|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| Cranial bone can be carried on the temporoparietal fascia as an osteofascial flap, as either a pedicled flap or a free tissue transfer. Again, the distance between the recipient site vessels and the bony defect determines the length of the superficial temporal pedicle and the site of the cranial bone graft below the temporoparietal fascia. The curved cranial bone can be used to reconstruct mandibular defects. Full-thickness cranial bone or outer cortex alone can be transplanted with the fascia. After determining the pedicle length, the template for the bone is placed on the scalp to establish the extent of the fascial flap dissection superiorly.
Exposure of the superficial surface of the fascia has been described and is the same for the osteofascial flap. The bone template is then placed on the fascia, and the periphery is marked. The temporoparietal fascia is incised larger than the bone template to provide additional coverage for the bone. The fascia is elevated to the borders of the bone template circumferentially.
The surgical team includes a neurosurgeon to aid in elevating the cranial bone and to advise on positioning the template to avoid important intracranial structures. A combination of burr holes and a craniotome has been our method of harvesting full-thickness cranial bone. Osteotomes are used to split the two cortices when a single, outer table bone graft is necessary. Special care must be taken to maintain the fascial connections to the bone graft. Once the bone graft is free, the dissection is continued inferiorly in the loose, areolar tissue layer deep to the fascia. The pedicle can be left intact for a pedicled osteofascial flap.
The donor site for the temporoparietal fascial flap can be closed primarily, but the edge of the incision may require resection to avoid space below the closure. This edge is also the scalp tissue most prone to alopecia, which can be minimized through such a resection. The donor defect for the bone graft in an osteofascial flap can be closed by grafting the defect with split, outer table bone grafts from the periphery of the donor defect. A suction drain is used below the scalp closure unless an osteofascial flap is taken. In that case, a Penrose drain is used.
Transient alopecia has been associated with large flaps. We have had one case of permanent alopecia in a bipedicle flap. Although numbness has occurred near the incision, it has not been a problem.
PLATE X-1. Anatomy
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