• Surgeon
• Surgical assistant
• Surgical scrub technician
• Operating room nurse (circulator)
• The anesthesiologist and/or nurse anesthetist

• The patient should be risk-stratified and medically optimized for general anesthesia.
• A thorough preoperative head and neck examination, including assessment of facial nerve function, should be performed.
• Preoperative photography may be considered to document the shape and size and location of the defect.
• The patient should be appropriately counseled regarding the risks, benefits, and alternatives to the procedure. Pertinent to this procedure, it is important to mention flap compromise, alopecia, paresthesias, and facial nerve injury, among the other more common risks associated with surgery (e.g., pain, bleeding, infection, scarring, etc.).
• The surgeon should mark the skin incisions in the temporal scalp to ensure the maximal preservation of the hairline. The Y or T shaped incision is made parallel to the course of the STA. The arterial bifurcation is commonly found 3 centimeters above the helical root.
• Important landmarks are identified, including the STA and trajectory of the frontotemporal branch of the facial nerve.
• General anesthesia is recommended. Muscle paralytics are usually avoided to allow for intraoperative facial nerve monitoring. 
• A single dose of intravenous antibiotics covering skin flora is given preoperatively.

It is not necessary to shave any hair during this procedure, though it may be helpful to shave the hair 1 to 2 cm beyond the anticipated incision line.

1. A Y or T shaped incision is planned in the preauricular crease and extended several centimeters cranially. 
2. The incision is made through the skin, dermis, and subcutaneous fat. The cranial and outward dissection from this point is in a subcutaneous plane just below the level of the hair follicles. This step is of utmost importance as it assists the surgeon in maintaining the appropriate depth of dissection and preserves robust temporoparietal fascia flap thickness. Sharp, cold dissection is preferred to avoid thermal injury to the hair follicles and decreased the risk of alopecia.
3. Care should be taken to avoid injuring the underlying STA, which courses through the substance of the flap itself. Once the appropriate size of the required temporoparietal flap is exposed, the surgeon can incise the periphery of the temporoparietal fascia sharply with care to preserve the vascular pedicle. At this step, the distal branches of the superficial temporal artery are ligated. The surgeon may now rotate the flap into its desired defect. If hair-bearing skin is required, this flap may be harvested in the continuity of the overlying skin. NOTE: One should be mindful during anterior dissection as not to injury the frontotemporal branch of the facial nerve, which lies either within or just beneath the temporoparietal fascia. (See ANATOMY section above)
4. The superficial temporal artery may be dissected further proximally until the middle temporal artery is identified. In certain situations, the surgeon may require dissection of parotid tissue to facilitate this step. At this point, the flap may be harvested as a chimeric flap to include the deep temporal fascia and/or temporalis muscle. If desired, the surgeon can extend the anatomic boundaries of this fascial layer beyond the temporal fossa to include pericranium and/or to harvest a vascularized strip of calvarium (outer cortex).
5. The surgeon may either rotate or tunnel this flap into the desired defect or the vascular bundle may be ligated in anticipation of free microvascular reconstruction of distal defects.
6. The surgeon may select to place a closed suction drain. This is optional.
7. The skin flaps are then reapproximated with deep absorbable sutures, followed by staples or suture closure of skin.

Potential complications for a temporoparietal fascia flap may include[14]:

• Alopecia
• Flap necrosis
• Incomplete eye closure following an injury to the frontal branch of the facial nerve
• Venous congestion
• Wound breakdown
• Hematoma formation
• Infection
• Unfavorable scarring
• Paresthesia

The majority of complications can be avoided with meticulous dissection and careful flap elevation respecting the local scalp anatomy. Rates of flap loss (partial vs. total) are roughly 2.44%.[12] Some degree of alopecia may be documented in up to 8% of patients.[15] Injury to the frontotemporal branch of the facial nerve resulting in transient weakness to paralysis may range from 1% to 20%.[16]

A temporoparietal fascia flap can act as a work-horse reconstructive option in the armamentarium of a reconstructive surgeon. It is a low-risk option for the reconstruction of local (craniofacial) and distal soft tissue defects. It has found notoriety in head and neck reconstruction as a pedicled flap but may be harvested as a free flap for extremity reconstruction. In the hands of an experienced and knowledgeable surgeon, the outcomes can be very satisfactory. 

It remains imperative to identify the risk factors and perform a thorough assessment before performing a temporoparietal fascial flap. The patient should have the following done:

• Evaluation by a surgeon experienced in reconstructive surgery using a temporoparietal fascial flap.
• Medical optimization in anticipation of general anesthesia
• Monitoring by the preoperative, operative, and postoperative specialty nurse to assist with coordination of care and education. 

An interprofessional team of an experienced surgeon, anesthesiologist, surgical assistant, and operative nurse should perform the temporoparietal fascial flap for best outcomes. Close follow-up should monitor the patient for potential complications: flap necrosis, alopecia, wound breakdown, hematoma, and facial paralysis. Proper education should counsel the patient on appropriate wound care and activity level. 

This coordinated interprofessional care is essential to achieving the best results in reconstructive procedures utilizing a temporoparietal fascial flap. [Level 5]

Recovery following a temporoparietal fascia flap depends on the complexity of the original problem for which the reconstruction was performed. Local wound care is paramount to ensure a healthy and clean surgical environment.   Suction drains (if placed) can be removed when output has appropriately decreased (e.g., output less than 30 mL over 24 hours). The patient should avoid rigorous activity for the next 10 days following surgery to allow adequate wound healing. Following discharge, the patient is typically followed regularly for several weeks to months to ensure proper healing. 

Close follow-up should monitor for potential possible complications: flap necrosis, alopecia, wound breakdown, hematoma, and facial paralysis. The ancillary staff should assist in patient education, monitoring, and follow-up coordination.