The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
How I Do It
Temporoparietal Fascial Flap Repair of Middle Cranial Fossa Tegmen and Dural Defects Matthew Kircher, MD; Amy Pittman, MD; Eric Thorpe, MD; Sam Marzo, MD; John Leonetti, MD; Asterios Tsimpas, MD; Douglas Anderson, MD
INTRODUCTION The repair of middle cranial fossa tegmen defects, encephalocele, and cerebrospinal fluid (CSF) leaks frequently involve the use of nonvascularized free tissue grafts such as fascial, cartilage, and bone grafts. A number of processes can lead to the development of tegmen and dural defects, including but not limited to cholesteatoma disease, surgical and nonsurgical trauma, and spontaneous CSF otorrhea with or without encephalocele. Success with nonvascularized free tissue graft techniques in achieving primary tegmen repair and control of CSF leak is variable, with failure rates ranging from 2.3% to 28.6%.1 Cases requiring revision repair or with extensive dural defects should especially consider alternative reconstructive options. In addition, nonvascularized free tissue grafts may have poor viability in an infected field, which can be encountered in cholesteatoma disease. Vascularized tissue grafts offer a robust option in the closure of a variety of skull base defects with control of CSF leak.2–4 Patel et al. described their use of the temporoparietal fascial flap in reducing CSF leak after lateral skull base tumor resections.4 We report our use of the temporoparietal fascial (TPF) flap in a case of middle fossa CSF otorrhea failing multiple previous repairs, and in the case of a large tegmen defect with CSF leak and temporal lobe abscess stemming from middle ear cholesteatoma disease.
MATERIALS AND METHODS This study was approved by the Loyola University Medical Center Institutional Review Board. Through a middle cranial
fossa approach, a preauricular linear incision is made extending from the tragus to the top of the temporal fossa. The incision depth is down to but not through the subcutaneous tissue, which is grossly adherent to the underlying TPF. Skin flaps are elevated anterior and posterior, taking care to stay immediately beneath the hair follicles in this way protecting the underlying TPF. The anterior dissection is limited by the position of the frontal branch of the facial nerve, which lies along a line between a point 0.5 cm below the tragus to a point 1.5 cm above the lateral brow.5 The posterior flap is elevated posterior beyond the posterior margin of the auricle (Fig 1). The TPF is incised at the superior, anterior, and posterior margins down to the underlying temporalis muscle fascia and reflected inferior (Fig 2). The graft is pedicled and supplied by the superficial temporal artery vessels crossing immediately anterior to the tragus.6 Next, the temporal fascia, muscle, and underlying periosteum are divided vertically along the length of the temporal fossa down to the zygomatic root. Care is taken to protect the overlying superficial temporal vessels from being damaged during this step. A retractor is placed to retract the temporal muscle, and a middle fossa craniotomy is performed (Fig 3). Dura is elevated from the floor of the middle cranial fossa, locating the tegmen and dural defects. The distal end of the TPF flap is trimmed if necessary and advanced under the temporal lobe to cover the dural defect. A bone or cartilage graft is then placed along the middle cranial fossa floor to bridge the bony tegmen defect (Fig 4). The lateral margin of the flap may be tacked to overlying dura to prevent migration, and dural sealant may be added to the closure. The temporal bone is replaced and secured with plates and screws, and the wound is closed in layers. Postoperative care includes avoidance of strenuous exercise or straining and the use of stool softeners.
RESULTS From the Department of Otolaryngology–Head and Neck Surgery (M.K., A.P., E.T., J.L.); and the Department of Neurological Surgery (A.T., D.A.), Loyola University Medical Center, Maywood, Illinois, U.S.A. Editor’s Note: This Manuscript was accepted for publication March 24, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Matthew Kircher, MD, Department of Otolaryngology–Head and Neck Surgery, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL 60153. E-mail: matthewkircher@ gmail.com DOI: 10.1002/lary.25331
Laryngoscope 125: December 2015
2796
Our surgical technique utilizing the TPF flap in closure of tegmen defects was successful in two difficult cases. No particular complications occurred during the surgical procedures, and postoperatively both patients recovered fully without return of CSF leak. The first patient presented with cholesteatoma and temporal lobe abscess. A canal wall down tympanomastoidectomy with middle fossa craniotomy and drainage of temporal lobe abscess was performed with the above-described TPF closure of the tegmen defect. This patient was also Kircher et al.: TPF Flap Repair of Tegmen and Dural Defects
Fig. 1. Exposed temporoparietal fascia. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
managed with a ventriculostomy catheter placed under direct vision into the abscess cavity and tunneled under the skin. The second patient was undergoing her third attempt at closure of the middle fossa CSF otorrhea. Two previous procedures that utilized a transmastoid exposure with nonvascularized fascia and cartilage-free grafts were unsuccessful. At 1-month postoperative visit after middle fossa TPF closure, there was no evidence of recurrent CSF leak.
DISCUSSION Monks and Brown separately described the TPF flap in eyelid and auricular reconstruction, respectively in 1898.7,8 The flap has subsequently developed into a reliable ipsilateral pedicled reconstructive option in periorbital, auricular, and scalp defects.9–12 The TPF flap has also been reported in performing mastoid obliteration in chronic otitis media and temporal bone reconstruction after cancer ablation.13 We believe that this flap is relatively underutilized in CSF leak and tegmen
Fig. 2. Elevated temporoparietal fascial flap. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 125: December 2015
Fig. 3. The temporalis fascia, muscle, and periosteum are divided, and the craniotomy is performed. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
repair in those performing middle cranial fossa exposure. In contrast to temporalis muscle rotation flaps that can result in temporal wasting cosmetic deformity, the TPF provides a sizable, robust, and vascularized tissue that is well positioned to close tegmen defects with no added morbidity. The TPF flap is a thin, pliable flap, and there should be ample room to secure the bony plate back into position without compressing and possibly compromising the flap. In most instances, the initial temporal craniotomy does not extend completely to the middle cranial fossa floor, and further resection of bone is required such that, with replacement of the bony flap, an inferior bony gap exists to accommodate the TPF flap to extend through this gap.
Fig. 4. The temporoparietal fascial flap is advanced into position under the temporal lobe to cover the dural defect, and a bone or cartilage graft is placed along the middle cranial fossa floor to bridge the bony tegmen defect. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Kircher et al.: TPF Flap Repair of Tegmen and Dural Defects
2797
CONCLUSION The TPF flap is a robust and pliable vascular flap that is anatomically well positioned for the repair of middle cranial fossa defects. This flap should be considered in cases of revision CSF leak repair and/or an infected operative field. At the very least, this flap should be preserved when making a middle cranial fossa incision to afford the option for a vascularized flap to augment repair of middle cranial fossa tegmen and dural defects.
BIBLIOGRAPHY 1. Sanna M, Fois P, Russo A, Falcioni M. Management of meningoencephalic herniation of the temporal bone: Personal experience and literature review. Laryngoscope 2009;119:1579–1585. 2. Smith JE, Ducic Y. The versatile extended pericranial flap for closure of skull base defects. Otolaryngol Head Neck Surg 2004;130:704–711. 3. Jackson CG, Netterville JL, Glasscock ME, 3rd, et al. Defect reconstruction and cerebrospinal fluid management in neurotologic skull base tumors with intracranial extension. Laryngoscope 1992;102:1205–1214.
Laryngoscope 125: December 2015
2798
4. Patel R, Buchmann LO, Hunt J. The use of the temporoparietal fascial flap in preventing CSF leak after lateral skull base surgery. J Neurol Surg B Skull Base 2013;74:311–316. 5. Chiarelli A, Baldelli A, Di Vincenzo A, Martini G. Utilization of the superficial temporoparietal fascia in reconstructive plastic surgery. A clinical case. Ophthal Plast Reconstr Surg 1989;5:274–276. 6. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77:17–28. 7. Monks GH. The restoration of a new lower lid by a new method. Boston Medical Surgical Journal 1898:385–387. 8. Brown WJ. Extraordinary case of horse bite: the external ear completely bitten off and successfully replaced. Lancet 1898;1:1533. 9. Cheney ML, Varvares MA, Nadol JB Jr. The temporoparietal fascial flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1993;119:618–623. 10. Fox JW, Edgerton MT. The fan flap: an adjunct to ear reconstruction. Plast Reconstr Surg 1976;58:663–667. 11. Panje WR, Morris MR. The temporoparietal fascia flap in head and neck reconstruction. Ear Nose Throat J 1991;70:311–317. 12. Teichgraeber JF. Temporoparietal fascial flap in orbital reconstruction. Laryngoscope. 1993;103:931–935. 13. Cheney ML, Megerian CA, Brown MT, McKenna MJ, Nadol JB. The use of the temporoparietal fascial flap in temporal bone reconstruction. Am J Otol 1996;17:137–142.
Kircher et al.: TPF Flap Repair of Tegmen and Dural Defects
Rhinological and Otological Society, Inc.
How I Do It
Temporoparietal Fascial Flap Repair of Middle Cranial Fossa Tegmen and Dural Defects Matthew Kircher, MD; Amy Pittman, MD; Eric Thorpe, MD; Sam Marzo, MD; John Leonetti, MD; Asterios Tsimpas, MD; Douglas Anderson, MD
INTRODUCTION The repair of middle cranial fossa tegmen defects, encephalocele, and cerebrospinal fluid (CSF) leaks frequently involve the use of nonvascularized free tissue grafts such as fascial, cartilage, and bone grafts. A number of processes can lead to the development of tegmen and dural defects, including but not limited to cholesteatoma disease, surgical and nonsurgical trauma, and spontaneous CSF otorrhea with or without encephalocele. Success with nonvascularized free tissue graft techniques in achieving primary tegmen repair and control of CSF leak is variable, with failure rates ranging from 2.3% to 28.6%.1 Cases requiring revision repair or with extensive dural defects should especially consider alternative reconstructive options. In addition, nonvascularized free tissue grafts may have poor viability in an infected field, which can be encountered in cholesteatoma disease. Vascularized tissue grafts offer a robust option in the closure of a variety of skull base defects with control of CSF leak.2–4 Patel et al. described their use of the temporoparietal fascial flap in reducing CSF leak after lateral skull base tumor resections.4 We report our use of the temporoparietal fascial (TPF) flap in a case of middle fossa CSF otorrhea failing multiple previous repairs, and in the case of a large tegmen defect with CSF leak and temporal lobe abscess stemming from middle ear cholesteatoma disease.
MATERIALS AND METHODS This study was approved by the Loyola University Medical Center Institutional Review Board. Through a middle cranial
fossa approach, a preauricular linear incision is made extending from the tragus to the top of the temporal fossa. The incision depth is down to but not through the subcutaneous tissue, which is grossly adherent to the underlying TPF. Skin flaps are elevated anterior and posterior, taking care to stay immediately beneath the hair follicles in this way protecting the underlying TPF. The anterior dissection is limited by the position of the frontal branch of the facial nerve, which lies along a line between a point 0.5 cm below the tragus to a point 1.5 cm above the lateral brow.5 The posterior flap is elevated posterior beyond the posterior margin of the auricle (Fig 1). The TPF is incised at the superior, anterior, and posterior margins down to the underlying temporalis muscle fascia and reflected inferior (Fig 2). The graft is pedicled and supplied by the superficial temporal artery vessels crossing immediately anterior to the tragus.6 Next, the temporal fascia, muscle, and underlying periosteum are divided vertically along the length of the temporal fossa down to the zygomatic root. Care is taken to protect the overlying superficial temporal vessels from being damaged during this step. A retractor is placed to retract the temporal muscle, and a middle fossa craniotomy is performed (Fig 3). Dura is elevated from the floor of the middle cranial fossa, locating the tegmen and dural defects. The distal end of the TPF flap is trimmed if necessary and advanced under the temporal lobe to cover the dural defect. A bone or cartilage graft is then placed along the middle cranial fossa floor to bridge the bony tegmen defect (Fig 4). The lateral margin of the flap may be tacked to overlying dura to prevent migration, and dural sealant may be added to the closure. The temporal bone is replaced and secured with plates and screws, and the wound is closed in layers. Postoperative care includes avoidance of strenuous exercise or straining and the use of stool softeners.
RESULTS From the Department of Otolaryngology–Head and Neck Surgery (M.K., A.P., E.T., J.L.); and the Department of Neurological Surgery (A.T., D.A.), Loyola University Medical Center, Maywood, Illinois, U.S.A. Editor’s Note: This Manuscript was accepted for publication March 24, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Matthew Kircher, MD, Department of Otolaryngology–Head and Neck Surgery, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL 60153. E-mail: matthewkircher@ gmail.com DOI: 10.1002/lary.25331
Laryngoscope 125: December 2015
2796
Our surgical technique utilizing the TPF flap in closure of tegmen defects was successful in two difficult cases. No particular complications occurred during the surgical procedures, and postoperatively both patients recovered fully without return of CSF leak. The first patient presented with cholesteatoma and temporal lobe abscess. A canal wall down tympanomastoidectomy with middle fossa craniotomy and drainage of temporal lobe abscess was performed with the above-described TPF closure of the tegmen defect. This patient was also Kircher et al.: TPF Flap Repair of Tegmen and Dural Defects
Fig. 1. Exposed temporoparietal fascia. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
managed with a ventriculostomy catheter placed under direct vision into the abscess cavity and tunneled under the skin. The second patient was undergoing her third attempt at closure of the middle fossa CSF otorrhea. Two previous procedures that utilized a transmastoid exposure with nonvascularized fascia and cartilage-free grafts were unsuccessful. At 1-month postoperative visit after middle fossa TPF closure, there was no evidence of recurrent CSF leak.
DISCUSSION Monks and Brown separately described the TPF flap in eyelid and auricular reconstruction, respectively in 1898.7,8 The flap has subsequently developed into a reliable ipsilateral pedicled reconstructive option in periorbital, auricular, and scalp defects.9–12 The TPF flap has also been reported in performing mastoid obliteration in chronic otitis media and temporal bone reconstruction after cancer ablation.13 We believe that this flap is relatively underutilized in CSF leak and tegmen
Fig. 2. Elevated temporoparietal fascial flap. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 125: December 2015
Fig. 3. The temporalis fascia, muscle, and periosteum are divided, and the craniotomy is performed. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
repair in those performing middle cranial fossa exposure. In contrast to temporalis muscle rotation flaps that can result in temporal wasting cosmetic deformity, the TPF provides a sizable, robust, and vascularized tissue that is well positioned to close tegmen defects with no added morbidity. The TPF flap is a thin, pliable flap, and there should be ample room to secure the bony plate back into position without compressing and possibly compromising the flap. In most instances, the initial temporal craniotomy does not extend completely to the middle cranial fossa floor, and further resection of bone is required such that, with replacement of the bony flap, an inferior bony gap exists to accommodate the TPF flap to extend through this gap.
Fig. 4. The temporoparietal fascial flap is advanced into position under the temporal lobe to cover the dural defect, and a bone or cartilage graft is placed along the middle cranial fossa floor to bridge the bony tegmen defect. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Kircher et al.: TPF Flap Repair of Tegmen and Dural Defects
2797
CONCLUSION The TPF flap is a robust and pliable vascular flap that is anatomically well positioned for the repair of middle cranial fossa defects. This flap should be considered in cases of revision CSF leak repair and/or an infected operative field. At the very least, this flap should be preserved when making a middle cranial fossa incision to afford the option for a vascularized flap to augment repair of middle cranial fossa tegmen and dural defects.
BIBLIOGRAPHY 1. Sanna M, Fois P, Russo A, Falcioni M. Management of meningoencephalic herniation of the temporal bone: Personal experience and literature review. Laryngoscope 2009;119:1579–1585. 2. Smith JE, Ducic Y. The versatile extended pericranial flap for closure of skull base defects. Otolaryngol Head Neck Surg 2004;130:704–711. 3. Jackson CG, Netterville JL, Glasscock ME, 3rd, et al. Defect reconstruction and cerebrospinal fluid management in neurotologic skull base tumors with intracranial extension. Laryngoscope 1992;102:1205–1214.
Laryngoscope 125: December 2015
2798
4. Patel R, Buchmann LO, Hunt J. The use of the temporoparietal fascial flap in preventing CSF leak after lateral skull base surgery. J Neurol Surg B Skull Base 2013;74:311–316. 5. Chiarelli A, Baldelli A, Di Vincenzo A, Martini G. Utilization of the superficial temporoparietal fascia in reconstructive plastic surgery. A clinical case. Ophthal Plast Reconstr Surg 1989;5:274–276. 6. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77:17–28. 7. Monks GH. The restoration of a new lower lid by a new method. Boston Medical Surgical Journal 1898:385–387. 8. Brown WJ. Extraordinary case of horse bite: the external ear completely bitten off and successfully replaced. Lancet 1898;1:1533. 9. Cheney ML, Varvares MA, Nadol JB Jr. The temporoparietal fascial flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1993;119:618–623. 10. Fox JW, Edgerton MT. The fan flap: an adjunct to ear reconstruction. Plast Reconstr Surg 1976;58:663–667. 11. Panje WR, Morris MR. The temporoparietal fascia flap in head and neck reconstruction. Ear Nose Throat J 1991;70:311–317. 12. Teichgraeber JF. Temporoparietal fascial flap in orbital reconstruction. Laryngoscope. 1993;103:931–935. 13. Cheney ML, Megerian CA, Brown MT, McKenna MJ, Nadol JB. The use of the temporoparietal fascial flap in temporal bone reconstruction. Am J Otol 1996;17:137–142.
Kircher et al.: TPF Flap Repair of Tegmen and Dural Defects
