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 B. Both anterior and posterior skin flaps are elevated with this technique. After the flap template is marked on the fascial surface, the edges of the flap are incised superiorly and posteriorly. The fascial flap is elevated in the loose, areolar tissue plane over the temporalis muscle and fascia. Dissection on the anterior border is undertaken carefully to preserve the frontal branch of the facial nerve, which is not always exposed or seen during the operation.
 C. The temporoparietal fascial flap is reflected off the underlying temporalis muscle fascia. The artery and vein are freed in the pretragal area, and the two dissections are joined from below and above. The flap is ready for transfer and remains perfused.
PLATE X-3
 A. In the osteofascial flap, the length of pedicle between the recipient vessels (in a free flap transfer) or point of rotation (in a pedicle flap) and the bone defect determines where on the TPF the bone graft will be harvested. The mandibular defect has been defined. The cranial bone donor site is selected to allow a relaxed arc of rotation on the superficial temporal vessels.
 B. The TPF flap is incised to allow dissection around the cranial bone graft. A tunnel under the fascial layer must be created inferior to the bone graft. The border of the fascial flap is purposefully made larger than the cranial bone template to provide additional soft tissue coverage.
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 C. The fascial edges are elevated just to the edges of the bone template. Burr holes combined with a craniotome a used to obtain the full-thickness cranial bone graft. The fascial attachments to the underlying bone graft are carefully preserved as the neurosurgeon elevates the fullthickness bone graft.
 D. After the graft is freed, the fascial flap is separated in the loose, areolar tissue layer toward the pedicle.
 E. The osteofascial flap has been freed to its point of rotation and is perfused through the superficial temporal vessels. The donor site for the cranial bone is reconstructed with split, outer table grafts from the periphery of the defect.
 F. The excess fascia is used to wrap around the cranial bone to complete the vascularized cover for the bone graft.
Clinical Cases
CASE 1
A gunshot wound to the dominant hand on its ulnar aspect fractured the metacarpal neck, cut both flexor tendons and digital nerves, and devascularized the fifth digit. The injured
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