Dermatologic surgeryDual transposition flaps for the reconstruction of large scalp defects
Introduction
Closure of large scalp defects presents a formidable challenge to the reconstructive surgeon. The scalp tissue and the underlying cranium have multiple limitations that must be overcome to achieve successful closure of tissue defects. First, the scalp is a relatively inelastic tissue with limited mobility. Second, mobilizing tissue over the spherical curvature of the cranium often requires additional length incorporated into flap design. Third, careful planning of flaps must be performed in order to preserve the axial blood supply, and this can further limit the available tissue reservoirs.
Second-intent healing or skin grafts are potential options for the closure of large scalp defects. However, the resultant alopecia and poor tissue match are undesirable, and granulation may take several months. The use of tissue expanders and galeotomies are additional techniques that should also be considered when planning a reconstruction of large scalp wounds; however, these techniques have associated risks and complications. When feasible, local tissue flaps provide the best cosmetic outcome, with preservation of hair-bearing tissue and rapid healing.
We describe the use of dual transposition flaps for the closure of a large defect on the vertex scalp. This two-flap technique resulted in the complete closure of the tissue defect, an excellent cosmetic result, and superior patient satisfaction with the outcome.
Section snippets
Methods
A 30-year-old man was referred for Mohs micrographic surgery for a 3-cm basal cell carcinoma of the vertex scalp. The tumor required 6 Mohs stages to obtain clear margins. After tumor extirpation, the final wound was a full-thickness, 78.5 cm2 defect with exposed cranium (Fig 1). Closure was delayed for 3 weeks to allow the pericranium to regenerate and to permit wound contracture to reduce the size of the defect. During the delay period, wound care consisted of an occlusive
Results
The postoperative course was uneventful. The flaps remained well perfused and demonstrated rapid healing. Surgical staples were removed at postoperative week 2. No complications were encountered during the postoperative period. At a 3-month follow-up visit, the cosmetic outcome was excellent with minimal stretch-back and alopecia limited only to the surgical scars (Fig 5). Although the follicular orientation in this region was modified from its preoperative configuration, it still retained a
Discussion
Reconstructing large scalp defects can be challenging. Multiple physical and cosmetic properties unique to the scalp significantly limit the available tissue reservoirs. The scalp is composed of multiple layers including epidermis, dermis, and subcutaneous, adipose, and fibrous connective tissues. The deepest layer of the scalp, the galea aponeurotica, is a dense fibroconnective tissue layer that spans the length of the scalp connecting the frontalis muscle anteriorly, the temporalis laterally,
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Funding sources: None.
Conflicts of interest: None declared.