distant pedicled flaps for use in orofacialeconstruction. The use of free tissue transfer hasxpanded greatly over the past 25 years, and there areow a large number of flaps available for reconstruc-ion. Despite these surgical advances, there is still aaucity of thin flaps, especially for reconstruction ofhe head and neck.1

Emphasis has shifted from simply obtaining flapurvival to better flap selection and refinement ineconstruction. Flap prefabrication is a new andvolving technique that adds to the armamentariumf flap choice. This technique allows the surgeon toustomize thin vascularized flaps with surface charac-eristics similar to those of the recipient sites.

The temporoparietal fascial flap is a thin, broad,liable, and well-vascularized flap. It is based on theuperficial temporal vessels, which carries a bloodupply to both the superficial and the deep temporalascia. It is a relatively well vascularized flap; how-ver, it does not contain mucosal or skin lining.The transfer of the temporalis fascia flap as a free

ap widened the spectrum of its applications. Itsascular pedicle can be dissected through the parotidland, making it quite long. The temporoparietal fas-ia can be a reliable flap for nasal,2 and extremities

eceived from the Department of Maxillofacial Surgery, University-

ospital “S. Maria della Misericordia” of Udine, Udine, Italy.

*Clinical Fellow.

†Associate Professor.

‡Clinical Fellow.

§Clinical Assistant.

¶Professor and Chairman.

Address correspondence and reprint requests to Dr Toro: Univer-

ity-Hospital “S. Maria della Misericordia,” PAD. Petracco, Depart-

ent of Maxillofacial Surgery, P.le S. Maria della Misericordia,

3100 Udine, Italy; e-mail: [email protected]

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6703-0037$36.00/0

poi:10.1016/j.joms.2008.06.090

683

econstruction.3 The thin contour of the flap is esthet-cally superior to thicker skin flaps and eliminates theeed for secondary defatting or touch-up procedures.Free flaps such as the radial forearm flap, lateral arm

ree flap, and anterolateral thigh free flap have beensed in the reconstruction of the face and of the oralavity with various benefits and drawbacks, particu-arly in relation to the donor site morbidity or thexcessive bulk.Our effort to reconstruct while minimizing donor-

ite morbidity has led us to perform a technique tobtain prefabricated fascio-cutaneous free flaps.erein, we present a series of 17 cases whose facial orral soft tissue defects were restored by free tem-oroparietal fascial flaps with a prefabricated skin

ayer.

atients and Methods

From December 2005 to December 2006, in theepartment of Maxillofacial Surgery of the Universityf Udine, 17 patients (6 female, 11 male; aged be-ween 52 and 79 years; mean 69) were included inhis prospective study and had a reconstruction of theurgical defect by using a prefabricated fascio-cutane-us free flap. Exclusion criteria were conditions that

mplied a surgical resection greater than 10 cm in theaximum diameter, or a composite defect.The histologic diagnoses were: basal cell carcinoma

f the face (6 cases), oral squamous cell carcinoma (5ases), squamous cell carcinoma of the face (4 cases),errucosus carcinoma of the gingiva (1 case), andysplastic cheek mucosa (1 case).The location and branching pattern of the superfi-

ial temporal vessels were investigated preoperativelyith a Doppler probe to exclude anatomic anomalies.o anatomic variations of the branching pattern of

he temporal vessels were found in all 17 patients.The reconstructions were performed in 2 stages. In

he first stage, under local anesthesia, a split thicknesskin graft (0.3 mm) was harvested from the thigh afternfiltration of the entire area. The skin graft waslaced in a pocket between the deep temporalis fas-ia and the temporalis muscle. All the surgical ap-
roaches were performed with a limited arched inci-
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684 PREFABRICATED FREE FLAP

ion (6 cm) of the scalp on the parietal region,pproximately at the level of the upper component ofhe temporal muscle. The incision was carriedhrough the subcutaneous tissue, the superficial tem-oralis fascia, and the areolar fat tissue. This surgicalechnique placed the incision of the upper and lowerayer of the deep temporalis fascia, completelyhrough the fat tissue (under the deep temporal fas-ia).The upper surface of the skin grafts were oriented

uperficial to the temporal muscle with the interpo-ition of a pliable silicone sheet (Silatos Silicone Sheet-ng; Atos Medical AB, Hörby, Sweden; Fig 1). The skinrafts were placed by extending the dissection in aosterior and parietal direction (Fig 2); in this region,he fascia is thick and robust in contrast to the fron-alis area, where it is often very thin and where fur-her dissection also risks injury to the facial nerve.

At the second stage, 3 weeks later, harvest of theaps were conducted simultaneously with the abla-ive procedures.

All the skin grafts healed entirely on the undersur-ace of the fascia with a meaningful thickening (Fig 3).he free flaps with the thick skin and both the super-

IGURE 1. The split thickness skin graft, fixed on the silicone sheeturing the prefabrication stage, under local anesthesia.

coro et al. Prefabricated Free Flap. J Oral Maxillofac Surg 2009.

cial and deep layers of the temporal fascia wereaised (Fig 4). Incisional biopsies were performed onll the 17 prefabricated flaps to evaluate the degree ofhickening of the skin (Fig 5). All the flaps wereicrosurgically transferred. Postoperatively, direct

bservation of the flaps and Doppler measurementsere used to monitor the perfusion. The level of

etraction of the flaps was also measured. Postopera-ive follow-up ranged from 24 to 12 months.

eport of a Case

We report an exemplifying case. A 52-year-old man waseferred to our clinic for treatment of a recurrence of a basalell carcinoma localized on the left temporal area (Fig 6).reoperative sonography showed an infiltration of the deep

ayers and of the anterior branch of the left superficialemporal artery.

The prefabrication of the fasciocutaneous flap was per-ormed under local anesthesia. A split thickness skin graft0.3 mm) was harvested from the inguinal region and waslaced in the pocket between the right temporalis fasciand muscle (Fig 7).

At the second stage, 3 weeks later, the tumor was radi-

IGURE 2. The repositioning of the temporoparietal fascia on theraft.

oro et al. Prefabricated Free Flap. J Oral Maxillofac Surg 2009.

ally resected on the left side (Fig 8), the flap was harvested

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TORO ET AL 685

n the right side (Fig 9), and it was microsurgically trans-erred on the left recipient temporal vessels (Fig 10).

There were no signs of recurrence 1 year after surgery,ith excellent functional and cosmetic results on the re-

onstructed area and on the donor site (Fig 11).

esults

Operating time for the first stage averaged 1 hour.n the second stage, about 4 hours were required forhe entire procedures. All the 17 flaps survived and

IGURE 3. The flap dissection over the silicone plane, during theecond surgical stage, under general anesthesia.


FIGURE 4. The free flap and its pedicle raised.

oro et al. Prefabricated Free Flap. J Oral Maxillofac Surg 2009. T

mproved function. The biopsies showed a meanhickening of the skin grafts of 1.6 mm (range, 1.2m to 1.7 mm). All the patients had excellent cos-etic results, no donor-site alopecia, and no evidence

f recurrence of the malignancy. One year after theeconstructions, all the flaps demonstrated a contrac-ion (mean one quarter of the maximum diameter) inomparison to the immediate postoperative period.

IGURE 5. Micrograph of an incisional biopsy of the prefabri-ated temporalis fascio-cutaneous flap. It is possible to appreciatehe growth of the epithelial cellular layers above the fascial fibershematoxylin-eosin stain; original magnification �250).


IGURE 6. Preoperative view of a patient affected by an infiltrat-ng basal cell carcinoma of the left temporal region.


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Regarding subjective evaluation of the donor siteorbidity, all 17 patients had no complaints.

iscussion

Reconstruction of large ablative resections haseen relatively easy, while the small and moderatelyized defect not amenable to local flaps have posed areat challenge.4 The fasciocutaneous radial forearmap does not provide excessive bulk and is excellentor reconstruction of moderate defects, but the con-equent donor site morbidity includes functional andsthetic outcome.5

The anterolateral thigh flap is a suitable reconstruc-ive alternative with minimal donor site morbidity,ut frequently it is too bulky. Thinning of the antero-

ateral thigh flap may extend its usefulness to situa-ions requiring less bulk, but thinning of the flapauses significant vascular problems.6 Thinning of theap is shown to disrupt the blood supply to the skin

n cadaver specimens and it may be inadvisable in theestern European population.7

IGURE 7. An intraoperative image of the prefabrication stage,nder local anesthesia. A split thickness skin graft is fixed on theilicone sheet and inserted in the right temporo-parietal pocket.

oro et al. Prefabricated Free Flap. J Oral Maxillofac Surg 2009. T

Successful reconstruction requires thoughtful se-ection of a donor site tailored to each patient’s needs.

e have passed the era when successful oro-maxillo-acial reconstruction is judged by survival of the flap.

IGURE 8. An intraoperative image of the surgical procedure,nder general anesthesia, 3 weeks after prefabrication. Note theadical resection of the tumor on the left side.


FIGURE 9. Harvest of the flap on the right side.


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ith flap survival rates nearly 100%, the focus is nown function and on donor site morbidity.The principles of prefabrication were introduced

0 years ago.8 Flap prefabrication is a relatively new

IGURE 10. The microvascular transplantation of the flap on theeft side.


IGURE 11. The same patient, 1 year after surgery. There were nhe donor site.


nd evolving technique in reconstructive surgery, butts overall usefulness and place in the reconstructivermamentarium is yet to be determined.

The temporalis fascia flap has been investigated byeveral authors.9,10

Proceeding from the skin toward the temporal mus-le, we find:11

1) Subcutaneous tissue2) Superficial temporalis fascia (temporoparietal

fascia)3) Loose areolar tissue (areolar fat tissue)4) Deep temporalis fascia (temporalis muscle fas-

cia), that is divided into:a) superficial layer (innominate fascia)b) deep layer

5) Temporal muscle.

There are 3 fascial layers within the temporal re-ion: the superficial temporalis fascia and the deepemporalis fascia, which consists of a superficial layernd a deep layer. The superficial temporalis fasciaepresents a cephalad extension of the superficialuscular aponeurotic system. This fascial layer lies

uperficial to the zygomatic arch and encompasseshe frontal branch of the facial nerve and the super-cial temporal vessels. Loose areolar tissue separateshe superficial from the deep temporalis fascia. Theeep temporalis fascia is a dense connective tissue

ayer, strictly in contact with the temporalis muscle,nd represents the natural continuation of the peri-ranium of the parietal bone.The variation of temporoparietal-scalp free flap can

e used for upper lip reconstruction in man,12 butalton and Bunkis13 cited concerns about this flap as

of recurrence, with good results on the reconstructed area and on
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result of the possibility of future male pattern bald-ess and exposure of the donor-site scar.Upton et al14 reported a series of 11 temporopari-

tal fascial flaps for oral and nasal cavity reconstruc-ion. In their patients, a skin graft was placed over theemporoparietal and all the oral reconstructions re-orted were performed with flaps raised as pedicled.n our technique, the skin was placed under theemporalis fascia and it was separated from the mus-le interposing a silicone sheet; this method appearso be very useful in the first stage of the prefabrica-ion, avoiding adherences between the skin graft andhe muscle fibers, and improving immobilization anddherence of the graft under the fascia avoiding theormation of dead spaces or accumulations of fluids.urthermore, it facilitates the stage of flap raising,reating an immediate dissection plane.Placing the skin graft under the fascia in the first

tage and transferring the prefabricated flap to theral cavity in the second stage would render theperation safer, in terms of increasing the success ofkin graft acceptance. Furthermore, the microsurgicalransplant potentially permits the reconstruction ofll distant areas.

As with any prefabricated flap, there is a delay inurgery that is acceptable in all secondary reconstruc-ions. In primary resection and reconstruction, the-week delay for the 2 stages of the procedure mayppear as a disadvantage if we compare this kind ofap with the not-prefabricated flap, but it has no

mplication with the prognosis of the patients and isometimes useful for the completion of the preoper-tive assessments or clinical staging.

To our knowledge, this study presents a newethod for the prefabrication of a fascio-cutaneous

ap, and it reports the first series of intraoral recon-tructions with prefabricated fasciocutaneous tempo-
alis free flaps.
Although all possible applications for this flap haveot been explored fully, there appears to be greatotential for the use of this simple procedure inefined reconstruction of moderately sized defects,ith the advantage of the absence of donor-site mor-idity.

eferences1. Pribaz JJ, Fine N, Orgill DP: Flap prefabrication in the head and

neck: A 10-year experience. Plast Reconstruct Surg 103:808,1999

2. Acikel C, Bayram I, Fikret E, et al: Free temporoparietal fascialflaps and full-thickness skin grafts in aesthetic restoration of thenose. Aest Plast Surg 26:416, 2002

3. Upton J, Rogers C, Durham-Smith G, et al: Clinical applicationsfor free temporoparietal fascial flaps in hand reconstruction.J Hand Surg (Am) 11:475, 1986

4. Bunkis J, Mulliken JB, Upton J, et al: The evolution of tech-niques for reconstruction of full-thickness cheek defects. PlastReconstruct Surg 70:319, 1982

5. de Witt CA, de Bree R, Verdonck-de Leeuw IM, et al. Donor sitemorbidity of the fasciocutaneous radial forearm flap: Why doesthe patient really bother? Eur Arch Otorhinolaryngol 264:929,2007

6. Ross GL, Dunn R, Kirkpatric J, et al: To thin or not to thin: Theuse of the anterolateral thigh flap in the reconstruction ofintraoral defects. Br J Plast Surg 56:409, 2003

7. Alkureishi LWT, Shaw-Dunn J, Ross GL: Effects of thinning theanterolateral thin flap on the blood supply to the skin. Br J PlastSurg 56:401, 2003

8. Erol O: The transformation of a free skin graft into a vascular-ized pedicled flap. Plast Reconstr Surg 58:470, 1976

9. Abdul-Hassan HS, von Drasek Ascher G, Acland RD: Surgicalanatomy and blood supply of the fascial layers of the temporalregion. Plast Reconstr Surg 77:17, 1986

0. Rose EH, Norris MS: The versatile temporoparietal fascial flap.Adaptability to a variety of composite defects. Plast ReconstrSurg 85:224, 1990

1. Politi M, Toro C, Cian R, et al: The deep subfascial approach tothe temporomandibular joint. J Oral Maxillofac Surg 62:1097,2004

2. Paniello RC: Temporoparietal scalp free flap for upper lipreconstruction. Op Tech Otolaryngol Head Neck Surg 2:121,2000

3. Walton RL, Bunkis J: A free occipital hair-bearing flap forreconstruction of the upper lip. Br J Plast Surg 36:168, 1983

4. Upton J, Rogers C, Durham-Smith G, et al: Clinical applications
for free temporoparietal fascial flaps in hand reconstruction.J Hand Surg (Am) 11:475, 1986

Documents

The Prefabricated Temporalis Fascio-Cutaneous Free Flap