Dermatologic surgery
Dual transposition flaps for the reconstruction of large scalp defects

https://doi.org/10.1016/j.jaad.2009.01.009Get rights and content

Background

Large scalp defects can be challenging to repair because of the inelasticity of the scalp. While there are several methods to close this type of wound, they result in either alopecia or unacceptable scarring. We present a dual transposition flap to close a large defect following Mohs surgery for a basal cell carcinoma on the scalp.

Methods

We describe and report the case of a man with a basal cell carcinoma on the scalp vertex who had been referred for Mohs micrographic surgery. The surgery resulted in a large scalp defect.

Results

A dual transposition flap performed with tumescent anesthesia was used in a delayed closure of a 78.5-cm2 defect. It resulted in minimal alopecia, minimal distortion of the hair orientation, and minimal scar stretch-back.

Limitations

The limitation of this study is that this technique is based on one case report.

Conclusions

This dual transposition flap is a good reconstructive option for large, immobile scalp defects. It can be performed under local anesthesia with minimal alopecia and camouflaged scars.

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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    This axial pattern flap, based on the superficial temporal vessels, is no longer used by most contemporary hair restoration surgeons but still may have limited application as a reconstructive flap. Fincher and Gladstone35 described a case report of dual transposition flap for delayed closure of a 78.5 cm2 defect following Mohs micrographic surgery. This flap was designed to borrow tissue from the occipitoparietal regions with coronally oriented axial blood supply.

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Funding sources: None.

Conflicts of interest: None declared.

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