Master Techniques in Otolaryngology - Head and Neck Surgery: Reconstructive Surgery, 1ed.

19. The Subtotal Maxillary Defect: Temporalis Muscle Flap

Peter D. Costantino

INTRODUCTION

Acquired palatomaxillary defects always present a challenge for the head and neck reconstructive surgeon. Maxillectomy defects can have a negative impact on deglutition and nutrition, speech, and communication, in addition to self-image and social acceptability. The lack of a uniform classification of these defects has limited prospective multicentered studies for assessment of the ideal method of reconstruction. Obturators/dental prostheses, local tissue flaps, pedicled myocutaneous flaps, myofascial flaps, and free bone/tissue transfer have all been employed successfully over the years. In my experience, midfacial and specifically palatomaxillary reconstruction can be achieved safely, effectively, and with minimal risk by implementing local pedicled tissue transfer from the lateral side of the head through a hemicoronal or bicoronal approach, using the temporalis muscle flap (TMF) and/or temporoparietal fascia flap (TPFF). The latter can also be harvested with calvarial bone attached as a composite flap. Both flaps can also be used in combination with any type of hardware prosthesis for both primary and secondary reconstruction of the palate with excellent functional and aesthetic results.

Previously, when direct visual surveillance was the way we monitored cancer recurrence, resection cavities were left open and the obturator was the only measure used to achieve a better functional outcome after ablative surgery. The use of a prosthesis is no longer the standard for many of these patients who are part of the working, socially active population. Obturators are imperfect and can still result in oronasal leakage, hypernasality, and reflux of liquids into the nasal cavity. Scarring and healing may also necessitate multiple revisions and fitting procedures. In addition, patients commonly feel the burden of frequent cleaning and the requirement for adhesive anchoring, as well as the need for wearing obturators whenever they need to speak or drink, which can be inconvenient. With advances in radiologic surveillance tools and the evolution of surgical techniques, tissue reconstruction has become the standard of care. This concept was confirmed in a study of palatal defects in which a group of 10 radial forearm free flap patients was compared to a group of 10 patients wearing obturators. Both groups had similar mastication, taste, and appearance satisfaction; however, patients with flap reconstruction had better scores in speech, comfort, and social interaction.

There have been alternative local tissue flaps that have become historical footnotes and are no longer used. The laterally based forehead flap was soon rejected due to the resulting facial deformity. The functional deficits of swallowing and lingual function have eliminated the tongue flap. The masseter flap provided limited pedicle length and resulted in contracture and atrophy. Palatal island flaps are still used but are not recommended in radiated patients.

The TMF, vascularized by the deep temporal arteries, was first mentioned in 1872 for temporomandibular joint reconstruction and then several years later for reconstruction of middle fossa skull base defects. Gillies and Konig, in the1920s, were the first to use the TMF for maxillary reconstruction and posttumor reconstruction, respectively. Campbell in 1948 was the first to use it for palatal defects. Sheehan then advanced the harvesting technique by removing the zygomatic arch to allow for improved mobilization and rotation toward the palatomaxillary complex. Wise and Baker took this further by detaching the muscle from the mandibular condyle. Bakamjian also contributed by describing the condylectomy for attaining additional flap length as well as using the temporalis reconstruction for isolated palatal defects. It was then Demas and Sotereanos who described the current technique of transposition through the posterolateral wall of the maxillary sinus. Over the past two decades, the TMF has been thoroughly described for palatal defects in multiple large series. These studies have confirmed the safety and efficacy and versatility of the flap for the reconstruction of maxillectomy and palatectomy defects following tumor resection.

The temporoparietal fascial flap also has a long history dating back to the late 19th century. Monks and Brown, independently from different sides of the Atlantic, described the use of the TPFF that was nourished by the superficial temporal vessels for the reconstruction of eyelid and auricular defects. It took about 80 years for this flap to begin to gain further popularity for oral cavity reconstruction. Recently, however, the TPFF has been employed for many types of oral, maxillary, and palatal defects as both a fascial and osteofascial flap. The harvest technique has varied little over time.

When considering a temporal muscle flap for reconstruction of the subtotal maxillary defect, both general and local issues must be considered. The general issues affecting wound healing such as weight loss, diabetes, hypothyroidism, and substance abuse must be sought in the history. A history of trauma to the temporal region is of course of great importance since this scarring or loss of blood supply may interfere with the development of temporalis flap. Similarly, a history of radiation to this area would interfere with healing. Since inevitably a concavity will remain in the area of the temporalis muscle donor site, a query should be made to the patients about their occupation and whether they have specific cosmetic issues in which a defect in this area may interfere with their livelihood. In this case, plans should be made for reconstructing the donor site or selecting an alternative one.

Cosmetic deformities resulting from palatomaxillary resection include a wide variety of defects from facial asymmetry and eye malposition to skin defects and cavity formation. Reestablishment of a scaffold-like phenomenon is crucial taking into consideration vertical and horizontal parts of the palatomaxillary complex. Functionality is also to be taken into consideration in reconstructing a palatomaxillary defect. The primary goal is to achieve a complete separation between the nasal and oral cavities that will facilitate normal speech, swallowing, and mastication.

The physical examination is important with regard to the anatomy and viability of the flaps as well as with size and precise location of the tumor in the context of a postablation reconstruction. In order to provide the most appropriate reconstruction and the best functional outcome, the surgeon must have a complete understanding of the postablation defect, or in other words, the total extent of the tumor. The examination is important with regard to the involved surrounding structures, the size of the tumor, and the necessary extent of bone and tooth removal. In theory, one would like to implement one of the previously described classification systems of palatomaxillary defects in their evaluation (although none are completely effective).

Examination of the donor site should reveal any previous incisions, trauma, or radiation changes, in addition to an adequate pulse for the TPFF. The strength and/or atrophy of the temporalis muscle is crucial in the examination and can further be emphasized while having the patient clench the teeth. The integrity of all the cranial nerves, specifically CN V and VII, should be thoroughly evaluated. Any deficit could provide information regarding extent of tumor involvement. Nasal endoscopy, examination of the orbit and extraocular movements and loss of sensation in the infraorbital nerve distribution, and the presence of loose teeth give relevant information regarding the extent of the tumor.

Maxillary defects often involve soft tissue, bone, and even skin. Sometimes, reconstruction has to take into consideration each part separately. After Ohngren’s first classification for maxillectomy defects in 1933, several classifications came out later and were mainly oriented toward safe oncologic boundaries disregarding resumption of normal function. The medical literature had to wait many decades to see reports describing classifications oriented toward reconstruction. The goal of these classifications is to try to achieve uniform data usable to devise a standard reconstruction algorithm. Spiro et al. in 1997 suggested a classification based on the number of maxillary walls involved, divided into limited, subtotal, and total defects. Soon thereafter, based on their experience in 108 patients, Davison et al. proposed a reconstruction algorithm involving prosthetic obturation, nonvascularized bone grafts, local or regional flaps, and microvascular free tissue transfer. He divided the defects into “complete” and “partial.” Most recently, Brown and Shaw presented their 15-year experience that implemented a classification system in which classes 1 to 5 describe the increasing extent of maxillary defect in its vertical dimension, with a focus on the functional aspect of the loss. Out of their 147 patients, only one stage 3 and three stage 5 patients had a TMF or TPFF flaps, whereas all the rest had either soft tissue or composite free flaps (see Chapter 22).

Both temporalis and temporoparietal pedicled flaps are generally preferred to free flap reconstruction in many cases because they are reliable, versatile, pedicled flaps that are regionally located and carry minimal morbidity and minimal functional deficit after their harvest. Complex donor sites, prolonged anesthesia time, as well as financial costs can be avoided by implementation of these flaps. Additionally, they are employed in place of appropriate microvascular transfers when there are limitations at the flap harvest site and the recipient vessels in the neck, as well as medical comorbidities that requires shorter anesthesia time. These flaps can be the primary flap for reconstruction in the edentulous patient and are also very reliable and stable in the face of radiation treatment. In general, local flaps are especially necessary when the technology and expertise required for free flap reconstruction are unavailable.

The TMF and TPFF are often my preferred method of reconstruction for the less complex defects, that is, those defects that are partial maxillary defects and involve the lateral maxilla, alveolus, and the palate. Both flaps, especially the temporalis flap, have proven to be reliable in their harvest and effective in their reconstruction. The TMF due to its reliable vascularity provides adequate bulk and proximity to the larger defects, while the TPFF, the thinnest flap in the human body, is pliable and durable and has been appropriate for smaller defects less than 2 cm. Only the TPFF is implemented for anterior palatal defects that include the alveolus due to its malleability and lack of bulk when placed in the premaxillary region. The TPFF is also preferred for centrally located palatal defects. The temporalis muscle can be used for subtotal palatal defects and can be harvested bilaterally for total palatal defects.

The contraindications to the TMF or TPFF are related to any previous trauma, surgery, or radiation to the temporal scalp and temporal fossa region. Any planned sacrifice of the lateral internal maxillary artery where the deep temporal arteries exit would compromise the TMF. Similarly, if there is no detectable pulse either by palpation or by Doppler evaluation of the superficial temporal artery, then the TPFF cannot be employed. Most importantly, as discussed above, the indications for the flap must be fulfilled and the patient must counseled appropriately on what to expect from this type of reconstruction and the need for delayed dental restoration.

The two primary components of the preoperative evaluation are the extent of tumor involvement and the availability and appropriateness of the TMF and TPFF for reconstruction. In addition to the physical examination outlined above, radiologic imaging including computed tomography scan and magnetic resonance imaging, or both, is required preoperatively. Due to the lack of direct visualization and ability to fully characterize tumors in the palatomaxillary complex, the radiologic imaging provides integral information that determines the extent of the tumor resection and, therefore, helps in the determination of which reconstructive flap is most suitable to the situation. Specifically, the size of the defect, its specific location in the palate—anterior, midline, and posterior—and the extent of the resection must be estimated prior to the operation (Table 19.1). Pathologic diagnosis also determines the aggressiveness of the surgery, the need for immediate reconstruction, and the likelihood of postoperative radiation. The physical examination and imaging also confirm that vascular supply to the muscle and the fascia will be available once the resection has been performed. From a practical setup standpoint, the temporal and infratemporal fossa can easily be prepared in the surgical site and do not require any specialized instrumentation or complex technology.

TABLE 19.1 Indications for Different Palatal Defects of TMF Versus TPFF

Before discussing the surgical technique for harvesting either of these flaps, the surgeon must have a full understanding of the layers of the scalp and the anatomy of the temporal fossa. Because of the variety of terms applied to the layers of this area, the following is a description using their preferred terminology.

The scalp is a five-layered structure. The most superficial layer is the skin with its hair follicles and sebaceous and sweat glands. The skin is firmly adherent to the underlying subcutaneous tissue that consists of strong collagen bundles and the superficial vessels of the scalp. In the temporal scalp, just deep to this layer is the temporoparietal fascia. Then comes a layer of loose areolar tissue and the superficial layer of the deep temporal fascia, the temporalis muscle, and the deep layer of the deep temporal fascia that is continuous with the pericranium in that region (Fig. 19.1).

FIGURE 19.1 Anatomy of the layers of the scalp superior to the superior temporal line.

More specifically, immediately deep to the skin and the subcutaneous tissue, just beneath the hair follicles and adipose tissue exists the temporoparietal fascia (sometimes called superficial temporal fascia). This layer is contiguous with the superficial musculoaponeurotic system as it passes over the zygomatic arch into the midface inferiorly. The fascia is contiguous with the galea aponeurotica above the temporal line superiorly and the occipitalis posteriorly. The fascia ranges from 2 to 4 mm in thickness and can be harvested in dimensions up to 17 × 14 cm. Deep to the temporoparietal fascia is a loose areolar and avascular tissue layer that separates the fascia from the temporalis muscular fascia. This areolar layer allows the superficial scalp to move freely over the deeper structures, that is, the more fixed temporalis muscular fascia, that is, the superficial layer of the deep temporal fascia. The temporalis muscle and pericranium are then deep to these fascial layers. Confusing the issue further is the division of the temporalis muscular fascia as it splits into a superficial and deep layer (of the superficial deep temporal fascia) surrounding a pad of adipose tissue at the temporal line of fusion, at about 2 cm above the zygomatic arch (Fig. 19.1). The temporalis muscle fascia is contiguous with the pericranium above the superior temporal line and is contiguous with the masseter muscle fascia deep to the arch of the zygoma.

In the lateral aspect of the scalp, the blood supply is by way of the superficial temporal artery, a terminal branch of the external carotid artery that ascends posterior to the ramus of the mandible and becomes superficial 4 to 5 mm anterior to the tragus as it emerges from the parotid tissue. The vasculature fans out in an axial pattern from the inferior aspect of the temporoparietal fascia, giving off the middle temporal artery. Approximately 3 cm above the zygomatic arch, it divides into the terminal frontal and parietal branches (Fig. 19.2). The superficial temporal vein generally runs superficial to and with the artery, but variability, including branching or a posterior course, may be encountered. The auriculotemporal nerve, a sensory branch of the mandibular nerve, lies posterior to the superficial temporal artery within the temporoparietal fascia. The frontal branch of the facial nerve traverses an oblique course over the zygomatic arch, which can be estimated by a line connecting a point 0.5 cm inferior to the tragus to a point 1.5 cm lateral to the superior brow. This nerve also lies within the temporoparietal fascia, and elevation of the flap anterior to the frontal branch of the superficial temporal artery should proceed with caution to avoid injuring this nerve.

FIGURE 19.2 Gross vascular anatomy of the TPFF and TMF.

Prior to making the incision, a facial nerve monitor is placed in the medial brow to provide continuous monitoring of the frontal branch of the facial nerve. It is secured with a 5-0 silk suture. The incision is then designed as described below. Shaving the hair is avoided by braiding in such a fashion that the incision is clearly demarcated. The patient is then prepped and draped with the patient supine with the head in a lateral position.

Exposure is obtained through a bicoronal incision over the vertex of the cranium in the case of men with hair loss. In women, a curvilinear incision is created beginning from off midline anteriorly on the forehead and then curving in a C-shaped fashion first posteriorly and then anteriorly to the pretragal crease or posttragal region. Inferior extension of the incision is performed as needed. A coronal incision sweeping anteriorly within the hairline is created over a length of approximately 15 cm. (A T-shaped incision over the parietal region has also been described.) A superior–posterior flap just deep to the subcutaneous adipose tissue of the scalp through the dense connective tissue is then elevated. Visualizing and preserving the hair follicles and subcutaneous adipose tissue superficially and the superficial temporal vessels in the flap deep is necessary to prevent alopecia and to maintain the vascular integrity of the scalp and hair follicles as well as those of the flap. One series reported a vessel injury rate of 22.6%. This dissection can be quite tedious. Upon elevation of the scalp, the pericranium is left attached to the lateral skull superiorly in a fan-shaped fashion. The anterior flap is elevated in the same subfollicular plane until the suspected location of the frontal branch of the facial nerve. The location can be estimated by a line from the tragus to the lateral aspect of the eyebrow or by the temporal hairline. The nerve stimulator may be used to assist and to confirm the location of the facial nerve.

The frontal branch of the superficial temporal artery is now ligated, the anterior flap is divided, and the dissection is carried deep to the temporal adipose tissue pad to the superficial layer of the deep temporal fascia. A separate posteroinferior flap is similarly elevated, thereby exposing the temporoparietal fascia over the entire right temporoparietal region. The length of the flap can then be elevated by incising the temporoparietal fascia in a paddle-like fashion that can be up to 17 cm in length and 14 cm in width. The TPFF is then sequentially elevated and dissected from the superficial layer of the deep temporal fascia along with the deeper loose areolar tissue and the superficial temporal artery and vein pedicle down below the zygomatic arch to the level of the auditory canal. The pedicle can be narrowed to approximately 2 cm (Fig. 19.3). The preauricular crease is dissected so that maximal rotation of the flap is possible. The zygomatic arch is then exposed posteriorly, and the superolateral orbit is exposed anteriorly. The layers of the anterior scalp and the temporal region are retracted in a more anterior direction to expose the lateral edge of the orbit and the anterior border of the temporalis muscle. The temporalis fascia insertion at the lateral edge of the orbit is incised, and using blunt dissection, a tract is made over the surface of the temporalis muscle but deep to the zygomatic malar eminence medial to the coronoid process to the lateral wall of the maxillary sinus into the infratemporal fossa. A wide tunnel is then created into the maxillary sinus and the palatal defect. It should be large enough to accommodate for postoperative edema of the flap and prevent strangulation of the pedicle. The pedicle is then transposed into the defect through the created tunnel. One must be careful not to torque or twist the flap nor put it under tension in order to preserve maximal flow. In the case of centrally located defects, a Caldwell-Luc approach should be added to ensure that the posterior maxillary defect is adequate and that there are no restrictions or sharp bony edges in the nasal cavity. The palatal defect must be prepared and demucosalized if this is a secondary procedure. The flap is then sutured circumferentially into the defect. The wound is then closed over a drain with a single layer of staples superiorly and in a multilayered fashion inferiorly in the tragal region. A sterile compression dressing is then applied.

FIGURE 19.3 Harvest of large TPFF. Note the primary vascular pedicle running centrally through the flap (arrow). Inset. narrowing of the pedicle to less than 2 cm, thereby allowing for maximum extension and rotation.

Temporalis Muscle Flap

Surgical Anatomy

The temporalis muscle resides in the temporal fossa at the lateral portion of the skull deep to the TPFF. The muscle origin is the temporal line and can be palpated in most patients. The tendinous insertion is on the coronoid process and along the anterior ramus of the mandible. The temporalis flap can be approximately 11 × 12 cm in length and width and 1 cm in thickness at its maximum (Fig. 19.4A). The arterial supply is from the external carotid artery by two routes. The first more superficial one is immediately above the zygomatic arch. Here the superficial temporal artery gives off the middle temporal artery that is directed to the temporalis muscle. The principal arterial supply of the flap is the deep temporal arteries that branch off the internal maxillary artery. The temporalis muscle gets its vascular supply from the deep temporal artery entering the muscle at the level of the TMJ medially, often described as being medial to the level of the coronoid process of the mandible. The anterior and posterior deep temporal vessels course along the undersurface of the muscle.

FIGURE 19.4 A. Harvested TMF with elevation of the temporal adipose tissue pad along with the scalp. Preservation of the facial nerve was elevated along with the flap. The superolateral orbital rim and zygomatic arch is exposed (inset). The full extent of the muscle elevation is demonstrated. B. Right palatal defect greater than 2 cm in a patient with previous maxillectomy and chemoradiation treatment of a squamous cell carcinoma. C. The TMF is tunneled through the posterior wall of the maxillary sinus into the defect. D. The flap is inset and circumferentially sutured with a watertight closure into the defect previously shown in Figure 19.4B.

The muscle bulk of the TMF allows for a sturdy reconstruction of the palatal defect (Fig. 19.4B). The muscle is easily manipulated, rotated, and overturned in its placement depending on the defect and the necessary arc of rotation. It can easily be incorporated with other reconstructive materials for large palatomaxillary defects. Harvesting the temporalis muscle involves dissecting the superficial temporal fascia and the deep pericranium in continuity with the flap. Doing so reserves all of the neurovascular integrity of the flap. If the additional length is needed, the zygomatic arch can be temporarily removed and replaced after rotation of the flap. A coronoidectomy can also be performed to lessen tension on the muscle and to add additional length.

Technique

The patient is positioned and prepped, and an incision is created in a similar fashion to the TPFF. For the temporalis harvest, the incision is made and carried down through the skin, subcutaneous tissue, and galea, down to periosteum centrally extending laterally to preserve the temporalis muscle. More inferior–lateral the incision is carried down to the deep temporal fascia extending to the preauricular sulcus in posttragal fashion. A subperiosteal elevator is used to elevate flaps anteriorly and posteriorly. Rainey clips can be applied to assist with scalp hemostasis. Subperiosteal scalp flap elevation is performed superiorly. Elevation of the flap over the layer of the superficial deep temporal fascia is continued anteriorly until the lateral margin of the orbit. The temporal pad of adipose tissue is now entered, and further elevation is performed protecting the frontal branch of the facial nerve. Once the zygomatic arch is reached, care is taken to elevate the remaining soft tissue in the subperiosteal layer of the arch to protect the zygomatic branch of the facial nerve. Upon complete exposure of the zygomatic arch, zygomatic or orbitozygomatic osteotomies can be performed to allow for additional extension and rotation of the flap and improved exposure of the infratemporal fossa. The coronoid process can also be dissected and removed at the sigmoid notch to add even more rotation and extension.

The TMF is now elevated using Bovie cautery within the confines of the temporal fossa. The flap is elevated inferiorly to the zygomatic arch. The temporalis muscle is then released from the undersurface of the zygomatic arch to free the entire temporalis muscle for transposition into the palatomaxillary defect. Similarly to the TPFF, a wide tunnel is then created into the maxillary sinus. It should be large enough to accommodate for postoperative edema of the flap and prevent strangulation of the pedicle. Blood pressure can be dropped below 65 mm Hg to temporarily shrink the muscle bulk. The pedicle is then transposed into the defect through the created tunnel. The muscle can be transposed with either the superficial fascia facing into the defect of the deep surface of the muscle or with inversion of the muscle (Fig. 19.4C). One must be careful not to torque or twist the flap nor put it under tension in order to preserve maximal flow. The flap is otherwise sutured circumferentially into the defect (Fig. 19.4D). The muscle flap can also be divided into an anterior and posterior flap. When this occurs, the anterior flap is used for the defect reconstruction and the posterior flap is left in the temporal fossa and brought anteriorly to fill in the donor site soft tissue defect.

Prior to closure, the donor site defect can either be left alone or the temporal fossa can be filled with a variety of materials. I prefer adipose tissue grafts for tissue replacement over alloplastic materials due to the surgical communication with the oral cavity and the theoretical risk of infection of an implant. Once adipose tissue is placed and secured to the surrounding tissue, the wound is closed in a two-layered fashion over a drain and then dressed with a compression dressing over the adipose tissue graft.

The patient is admitted for observation after both TMF and TPFF reconstruction. The Hemovac drain is kept until there is less than 10 cc of output over a 24-hour period. This is especially important when there is an autologous adipose tissue graft for fear of seroma and subsequent infection. The patient is also observed for hematoma and flap viability. The patient is placed on a clear diet for 24 hours and then advanced to full liquids for 5 to 7 days postoperatively. When the flap appears to be viable at a week, the patient may advance to a soft diet. As an outpatient, the patient must continue to be followed for the presence of any fluid collection or flap dehiscence. Mucosalization of the flaps is usually complete within 4 to 8 weeks. Mouth rinses other than saline are not recommended as they may cause some sloughing of the flaps, especially the TPFF.

Complications that are common to both procedures include hematoma, temporary or permanent facial nerve paralysis, flap dehiscence and/or flap necrosis leading to fistula, and flap contracture. Postoperative alopecia is more common after TPFF reconstruction due to the subfollicular dissection. Temporal hollowing and changes in mastication are more common in TMF reconstruction especially in the cases when the entire muscle is used and a coronoidectomy is performed. Hyponasality and temporary nasal obstruction may occur if the muscle is also transposed into the nasal cavity. Occasionally, a second-stage tissue augmentation is needed after TMF for a persistent concavity of the donor site. The literature reports a 13% incidence of flap loss, 19% facial nerve paresis, and 3% facial nerve paralysis for the TMF. Specific studies propose that the larger the defect, the greater the risk of complications especially with regard to chewing difficulty and flap dehiscence. Due to the thin scalp flap in TPFF harvest, there have been reports of scalp epidermolysis. There have been no complications such as necrosis or fistula formation after irradiation of these flaps reported in the literature.

In my experience, both the TMF and TPFF have exceeded expectations with regard to palatal reconstruction. Postoperatively, patients have minimal short-term problems, but there have been no long-term complications and almost all patients have had excellent results with regard to functional and aesthetic outcome. While some revisions were necessary for fistula formation, there has been no incidence of permanent facial nerve paralysis or total flap loss. On one occasion, a TPFF was used in a patient who had previously undergone chemoradiation and had a significant enough dehiscence that a TMF was used as an adjunct. Experiences such as these have helped to shape my approach and indications for each of these flaps. More recently, these flaps, especially the TPFF, have been employed endoscopically for a variety of skull base defects. They continue to demonstrate flexibility and a broad spectrum of use.

• The surgeon should have an understanding of the indications for local versus free flap reconstruction of the palate as well as the contraindications for both.

• Preoperative evaluation must include a comprehensive understanding of the postablative defect. A complete physical examination and appropriate radiologic imaging must be performed prior to surgery to demonstrate the complete extent of the tumor.

• Prior to the operation, the donor site must be examined carefully. Signs of trauma, previous surgery, and/ or radiation must be noted. The muscle strength and bulk of the temporalis muscle should be confirmed. Palpation or Doppler of the superficial temporal artery is imperative prior to TPFF harvest.

• The surgical anatomy of the scalp and underlying layers of the temporal fossa must be completely understood including the location of the vascular supply of each flap, that is, the deep temporal arteries and superficial temporal artery, in addition to the location of the frontal branch of the facial nerve.

• The surgeon should be aware of the methods to extend and prolong the length of each flap—specifically, removal of the zygomatic arch and coronoidectomy for the TMF and the dissection of the superficial temporal pedicle for the TPFF.

• The tunnels through which the flaps are transposed must be large enough to accommodate the expected flap edema in the immediate postoperative period to avoid strangulation of the flap.

• Close follow-up in the postoperative period with regard to wound care and the appropriate advancement of diet is important for long-term success of the flap reconstruction.

• Standard head and neck surgical tray

• Soft tissue elevators

SUGGESTED READING

Brown WJ. Extraordinary case of horse bite: the external ear completely bitten off and replaced. Lancet 1898;1:1533.

Bakamjian V. A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Plast Reconstr Surg 1963;31:103–117.

Demas PN, Sotereanos GC. Transmaxillary temporalis transfer for reconstruction of a large palatal defect: report of a case. J Oral Maxillofac Surg 1989;47:197–202.

Panje WR, Morris MR. The temporoparietal fascial flap in head and neck reconstruction. Ear Nose Throat J 1991;70:311–317.

Genden EM, Wallace DI, Okay D, et al. Reconstruction of the hard palate using the radial forearm free flap: indications and outcomes. Head Neck 2004;26(9):808–814.