Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 10:
Temporoparietal Fascia Transplantation and Temporoparietal Composite Osteofascial Reconstruction
  A. The temporoparietal fascia forms the galea aponeurotica over the temporal, parietal, and occipital areas. It is a superior extension of the SMAS. Cephalad to the temporalis muscle origin are the five layers to the scalp. From superficial to deep, they are (1) the hair-bearing scalp, (2) the subcutaneous fat layer, (3) the galea aponeurotica or temporoparietal fascia, (4) a loose, areolar tissue layer, and (5) the pericranium. Caudad to the temporalis muscle origin, the temporalis muscle and its muscle fascia lie below the temporoparietal fascia. The temporoparietal fascia (galea aponeurotica) and the temporalis muscle are two distinct structures, separated by the loose, areolar tissue layer. The superficial temporal artery and vein, ascending in front of the ear, supply blood to free fascia. The vein is more superficial and larger than the artery. The auriculotemporal nerve lies posterior to the vascular pedicle. The frontal branch of the facial nerve lies anteriorly along the line determined by a point 1.5 cm above the lateral brow and a point 0.5 cm below the tragus. Branches of the superficial temporal artery, one frontal and one occipital branch, supply the distal portion of the flap. At the zygomatic arch, the temporoparietal fascia remains superficial and the temporalis muscle passes below it. The dotted line demonstrates our preferred placement of the initial incision.


A. The skin incision lies posterior to the vascular pedicle, located by Doppler ultrasound probe. The subcutaneous tissue layer has been infiltrated by 1:200,000 epinephrine solution for chemical hemostasis. Careful dissection in the pretragal area under the anterior flap exposes the superficial temporal vessels, the vein lying more superficial than the artery. The connective tissue bands between the scalp and the fascia are less dense in the pretragal area, but the subcutaneous fat layer is thinner. Conversely, the connections are denser as the dissection proceeds more cephalad, but the subcutaneous fat layer is thicker. Skin-hook traction on the scalp edge combined with manual countertraction on the temporoparietal fascia (TPF) stretches the connective tissue bands to allow the surgeon to divide them sharply. Bipolar cautery is necessary to control the multiple small vessel connections passing in this layer to the scalp.

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