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Original Article |

Hair-Bearing Temporoparietal Fascial Flap Reconstruction of Upper Lip and Scalp Defects FREE

Jennifer C. Kim, MD; Tessa Hadlock, MD; Mark A. Varvares, MD; Mack L. Cheney, MD
[+] Author Affiliations

From the Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston.


From the Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston.

More Author Information
Arch Facial Plast Surg. 2001;3(3):170-177. doi:.
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Background  The temporoparietal fascial flap has proven to be a versatile flap for a broad spectrum of reconstructive problems in the head and neck. The temporoparietal fascial flap is a thin, pliable layer of richly vascularized tissue that may be transferred either pedicled or free and alone or as a carrier of subjacent bone or overlying skin and scalp.

Objective  To report our experience using a hair-bearing temporoparietal fascial flap for reconstruction in 6 male patients with extensive upper lip and scalp defects, including a discussion of the surgical anatomy and technique.

Methods  Temporoparietal fascial flaps with overlying scalp were used as pedicled and free flaps for the reconstruction of upper lip and scalp defects.

Results  All reconstructive results were satisfactory. Oral competence, measured by both speech and mastication performance, was achieved in patients with upper lip defects. Healthy scalp coverage was obtained in patients with local defects. The cosmetic appearance was satisfactory to all patients.

Conclusions  Ideal reconstruction of large upper lip and scalp defects is achieved with local tissue that best mimics the normal face color, texture, and hair-bearing qualities. Hair-bearing temporoparietal fascial flaps possess these characteristics and are an excellent choice for the restoration of function and aesthetics.

Figures in this Article

THE USE of scalp tissue in facial reconstruction has been appreciated for thousands of years. Gillies1 was one of the first to describe the use of the pedicled scalp flap based on the superficial temporal artery for reconstruction of lip and eyebrow defects. The advent of microvascular surgery renewed interest in the vascular supply of the temporal region as a potential free flap donor site. Numerous anatomical studies that described the layers and blood supply of the scalp followed.2-4 Since then, there has been a greater appreciation of the anatomy, with a succession of advances and refinements in the use of this tissue.

The skin of the scalp can survive as a random local flap, or it can be carried with some or all of the underlying tissue layers. Similarly, the temporoparietal fascia can be used as a random local fascial flap or as an axial flap based on the superficial temporal vessels. Its rich vascularity, proximity, and similar texture offer distinct advantages in the reconstruction of complex head and neck defects. This versatile flap has been used as a pedicled, free, or composite flap with calvarium or hair-bearing skin to reconstruct defects of the extremities, auricle, orbit, cheek, and oral cavity.5-11 The temporoparietal fascial flap (TPFF) has also been used to address Frey syndrome,12 osteoradionecrosis,6 nasal septal perforations,13 and temporal bone pathology.14-15

Many treatment options are available for large upper lip and scalp defects, including skin grafts, local flaps, regional compound flaps, and free flaps.16-19 Lip and scalp tissues have specific intrinsic qualities, along with functional and aesthetic requirements, which limit optimal reconstructive choices. For example, scalp tissue lacks elasticity by nature, and its layout is dictated by hair follicle orientation.

Hair-bearing TPFFs provide an ideal reconstructive option for significant upper lip and scalp defects given their high vascularity, anatomical proximity, minimal associated donor site morbidity, and overlying hair.

We describe a series of 5 male patients in whom a hair-bearing TPFF was used for reconstruction of large upper lip and scalp defects. One patient with alopecia had a non–hair-bearing TPFF covered with a split-thickness skin graft.

ANATOMICAL FEATURES

Various nomenclature has been used interchangeably with temporoparietal fascia, including superficial temporal fascia, epicranial aponeurosis, and galeal extension.2 These all accurately reflect the anatomy of the tissue (Figure 1). A TPFF is a thin, highly vascularized connective tissue layer just deep to the hair follicles and subdermal layer of fibrofatty tissue in which they lie. The temporoparietal fascial layer becomes increasingly adherent to this overlying layer as more fibrous septae and blood vessels traverse the layers toward the vertex. Above the temporal line, the temporoparietal fascia becomes galea aponeurotica. In contrast, the temporoparietal fascial layer glides over its medial or deep surface, where it is separated from the deep temporalis fascia by a loose areolar tissue layer.20-21

Place holder to copy figure label and caption
Figure 1.

The layers of the scalp are follows: A, hair bearing; B, subcutaneous tissue; C, frontalis muscle and galea aponeurotica; D, periosteum; E, cranium; F, temporalis muscle; G, deep temporalis fascia; H, loose areolar tissue; and I, temporoparietal fascia with superficial temporal vessels.

Graphic Jump Location

A temporoparietal fascia is continuous with the galea above, the frontalis muscle in front, the occipitalis behind, and the subcutaneous musculoaponeurotic layer of the face. The flap ranges from 2 to 4 mm in thickness and can be harvested with dimensions up to 17 × 14 cm.2, 20-21

The superficial temporal artery and vein nourish the temporoparietal fascial layer. Coursing through this layer, the artery arborizes approximately 2 cm above the zygomatic arch into anterior and posterior branches. Each of the main branches then sends perforators to the overlying subdermal layer. The superficial temporal vein runs more superficially and less predictably in this layer, increasing its risk of injury during harvest. The artery averages 2.0 mm in diameter as it exits the parotid salivary gland; the vein is slightly larger.2, 20-21

Two nerves lie in close proximity to the temporoparietal fascia. The frontal branch of the facial nerve runs just deep to the temporoparietal fascia. It traverses the zygomatic arch obliquely one finger breadth behind the posterior edge of the zygomatic process of the frontal bone. The auriculotemporal nerve is within 5 mm of the superficial temporal artery until 1.5 cm above the helix and may be preserved by staying at least 5 mm from the pedicle during inferior flap elevation.2

SURGICAL TECHNIQUE

A Doppler ultrasound is used to mark out the course of the anterior and posterior branches of the superficial temporal vessels. The hair-bearing skin is most often based on the posterior branch, well posterior to the hairline and danger zone of the frontal branch. A template of the defect is outlined on the scalp. The distance from the point of rotation at the level of the tragus to the proximal extent of the defect is measured. Then, if needed, the flap can cross the midline for 2 to 3 cm without vascular compromise.

For our pedicled flaps, a 2-cm strip of scalp along the course of the vessels is preserved. Flap dissection is started along the superior cutaneous margin of the flap and elevated in the loose areolar layer between the galea and pericranium The pedicle is elevated inferiorly as far as is practical, most often up to the zygomatic arch. For the bipedicled flaps, the same concepts are upheld, but we maintain a continuous strip of scalp extending over the vertex, analogous to a bucket handle. The donor site is closed in 2 layers over a suction drain.

The pedicled flap is sutured into the defect where it remains for a minimum of 3 weeks. In the bipedicled flaps, the release of the pedicles is staged at least 1 week apart, and challenged with a tourniquet prior to transection. The pedicles are transected proximally at their bases.

For our free hair-bearing grafts, the axial vessels are isolated via a preauricular incision. Once the pedicle is identified, the anterior and posterior scalp flaps are elevated just deep to the hair follicles; this is best initiated just above the ear where it is looser and easier to enter the correct subcutaneous plane. As previously mentioned, the TPFF is densely adherent to the subcutaneous layer of the scalp. The lateral aspect of the flap dissection seems to be in an unnatural plane requiring attention to preserve the hair follicles and the vascular pedicle.

Bipolar cautery for hemostasis helps avoid damage to hair follicles and vessels. Pedicle lengths up to 6 cm may be obtained. Additional length may be gained inferiorly, but may require mobilization of the parotid salivary gland to identify and preserve the facial nerve branches.

If used as a free flap, the vascular pedicle is divided anterior to the root of the helix. Saphenous veins are harvested for use as interposition grafts.

CASE 1

A 64-year-old man underwent resection of a squamous cell carcinoma of the left nasal alar–nasolabial region. This resulted in a complex midfacial soft tissue defect including full-thickness loss of the lateral ala, oronasal fistula, and scarred upper lip sparing the vermilion (Figure 2A).

Place holder to copy figure label and caption
Figure 2.

A, Left upper lip defect; B and C, left pedicled temporoparietal fascial flap; and D, final postoperative result.

Graphic Jump Location

A pedicled hair-bearing TPFF to repair a 3.5 × 2-cm upper lip defect was harvested and inset as the first stage (Figure 2B-C). The lateral alar defect was repaired concurrently using a midline forehead flap. The pedicle was divided after 4 weeks (Figure 2D). The wound healed well with excellent cosmetic and functional results.

CASE 2

A 48-year-old man underwent multiple resections of a basal cell carcinoma and multiple reconstructive procedures, including a scapula osteocutaneous free flap. He also underwent radiotherapy. Recurrent wound breakdown resulted in a complex midfacial soft tissue defect involving near-total upper lip and wound dehiscence of the lower lip (Figure 3A).

Place holder to copy figure label and caption
Figure 3.

A, Complex upper lip defect; B, superficial temporal vessels traced using Doppler ultrasonography; C, flap design for upper lip defect; D, prefabrication of deep surface with skin graft; E, bipedicled temporoparietal fascial flap inset; and F, final postoperative result.

Graphic Jump Location

A bipedicled hair-bearing TPFF prefabricated with full-thickness skin graft was used for reconstruction in 3 stages. In the first stage, the midportion of the scalp flap was designed in the shape of the defect and prefabricated with a skin graft. The scalp flap was elevated like a bucket handle, pedicled bilaterally on both superficial temporal vessels, and stapled in place for delayed release (Figure 3B-C).

In the second stage, the bipedicled prefabricated flap was released and sutured into the defect (Figure 3D). Six weeks later, 1 pedicle was divided followed by the second pedicle the next week (Figure 3E). Postoperatively, he had moderate wound dehiscence of the left commissure requiring revision.

CASE 3

A 38-year-old man underwent total maxillectomy for osteosarcoma followed by reconstruction with rectus free flap and a conventional iliac bone graft. The patient subsequently experienced upper lip necrosis leaving only 0.5 cm of upper lip at each commissure (Figure 4A).

Place holder to copy figure label and caption
Figure 4.

A, Upper lip defect; B and C, bipedicled temporoparietal fascial flap inset; and D, final postoperative result.

Graphic Jump Location

A bipedicled bitemporal hair-bearing TPFF was designed and inset into the defect (Figure 4B-C). The pedicles were divided in a staged fashion 2½ and 3½ weeks postoperatively (Figure 4D). The wound healed well and the patient was able to wear his dentures, eat, and speak normally. Additionally, he experienced some return of sensation in the neoupper lip.

CASE 4

A 40-year-old man had severe scarring and alopecia of the right superior temporoparietal scalp as a result of battery acid burns (Figure 5A). For 2 months tissue expanders were placed adjacent to the expected defect site (Figure 5B). The incisions for expander insertion were incorporated into the final flap design. Skin incisions were designed to restore the natural hairline and hair-bearing skin to the scarred temporoparietal region. An island of hair-bearing TPFF was elevated on its pedicle and used to fill the defect following scar-alopecia excision (Figure 5C-E). The previous tissue expansion allowed for primary closure of the scalp (Figure 5F-H).

Place holder to copy figure label and caption
Figure 5.

A and B, Right temporoparietal alopecia-scar and tissue expanders; C, marking of pedicle; D, elevated island of hair-bearing temporoparietal fascial flap; E and F, insetting of flap island; and G and H, final postoperative result.

Graphic Jump Location
CASE 5

A 48-year-old man with recurrent scalp melanoma had previously undergone a wide local excision with preservation of the pericranium and immediate split-thickness skin graft for coverage. Five months after initial resection, he had a recurrence at the margins. He underwent a radical resection with removal of the outer calvarium in conjunction with a posterior neck dissection. This resulted in a 9 × 7-cm defect in the parietal scalp and a 3 × 3-cm subjacent defect of the calvarium (Figure 6A-B). Mobilization of the adjacent hair-bearing TPFF using a V- to Y-technique was performed for reconstruction. The vascular pedicle was extended using an interposition vein graft (Figure 6C-E). Postoperatively, the patient did well with complete coverage of the cranial defect. A persistent proximal area of alopecia remained in an area over which a split-thickness skin graft was placed.

Place holder to copy figure label and caption
Figure 6.

A, Recurrent scalp melanoma; B, 9 × 7-cm parietal scalp defect; C, temporoparietal fascial flap with interpositional vein grafts; D, hair-bearing skin island transposed in V- to Y-fashion; E, flap inset with skin graft closure of defect superior to pinna; and F, final postoperative result.

Graphic Jump Location
CASE 6

A 76-year-old man underwent resection of a basal cell carcinoma of the scalp leaving a 6 × 8-cm, full-thickness defect including the periosteum (Figure 7A). Similar to patient 5, he underwent reconstruction with TPFF with saphenous vein interposition. However, owing to his natural state of alopecia, a split-thickness skin graft was used to cover the graft. The wound healed without event and with excellent cosmesis.

Place holder to copy figure label and caption
Figure 7.

A and B, Basal cell carcinoma of scalp; C, outline of superficial temporal vessels; D, temporoparietal fascial flap with interpositional vein grafts; and E and F, inset of flap with skin graft coverage.

Graphic Jump Location

All flaps (N = 6) survived. No major perioperative complications occurred. One patient (case 2) had moderate dehiscence in the previously irradiated wound bed, requiring a secondary revision. One patient (case 3) had some return of sensation in the upper lip. In long-term follow-up (minimum of 2 years), adequate functional and aesthetic outcomes were obtained in all cases. All 3 patients with upper lip reconstruction were able to eat and speak satisfactorily. All 6 patients were satisfied with the improvement in their appearance.

Optimal reconstruction of extensive upper lip and scalp defects is achieved with local tissue that best mimics the normal face color, texture, and hair-bearing qualities. For upper lip defects, functional considerations, including the ability to articulate and maintain oral competence during mastication, are important. This require reconstruction with tissue of adequate bulk, volume, texture, pliability, and color, as well as maximizing the preservation of motion and sensation. Unfortunately, the complex function and contour of the lip make the dual goals of restoring form and function difficult to achieve.

When lip defects exceed more than 60% of lip width, the conventional methods of local flaps (ie, Gillies fan flap,22 or Bernard-Burow flap23) are less satisfactory aesthetically and functionally due to displacement of the modiolus and invariable microstomia. When skin grafts or distant flaps are used, bulk, color, and texture are frequently compromised and the orbicularis sphincter is not restored. There is also increased donor site morbidity and surgical time with distant flaps.

For males, the scalp most closely approximates the hair density and quality of the upper lip. Our 3 cases demonstrate acceptable cosmetic outcomes in patients with near-total upper lip defects by simulating the lip contour, thickness, texture, and height. The growth of a mustache may camouflage scars and reestablish facial character with consequent improvement in cosmetic as well as psychological results.

Furthermore, the modiolus is undisturbed and the orbicularis sphincter is bridged to each side of the graft. Although the oral sphincter is not restored, continuity is reestablished. The patients achieve good functional results for speech and mastication. There is also potential sensory return in the neo–upper lip with preservation of the auriculotemporal nerve acting as a scaffold.3

Disadvantages include the multistaged procedure. The alternative would be to perform a single-staged free tissue transfer for upper lip reconstruction or tunnel a hair-bearing island of skin. These options come with their own attendant risks, including increased risk of injury to the facial nerve. There is limited applicability to female patients.

An examination of reconstructive option in scalp defects highlights shortcomings. Skin grafts, while quick and easy, have poor tissue texture and thickness, and are non–hair-bearing. They rely on intact subjacent periosteum and are, therefore, subject to more frequent loss. Local advancement, transposition, and rotational flaps as emphasized by Orticochea24 are ideal, but limited to small to medium-sized defects. Myofascial or musculocutaneous flaps have good vascular supply, but can be too bulky, time-consuming, non–hair-bearing, and have more significant donor site morbidity.

Reconstruction using hair-bearing TPFF as local advancement flaps were made possible by the use of tissue expanders and interpositional vein grafts. Tissue expanders are indicated when there is a shortage of suitable donor tissue. The neovascularization of the expanded skin allows the flap to behave like a delayed flap, permitting a larger viable donor length than random advancement or rotation flaps.25 Further benefits include a single, inconspicuous operative site with minimal to no morbidity.

These cases illustrate not only one of many potential reconstructive options for large upper lip and scalp defects in males but the advantages of using the hair-bearing TPFF. The reliable vascular supply, inconspicuous donor site, match in tissue characteristics, and proximity to the reconstructive site make it an optimal choice.

Accepted for publication January 25, 2001.

Presented in part at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Washington, DC, September 21, 2000.

Corresponding author and reprints: Mack L. Cheney, MD, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114 (e-mail: Mack_Cheney@MEEI.HARVARD.EDU).

Gillies  HDPlastic Surgery of the Face. New York, NY Gower Medical Publishing Ltd1983;
Abul-Hassan  HSvon Drasek  Ascher GAcland  RD Surgical anatomy and blood supply of the fascial layers of the temporal region Plast Reconstr Surg. 1986;7717- 23
David  SKCheney  ML An anatomic study of the temporoparietal fascial flap Arch Otolaryngol Head Neck Surg. 1995;1211153- 1156
Tellioglu  ATTekdemir  IErdemli  EATuccar  EUlusoy  G Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications Plast Reconstr Surg. 2000;10540- 45
Brent  BUpton  JAcland  RD  et al.  Experience with the temporoparietal fascial free flap Plast Reconstr Surg. 1985;76177- 188
Cheney  MLVarvares  MANadol  JB  Jr The temporoparietal fascial flap in head and neck reconstruction Arch Otolaryngol Head Neck Surg. 1993;119618- 623
Rose  EHNorris  MS The versatile temporoparietal fascial flap: adaptability to a variety of composite defects Plast Reconstr Surg. 1990;85224- 232
Upton  JFerraro  NHealy  GKhouri  RMerrell  C The use of prefabricated fascial flaps for lining of the oral and nasal cavities Plast Reconstr Surg. 1994;94573- 579
Ellis  DSToth  BAStewart  WB Temporoparietal fascial flap for orbital and eyelid reconstruction Plast Reconstr Surg. 1992;89606- 611
Panje  WRMorris  MR The temporoparietal fascia flap in head and neck reconstruction Ear Nose Throat J. 1991;70311- 317
Cheney  MLMcKenna  MJMegerian  CAOjemann  RG Early temporalis muscle transposition for the management of facial paralysis Laryngoscope. 1995;105993- 1000
Sultan  MRWider  TMHugo  NE Frey's syndrome: prevention with temporoparietal fascial flap interposition Ann Plast Surg. 1995;34292- 296
Delaere  PRGuelinckx  PJOstyn  F Vascularized temporoparietal fascial flap for closure of a nasal septal perforation: report of a case Acta Otorhinolaryngol Belg. 1990;4447- 49
Cheney  MLMegerian  CABrown  MTMcKenna  MJNadol  JB The use of the temporoparietal fascial flap in temporal bone reconstruction Am J Otol. 1996;17137- 142
Cheney  MLMegerian  CABrown  MTMcKenna  MJ Mastoid obliteration and lining using the temporoparietal fascial flap Laryngoscope. 1995;1051010- 1013
Lesavoy  MADubrow  TJSchwartz  RJWackym  PAEisenhauer  DMMcGuire  M Management of large scalp defects with local pedicle flaps Plast Reconstr Surg. 1993;91783- 790
Potparic  ZStarovic  B Reconstruction of extensive defects of the cranium using free-tissue transfer Head Neck. 1993;1597- 104
Williams  EF  IIISetzen  GMulvaney  MJ Modified Bernard-Burow cheek advancement and cross-lip flap for total lip reconstruction Arch Otolaryngol Head Neck Surg. 1996;1221253- 1258
Yih  WYHowerton  DW A regional approach to reconstruction of the upper lip J Oral Maxillofac Surg. 1997;55383- 389
Marty  FMontandon  DGumener  RZbrodowski  A Subcutaneous tissue in the scalp: anatomical, physiological, and clinical study Ann Plast Surg. 1986;16368- 376
Tolhurst  DECarstens  MHGreco  RJHurwitz  DJ The surgical anatomy of the scalp Plast Reconstr Surg. 1991;87603- 626
Gillies  HDMillard  DR  JrPrinciples and Practice of Plastic Surgery. Boston, Mass Little Brown & Co Inc1957;
Bernard  C Cander de la levre infericure opere par un procede nouveau Bull Mem Soc Hir (Paris). 1853;3357
Orticochea  M New three-flap scalp reconstruction technique Br J Plast Surg. 1971;24184- 188
Cherry  GWAusted  EDPasyk  KMcClatchey  KRohrich  RJ Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin Plast Reconstr Surg. 1983;72680

Figures

Place holder to copy figure label and caption
Figure 1.

The layers of the scalp are follows: A, hair bearing; B, subcutaneous tissue; C, frontalis muscle and galea aponeurotica; D, periosteum; E, cranium; F, temporalis muscle; G, deep temporalis fascia; H, loose areolar tissue; and I, temporoparietal fascia with superficial temporal vessels.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A, Left upper lip defect; B and C, left pedicled temporoparietal fascial flap; and D, final postoperative result.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A, Complex upper lip defect; B, superficial temporal vessels traced using Doppler ultrasonography; C, flap design for upper lip defect; D, prefabrication of deep surface with skin graft; E, bipedicled temporoparietal fascial flap inset; and F, final postoperative result.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

A, Upper lip defect; B and C, bipedicled temporoparietal fascial flap inset; and D, final postoperative result.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

A and B, Right temporoparietal alopecia-scar and tissue expanders; C, marking of pedicle; D, elevated island of hair-bearing temporoparietal fascial flap; E and F, insetting of flap island; and G and H, final postoperative result.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

A, Recurrent scalp melanoma; B, 9 × 7-cm parietal scalp defect; C, temporoparietal fascial flap with interpositional vein grafts; D, hair-bearing skin island transposed in V- to Y-fashion; E, flap inset with skin graft closure of defect superior to pinna; and F, final postoperative result.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

A and B, Basal cell carcinoma of scalp; C, outline of superficial temporal vessels; D, temporoparietal fascial flap with interpositional vein grafts; and E and F, inset of flap with skin graft coverage.

Graphic Jump Location

Tables

References

Gillies  HDPlastic Surgery of the Face. New York, NY Gower Medical Publishing Ltd1983;
Abul-Hassan  HSvon Drasek  Ascher GAcland  RD Surgical anatomy and blood supply of the fascial layers of the temporal region Plast Reconstr Surg. 1986;7717- 23
David  SKCheney  ML An anatomic study of the temporoparietal fascial flap Arch Otolaryngol Head Neck Surg. 1995;1211153- 1156
Tellioglu  ATTekdemir  IErdemli  EATuccar  EUlusoy  G Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications Plast Reconstr Surg. 2000;10540- 45
Brent  BUpton  JAcland  RD  et al.  Experience with the temporoparietal fascial free flap Plast Reconstr Surg. 1985;76177- 188
Cheney  MLVarvares  MANadol  JB  Jr The temporoparietal fascial flap in head and neck reconstruction Arch Otolaryngol Head Neck Surg. 1993;119618- 623
Rose  EHNorris  MS The versatile temporoparietal fascial flap: adaptability to a variety of composite defects Plast Reconstr Surg. 1990;85224- 232
Upton  JFerraro  NHealy  GKhouri  RMerrell  C The use of prefabricated fascial flaps for lining of the oral and nasal cavities Plast Reconstr Surg. 1994;94573- 579
Ellis  DSToth  BAStewart  WB Temporoparietal fascial flap for orbital and eyelid reconstruction Plast Reconstr Surg. 1992;89606- 611
Panje  WRMorris  MR The temporoparietal fascia flap in head and neck reconstruction Ear Nose Throat J. 1991;70311- 317
Cheney  MLMcKenna  MJMegerian  CAOjemann  RG Early temporalis muscle transposition for the management of facial paralysis Laryngoscope. 1995;105993- 1000
Sultan  MRWider  TMHugo  NE Frey's syndrome: prevention with temporoparietal fascial flap interposition Ann Plast Surg. 1995;34292- 296
Delaere  PRGuelinckx  PJOstyn  F Vascularized temporoparietal fascial flap for closure of a nasal septal perforation: report of a case Acta Otorhinolaryngol Belg. 1990;4447- 49
Cheney  MLMegerian  CABrown  MTMcKenna  MJNadol  JB The use of the temporoparietal fascial flap in temporal bone reconstruction Am J Otol. 1996;17137- 142
Cheney  MLMegerian  CABrown  MTMcKenna  MJ Mastoid obliteration and lining using the temporoparietal fascial flap Laryngoscope. 1995;1051010- 1013
Lesavoy  MADubrow  TJSchwartz  RJWackym  PAEisenhauer  DMMcGuire  M Management of large scalp defects with local pedicle flaps Plast Reconstr Surg. 1993;91783- 790
Potparic  ZStarovic  B Reconstruction of extensive defects of the cranium using free-tissue transfer Head Neck. 1993;1597- 104
Williams  EF  IIISetzen  GMulvaney  MJ Modified Bernard-Burow cheek advancement and cross-lip flap for total lip reconstruction Arch Otolaryngol Head Neck Surg. 1996;1221253- 1258
Yih  WYHowerton  DW A regional approach to reconstruction of the upper lip J Oral Maxillofac Surg. 1997;55383- 389
Marty  FMontandon  DGumener  RZbrodowski  A Subcutaneous tissue in the scalp: anatomical, physiological, and clinical study Ann Plast Surg. 1986;16368- 376
Tolhurst  DECarstens  MHGreco  RJHurwitz  DJ The surgical anatomy of the scalp Plast Reconstr Surg. 1991;87603- 626
Gillies  HDMillard  DR  JrPrinciples and Practice of Plastic Surgery. Boston, Mass Little Brown & Co Inc1957;
Bernard  C Cander de la levre infericure opere par un procede nouveau Bull Mem Soc Hir (Paris). 1853;3357
Orticochea  M New three-flap scalp reconstruction technique Br J Plast Surg. 1971;24184- 188
Cherry  GWAusted  EDPasyk  KMcClatchey  KRohrich  RJ Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin Plast Reconstr Surg. 1983;72680

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