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Use of Composite Osteotemporoparietal Fascia Flap for Midface Reconstruction After En Bloc Resection of Squamous Cell Carcinoma Involving the Zygomaticomaxillary Complex

Summary: The osteotemporoparietal fascia flap (OTPFF) has been used for bony defects, especially on the maxilla and orbital floor. However, there are limited reports about the reconstruction of the zygoma. We report the use of composite OTPFF for reconstruction of zygomaticomaxillary complex. The patient had undergone zygomaticomaxillary complex reconstruction with composite OTPFF because of the resection of recurrent postradiation tumor. Extratemporoparietal fascia was harvested and rotated to cover the medullary surface of the bone flap. Flap was successfully transferred with complete bone integration. There were no surgical complications and excellent cosmetic result. The patient is free of disease 12 months post surgery. The OTPFF seems to be a good option in zygomatic reconstruction, even in previously irradiated fields. Utilization of extratemporoparietal fascia to cover the medullary surface of the bone flap has potential to be an advantageous technique to minimize bone exposure and improve flap integration.


Summary:
The osteotemporoparietal fascia flap (OTPFF) has been used for bony defects, especially on the maxilla and orbital floor. However, there are limited reports about the reconstruction of the zygoma. We report the use of composite OTPFF for reconstruction of zygomaticomaxillary complex. The patient had undergone zygomaticomaxillary complex reconstruction with composite OTPFF because of the resection of recurrent postradiation tumor. Extratemporoparietal fascia was harvested and rotated to cover the medullary surface of the bone flap. Flap was successfully transferred with complete bone integration. There were no surgical complications and excellent cosmetic result. The patient is free of disease 12 months post surgery. The OTPFF seems to be a good option in zygomatic reconstruction, even in previously irradiated fields. Utilization of extratemporoparietal fascia to cover the medullary surface of the bone flap has potential to be an advantageous technique to minimize bone exposure and improve flap integration. the predetermined margins. A diamond bur and curved osteotomes were used to separate the outer cortical from the inner cortical. The temporoparietal fascia was elevated from the deep temporalis fascia, and the conjunction of bone attached to the fascia was freely mobile.
A tunnel for the flap transposition was developed deep to the temporalis fascia to the zygomatic defect. The medullary surface of the osteopericranial flap was completely covered by extratemporoparietal fascia and transposed into the zygomaticomaxillary defect. The natural curve of the calvarium appropriately approximated the natural curve of the zygoma and malar eminence. A polyethylene Medopor Titan implant was used to reconstruct the orbital floor defect. A vascularized buccal fat flap was harvested and used to cover the roof of the maxillary sinus. Deep and soft tissues were approximated and incisions were closed.

DISCUSSION
The TPFF is one of the most reliable flaps for head and neck reconstruction because it is thin and pliable and has a long pedicle and a rich vascularity. 1 Harvesting the underlying calvarium provides additional support, especially for bony defects of the head and neck. 2 Successful head and neck reconstructions have been done using free grafts from the iliac crest, fibula, radius, rib, and scapula. 5 Although these are acceptable options, free flaps require revascularization, necessitating the need for complex microvascular techniques and prolonged operative times. 5 The calvarium is an ideal site of harvest because of its proximity to the head and neck, allowing the flap to remain vascularized from perforators of the superficial temporal artery. 5 Vascularized flaps are reported to be more reliable, have lower rates of infection, and allow earlier bone integration. 3 The OTPFF is commonly reported for the reconstruction of the palate and orbital floor; however, few reports mention the use of OTPFF with or without the temporalis muscle for midface reconstruction. These studies describe a small series of patients with different diagnosis, including trauma, congenital defects, and tumor resections. The OTPFF seems to show good reliability and integration for head and neck reconstruction; however, very few cases report using this flap specifically for the zygoma.
In our patient, the flap was used to reconstruct a previously irradiated area. Irradiated fields create a poor environment for angiogenesis and osteogenesis, leading to increased risk of flap failure. 3 Well-vascularized bone grafts, such as the OTPFF, seem to overcome the unfavorable effects of irradiation, as our patient displayed excellent bone integration at the 12-month follow-up.
During the procedure, extratemporoparietal fascia was harvested and folded to cover the medullar surface of the bone. This was indicated to theoretically decrease the risk of bone exposure. Creation of this barrier eliminates direct communication between the bone and the nose, which could subsequently decrease the risk of flap infection. To the best of our knowledge, there is no literature report on this technique.