The volume limitation of the galeal temporalis flap in facial augmentation

Anatomical Study of Perfusion of a Periosteal Flap with a Lateral Pedicle

Background:

Pedicled periosteal flaps are commonly used for tissue defects between the base of the skull and the midfacial area. This study aimed to clarify the 3-dimensional vascular distribution of temporal region flaps.

Methods:

Ten fresh cadavers were used. Full-thickness cranial flaps were elevated from the cranial bone and each layer was detached separately. Contrast enhancement of the full thickness of the scalp, macroscopic evaluation, and histologic analyses were performed. Radiographs were obtained and image analysis was performed using a 3-dimensional monitor.

Results:

The mean number of deep vessels extending from the parietal branch of the superficial temporal artery was 68.7, including 14.2 and 54.5 vessels on the proximal and distal sides, respectively. The mean number of deep vessels extending from the frontal branch of the superficial temporal artery was 71.6, including 17.6 and 54.0 vessels on the proximal and distal sides, respectively. There were significantly more perforating branches in the distal area than in the proximal area of both the frontal and parietal branches (P = 0.005). There was no significant difference in the number of perforating branches between the frontal and parietal branches.

Conclusions:

Contrast-enhanced images of the loose areolar tissue and periosteal layers revealed vessels that extended radially. We successfully identified the 3-dimensional structure of the perforating vessels peripheral to the temporal fossa. Our findings provide a theoretical foundation for the feasibility of elevating a periosteal/loose areolar tissue flap with a reliable blood supply without sacrificing the temporal muscle.

Chronologic presentation of a severe case of progressive hemifacial atrophy (parry-romberg syndrome) with the loss of an eye

Progressive hemifacial atrophy, also known as Parry-Romberg syndrome, is a slowly advancing degenerative disease that mostly affects the cutaneous, subcutaneous fatty tissue, muscle tissue, and bone structures on one side of the face. We describe the chronological progression of this very rare syndrome from early childhood until adulthood in a patient who developed severe atrophy and lost one eye. We also discuss the aetiology and pathophysiology of this syndrome.

Use of pericranial flaps in the management of cranial base trauma

Pericranial flaps based on the musuloaponeurotic or myofacial layers of the scalp have great utility in the management of acquired and congenital craniofacial deformities. Their use in traumatic deformities is indicated in the presence of craniopharyngeal communications and significant anterior cranial fossa dead space created from frontal sinus obliteration. The indications and operative techniques and the results of the use of these flaps in 10 consecutive patient with extensive cranial base trauma are presented.

Bilateral temporoparietal fascial free flaps for reconstruction of bilateral hand defects: a report of two cases

Bilateral temporoparietal fascial free flaps were used for reconstruction of bilateral hand defects in two male patients. A 42-year-old man sustained crushed injury to both hands with avulsion defects and exposed bones and tendons. The two separate procedures were performed under general anesthesia. The temporoparietal fascial free flap was skin grafted on the ward on the following day after the operation. The other patient was a 61-year-old leprosy patient who had bilateral high ulnar nerve palsy for 28 years. One simultaneous procedure was performed under local anesthesia for harvesting the temporoparietal fascial free flaps and under brachial block for preparation of the recipient sites. The free flaps were used for augmentation of the atrophic first web spaces. The postoperative results of the two cases were satisfactory. The functions of both hands were restored with normal gliding mechanism of the tendons in the first case, and permanent correction of the atrophic web spaces was demonstrated in the second case. The temporoparietal fascial free flap is an ideal flap for coverage of hand defects as well as augmentation of first web space atrophy.

Temporoparietal fascial free flap for correction of first web space atrophy

Fourteen temporoparietal fascial free flaps were used for correction of first web space atrophy from ulnar nerve palsy in 13 patients. Ten sustained ulnar nerve injuries and three suffered from leprosy. The procedures were performed under general anesthesia except one leprosy patient with bilateral ulnar nerve palsy in which local anesthesia and brachial block were employed to harvest bilateral free flaps and recipient site preparations, respectively. The follow-up time varied from 4 to 64 months. The postoperative results were satisfactory and there was no resorption of the free flaps. The consistency of the augmented first web space was soft and compressible like natural feel. The size of the flap was more than enough for augmentation of first web space and donor site morbidity was minimal and accepted by all patients. We conclude that temporoparietal fascial free flap is an ideal autogenous tissue for correction of first web space atrophy.

Classification and treatment of facial tissue atrophy in Parry-Romberg disease

BACKGROUND

This report aims to show procedures that the senior author has used for the rehabilitation of facial deformities in Parry-Romberg disease since 1983. The authors also report the classification they use to plan the most appropriate surgical procedure for these patients.

METHODS

For this study, 95 patients (67 females and 28 males) with different types of facial tissue depression were classified according to the depth of the defect so adequate treatment could be planned. The cases were classified into four types. For types 1 and 2, only fat grafts were used, whereas for types 3 and 4, a combined procedure was used according to the case using cartilage and bone grafts, free dermis-fat grafts, and galeal flaps.

RESULTS

The results were successful, with few or no complications. Objective examinations showed excellent aesthetic improvement, with obvious deformity alleviated and the emotional status of the patients improved.

CONCLUSIONS

The authors' practice frequently sees cases of Parry-Romberg disease, which has allowed them to gain significant experience in this field. For depression types 1 and 2, they recommend only fat infiltration, and for types 3 and 4, they favor combined treatment with lipoinjection, galeal flaps, free dermis-fat grafts, and bone and cartilage grafts. Occasionally, in areas of soft tissue with fibrosis, the authors infiltrated around 4 ml of fragmented fascia grafts instead of fat grafts.

Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft--a new technique

Long standing oral submucous fibrosis is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. This article introduces a new technique of release of submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft. The surgical technique involves a pre-auricular incision extending into the temporal region with dissection carried out in the sub follicular plane to develop the superficial temporal fascia flap to its maximum extent. The masseter muscle origin is released from the zygomatic arch and the temporalis muscle insertion is released from the coronoid process through an external approach. The entire fibrosed mucosa is released intraorally to create a mucomuscular defect thus achieving full mouth opening. The superficial temporal fascia flap is then brought in and sutured to the intraoral defect, which is then covered with a split thickness skin graft. This procedure is performed bilaterally. A total of five patients were treated with this new technique and all of them showed good mouth opening in long term follow up. There was no donor site morbidity. The incision line is well hidden in the hair bearing area. A well vascularised superficial temporal fascia flap brings in good blood supply to the area of affected muscle and mucosa to improve its function.

[Reconstruction of facial defects due to war injuries using vascularized pedicled galeal and parietal bone grafts]

Combat wounds are basically extensive and destructive. Such injuries cause defects of soft and bone structures of the face and neck. During primary surgical management of maxillofacial combat wounds the principle of minimal bone and soft tissue debridment was respected. Definitive reconstruction of the defect was performed after two or three months, when infection was cured and adjacent tissues were restituted. Each combat wound leaves behind fibrous changes in surrounding tissues. Success of the reconstructive procedures is more certain if flaps with its own blood supply are used, either arterial or vascularized grafts from the other parts of body (by microvascular technique). This paper presents our experiences with galeal flap in reconstruction of facial soft tissue defects, as well as galea, together with external table of parietal bone in reconstruction of soft and bony tissues of maxillofacial in 15 patients.

[Reconstructive surgery of the soft tissue in hemifacial microsomia]

Hypoplasia of soft tissues constitutes one of the major elements of hemifacial microsomia. Despite the fact that it occurs in 95% of cases of microsomia, hypoplasia is one aspect of the syndrome that is often neglected. The authors, by a general review of the relevant literature, describe the quantitative and qualitative importance of hypoplasia, as well as its statistical rapport with other elements of the syndrome. In studying the different treatments available for hypoplasia of soft tissues, several factors stand out. New techniques of bone distraction have transformed surgical indications by allowing an extension of soft tissues, particularly of skin. The treatment of hypoplasia follows two major axes; firstly, the use of grafts by injection of adiposal tissue for cases in which the deficit is only moderate, and secondly, microsurgical flaps, mainly of the fasciocutaneous type, for the relatively small portion of cases (9%) in which the deficit is more severe. By first analysing any constraints due to the treatment of bone and ear malformations, the schedule of the different stages of necessary surgery can be effectively planned.

The use of multifolded pericranial flaps as "plugs" and "pads"

Pericranial flaps are thin and, hence, their volumes are small. Therefore, their use for soft-tissue augmentation has not been popular. In this article, the author introduces a new concept: the use of a multifolded pericranial flap as a "plug" or a "pad" for localized contour defects. Eight patients were included in the study. In all cases, an anteriorly based pericranial flap was used, and the flap was folded on itself several times to increase its bulk. The results were satisfactory in all patients. The literature on the topic is reviewed, and the blood supply of pericranial flaps is discussed.

Galeo-pericranial flaps in the forehead: a study of blood supply and volumes

Despite their extensive use in anterior cranial base reconstruction, very little is understood about the blood supply of galeo-pericranial flaps derived from the forehead region. The goal of this study was to define the extent of the reliable axial blood supply and to determine the volumes of these flaps. The blood supply to anteriorly based galeo-pericranial flaps depends entirely upon the deep branches and a variable component of the superficial branches of the supraorbital and the supratrochlear vessels. The axial component of the blood supply to these flaps is 20-70 mm. The extent of "random' pattern blood supply distal to this could not be adequately assessed. The volumes of various galeo-pericranial flaps range from 3 to 48 cc. The well vascularized proximal portions of galeo-pericranial flaps may well serve the reconstructive needs of the anterior cranial base. Use of more distal portions of these flaps should be undertaken with caution. Some increase in bulk and vascularity may be achieved if the pericranial and the galeal-frontalis myofascial flaps are harvested as a single unit, the composite galeal-frontalis-pericranial flap. Due to the vascular and volume limitations of galeo-pericranial flaps, consideration should be given to the use of microvascular free tissue transfers in instances where large soft tissue defects and a large "dead space' occur.

Restricted mandibular opening complicating intraoral galeal flap reconstruction and radiotherapy: case report

Despite many advantages over musculocutaneous and free flaps, galeal flaps are seldom used intraorally by the head and neck surgeon. The literature reveals little in the way of complications of such flaps. A case is reported in which a temporoparietal galeal flap used in reconstruction after resection of an intraoral squamous cell carcinoma, followed by a course of radiotherapy, led to postoperative restriction of mandibular opening. The combination of surgery and radiotherapy with the intraoral use of this flap may lead to flap fibrosis and limited mouth opening.

The arterial anatomy of the temporal region and the vascular basis of various temporal flaps

The arterial anatomy of the temporal region was examined macroscopically and radiographically in 10 fresh cadavers which had been injected with lead oxide. The blood supply of the temporal region is derived from the superficial temporal, middle temporal, deep temporal, posterior auricular, transverse facial, zygomatico-orbital, zygomaticotemporal, zygomaticofacial, and middle meningeal arteries. The vascular network formed by these arteries can be divided into four arterial networks corresponding to the different layers of the temporal region. With a new understanding of the arterial networks and their anastomoses, the techniques for elevating various flaps in the temporal region are discussed.

Correction of facial deformities with pericranial and osteopericranial flaps

Pericranial or osteopericranial flaps pedicled on the superficial temporal vessels were used in the correction of various facial deformities in 16 patients. In 5 patients orthognathic surgery was also performed. In all patients a significant aesthetic improvement was achieved. In order to achieve a satisfactory tissue volume and thickness it was necessary to create a folded pericranial flap. It is possible, as a one stage procedure, to combine osteopericranial with pericranial flaps to correct severe facial deformities. It is concluded that by using this method alone or in combination with orthognathic surgery, when indicated, it is possible to achieve good long term aesthetic and functional results.

Clinical evaluation of techniques used in the surgical treatment of progressive hemifacial atrophy

We critically review 13 patients with progressive hemifacial atrophy treated with three basic surgical procedures (free flap transplantation, alloplastic implants, micro-fat injections 'lipofilling') and further ancillary techniques. In spite of the satisfactory results achieved with the procedures, with the exception of alloplasts, we feel that lipofilling may be considered an interesting solution for soft tissue augmentation of the face especially for moderate adipose defects, due to its repeatability, no donor site morbidity, no complications at the recipient site such as lesions resulting from dissection, bleeding, necrosis, etc. This technique can be performed in a day-hospital with short surgery time, at low cost and without a highly skilled team. For severe grades of adipose atrophy, because of the low blood supply to these tissues which interferes with take of any type of autograft, we think that free flaps actually represent one of the best solutions for soft tissue augmentation.