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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
Arch Facial Plast Surg. 2001;3:170-177.
ABSTRACT
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Background The temporoparietal fascial flap has proven to be a versatile flap for
a broad spectrum of reconstructive problems in the head and neck. The temporoparietal
fascial flap is a thin, pliable layer of richly vascularized tissue that may
be transferred either pedicled or free and alone or as a carrier of subjacent
bone or overlying skin and scalp.
Objective To report our experience using a hair-bearing temporoparietal fascial
flap for reconstruction in 6 male patients with extensive upper lip and scalp
defects, including a discussion of the surgical anatomy and technique.
Methods Temporoparietal fascial flaps with overlying scalp were used as pedicled
and free flaps for the reconstruction of upper lip and scalp defects.
Results All reconstructive results were satisfactory. Oral competence, measured
by both speech and mastication performance, was achieved in patients with
upper lip defects. Healthy scalp coverage was obtained in patients with local
defects. The cosmetic appearance was satisfactory to all patients.
Conclusions Ideal reconstruction of large upper lip and scalp defects is achieved
with local tissue that best mimics the normal face color, texture, and hair-bearing
qualities. Hair-bearing temporoparietal fascial flaps possess these characteristics
and are an excellent choice for the restoration of function and aesthetics.
INTRODUCTION
THE USE of scalp tissue in facial reconstruction has been appreciated
for thousands of years. Gillies1 was one of
the first to describe the use of the pedicled scalp flap based on the superficial
temporal artery for reconstruction of lip and eyebrow defects. The advent
of microvascular surgery renewed interest in the vascular supply of the temporal
region as a potential free flap donor site. Numerous anatomical studies that
described the layers and blood supply of the scalp followed.2-4
Since then, there has been a greater appreciation of the anatomy, with a succession
of advances and refinements in the use of this tissue.
The skin of the scalp can survive as a random local flap, or it can
be carried with some or all of the underlying tissue layers. Similarly, the
temporoparietal fascia can be used as a random local fascial flap or as an
axial flap based on the superficial temporal vessels. Its rich vascularity,
proximity, and similar texture offer distinct advantages in the reconstruction
of complex head and neck defects. This versatile flap has been used as a pedicled,
free, or composite flap with calvarium or hair-bearing skin to reconstruct
defects of the extremities, auricle, orbit, cheek, and oral cavity.5-11
The temporoparietal fascial flap (TPFF) has also been used to address Frey
syndrome,12 osteoradionecrosis,6
nasal septal perforations,13 and temporal bone
pathology.14-15
Many treatment options are available for large upper lip and scalp defects,
including skin grafts, local flaps, regional compound flaps, and free flaps.16-19 Lip
and scalp tissues have specific intrinsic qualities, along with functional
and aesthetic requirements, which limit optimal reconstructive choices. For
example, scalp tissue lacks elasticity by nature, and its layout is dictated
by hair follicle orientation.
Hair-bearing TPFFs provide an ideal reconstructive option for significant
upper lip and scalp defects given their high vascularity, anatomical proximity,
minimal associated donor site morbidity, and overlying hair.
PATIENTS AND METHODS
We describe a series of 5 male patients in whom a hair-bearing TPFF
was used for reconstruction of large upper lip and scalp defects. One patient
with alopecia had a non–hair-bearing TPFF covered with a split-thickness
skin graft.
ANATOMICAL FEATURES
Various nomenclature has been used interchangeably with temporoparietal fascia, including superficial temporal
fascia, epicranial aponeurosis, and galeal extension.2 These
all accurately reflect the anatomy of the tissue (Figure 1). A TPFF is a thin, highly vascularized connective tissue
layer just deep to the hair follicles and subdermal layer of fibrofatty tissue
in which they lie. The temporoparietal fascial layer becomes increasingly
adherent to this overlying layer as more fibrous septae and blood vessels
traverse the layers toward the vertex. Above the temporal line, the temporoparietal
fascia becomes galea aponeurotica. In contrast, the temporoparietal fascial
layer glides over its medial or deep surface, where it is separated from the
deep temporalis fascia by a loose areolar tissue layer.20-21
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Figure 1. The layers of the scalp are follows:
A, hair bearing; B, subcutaneous tissue; C, frontalis muscle and galea aponeurotica;
D, periosteum; E, cranium; F, temporalis muscle; G, deep temporalis fascia;
H, loose areolar tissue; and I, temporoparietal fascia with superficial temporal
vessels.
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A temporoparietal fascia is continuous with the galea above, the frontalis
muscle in front, the occipitalis behind, and the subcutaneous musculoaponeurotic
layer of the face. The flap ranges from 2 to 4 mm in thickness and can be
harvested with dimensions up to 17 x 14 cm.2, 20-21
The superficial temporal artery and vein nourish the temporoparietal
fascial layer. Coursing through this layer, the artery arborizes approximately
2 cm above the zygomatic arch into anterior and posterior branches. Each of
the main branches then sends perforators to the overlying subdermal layer.
The superficial temporal vein runs more superficially and less predictably
in this layer, increasing its risk of injury during harvest. The artery averages
2.0 mm in diameter as it exits the parotid salivary gland; the vein is slightly
larger.2, 20-21
Two nerves lie in close proximity to the temporoparietal fascia. The
frontal branch of the facial nerve runs just deep to the temporoparietal fascia.
It traverses the zygomatic arch obliquely one finger breadth behind the posterior
edge of the zygomatic process of the frontal bone. The auriculotemporal nerve
is within 5 mm of the superficial temporal artery until 1.5 cm above the helix
and may be preserved by staying at least 5 mm from the pedicle during inferior
flap elevation.2
SURGICAL TECHNIQUE
A Doppler ultrasound is used to mark out the course of the anterior
and posterior branches of the superficial temporal vessels. The hair-bearing
skin is most often based on the posterior branch, well posterior to the hairline
and danger zone of the frontal branch. A template of the defect is outlined
on the scalp. The distance from the point of rotation at the level of the
tragus to the proximal extent of the defect is measured. Then, if needed,
the flap can cross the midline for 2 to 3 cm without vascular compromise.
For our pedicled flaps, a 2-cm strip of scalp along the course of the
vessels is preserved. Flap dissection is started along the superior cutaneous
margin of the flap and elevated in the loose areolar layer between the galea
and pericranium The pedicle is elevated inferiorly as far as is practical,
most often up to the zygomatic arch. For the bipedicled flaps, the same concepts
are upheld, but we maintain a continuous strip of scalp extending over the
vertex, analogous to a bucket handle. The donor site is closed in 2 layers
over a suction drain.
The pedicled flap is sutured into the defect where it remains for a
minimum of 3 weeks. In the bipedicled flaps, the release of the pedicles is
staged at least 1 week apart, and challenged with a tourniquet prior to transection.
The pedicles are transected proximally at their bases.
For our free hair-bearing grafts, the axial vessels are isolated via
a preauricular incision. Once the pedicle is identified, the anterior and
posterior scalp flaps are elevated just deep to the hair follicles; this is
best initiated just above the ear where it is looser and easier to enter the
correct subcutaneous plane. As previously mentioned, the TPFF is densely adherent
to the subcutaneous layer of the scalp. The lateral aspect of the flap dissection
seems to be in an unnatural plane requiring attention to preserve the hair
follicles and the vascular pedicle.
Bipolar cautery for hemostasis helps avoid damage to hair follicles
and vessels. Pedicle lengths up to 6 cm may be obtained. Additional length
may be gained inferiorly, but may require mobilization of the parotid salivary
gland to identify and preserve the facial nerve branches.
If used as a free flap, the vascular pedicle is divided anterior to
the root of the helix. Saphenous veins are harvested for use as interposition
grafts.
REPORT OF CASES
CASE 1
A 64-year-old man underwent resection of a squamous cell carcinoma of
the left nasal alar–nasolabial region. This resulted in a complex midfacial
soft tissue defect including full-thickness loss of the lateral ala, oronasal
fistula, and scarred upper lip sparing the vermilion (Figure 2A).
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Figure 2. A, Left upper lip defect; B and
C, left pedicled temporoparietal fascial flap; and D, final postoperative
result.
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A pedicled hair-bearing TPFF to repair a 3.5 x 2-cm upper lip
defect was harvested and inset as the first stage (Figure 2B-C). The lateral alar defect was repaired concurrently
using a midline forehead flap. The pedicle was divided after 4 weeks (Figure 2D). The wound healed well with excellent
cosmetic and functional results.
CASE 2
A 48-year-old man underwent multiple resections of a basal cell carcinoma
and multiple reconstructive procedures, including a scapula osteocutaneous
free flap. He also underwent radiotherapy. Recurrent wound breakdown resulted
in a complex midfacial soft tissue defect involving near-total upper lip and
wound dehiscence of the lower lip (Figure
3A).
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Figure 3. A, Complex upper lip defect; B,
superficial temporal vessels traced using Doppler ultrasonography; C, flap
design for upper lip defect; D, prefabrication of deep surface with skin graft;
E, bipedicled temporoparietal fascial flap inset; and F, final postoperative
result.
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A bipedicled hair-bearing TPFF prefabricated with full-thickness skin
graft was used for reconstruction in 3 stages. In the first stage, the midportion
of the scalp flap was designed in the shape of the defect and prefabricated
with a skin graft. The scalp flap was elevated like a bucket handle, pedicled
bilaterally on both superficial temporal vessels, and stapled in place for
delayed release (Figure 3B-C).
In the second stage, the bipedicled prefabricated flap was released
and sutured into the defect (Figure 3D).
Six weeks later, 1 pedicle was divided followed by the second pedicle the
next week (Figure 3E). Postoperatively,
he had moderate wound dehiscence of the left commissure requiring revision.
CASE 3
A 38-year-old man underwent total maxillectomy for osteosarcoma followed
by reconstruction with rectus free flap and a conventional iliac bone graft.
The patient subsequently experienced upper lip necrosis leaving only 0.5 cm
of upper lip at each commissure (Figure 4A).
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Figure 4. A, Upper lip defect; B and C,
bipedicled temporoparietal fascial flap inset; and D, final postoperative
result.
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A bipedicled bitemporal hair-bearing TPFF was designed and inset into
the defect (Figure 4B-C). The pedicles
were divided in a staged fashion 2 and 3 weeks postoperatively
(Figure 4D). The wound healed well
and the patient was able to wear his dentures, eat, and speak normally. Additionally,
he experienced some return of sensation in the neoupper lip.
CASE 4
A 40-year-old man had severe scarring and alopecia of the right superior
temporoparietal scalp as a result of battery acid burns (Figure 5A). For 2 months tissue expanders were placed adjacent to
the expected defect site (Figure 5B).
The incisions for expander insertion were incorporated into the final flap
design. Skin incisions were designed to restore the natural hairline and hair-bearing
skin to the scarred temporoparietal region. An island of hair-bearing TPFF
was elevated on its pedicle and used to fill the defect following scar-alopecia
excision (Figure 5C-E). The previous
tissue expansion allowed for primary closure of the scalp (Figure 5F-H).
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Figure 5. A and B, Right temporoparietal
alopecia-scar and tissue expanders; C, marking of pedicle; D, elevated island
of hair-bearing temporoparietal fascial flap; E and F, insetting of flap island;
and G and H, final postoperative result.
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CASE 5
A 48-year-old man with recurrent scalp melanoma had previously undergone
a wide local excision with preservation of the pericranium and immediate split-thickness
skin graft for coverage. Five months after initial resection, he had a recurrence
at the margins. He underwent a radical resection with removal of the outer
calvarium in conjunction with a posterior neck dissection. This resulted in
a 9 x 7-cm defect in the parietal scalp and a 3 x 3-cm subjacent
defect of the calvarium (Figure 6A-B).
Mobilization of the adjacent hair-bearing TPFF using a V- to Y-technique was
performed for reconstruction. The vascular pedicle was extended using an interposition
vein graft (Figure 6C-E). Postoperatively,
the patient did well with complete coverage of the cranial defect. A persistent
proximal area of alopecia remained in an area over which a split-thickness
skin graft was placed.
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Figure 6. A, Recurrent scalp melanoma; B,
9 x 7-cm parietal scalp defect; C, temporoparietal fascial flap with
interpositional vein grafts; D, hair-bearing skin island transposed in V-
to Y-fashion; E, flap inset with skin graft closure of defect superior to
pinna; and F, final postoperative result.
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CASE 6
A 76-year-old man underwent resection of a basal cell carcinoma of the
scalp leaving a 6 x 8-cm, full-thickness defect including the periosteum
(Figure 7A). Similar to patient
5, he underwent reconstruction with TPFF with saphenous vein interposition.
However, owing to his natural state of alopecia, a split-thickness skin graft
was used to cover the graft. The wound healed without event and with excellent
cosmesis.
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Figure 7. A and B, Basal cell carcinoma
of scalp; C, outline of superficial temporal vessels; D, temporoparietal fascial
flap with interpositional vein grafts; and E and F, inset of flap with skin
graft coverage.
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RESULTS
All flaps (N = 6) survived. No major perioperative complications occurred.
One patient (case 2) had moderate dehiscence in the previously irradiated
wound bed, requiring a secondary revision. One patient (case 3) had some return
of sensation in the upper lip. In long-term follow-up (minimum of 2 years),
adequate functional and aesthetic outcomes were obtained in all cases. All
3 patients with upper lip reconstruction were able to eat and speak satisfactorily.
All 6 patients were satisfied with the improvement in their appearance.
COMMENT
Optimal reconstruction of extensive upper lip and scalp defects is achieved
with local tissue that best mimics the normal face color, texture, and hair-bearing
qualities. For upper lip defects, functional considerations, including the
ability to articulate and maintain oral competence during mastication, are
important. This require reconstruction with tissue of adequate bulk, volume,
texture, pliability, and color, as well as maximizing the preservation of
motion and sensation. Unfortunately, the complex function and contour of the
lip make the dual goals of restoring form and function difficult to achieve.
When lip defects exceed more than 60% of lip width, the conventional
methods of local flaps (ie, Gillies fan flap,22
or Bernard-Burow flap23) are less satisfactory
aesthetically and functionally due to displacement of the modiolus and invariable
microstomia. When skin grafts or distant flaps are used, bulk, color, and
texture are frequently compromised and the orbicularis sphincter is not restored.
There is also increased donor site morbidity and surgical time with distant
flaps.
For males, the scalp most closely approximates the hair density and
quality of the upper lip. Our 3 cases demonstrate acceptable cosmetic outcomes
in patients with near-total upper lip defects by simulating the lip contour,
thickness, texture, and height. The growth of a mustache may camouflage scars
and reestablish facial character with consequent improvement in cosmetic as
well as psychological results.
Furthermore, the modiolus is undisturbed and the orbicularis sphincter
is bridged to each side of the graft. Although the oral sphincter is not restored,
continuity is reestablished. The patients achieve good functional results
for speech and mastication. There is also potential sensory return in the
neo–upper lip with preservation of the auriculotemporal nerve acting
as a scaffold.3
Disadvantages include the multistaged procedure. The alternative would
be to perform a single-staged free tissue transfer for upper lip reconstruction
or tunnel a hair-bearing island of skin. These options come with their own
attendant risks, including increased risk of injury to the facial nerve. There
is limited applicability to female patients.
An examination of reconstructive option in scalp defects highlights
shortcomings. Skin grafts, while quick and easy, have poor tissue texture
and thickness, and are non–hair-bearing. They rely on intact subjacent
periosteum and are, therefore, subject to more frequent loss. Local advancement,
transposition, and rotational flaps as emphasized by Orticochea24
are ideal, but limited to small to medium-sized defects. Myofascial or musculocutaneous
flaps have good vascular supply, but can be too bulky, time-consuming, non–hair-bearing,
and have more significant donor site morbidity.
Reconstruction using hair-bearing TPFF as local advancement flaps were
made possible by the use of tissue expanders and interpositional vein grafts.
Tissue expanders are indicated when there is a shortage of suitable donor
tissue. The neovascularization of the expanded skin allows the flap to behave
like a delayed flap, permitting a larger viable donor length than random advancement
or rotation flaps.25 Further benefits include
a single, inconspicuous operative site with minimal to no morbidity.
These cases illustrate not only one of many potential reconstructive
options for large upper lip and scalp defects in males but the advantages
of using the hair-bearing TPFF. The reliable vascular supply, inconspicuous
donor site, match in tissue characteristics, and proximity to the reconstructive
site make it an optimal choice.
AUTHOR INFORMATION
Accepted for publication January 25, 2001.
Presented in part at the fall meeting of the American Academy of Facial
Plastic and Reconstructive Surgery, Washington, DC, September 21, 2000.
Corresponding author and reprints: Mack L. Cheney, MD, Department
of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School,
243 Charles St, Boston, MA 02114 (e-mail: Mack_Cheney{at}MEEI.HARVARD.EDU).
From the Department of Otolaryngology, Massachusetts Eye and Ear Infirmary,
Harvard Medical School, Boston.
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