J Oral Maxillofac Surg 61:1228-1230, 2003

Clinical Application of the Temporoparietal-Galeal Flap in Closure of a Chronic Oronasal Fistula: Review of the Anatomy, Surgical Technique, and Report of a Case
David M. Fallah, DDS,* Dale A. Baur, DDS, MD, Henry W. Ferguson, DMD, and Joseph I. Helman, DMD
The reconstructing surgeon has a variety of options when closing defects of the hard and soft palate. Techniques can be as simple as a palatal island ap or as complex as the radial forearm ap. We present here a method of closing a medium to large defect of the palate using the temporoparietal-galeal (TPG) ap, a regional and very reliable ap for reconstructing defects of the oral cavity and face. The TPG is a thin and pliable ap with an axial blood supply and a good arc of rotation to the oral cavity. The ap can be used as a fascial ap, a fasciocutaneous ap, or an osteofascial ap. It provides an excellent source of vascularized tissue.

Anatomy
The temporoparietal fascia represents the cephalad extension of the supercial musculoaponeurotic system. Superiorly, it is continuous with the galea. Supercial to the fascia are the skin and subcutaneous tissue. The frontal branch of the facial nerve is usually found between this fascia and the supercial layer of the deep temporal fascia. Stuzin et al,1 in a study of 12 fresh cadaver dissections, reported that the frontal branch always traveled in an anatomically predictable and constant plane deep to supercial temporal fascia. Within the TPG fascia, the supercial temporal artery divides into anterior and posterior divisions about 2 cm above the zygomatic arch.2,3 The auriculotemporal nerve, a sensory branch of the trigeminal nerve, crosses the zygomatic arch just posterior to the supercial temporal vessels. Its branches lie within the supercial temporal fascia, which provide sensory innervation to the skin of the upper part of the temporal region.2,3

*Major, US Army; Formerly, Chief Resident, Department of Oral and Maxillofacial Surgery, Eisenhower Army Medical Center, Fort Gordon, GA; Currently, Chief, Oral and Maxillofacial Surgery, 121st General Hospital, Seoul, Korea. Colonel, US Army; Chief, Department of Oral and Maxillofacial Surgery, and Residency Program Director, Eisenhower Army Medical Center, Fort Gordon, GA. LTC, US Army; Assistant Program Director, Eisenhower Army Medical Center, Fort Gordon, GA. Director, Oncologic Maxillofacial/Head and Neck Surgery, and Chairman, Section of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI. The opinions expressed in this case report are the authors and do not represent the ofcial opinion of the United States Army, the Department of Defense, or the United States Government. Address correspondence and reprint requests to Col Baur: Eisenhower Army Medical Center, Bldg 300, Department of Oral and Maxillofacial Surgery, Fort Gordon, GA 30905; e-mail: dale. baur@se.amedd.army.mil Published by Elsevier on behalf of the American Association of Oral and Maxillofacial Surgeons.
0278-2391/03/6110-0022$0.00/0 doi:10.1016/S0278-2391(03)00689-0

Report of a Case
A 52-year-old man who was status post right hemimaxillectomy in 1998 for a low-grade adenocarcinoma of the palate was seen in the Oral and Maxillofacial Surgery Service at Eisenhower Army Medical Center. He showed no evidence of recurrence. He requested a surgical option to avoid the use of an obturator. The TPG ap was chosen to reconstruct the oronasal defect (Fig 1) because of its reliability, size, excellent blood supply, and ease of manipulation. SURGICAL TECHNIQUE The right supercial temporal artery and its branches were identied and marked using a Doppler ultrasound device. The proposed course of the temporal branch of the facial nerve was marked about 3 cm above and 2 cm lateral to the supraorbital rim.4 A preauricular incision was outlined extending from the tragus of the right ear, within a skin crease, extending superiorly and posteriorly as a hemi-

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FIGURE 1. Oronasal defect before surgery. FIGURE 3. With blunt dissection, a tunnel was created supercial to the zygomatic arch, from the base of the pedicle, into the oral cavity. The instrument shows the position and direction of the dissection.

coronal-type incision extending over the temporoparietal region and ending two thirds of the distance to the apex of the skull. A very supercial incision was made using a No. 15 blade into the subcutaneous tissue just below the hair follicles,4 in the subfollicular plane of the scalp. Profuse bleeding suggests that the plane of dissection is too deep.4 The galea is adherent to the overlaying subcutaneous layer of the skin, and its elevation, in this subdermal fat layer, is tedious. Dissection progressed in a cephalad direction, using a series of No. 15 blades. This dissection creates an articial plane; thus sharp dissection is needed. Essentially, only hair follicles are seen and are used as a landmark (Fig 2). If the skin ap is made too thin; however, hair follicles will be damaged, resulting in alopecia, or buttonholing of the skin ap may occur. Once an adequate width and length of ap are exposed, the ap is initially mobilized. The ap is easily mobilized by sharply incising into the subgaleal plane at the superior extent of the ap. Once in the relatively avascular subgaleal plane, the ap can then be mobilized down to the zygomatic arch. When mobilizing the ap near the arch, care must be taken to avoid injury to the frontal branch of the

facial nerve. As mentioned earlier, the nerve travels in the deeper aspects of the TPG fascia or between the TPG fascia and the temporalis fascia. It is advisable to use a nerve stimulator in this area before incising tissue on the anterior extent of the ap. Once the ap is fully mobilized, a tunnel must be created from the base of the pedicle to the oral cavity defect (Fig 3). Blunt dissection was used from the temporal region, supercial to the zygomatic arch, and into the oral cavity, piercing the mucosa near the defect. To avoid strangulating the ap, the tunnel was easily able to accommodate the width of 2 ngers. Before ap advancement, the entire soft tissue bed to receive the ap was deepithelialized using a No. 15 surgical blade. The ap was advanced through the tunnel into the oral cavity and was properly oriented on the large oronasal stula region, tension free. Twisting of the ap must be avoided to maintain good perfusion. The ap was secured

FIGURE 2. Articial plane of dissection is created, and hair follicles are seen. Also note the use of Doppler ultrasound to verify position of the supercial temporal artery.

FIGURE 4. Temporoparietal-galeal ap 3 weeks postoperatively. The ap is partially covering the bar connecting the implants.

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CLINICAL APPLICATION OF THE TPG FLAP

FIGURE 5. Temporoparietal-galeal ap was debulked 6 weeks postoperatively. Shown is complete closure of the stula about 8 weeks postoperatively.

in place, using a 4-0 Vicryl suture (Ethicon, a Johnson & Johnson Co, Somerville, NJ), in an interrupted as well as horizontal mattress fashion. The ap pedicle, however, was not sutured to prevent strangulating the blood supply. The dimensions of this ap were approximately 15 cm long and 6 cm wide. Once the ap was secured, attention was directed to the donor site where further hemostasis was achieved using a bipolar electrocautery. A suction drain was passed with the drain site exiting posterior to the right ear and was secured in place, and the wound was closed. Postoperative enteral feeding via a nasogastric tube was initiated for 7 days to protect the ap. Postoperatively, the patient had full function of the frontal branch of the facial nerve. Some areas of alopecia developed along the incision line, but gradually the hair returned. The oronasal stula closed without event (Fig 4). Six weeks later, the ap was debulked under intravenous sedation to facilitate the fabrication of a new prosthesis (Fig 5).

easily hidden by hair growth with minimal morbidity. It is well vascularized and can be maneuvered into a variety of sites about the face and oral region with little difculty. The use of the TPG ap has been well documented in the literature. Avelar and Psillakis7 described the use of the galeal layers in facial reconstruction, and Horowitz et al8 described the use of galeal-pericranial aps in a variety of situations in orbital and facial reconstruction. The TPG ap has several advantages: It is reliable with excellent blood supply. It has a good arc of rotation8,9 into the oral cavity or face. It has minimal donor site morbidity. It is thin and pliable.8,9 The donor site scar is hidden with hair growth.8,9 Patient position is supine, and there is no need for interoperative position changes.8,9 Potential complications include 1) loss of hair follicles and subsequent scalp alopecia; maintaining a thin layer of fat on the skin ap can minimize this, 2) a surgical scar is seen in men with male pattern baldness, and 3) damage to auriculotemporal nerve, and to the branches of the facial nerve, which can be avoided with careful surgical technique.

References
1. Stuzin JM, Wagstrom L, Kawamoto HK, et al: Anatomy of the frontal branch of the facial nerve: The signicance of the temporal fat pad. Plast Reconstr Surg 83:265, 1989 2. Abdul-Hassan HS, von Drasek Ascher G, Acland RD: Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 77:17, 1986 3. Gray H: The arteries of the head and neck, in Goss CM (ed): Grays Anatomy. Philadelphia, PA, Lea and Febiger, 1973, pp 579-596 4. Helman JI, Cesteleyn L: Local Flaps in Facial Reconstruction. A Comprehensive Approach for the Oral and Maxillofacial Surgeon. Dissection Manual, The University of Michigan Section of Oral and Maxillofacial Surgery, Ann Arbor, MI, 1998 5. Rose EH, Norris MS: The versatile temporoparietal fascial ap: Adaptability to a variety of composite defects. Plast Reconstr Surg 85:224, 1990 6. Tolhurst DE, Carstens MH, Greco RJ, et al: The surgical anatomy of the scalp. Plast Reconstr Surg 87:603, 1991 7. Avelar JM, Psillakis JM: The use of galea aps in craniofacial deformities. Ann Plast Surg 6:464, 1981 8. Horowitz JH, Persing JA, Nichter LS, et al: Galeal-pericranial aps in head and neck reconstruction: Anatomy and application. Am J Surg 148:489, 1984 9. Upton J, Rogers C, Durham-Smith G, et al: Clinical applications of free temporoparietal aps in hand reconstruction. J Hand Surg 11:475, 1986

Summary
There are a variety of techniques to close a large chronic oronasal stula, such as use of a prosthetic obturator, a local ap, or a microvascular ap. We elected to use a TPG ap, which is very versatile and allows for a variety of applications in head and neck surgery. Its thin texture is aesthetically superior to bulkier aps, and it will conform to the shape of underlying soft tissue.5,6 The donor site is inconspicuous and