Temporal flap variations for craniofacial reconstruction

Vascularized Composite Parietal Bone Flap for Immediate Reconstruction of a Hemi-Maxillectomy Defect in an Infant

BACKGROUND

Surgical resection of maxillary tumors can result in defects that can be difficult to reconstruct by conventional means due to the complex functional and anatomic nature of the midface and lack of regional bone flap options in the head and neck. Many reconstructive methods have been used to repair maxillary defects, but the ideal technique for the reconstruction of hemi-maxillectomy defects in growing pediatric patients has yet to be determined.

METHODS

The authors present a rare pediatric patient with melanotic neuroectodermal tumor of infancy resulting in a hemi-maxillectomy defect after resection that was reconstructed using a pedicled vascularized composite flap consisting of temporalis muscle, pericranium, and parietal bone.

RESULTS

The patient achieved successful long-term bony reconstruction of his right maxilla with this flap. Stable skeletal fixation with adequate orbital support was maintained over a >3-year follow-up period.

CONCLUSION

A vascularized composite parietal bone flap is a reliable reconstructive option for reconstruction of large maxillectomy defects providing low donor-site morbidity, adequate globe support, excellent long-term skeletal stability, and malar symmetry in rapidly growing pediatric patients. Successful reconstruction for a rare patient with maxillary melanotic neuroectodermal tumor of infancy requiring hemi-maxillectomy was demonstrated with >3-year follow-up.

Retrospective analysis of free temporoparietal fascial flap for defect reconstruction of the hand and the distal upper extremity

INTRODUCTION

Soft tissue reconstruction of the hand and distal upper extremity is challenging to preserve the function of the hand as good as possible. Therefore, a thin flap has been shown to be useful. In this retrospective study, we aimed to show the use of the free temporoparietal fascial flap in soft tissue reconstruction of the hand and distal upper extremity.

METHODS

We analysed the outcome of free temporoparietal fascial flaps that were used between the years 2007and 2016 at our institution. Major and minor complications, defect location and donor site morbidity were the main fields of interest.

RESULTS

14 patients received a free temporoparietal fascial flap for soft tissue reconstruction of the distal upper extremity. Minor complications were noted in three patients and major complications in two patients. Total flap necrosis occurred in one patient.

CONCLUSION

The free temporoparietal fascial flap is a useful tool in reconstructive surgery of the hand and the distal upper extremity with a low donor site morbidity and moderate rates of major and minor complications.

Superficial temporal artery perforator flaps for reconstruction of intraoral defects

BACKGROUND

Intraoral defects after tumor resection are often reconstructed with free tissue transfer. However, in patients who are not good candidates for free tissue transfer, regional flaps based on the superficial temporal artery can be utilized. The authors present our technique to reconstruct intraoral defects with the superficial temporal artery perforator (STAP) flap and early outcomes.

METHODS

Five patients underwent STAP flaps for defects including the hard palate, buccal sulcus, floor of mouth, and retromolar trigone between 2017 and 2019. The mean defect size was 5.6 × 3.4 cm² (3 × 3 cm² - 7 × 4 cm² ). The mean age was 74 (57-88) and all patients had recurrent cancer. External Doppler, indocyanine green laser angiography, and FLIR thermal imaging were used intra-operatively to identify the best perforators and plan for flap design.

RESULTS

The mean flap size was 7.6 × 3.5 cm² (6 × 3 cm² - 10 × 5 cm² ). Four flaps were based off of the posterior branch of the STA, while the fifth was based off of the anterior branch. Two donor sites were closed primarily, and three required skin grafts. One patient experienced partial flap necrosis. There were no complete flap losses and no donor site complications. Average follow up was 14.6 months (9-20 months). All patients maintained preoperative level of speech, mastication, and oral continence.

CONCLUSIONS

The STAP flap can be based on the anterior or posterior branch of the superficial temporal artery and is a useful regional flap for intraoral defects after tumor resection.

Superficial Temporal Artery Perforator Flap: Indications, Surgical Outcomes, and Donor Site Morbidity

The aim of this retrospective case series was to discuss indications, surgical outcomes, and donor site morbidity in the use of superficial temporal artery perforator (STAP) flaps in intra-oral or extra-oral facial reconstruction. This study involved 9 patients treated with a STAP flap at the Maxillo-Facial Surgery Unit of the University of Campania “Luigi Vanvitelli”, Naples. A STAP flap was used alone or in combination with other local flaps, for the coverage of facial soft tissue defects, after the resection of craniofacial malignant tumors (n = 7) or as a salvage flap, in partial or total microvascular flap loss (n = 2). The STAP flap was proven to be a valuable surgical option despite it not being frequently used in facial soft tissue reconstruction nor was it chosen as the first surgical option in patients under 70 year’s old. Donor site morbidity is one of the major reasons why this flap is uncommon. Appropriate patient selection, surgical plan, and post-surgical touch-ups should be performed in order to reduce donor site scar morbidity.

Use of Permacol™ to restore depression after temporal muscle flap: A case report

The temporal muscle has been an essential tool in maxillo-facial reconstruction for more than a century. Despite many technical advances, depression in the temporal fossa after its use is a constant issue. There are several ways to fill this defect. However, their efficiency has not been proven. Currently, biomaterials (e.g. polymethylmethacrylate [PMMA] and polyethylene [PE]) are the alternative most frequently used and studied. This is the first case report of temporal depression filling with a porcine dermal matrix (Permacol™). A 58-year-old woman underwent limited maxillectomy for squamous cell carcinoma of the upper vestibular mucosa, after which a pure temporalis muscle flap was used for immediate reconstruction. A custom-shaped Permacol™ sheet was used with a PMMA spacer to fill the resulting depression at the temporal fossa. The procedure went smoothly without any complications. The surgeon and the patient are satisfied with the cosmetic result. Permacol™ is a safe and effective tool to fill defects after temporalis muscle flap and is an excellent alternative to other biomaterials currently on the market.

Reconstruction of Facial Defects with Three-Stage Frontal Expanded Bipedicled Flaps

BACKGROUND

The aim of the present study was the therapeutic effect of the frontal expanded bipedicled flaps that are used in the reconstruction of facial defects. Patients were treated with mostly unilateral facial defects which affected temple area and cross the midline with frontal expanded flaps to investigate the therapeutic effect of reconstruction of facial defects with frontal expanded bipedicled flaps from June 2012 to August 2017 and 2 patients were discussed in this study.

METHODS

The surgery procedure was divided into 3 stages. At the first stage, expanders were implanted and the expanded frontal flaps were transferred at second stage. After that pedicle division was performed and the pedicle skin tissue was used to repair the residue defect at the third stage.

RESULTS

All 7 flaps survived completely with satisfactory color and texture. Satisfied results were achieved during the follow-up period of 1 year.

CONCLUSION

The bipedicled frontal expanded flap is very suitable for large facial defect due to its reliable blood supply.

Superficial temporal artery flap for reconstruction of complex facial defects: A new algorithm. Arch Plast Surg. 2018;45:118-127. [PMID: 29506337 PMCID: PMC5869424 DOI: 10.5999/aps.2017.00360]

Background

A variety of island flaps can be based on the superficial temporal artery with variable tissue composition. They can be used for defect reconstruction, cavity resurfacing, facial hair restoration, or contracture release.

Methods

Seventy-two patients underwent facial reconstruction using a superficial temporal artery island flap from October 2010 to October 2014. The defects had various etiologies, including trauma, burns, tumors, exposed hardware, and congenital causes. We classified the patients by indication into 5 groups: cavity resurfacing, contracture release, facial hair restoration, skin coverage, and combined. The demographic data of the patients, defect characteristics, operative procedures, postoperative results, and complications were retrospectively documented. The follow-up period ranged from 24 to 54 months.

Results

A total of 24 females and 48 males were included in this study. The mean age of the patients was 33.7±15.6 years. The flaps were used for contracture release in 13 cases, cavity resurfacing in 10 cases, skin coverage in 17 cases, facial hair restoration in 19 cases, and combined defects in 13 cases. No major complications were reported. Conclusion: Based on our experiences with the use of superficial temporal artery island flaps, we have developed a detailed approach for the optimal management of patients with composite facial defects. The aim of this article is to provide the reader with a systematic algorithm to use for such patients.

Continuous Validity of Temporalis Muscle Flap in Reconstruction of Postablative Palatomaxillary Defects

INTRODUCTION

Postablative palatomaxillary defects (PAPMDs) represent a challenging reconstructive problem. Temporalis muscle flap (TMF) has been widely used for reconstruction of these defects with minimal morbidity and satisfactory outcome.

AIM OF THE STUDY

To presents the authors' experience in the reconstruction of PAPMDs with TMF and to evaluate the validity of TMF in the reconstruction of such defects.

METHODS

This prospective study was conducted between July 2011 and July 2016 on selected patients for primary reconstruction of PAPMDs with TMF. Temporalis muscle flaps were assessed during surgery and postoperatively. Patients were followed up to evaluate functional and esthetic outcomes and detect complications.

RESULTS

This study included 32 patients with mean age 48.3 years. The pathology was squamous cell carcinoma in 15 patients (46.9%). Twenty-one patients (65.6%) had type II maxillectomy. Mean time of flap harvesting was 43 minutes. Zygomatic arch osteotomy was done in 3 patients while Coronoid osteotomy in 4 patients. Postoperatively, flaps were viable in 31 patients (96.9%) with good healing of recipient site. Flap epithelization completed within 28 to 59 days. Follow-up period was 13 to 55 months. Satisfactory functional and esthetic outcomes were reported in most of patients with no recurrence. Transient temporal nerve palsy occurred in 2 patients, limited mouth opening in 5 patients. One patient had Transient diplopia with enopthalmos and hypophthalmos. Flap failure occurred in another patient.

CONCLUSIONS

Temporalis muscle flap is still a valid reliable and versatile reconstructive tool in palatomaxillary reconstruction after ablative surgery. It has a good cosmetic and functional outcomes and minimal morbidity.

Superficial temporal artery perforator flap: Anatomic study of number and reliability of distal branches of the superficial temporal artery and clinical applications in three cases

BACKGROUND

Limited information is available about the anatomical feasibility and clinical applications of flaps based on distal divisions of the superficial temporal artery (STA). The aim of this study was to investigate the anatomy of the STA, focusing on the number and reliability of distal branches and to show representative cases for the use of such flaps for zygomatic, parieto-frontal and occipital reconstructions.

METHODS

Fifty volunteers were examined bilaterally by Doppler to investigate the presence and variability of the distal divisions of STA branches. Dissection was performed on 14 temporal regions of 7 fresh cadavers. Three cases of reconstruction following skin cancer in the zygomatic (7 × 5 cm defect), parieto-frontal (4 × 4 cm defect) and occipital areas (4 × 2 cm defect) are presented. All the flaps were pedicled and based on a single vessel.

RESULTS

In all the 50 volunteers, the parietal branch split into 2 ± 0 branches (anterior and posterior), bilaterally, while an average of 2.84 ± 0.46 and 2.82 ± 0.48 branches originated from the frontal vessel on the right and left side, respectively. 2 ± 0 parietal and 3 ± 0 frontal (superior, central, and inferior) cutaneous perforator branches were identified in all cadaveric specimens. Flaps (4 × 10 cm, 5 × 7 cm, and 2 × 5 cm, respectively, width × length) healed uneventfully providing stable coverage.

CONCLUSIONS

STA distal perforator branches proved to be anatomically constant in both the cadaveric and clinical settings. Although a larger series of cases is needed, island flaps based on such vessels may represent a versatile surgical option, allowing a wide range of reconstructions in the different facial subunits.

The Temporal Artery Island Flap: A Good Reconstructive Option for Small to Medium-Sized Facial Defects

PURPOSE

The reconstruction of facial defects is esthetically vital because of the unique skin color and texture of the face. The aim of this study was to show the utility of different temporal artery island flap designs for the reconstruction of upper and middle facial defects without contrast to the color and texture of the face.

MATERIALS AND METHODS

This study is a retrospective case series conducted from November 2004 through May 2015. Patients older than 18 years with upper and middle facial defects smaller than 5 cm were included.

RESULTS

The temporal artery island flap was used in 34 patients (21 men and 13 women). The etiologies were skin tumor in 17 patients, trauma in 10 patients, and burns in 7 patients. Major defect localization was in the temporal area in 12 patients, followed by the ear in 9 patients, the cheek in 6 patients, the eyebrow in 4 patients, and the nose in 3 patients. Flap designs consisted of the antegrade-flow island flap, the V-Y flap, and reverse-flow island flap in 23, 7, and 4 patients, respectively. All flaps survived completely except for 1 partial flap necrosis. Scars in the donor areas were inconspicuous. Patients' median age was 47.5 years (quartiles, 40.75 to 54), 61.8% were men, and median duration of follow-up was 11 months (range, 6 to 18 months).

CONCLUSIONS

The temporal artery island flap could be a good option for the closure of minor to medium-size defects of the upper and middle face because of its good color and texture match, constant and reliable pedicle, wide pivotal movement, low donor site morbidity, and reverse-flow pattern.

Bifurcated Superficial Temporal Artery Island Flap for the Reconstruction of a Periorbital Burn: An Innovation

Background:

Facial burns represent between one-fourth and one-third of all burns. The long-term sequelae of periorbital burns include significant ectropion and lagophthalmos as a result of secondary burn contractures in the lower and upper eyelids, in addition to complete or incomplete alopecia of the eyebrows.

Methods:

A retrospective study of 14 reconstructive procedures for 12 postburn faces was conducted with all procedures performed since 2010 at the Department of Plastic Surgery, Al-Hussein University Hospital, and at the Craniofacial Unit, Nasser Institute Hospital. Four patients experienced chemical burns, and 8 patients experienced thermal burns. All patients underwent periorbital reconstruction using a bifurcated superficial temporal artery island flap to reconstruct the eyebrows, correct the lagophthalmos, and release the ectropion in both the upper and the lower eyelids. Two patients underwent bilateral periorbital flap reconstruction. The mean age of patients was 29 years, and the study was conducted on 8 males and 4 females. Patient satisfaction was assessed using a questionnaire completed by all patients postoperatively.

Results:

The complete release of both the upper and the lower eyelids was achieved in all cases, together with ideal replacement of brow hair; no complications were noted, apart from one case in which a loss of hair density in the new eyebrow was observed, combined with the partial loss of the flap in the lower eyelid. Patient satisfaction results were collected and assembled in a table.

Conclusion:

A bifurcated superficial temporal artery island flap is an innovative flap for reconstructing both burned eyebrows and eyelids.

In vivo analysis of the vascular pattern of the superficial temporal artery based on digital subtraction angiography

BACKGROUND

Existing anatomic descriptions of the superficial temporal artery (STA) are mainly based on cadaver studies and do not accurately reflect the in vivo situation. In this study, the anatomical course and branching pattern of the STA were analyzed with digital subtraction angiographies (DSAs).

METHODS

DSAs of 93 Caucasian individuals between 16- and 79-years old were retrospectively analyzed regarding the course and branching pattern of the STA as well as surgically relevant inner diameters and lengths of its main branches.

RESULTS

In total, 11 variations in the branching pattern of the terminal STA were found. About 89% of the examined individuals demonstrated the classic variation in which the main trunk of the STA bifurcates into a single frontal and parietal branch. In 60% of cases with an existing bifurcation, the division of the main trunk of the STA was located above the zygoma. The mean inner diameters of the STA main trunk, the frontal branch and the parietal branch were 2.4 ± 0.6 mm, 1.3 ± 0.6 mm and 1.2 ± 0.4 mm, respectively. The surgically relevant "working lengths" of the frontal and parietal branches above the upper margin of the zygoma up to an inner diameter of 1 mm were 106.4 ± 62.1mm and 99.7 ± 40.9 mm, respectively.

CONCLUSIONS

The common variations of the branching pattern of the STA are described in this study. Furthermore, surgically relevant inner diameters and lengths of the main branches of the STA are determined. These findings should improve our understanding of the suitability and usefulness of the STA for various surgical procedures.

Reconstruction of periorbital soft tissue defect with reversed superficial temporal artery island flap

BACKGROUND

Periorbital soft tissue reconstruction is a challenge because of its difficulty in regaining both the form and the function. Local flap is the priority method because it could provide excellent match in skin color and texture.

OBJECTIVE

We aim to investigate the application of pedicled reversed superficial temporal artery island flap in the reconstruction of periorbital soft tissue defect.

METHOD

Different kinds of reversed superficial temporal artery island flaps were harvested from the auricular area to cover the defect in the periorbital area.

RESULTS

Ten patients who suffered congenital or acquired periorbital diseases were treated with this method. One case suffered minor venous congestion postoperatively. All the other cases achieved good aesthetic result in both the donor and the recipient sites.

CONCLUSION

Reversed superficial temporary artery island flap could be safely harvested from the auricular region even in a split pattern. It could be used to cover the periorbital defect with an unconscious scar at the donor site.

The application of axial superficial temporal artery island flap for repairing the defect secondary to the removal of the lower eyelid basal cell carcinoma

Our aim was to investigate the repair of the defect that follows excision of a basal cell carcinoma (BCC) of the lower eyelid. Skin projections of the superficial temporal artery and its frontal branches were marked using Doppler ultrasonography. The lesion was excised with 0.5-1.5cm margins. Frozen sections were taken to clarify the diagnosis. The frontal flap was designed according to the preoperative labelling, and was 0.5cm larger than the defect. The pedicle was 1.0-1.5cm longer than the distance between the pedicle and the defect, and the width of the pedicle was 3cm. If the lesion affected the full thickness of the lower eyelid, a conjunctival flap was sutured with the flap. A skin graft was applied when the defect was large. Such defects have been repaired successfully in 10 patients. There was no secondary defect or ectropion postoperatively. The superficial temporal artery frontal branch island flap is a satisfactory method for the repair of a defect secondary to a BCC of the lower eyelid.

Osteomyelitis of the craniofacial skeleton

Skull-based osteomyelitis, which is a true bony infection, originates from a chronic, inadequately treated infection. Because of the complex craniofacial skeletal anatomy and associated aesthetic concerns, osteomyelitis of the craniofacial skeleton must be uniquely managed and is more difficult to treat than osteomyelitis of other bones of the body. It is thought that osteomyelitis is decreasing in prevalence due to broad-spectrum antibiotic treatment; however, it still remains a challenging clinical entity in developing countries and lower socioeconomic areas.

Functional and aesthetic reconstruction of extensive oral ablative defects using temporalis muscle flap: a case report and a sort review

PURPOSE

Temporalis muscle flap (TMF) provides a reliable solution in reconstruction of extensive intraoral ablative defects, providing a valuable alternative to more complex and extensive reconstructive procedures, combining excellent functional and aesthetic rehabilitation with minimal complications. In this article is described in detail the TMF surgical technique with attention to specific methods useful for preventing facial nerve injury and donor-site deformity.

MATERIALS AND METHODS

It is presented the case of a patient with malignant tumour in the region of the upper jaw, palate and inferior half of the nasal cavity, who underwent extensive surgical excision and the resultant defect was successfully reconstructed with TMF.

RESULTS

The reconstructive procedure resulted in excellent immediate and long-term functional (aspiration, feeding and speech) and aesthetic results. During the 5-year follow-up period no complications associated with the flap or the temporal implant, used for donor-site reconstruction were encountered and no local recurrence or tumour metastasis was observed.

CONCLUSION

The TMF is a reliable, technically easy and anatomically sound technique, which combines excellent aesthetic and functional results with minimal complications, if performed correctly.

Ultralong pedicled superficial temporal fascia island flaps for lower nasal defect

OBJECTIVE

To explore the method of repairing nose defects of the apex, ala, septum, and even opposite ala nasi with ultralong pedicled superficial temporal fascia (STF) island flaps.

METHODS

There were 29 cases of defects of the apex nasi, ala nasi, and nasal columella that were reconstructed, of which 12 cases were repaired with frontal-branched STF island flaps, 14 cases with apical-branched STF postauricular island flaps, and 3 cases with prefabricated apical-branched STF postauricular island flaps. The flap areas were arranged from 1.2 x 2.3 to 2.0 x 2.8 cm2, the length more than 15 cm on average. Liners were reconstructed at the stage of the prefabricating flaps, with free skin graft in the cases of the alae nasi defects. The surfaces of the wound after flap prefabrications were covered by skin graft as well.

RESULT

Twenty-seven cases were successfully taken without blood circulation blocks; the color, texture, and figure were good, and the outcomes were satisfying. Seven nonprefabricated flap cases have epidermis necrosis due to the lack of artery perfusion pressure and venous return handicap, and the epidermis fall off after 1 month; 2 cases of which required secondary surgeries because of partial necrosis.

CONCLUSIONS

An ultralong pedicled STF island flap is an available way to repair defects of the apex nasi, ala nasi, and nasal columella. The benefits of a prefabricated flap are good blood circulation, primary made liner, and minute injury of the donor site. It is a good method of repairing defects of the apex nasi, ala nasi, nasal septum, and opposite ala nasi simultaneously.

Ultralong pedicled superficial temporal fascia island flaps for lower nasal defect

To explore the method of repairing nose defects of apex, ala, septum, and even opposite ala nasi with ultralong pedicled superficial temporal fascia (STF) island flaps. There were 29 cases with defects of apex nasi, ala nasi, and nasal columella, of which 12 cases were repaired with frontal-branched STF island flaps, 14 cases with apical-branched STF postauricular island flaps, and 3 cases with prefabricated apical-branched STF postauricular island flaps. The flap areas were arranged from 1.2 x 2.3 to 2.0 x 2.8 cm2; the length was more than 15 cm on average. Liners were reconstructed at the stage of prefabricating flaps with free skin graft in the cases of ala nasi defects. The surfaces of wound after flap prefabrications were covered by skin graft as well. Twenty-seven cases were successfully taken without blood circulation blocks; the color, texture, and figure were good, and the outcomes were satisfying. Seven nonprefabricated flap cases have epidermis necrosis because of the lack of artery perfusion pressure and venous return handicap, and the epidermis fell off after 1 month, 2 cases of which required secondary surgery because of partial necrosis. Ultralong pedicled STF island flap is an available way to repair defects of apex nasi, ala nasi, and nasal columella. Prefabricated flaps are with benefits of good blood circulation, primary-made liner, and minute injury of the donor site. It is a good method to repair defects of apex nasi, ala nasi, nasal septum, and opposite ala nasi simultaneously.