Bilateral Bookend Pericranial Flaps

Sir:FigureThe pericranial flap has long been championed as a thin, pliable, and vascularized tissue source with osteogenic potential.1,2 Traditionally, a single anterior flap has been rotated or advanced to line the cranial fossa, plug the nasofrontal duct, or cover hardware following reconstruction. However, the distal tip is least apt to be perfused by the supraorbital and supratrochlear vessels,3 as with any unipedicled flap. Moreover, when repositioned underneath bone, anterior pericranial flaps carry the potential downsides of thinning the frontoparietal scalp and not providing a strong retaining layer. Although single, laterally based pericranial flaps have also been described,4,5 here we describe performing bilateral “bookend” flaps. Each is supplied by the superficial temporal artery, which branches into the layers of temporal fascia and periosteum. The midline, mirror-image configuration facilitates biomechanical resuspension, and carries the significant advantage of allowing contiguous repositioning of the temporalis. This lessens dissection along the muscle surface, possibly avoiding fat pad disturbance and hollowing. Between 2010 and 2012, this technique was used by two of the authors (J.H.P. and D.M.S.) for over 50 patients, ranging in age from 6 months to 76 years. Indications included craniosynostosis, frontal sinus fractures, and anterior skull base surgery or cranioplasty. A standard coronal flap is raised subgaleally, leaving the pericranium adherent to the bone. Laterally, the temporoparietal fascia is incised and the superficial layer of the deep temporal fascia is left down on the muscle. The supraorbital rims are palpated and the supraorbital notch and contents protected. Each flap is then marked (Fig. 1) emanating from the anterosuperior aspect of the temporal crest, along the frontal bandeau, and coursing posteriorly from the nasofrontal region in a midsagittal fashion to intersect with the posterior limb (that stems from the posterosuperior aspect of the temporalis).Fig. 1: The exposed pericranium of a supine patient, with laterally based flaps marked before incision.The flap is then gently lifted laterally from the bone, using an elevator (Fig. 2). Once the temporalis is encountered, the dissection continues underneath as necessary to allow for muscle exposure and/or mobilization. The resulting composite unit (pericranium and temporalis) can be stretched and advanced to cover frontotemporal structures. These bookends are sutured together in a midline, corset-like fashion.Fig. 2: Lifting of the left pericranial flap, in a medial to lateral manner, for redraping.This imparts conforming force and coverage over newly positioned bone segments and hardware. Free margins of each flap can be repositioned natively, along the supraorbital rim division and posteriorly along the parietal border, to provide additional biomechanical integrity. Moreover, securing the advanced, composite pericranial/temporalis extension, at a site remote from the superior muscle border, allows for a more seamless transition between the temporal crest and cranium (compared with conventional resuspension techniques involving screws, drill holes, and spanning sutures). Finally, accounting for flap design dynamics, two shorter, broad pedicles may exhibit enhanced vasculature compared with a single, narrow flap. Further vascular density studies and perfusion angiography should be performed for quantification. Bilateral bookend pericranial flaps are described with a robust blood supply and enhanced versatility. These flaps allow for corset-type bolstering and contiguous temporalis muscle repositioning. Kenneth R. Wong, B.A., B.S. Section of Plastic and Reconstructive Surgery, Craniofacial Center, Yale University, New Haven, Conn. John H. Phillips, M.D., M.A. Division of Plastic Surgery, Centre for Craniofacial Care and Research, The Hospital for Sick Children, Toronto, Ontario, Canada Derek M. Steinbacher, M.D., D.M.D. Yale University, Section of Plastic and Reconstructive Surgery, Craniofacial Center, New Haven, Conn. ACKNOWLEDGMENT This work was supported by the Charles W. Ohse Grant for Surgical Research (Department of Surgery, Yale University School of Medicine). DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

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