Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 10:
Temporoparietal Fascia Transplantation and Temporoparietal Composite Osteofascial Reconstruction
  Once the vascular axis is identified, a narrow strip is shaved along the planned incision line. We prefer to place the incision posterior to the vascular pedicle to avoid injuring the vessels with the initial incision. This placement also allows the pedicle to be approached through a controlled dissection below the scalp flaps. Larger flaps may require T- or Y-shaped extensions from this pretragal vertical incision. After the site is prepped and draped, the subcutaneous tissues over the flap are carefully injected with 1:200,000 epinephrine solution.

The initial exposure is developed in the pretragal area, where the skin is more loosely held by the fascia. The subcutaneous fat layer is thinner in this area, however, and the dissections must be done carefully and patiently at the level of the hair follicle bulbs. The thin-walled vein will be visible on the superficial aspect of the fascial layer. Once the pedicle has been identified, the dissection continues superiorly.

The subcutaneous tissue layer becomes thicker as one proceeds more cephalad. At the same time, the connective tissue bands holding the fascia to the overlying hair-bearing scalp become denser. Skin-hook traction on the scalp edges is used to expose the temporoparietal fascia so that the connective tissue bands can be sharply divided. Penetrating blood vessels pass between the scalp and fascia and require bipolar cauterization. Despite this, the thicker subcutaneous fat layer eases the dissection as the vertex is approached. The anterior and posterior skin flaps are elevated in the same manner.


The flap template is placed over the fascial layer and marked. The edges are incised, and the flap is elevated in the loose areolar tissue layer below it. The flap narrows as the pedicle is approached inferiorly, thus preserving the frontal branch. The artery and vein are isolated in the pretragal area. The dissections are connected between the superior flap elevation and the vascular pedicle isolation. Transection of the vessels is delayed until the recipient vessels have been prepared for the free fascial flap transplantation.

To use this tissue as a fasciocutaneous flap requires careful design and placement of the cutaneous island. Hairbearing or hairless skin can be chosen. Careful measurement between the vessels and the defect at the recipient site dictates the length of the superficial temporal vascular pedicle to the skin paddle. We have transferred a 3 cm wide island flap on a fascial carrier and have obtained primary closure at the donor site. Large skin islands, however, may require skin grafting at the donor site.

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