Scalp Flaps LAWRENCE M. FIELD, MD, FIACS
The particular anatomy of the scalp largely dictates utilization of its parts and adjacent attached integument for reconstructive purposes. Unusually large movements of scalp skin are generally required with a variety of basic techniques and ancillay procedures. Rotation flaps are considered the prime “work-horses” for scalp flap reconstructions.Anatomic factors will be interspersed with clinical applications, and a series of photographs and commentary will highlight these considerations. J Dermatol Surg Oncol 1991;17190199.
Anatomic Considerations Multiple special features of the scalp’s anatomy (Table 1) serve to differentiateit from other areas and limit its applicability for regional flap formation. It is thick, inelastic, bears hair in a variety ,of configurations depending upon age and sex, and is relatively insensitive when compared with other areas of the integument. It extends from the nape of the neck posteriorly to the orbital ridges anteriorly, is anchored at the pinnae bilaterally, and includes a layer of muscle extending over the calvarium. The frontal and occipital muscles (along with the gala aponeurotica) constitutethe epicranial occipitofrontalismuscle. The antagonistic muscle actions of the frontalis anteriorly and the occipitalis posteriorly draws the galea tightly over the skull. A subaponeurotic space of loose fibrous tissue allows easy separation and movement over the bony periosteum. Transverse wounds of the scalp therefore have an increased propensity toward gaping, and this should be considered when designing scalp flaps. The amount and
placement of hair involving the epithelial surface is of great importance in determining the variety of reconstructive designs available after extirpative procedures. Scalp skin may be combined with forehead, neck, and/or cheek skin, the final length and width of skin availablefor reconstruction being limited by the dimensions of the scalp and adjacent tissues.
Blood Supply and Lymphatics The scalp‘s vascular supply is abundant, with both internal and external carotid arteries contributing (Table 2). Large rotation flaps of the lateral scalp (Figures 1-4) are supplied by the superficial temporal and posterior auricular vessels. Bipedicled ”bridge” flaps containingthe parietal branches of the superficial temporal artery may be moved from the occipital area to reconstruct the anterior scalp, the posterior donor area being covered with a splitthickness graft. The vascular supply to the vertex of the midline area is, however, relatively deficient when compared with the rest of the scalp. It should be realized that increasing age progressively compromises the arterial blood supply to the scalp, especially affecting flap viability after the sixth decade of life. Because the richly abundant lymphatic filtration systems of the scalp are poorly organized, diffuse lymphatic spread may occur to a significant degree in a small percentage of patients. Deeply invasive tumors may spread far beyond visible tumor. Aggressive surgical treatments for difficult reconstructive problems of increasing complexity occur with frequency. Although preoperative radiographic study may not conclusively demonstrate bone invasion,.large areas of calvarium may be invaded clinically at the time of surgery.
Reconstructive Parameters From Stanford University Medical Center and University of California, Sun Francisco, California.
Because midline arterial anastomoses are relatively infrequent, flaps involving the central scalp must be very wide 0 1991 by Elsevier Science Publishing Co., lnc. 0148-0812/91/$3.50
I Dermatol Surg Oncol
FIELD SCALP FLAPS
1991;27:190-199
Table 1. Scalv Anatomy The Scalv Soft Tissue Consists of Five Lavers 1. Skin: Thick with abundant blood and lymphatic supply, numerous sweat and sebaceous glands. 2. Subcutaneous tissues: An inelastic firm layer containing blood vessels. These bleed freely when divided because they cannot contract. Scalp flaps survive with only a small pedicle because of abundant anastomoses of temporal, supraorbital, supratrochlear, posterior auricular, and occipital vessels. 3. Lax layer of supraorbital fibroareolar tissue. 4. Subgaleal space: Between epicranius muscle and pericranium. Transversed by small arteries and emissary veins. Site of hematoma, infection, and thrombosis. 5. Pericranium: The periosteum overlying the cranium.
or have bilateral pedicles. Consideration should be given delaying narrow flaps, first incising and then resuturing them rather than undermining these flaps. Increased vascularity and decreased mobility result from such delays. Scalp mobility is gained by actual movement over the epicraniurn rather than by stretching alone. Most scalp excisions exceeding 10 mm are best camed down to the subgaleal plane, allowing the overlying skin to move with the galea. Defects greater than 30 mm almost always require flap movements, relaxing incisions, and/or the application of skin grafts. An increased incision length may allow easier closure under less tension than short incisions. However, the superiority of flaps over grafts for scalp reconstruction from both functional and cosmetic viewpoints is unquestioned, and flaps should be considered the treatment of choice when practicable.
191
Table 3. S c a b Flav Technioues 1. Rotation flaps 2. a. Double rotation flaps (0-to-Z) b. Dieffenbach’s winged V-Plasties (A-T,V-T). 3. Rotation flaps combined with free-skin grafts. 4. Multiple rotation flap techniques, including “pinwheels” 5. Bipedicled “bridge” flaps. 6. Double bipedicled flaps with central anastomosis and double split grafting laterally. 7. Transposition flaps with or without grafting of secondary defects. 8. Expanded tissue from occipital neck, upper back. 9. Tubed-pedicle flaps, usually from neck. Scalp mobility is obtained by the sliding movement ofthe superficialscalp layerson the epicrunium. The loose fascia between epicrunium and galea makes this possible.
surgical excision through all investing layers, including to the pericranial space when appropriate. Coleman4 notes the following: Use of rotation flaps from the adjacent scalp is the preferred method for wound closure in all patients in whom there is sufficient scalp to insure closure. The flaps are raised in any quadrant of the scalp without regard for specific anatomical distribution of the blood vessels. If the geometric design of the flap is sound, the flaps can be [rotated]more than 90 degrees without compromising the blood supply. Rotation puckers developing as a consequence of rotational movements should usually be left intact, with focal undermining of the area allowing significant postopera-. tive adjustment and smoothing. Secondary excision several months later is unusual.
Considerations of Flap Formation Additional Scalp Flap Applications
A key point in all scalp flap techniques (Table 3) is to make them significantly larger than expected to repair the same size defect in other parts of the body. Assistance with near-closures may be afforded by several ancillary techniques (Table 4). Full thickness local flap reconstruction should follow
Oblique scalp flaps harvesting almost the entire dorsal scalp onto the nape of the neck and utilizing the contralatera1 internal and external carotid systems may be used for major resurfacing problems. Although the author has heard of people successfully
Table 2. Blood Supply and Lymphatics
Table.4. Aiding Scalp Closure
1. The external and internal carotid systems provide a luxuriant . blood supply. 2. If it is contemplated to use the forehead as a flap, the muscular branches of the verterbral system afford an excellent arterial blood supply. 3. Lack of organized lymphatic filtration systems predisposes the scalp to diffuse lymphatic spread. 4. The loose attachment to the pericranium permits 90” rotation without ischema. 5. Because the loose attachment permits significant peripheral spread and deep invasion, scalp surgery of malignant lesions should entail wide resection when appropriate.
1. Galeal scoring: The galea is inased parallel to the leading edge of the flap, with underlying vessels preserved. These incisions are placed at 5 - 10-nun intervals. Further galeal cuts at right angles to previous incisions allow increased flap stretching fit, but with significantly increased risk. 2. The scalp Stretching technique of ”presuturing” with phenomenon of ”creep.” Stress relaxation and “creep” constitute viscoelastic skin properties. 3. Preoperative and intra-operative expansion techniques. 4. Skin graft is a last resort when closure cannot be accomplished. A secondary defect must then be accepted that is not aesthetically pleasing.
192 FIELD
J Dertnafol Surg Oncol 1991;17:190- 199
using island flaps pedicled on the galea, two partial flap failures have since stayed his hand. To those who would sever the minimal vascular support to obtain additional movement, such maneuvers would have limited applicability. Parietal-occipital flaps may be useful for reconstruction of defects about the ear, parotid, and cheek, with non-hair-bearing skin incorporated in these reconstructions by using post-auricular and neck nape skin. Posterior cervical scalp flaps are also mobilized to reconstruct extensive defects about the ear, parotid, and upper neck, the flap base,extendingbeyond mid-occiput. Muscle may be incorporated in these reconstructions when required for augmentation. When postoperative irradiation has been planned, a temporal artery-based scalp/forehead flap may be used to reform areas around the orbit, cribiform, and dura. Ipsilateral and contralateral scalp flaps, sometimes pedicled, may also be used to close large post-irradiated maxillostomes. Composite,scalp flaps including skin, temporal muscle, and bone, along with adjacent forehead have been used for extensive cheek and sinus reconstructions. These techniques involve splitting the flaps and utilization of frontoparietal bone to reform maxilla and to support the orbit and lower lid.2 Extensive areas of the face may be repaired using large scalp flaps which are,frequently hair bearing. Appearance is improved via multiple stages, during which the hair-bearingscalp areas are returned to their loci of origin. The resultant facial area defect may itself then be repaired by different flap techniques or may accept a cosmetically appropriate graft. Return of any flap to an original donor area is done with increased risk of devascularization, telogen effluvium, or, following more advanced insults, necrosis. Two-stage methods for reconstructing the sideburn area exist, the first stage transposing a superiorly-based hair-bearing flap from the parietal scalp. An occipital tubed flap has also been used to reconstruct the sideburn. Massive flaps can be lifted in 3 - 4 segments and resituated to reconstitute almost the entire dorsal scalp. Extensive scalp defects may require myocutaneous reconstruction or transference of large free scalp flaps with microsurgical vascular reanastomoses.
Hairless areas of the anterior frontal scalp may be inverted to form the floor of the oral cavity or the inner upper lip using a bipedicle design based on the temporal artery. This format may also be used for nasal, upper lip, and cheek reconstructions, again based on the temporal artery. Utilization of a hemostatic scalpel blade, whether the electronically controlled Shaw Scalpel or the #15 blade addition to a special handle of the Elmed Elektrotom System (Elmed Inc., Addison, IL) facilitate controlling bleeding in large scalp wounds. The pericranium should be spared injury while raising the scalp flap. However if in the course of surgery periosteum has been removed and the denuded cranial calvarium has been exposed for some time, the outer bony plate may undergo progressive eburnation with subsequent necrosis. A vitalized bony base must be demonstrated following removal of avascular tissue. If flap reconstruction is not possible and there is no pericranium, osteotome removal of the outer plate will facilitate granulation tissue formation with probability of skin graft acceptance after 1.5 - 2 weeks. Flap donor areas covered by free grafts may occasionally be serially excised many months later or completely excised and covered with a hair-bearing flap in a second stage. These considerations are dependent on defect size and available tissue. There is considerable variation in the application of varying types of sutures and staples to scalp surgery. There is further disagreement on the necessity of galeal closure. For myself, I would advocate galeal closure with a deeply buried suture hopefully grasping 10 mm of galea on either side whenever tension is present. I have found stapling techniques excellent to close surface scalp wounds, and will frequently utilize a deep and running galeal suture combined with surface staples, the former being done over a 20-30 mm distance to be followed immediately by surface apposition, and then continuing this type of closure serially. In the "Photographic Legend" which follows, the reader will overview several flap techniques with concomitant commentary.
Figures 1- 26 followl
Figure 1. Rotation flap for reconstruction of triangulated defect on the scalp above the pinna. The incision is carried downward, parallel with the exit angle of hairs, into the subgaleal space and extending just to the glistening periosteal surface. Vessels along the cut sides are dessicated to control bleeding. Figure 2. A flap is quickly and easily undermined in the relatively avascular subgaleal space. Neurovascular and muscular attachments are preserved where possible, severing only enough to accomplish adequate flap movement. The hair-bearing flap is here reflected with a four-pronged rhytidectomy forcep, some remaining attachment being obvious. Flap mobility should be confirmed so there is no tension on the final anastomotic line.
Figure 3. A galeal closure has been completed. Stainless steel staples are used for surface approximation.
Figure 4. The result 3 months postoperatively with no intervening hair loss.
194 FIELD
Derrnatol Surg Oncol 1991;Z7390- 199
Figure 5. lncorporation of M-plasty to shorten incision projection onto the balded scalp. The arciform design of the incision at the junction of glabrous and nonglabrous posterior scalp assists in scar camouflage.
Figure 7. Multiple rotation flaps (“‘pinwheel” design of three or four rotating units) used to preserve or establish natural whorl pattern at occiput. The area to be undermined is within dotted line circ~mference.~
Figure 6. Result, 5 weeks after rotation with M-plasty.
Figure 8. Flaps raised and prepared for serial rotation.
Dermatol surg Oncol 1992;17:190- 199
FIELD SCALP FLAPS
195
Figure 9. Result, 6 months postoperatively.
Figure 11. Result, 6 months postoperatively.
Figure 10. Dual or double rotation (Oval-t0-z) flaps to close a large central scalp defect.
Figure 12. An extensive actinically induced carcinoma of balding scalp removed with midline scalp reduction bilateral advancement approach. Additional resection of non-hair-bearing skin as tolerated to allow closure.
196 FIELD
Dermatol Surg Oncol 1991;17:190- 199
Figure 13. Status 6 months postoperatively.
Figure 15. Closure.
Figure 14. Excision using longitudinal bilateral advancement Paps and dual M-plasties.
Figure 16. Bilateral hair-bearing rotation flaps of lateral central scalp (Diefienbach winged V-plasty, or V - T plasty).
Dermatol Surg Oncol 1991;17:190-199
FIELD SCALP FLAPS
Figure 17. Closure.
Figure 19. The transposition is completed.
Figure 18. A hair-bearing transposition Pap elevated with adjacent scalp skin undermined to allow advancement and flap donor-site closure. Operative defect on frontotemporal scalp.
Figure 20. Recurrent carcinoma in a scar from previous intervention elsewhere. Desired frontal hairline with intact widow's peak inked on at hair-bearing scalp junction.
197
198 FIELD
J Dermatol Surg Oncol 1991;1 7~190-199
Figure 21. An operative defect to periosteum.
Figure 23. Closure of dual hair-bearing rotation Paps as initial step, to be followed by forward movement to the forehead incised skin line.
Figure 22. Dual hair-bearing scalp Paps with forehead incision line sculpted to allow aesthetic scalp/forehead reformation.
Figure 24. Tailoring of anastomotic line, removing excess to obtain precise closure.
Dermatol Surg Oncol
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2991;17:190- 199
Figure 25. Final closure lines, incorporating two hair-bearing rotation paps, a single M-plasty posteriorly, and reconstruction of scalp/forehead curvatures with a widow's peak centrally.
References and Further Reading 1. Zoltan J, ed. Atlas of skin repair. Bosel, Switzerland:Karger, 1984:104- 109. 2. Harris T. Large flap repair (scalp flaps). In Emmet A,
O'Rourke M, eds. Malignant skin tumors. New York Churchill Livingston, 1982:271-72. 3. Tromovitch T, Stegman S, Glogau R. Lesions of the scalp, flaps and grafts in dermatologic surgery. Chicago: Yearbook, 1989~73- 82. 4. Coleman C. Tumors involving the craniofacial skeleton. In Converse, ed. ReconstructivePlasticSurgery.Vol5. Philadelphia: WB Saunders, 1977:2757-75. 5 . Orticochea M. Flaps of the cutaneous covering of the skull. In
199
Figure 26. Result, 12 months later.
Grabb W, Meyers M, eds. Skin flaps. Boston: Little Brown, 1975~155-83. Petres J, Hundeiker M. Special techniques for different regions of the body: Scalp. In Petres J, ed. Dermatosurgery. New York: Springer-Verlag, 1978:51-2. Conley J, ed. Regional flaps of the head and neck. Philadelphia: WB Saunders, 1976:19-20, 23-29, 46-47. Nordstrom R, ed. Tissue expansion, facial plastic surgery. New York: Thieme Medical Publishers, International Quarterly Monographs 1988;5:321-2. Field L. The scalp "pinwheel" flap. Am J Cosm Surg 1984;1:38-40.
.
The particular anatomy of the scalp largely dictates utilization of its parts and adjacent attached integument for reconstructive purposes. Unusually large movements of scalp skin are generally required with a variety of basic techniques and ancillay procedures. Rotation flaps are considered the prime “work-horses” for scalp flap reconstructions.Anatomic factors will be interspersed with clinical applications, and a series of photographs and commentary will highlight these considerations. J Dermatol Surg Oncol 1991;17190199.
Anatomic Considerations Multiple special features of the scalp’s anatomy (Table 1) serve to differentiateit from other areas and limit its applicability for regional flap formation. It is thick, inelastic, bears hair in a variety ,of configurations depending upon age and sex, and is relatively insensitive when compared with other areas of the integument. It extends from the nape of the neck posteriorly to the orbital ridges anteriorly, is anchored at the pinnae bilaterally, and includes a layer of muscle extending over the calvarium. The frontal and occipital muscles (along with the gala aponeurotica) constitutethe epicranial occipitofrontalismuscle. The antagonistic muscle actions of the frontalis anteriorly and the occipitalis posteriorly draws the galea tightly over the skull. A subaponeurotic space of loose fibrous tissue allows easy separation and movement over the bony periosteum. Transverse wounds of the scalp therefore have an increased propensity toward gaping, and this should be considered when designing scalp flaps. The amount and
placement of hair involving the epithelial surface is of great importance in determining the variety of reconstructive designs available after extirpative procedures. Scalp skin may be combined with forehead, neck, and/or cheek skin, the final length and width of skin availablefor reconstruction being limited by the dimensions of the scalp and adjacent tissues.
Blood Supply and Lymphatics The scalp‘s vascular supply is abundant, with both internal and external carotid arteries contributing (Table 2). Large rotation flaps of the lateral scalp (Figures 1-4) are supplied by the superficial temporal and posterior auricular vessels. Bipedicled ”bridge” flaps containingthe parietal branches of the superficial temporal artery may be moved from the occipital area to reconstruct the anterior scalp, the posterior donor area being covered with a splitthickness graft. The vascular supply to the vertex of the midline area is, however, relatively deficient when compared with the rest of the scalp. It should be realized that increasing age progressively compromises the arterial blood supply to the scalp, especially affecting flap viability after the sixth decade of life. Because the richly abundant lymphatic filtration systems of the scalp are poorly organized, diffuse lymphatic spread may occur to a significant degree in a small percentage of patients. Deeply invasive tumors may spread far beyond visible tumor. Aggressive surgical treatments for difficult reconstructive problems of increasing complexity occur with frequency. Although preoperative radiographic study may not conclusively demonstrate bone invasion,.large areas of calvarium may be invaded clinically at the time of surgery.
Reconstructive Parameters From Stanford University Medical Center and University of California, Sun Francisco, California.
Because midline arterial anastomoses are relatively infrequent, flaps involving the central scalp must be very wide 0 1991 by Elsevier Science Publishing Co., lnc. 0148-0812/91/$3.50
I Dermatol Surg Oncol
FIELD SCALP FLAPS
1991;27:190-199
Table 1. Scalv Anatomy The Scalv Soft Tissue Consists of Five Lavers 1. Skin: Thick with abundant blood and lymphatic supply, numerous sweat and sebaceous glands. 2. Subcutaneous tissues: An inelastic firm layer containing blood vessels. These bleed freely when divided because they cannot contract. Scalp flaps survive with only a small pedicle because of abundant anastomoses of temporal, supraorbital, supratrochlear, posterior auricular, and occipital vessels. 3. Lax layer of supraorbital fibroareolar tissue. 4. Subgaleal space: Between epicranius muscle and pericranium. Transversed by small arteries and emissary veins. Site of hematoma, infection, and thrombosis. 5. Pericranium: The periosteum overlying the cranium.
or have bilateral pedicles. Consideration should be given delaying narrow flaps, first incising and then resuturing them rather than undermining these flaps. Increased vascularity and decreased mobility result from such delays. Scalp mobility is gained by actual movement over the epicraniurn rather than by stretching alone. Most scalp excisions exceeding 10 mm are best camed down to the subgaleal plane, allowing the overlying skin to move with the galea. Defects greater than 30 mm almost always require flap movements, relaxing incisions, and/or the application of skin grafts. An increased incision length may allow easier closure under less tension than short incisions. However, the superiority of flaps over grafts for scalp reconstruction from both functional and cosmetic viewpoints is unquestioned, and flaps should be considered the treatment of choice when practicable.
191
Table 3. S c a b Flav Technioues 1. Rotation flaps 2. a. Double rotation flaps (0-to-Z) b. Dieffenbach’s winged V-Plasties (A-T,V-T). 3. Rotation flaps combined with free-skin grafts. 4. Multiple rotation flap techniques, including “pinwheels” 5. Bipedicled “bridge” flaps. 6. Double bipedicled flaps with central anastomosis and double split grafting laterally. 7. Transposition flaps with or without grafting of secondary defects. 8. Expanded tissue from occipital neck, upper back. 9. Tubed-pedicle flaps, usually from neck. Scalp mobility is obtained by the sliding movement ofthe superficialscalp layerson the epicrunium. The loose fascia between epicrunium and galea makes this possible.
surgical excision through all investing layers, including to the pericranial space when appropriate. Coleman4 notes the following: Use of rotation flaps from the adjacent scalp is the preferred method for wound closure in all patients in whom there is sufficient scalp to insure closure. The flaps are raised in any quadrant of the scalp without regard for specific anatomical distribution of the blood vessels. If the geometric design of the flap is sound, the flaps can be [rotated]more than 90 degrees without compromising the blood supply. Rotation puckers developing as a consequence of rotational movements should usually be left intact, with focal undermining of the area allowing significant postopera-. tive adjustment and smoothing. Secondary excision several months later is unusual.
Considerations of Flap Formation Additional Scalp Flap Applications
A key point in all scalp flap techniques (Table 3) is to make them significantly larger than expected to repair the same size defect in other parts of the body. Assistance with near-closures may be afforded by several ancillary techniques (Table 4). Full thickness local flap reconstruction should follow
Oblique scalp flaps harvesting almost the entire dorsal scalp onto the nape of the neck and utilizing the contralatera1 internal and external carotid systems may be used for major resurfacing problems. Although the author has heard of people successfully
Table 2. Blood Supply and Lymphatics
Table.4. Aiding Scalp Closure
1. The external and internal carotid systems provide a luxuriant . blood supply. 2. If it is contemplated to use the forehead as a flap, the muscular branches of the verterbral system afford an excellent arterial blood supply. 3. Lack of organized lymphatic filtration systems predisposes the scalp to diffuse lymphatic spread. 4. The loose attachment to the pericranium permits 90” rotation without ischema. 5. Because the loose attachment permits significant peripheral spread and deep invasion, scalp surgery of malignant lesions should entail wide resection when appropriate.
1. Galeal scoring: The galea is inased parallel to the leading edge of the flap, with underlying vessels preserved. These incisions are placed at 5 - 10-nun intervals. Further galeal cuts at right angles to previous incisions allow increased flap stretching fit, but with significantly increased risk. 2. The scalp Stretching technique of ”presuturing” with phenomenon of ”creep.” Stress relaxation and “creep” constitute viscoelastic skin properties. 3. Preoperative and intra-operative expansion techniques. 4. Skin graft is a last resort when closure cannot be accomplished. A secondary defect must then be accepted that is not aesthetically pleasing.
192 FIELD
J Dertnafol Surg Oncol 1991;17:190- 199
using island flaps pedicled on the galea, two partial flap failures have since stayed his hand. To those who would sever the minimal vascular support to obtain additional movement, such maneuvers would have limited applicability. Parietal-occipital flaps may be useful for reconstruction of defects about the ear, parotid, and cheek, with non-hair-bearing skin incorporated in these reconstructions by using post-auricular and neck nape skin. Posterior cervical scalp flaps are also mobilized to reconstruct extensive defects about the ear, parotid, and upper neck, the flap base,extendingbeyond mid-occiput. Muscle may be incorporated in these reconstructions when required for augmentation. When postoperative irradiation has been planned, a temporal artery-based scalp/forehead flap may be used to reform areas around the orbit, cribiform, and dura. Ipsilateral and contralateral scalp flaps, sometimes pedicled, may also be used to close large post-irradiated maxillostomes. Composite,scalp flaps including skin, temporal muscle, and bone, along with adjacent forehead have been used for extensive cheek and sinus reconstructions. These techniques involve splitting the flaps and utilization of frontoparietal bone to reform maxilla and to support the orbit and lower lid.2 Extensive areas of the face may be repaired using large scalp flaps which are,frequently hair bearing. Appearance is improved via multiple stages, during which the hair-bearingscalp areas are returned to their loci of origin. The resultant facial area defect may itself then be repaired by different flap techniques or may accept a cosmetically appropriate graft. Return of any flap to an original donor area is done with increased risk of devascularization, telogen effluvium, or, following more advanced insults, necrosis. Two-stage methods for reconstructing the sideburn area exist, the first stage transposing a superiorly-based hair-bearing flap from the parietal scalp. An occipital tubed flap has also been used to reconstruct the sideburn. Massive flaps can be lifted in 3 - 4 segments and resituated to reconstitute almost the entire dorsal scalp. Extensive scalp defects may require myocutaneous reconstruction or transference of large free scalp flaps with microsurgical vascular reanastomoses.
Hairless areas of the anterior frontal scalp may be inverted to form the floor of the oral cavity or the inner upper lip using a bipedicle design based on the temporal artery. This format may also be used for nasal, upper lip, and cheek reconstructions, again based on the temporal artery. Utilization of a hemostatic scalpel blade, whether the electronically controlled Shaw Scalpel or the #15 blade addition to a special handle of the Elmed Elektrotom System (Elmed Inc., Addison, IL) facilitate controlling bleeding in large scalp wounds. The pericranium should be spared injury while raising the scalp flap. However if in the course of surgery periosteum has been removed and the denuded cranial calvarium has been exposed for some time, the outer bony plate may undergo progressive eburnation with subsequent necrosis. A vitalized bony base must be demonstrated following removal of avascular tissue. If flap reconstruction is not possible and there is no pericranium, osteotome removal of the outer plate will facilitate granulation tissue formation with probability of skin graft acceptance after 1.5 - 2 weeks. Flap donor areas covered by free grafts may occasionally be serially excised many months later or completely excised and covered with a hair-bearing flap in a second stage. These considerations are dependent on defect size and available tissue. There is considerable variation in the application of varying types of sutures and staples to scalp surgery. There is further disagreement on the necessity of galeal closure. For myself, I would advocate galeal closure with a deeply buried suture hopefully grasping 10 mm of galea on either side whenever tension is present. I have found stapling techniques excellent to close surface scalp wounds, and will frequently utilize a deep and running galeal suture combined with surface staples, the former being done over a 20-30 mm distance to be followed immediately by surface apposition, and then continuing this type of closure serially. In the "Photographic Legend" which follows, the reader will overview several flap techniques with concomitant commentary.
Figures 1- 26 followl
Figure 1. Rotation flap for reconstruction of triangulated defect on the scalp above the pinna. The incision is carried downward, parallel with the exit angle of hairs, into the subgaleal space and extending just to the glistening periosteal surface. Vessels along the cut sides are dessicated to control bleeding. Figure 2. A flap is quickly and easily undermined in the relatively avascular subgaleal space. Neurovascular and muscular attachments are preserved where possible, severing only enough to accomplish adequate flap movement. The hair-bearing flap is here reflected with a four-pronged rhytidectomy forcep, some remaining attachment being obvious. Flap mobility should be confirmed so there is no tension on the final anastomotic line.
Figure 3. A galeal closure has been completed. Stainless steel staples are used for surface approximation.
Figure 4. The result 3 months postoperatively with no intervening hair loss.
194 FIELD
Derrnatol Surg Oncol 1991;Z7390- 199
Figure 5. lncorporation of M-plasty to shorten incision projection onto the balded scalp. The arciform design of the incision at the junction of glabrous and nonglabrous posterior scalp assists in scar camouflage.
Figure 7. Multiple rotation flaps (“‘pinwheel” design of three or four rotating units) used to preserve or establish natural whorl pattern at occiput. The area to be undermined is within dotted line circ~mference.~
Figure 6. Result, 5 weeks after rotation with M-plasty.
Figure 8. Flaps raised and prepared for serial rotation.
Dermatol surg Oncol 1992;17:190- 199
FIELD SCALP FLAPS
195
Figure 9. Result, 6 months postoperatively.
Figure 11. Result, 6 months postoperatively.
Figure 10. Dual or double rotation (Oval-t0-z) flaps to close a large central scalp defect.
Figure 12. An extensive actinically induced carcinoma of balding scalp removed with midline scalp reduction bilateral advancement approach. Additional resection of non-hair-bearing skin as tolerated to allow closure.
196 FIELD
Dermatol Surg Oncol 1991;17:190- 199
Figure 13. Status 6 months postoperatively.
Figure 15. Closure.
Figure 14. Excision using longitudinal bilateral advancement Paps and dual M-plasties.
Figure 16. Bilateral hair-bearing rotation flaps of lateral central scalp (Diefienbach winged V-plasty, or V - T plasty).
Dermatol Surg Oncol 1991;17:190-199
FIELD SCALP FLAPS
Figure 17. Closure.
Figure 19. The transposition is completed.
Figure 18. A hair-bearing transposition Pap elevated with adjacent scalp skin undermined to allow advancement and flap donor-site closure. Operative defect on frontotemporal scalp.
Figure 20. Recurrent carcinoma in a scar from previous intervention elsewhere. Desired frontal hairline with intact widow's peak inked on at hair-bearing scalp junction.
197
198 FIELD
J Dermatol Surg Oncol 1991;1 7~190-199
Figure 21. An operative defect to periosteum.
Figure 23. Closure of dual hair-bearing rotation Paps as initial step, to be followed by forward movement to the forehead incised skin line.
Figure 22. Dual hair-bearing scalp Paps with forehead incision line sculpted to allow aesthetic scalp/forehead reformation.
Figure 24. Tailoring of anastomotic line, removing excess to obtain precise closure.
Dermatol Surg Oncol
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2991;17:190- 199
Figure 25. Final closure lines, incorporating two hair-bearing rotation paps, a single M-plasty posteriorly, and reconstruction of scalp/forehead curvatures with a widow's peak centrally.
References and Further Reading 1. Zoltan J, ed. Atlas of skin repair. Bosel, Switzerland:Karger, 1984:104- 109. 2. Harris T. Large flap repair (scalp flaps). In Emmet A,
O'Rourke M, eds. Malignant skin tumors. New York Churchill Livingston, 1982:271-72. 3. Tromovitch T, Stegman S, Glogau R. Lesions of the scalp, flaps and grafts in dermatologic surgery. Chicago: Yearbook, 1989~73- 82. 4. Coleman C. Tumors involving the craniofacial skeleton. In Converse, ed. ReconstructivePlasticSurgery.Vol5. Philadelphia: WB Saunders, 1977:2757-75. 5 . Orticochea M. Flaps of the cutaneous covering of the skull. In
199
Figure 26. Result, 12 months later.
Grabb W, Meyers M, eds. Skin flaps. Boston: Little Brown, 1975~155-83. Petres J, Hundeiker M. Special techniques for different regions of the body: Scalp. In Petres J, ed. Dermatosurgery. New York: Springer-Verlag, 1978:51-2. Conley J, ed. Regional flaps of the head and neck. Philadelphia: WB Saunders, 1976:19-20, 23-29, 46-47. Nordstrom R, ed. Tissue expansion, facial plastic surgery. New York: Thieme Medical Publishers, International Quarterly Monographs 1988;5:321-2. Field L. The scalp "pinwheel" flap. Am J Cosm Surg 1984;1:38-40.
.
