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The combination of posterior scalping flap and gracilis free flap for mid-face reconstruction
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THE COMBINATION OF POSTERIOR SCALPING FLAP AND GRACILIS FREE FLAP FOR MID-FACE RECONSTRUCTION ERIC M. GENDEN, MD, DAVID MANDELL, MD, MARK L. URKEN, MD
A variety of donor sites have been reported for the restoration of mid-face cutaneous defects; however, the limited availability of tissue of similar color and texture to that of native facial skin greatly limits reconstructive options. Similarly, resection of the underlying mimetic musculature during the primary ablation compounds this reconstructive challenge, resulting in both a cosmetic and a functional deformity. The combination of the posterior scalping flap for cutaneous resurfacing, and microvascular transfer and reinnervation of the gracilis free flap for dynamic facial reanimation, offers a reconstructive alternative for extensive soft tissue defects of the mid-face.
Reconstruction of extensive soft tissue mid-facial defects requires reconstruction of both the underlying mimetic musculature as well as the cutaneous defect. Cervicofacial, 1 submental, 2 and forehead flaps 3 serve as options for resurfacing of such cutaneous defects; however, these options fail to address the functional deficit associated with a concomitant facial-nerve paralysis. A number of methods have been described to establish static facial symmetry 4-6 and dynamic facial motion 7-12 after facialnerve injury, yet there are few reconstructive options that offer a solution for both deficits. While the gracilis and latissimus dorsi free flaps may be reinnervated and transferred with a skin paddle, the skin color and texture dramatically contrast with that of the native facial skin. The complex defect involving both the facial musculature and the overlying skin may be optimally reconstructed with a combination of the innervated gracilis free flap and the posterior scalping flap. During World War I, surgeons commonly faced the dilemma of mid-face reconstruction following traumatic injury. During this time, surgeons popularized the use of pedicled, local skin flaps as a reliable means of reconstructing mid-facial cutaneous defects. 13 By the end of the Second World War, Converse 13 described the anterior scalping flap, a variation on the "up-and-down" flap described earlier by GillesJ °,12 This 2-staged scalp flap is composed of the forehead skin providing a well-vascularized cutaneous skin paddle, which matches the color and texture of the facial skin. The significant donor-site defect is difficult to conceal, resulting in limited popularity. 14 In 1969, Washio 15introduced the retroauricular-temporal
From the Department of Otolaryngology, Head and Neck Surgery, Mount Sinai Medical Center, New York, NY. Address reprint requests to Eric M. Genden, MD, Assistant Professor, Department of Otolaryngology, Box 1189, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029. Copyright © 2000 by W.B. Saunders Company 1043-1810/00/1102-0002510.00/0 doi:10.1053/otot.2000.8228
72
scalping flap. Arena 16 later extended the donor site to include the posterior scalp and nape-of-neck skin. Reported in 1977 by Arena, the posterior scalping flap accomplishes many of the objectives of the anterior scalping flap without the disfigurement of a forehead scar. Unlike the anterior forehead flap, the nape-of-neck donor site is easily camouflaged, particularly in women with long hair. The selection of an appropriate technique for the management of a facial-nerve deficit depends on the mimetic musculature available, and whether there is access to the main trunk or branches of the ipsilateral facial nerve. In conditions in which both the proximal and distal branches of the facial nerve are available, immediate nerve grafting offers the optimal solution for reanimation. When the main branch of the facial nerve is not accessible, a cross-facial nerve graft or a host of adynamic facial sling techniques may be used. The resection of the facial nerve with its facial musculature, however, presents a challenging reconstructive dilemma. In 1976, Harii et al 7 first described the microvascular transfer of a segment of gracilis muscle for dynamic facial reanimation. This original description entailed an anastomosis between the anterior branch of the obturator nerve with the deep temporal nerve, followed by suturing one end of the gracilis segment to the lateral oral commissure and the opposite end to the temporal fascia. Several refinements have been made to establish synchronous mimetic movement to the face, including using the facial stump as the donor nerve and performing cross-facial sural nerve grafts. This article addresses the pertinent anatomy and method of harvesting the posterior scalping flap, as well as highlighting the role of the reinnervated gracilis free flap for facial reanimation.
APPLICABLE ANATOMY The scalp is composed of 5 layers (Fig 1). The skin is most superficial, followed by the deeper layers including the
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 11, NO 2 (JUN), 2000: PP 72-75
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Cranium FIGURE 1. The 5 layers of the scalp including (from superficial to deep) the skin, subcutaneous tissue, galea aponeurotica, periosteum, and cranium. The epicranium is composed of the most superficial 3 layers.
subcutaneous tissue, galea aponeurotica, loose connective tissue, and the periosteum of the skull. The galea is continuous anteriorly with the paired frontalis muscles and posteriorly with the paired occipital muscles. The epicranium is composed of the skin, subcutaneous tissue, and galea aponeurotica, which are tightly adherent to one another, acting as a single unit. The loose areolar connective tissue layer represents the relatively avascular plane in which the posterior scalping flap is raised. Most nerves and blood vessels to the scalp enter and traverse superficial to the galea aponeurotica. The nutrient blood supply to the posterior scalping flap is the superficial temporal, supraorbital, and supratrochlear arteries (Fig 2). The occipital and postauricular arteries are transected during flap harvest. The veins of the scalp run parallel to the arteries, and are in communication with the cranial venous sinuses via a complex network of emissary veins.
description of the technique may be found elsewhere¢6 Once the appropriate segment of gracilis muscle has been harvested with its accompanying vascular pedicle and motor nerve, the vascular and neural anastomoses are completed. Reinnervated muscle will tend to maintain its bulk, atrophying only minimally, so that the cosmetic augmentation can be appropriately assessed intraoperatively. Although choosing the correct length and width of muscle for harvest plays an important role in functional and cosmetic results, Harii 17found that the recipient nerve had the greatest impact on the final result. The stump of the facial nerve offers the most consistent results; however, the 2-staged cross-facial nerve graft offers a satisfactory alternative. Determining the appropriate length of the muscle is estimated by suturing one end to the orbicularis oris at the lateral commissure, and the other end to the temporal fascia under tension (Fig 3). Ideally, the tension on the orbicularis otis should expose the second molar. The muscle will later relax, ultimately yielding an optimal result. The width of the muscle is largely dependent on the amount of bulk necessary to achieve the desired cosmetic result. If only a minimal amount of bulk is desired, a nerve stimulator can be used intraoperatively to select a small portion of the active muscle innervated by a single or double nerve fascicle. Otherwise, a segment 3 cm in width is sufficient.17 Once the microneural and microvascular anastomoses have been completed, the posterior scalping flap may be harvested and rotated anteriorly.
OPERATIVE TECHNIQUE INSET OF T H E G R A C I L I S FREE FLAP
The operative technique of harvesting the gracilis free flap is beyond the scope of this article; however, a complete ,-4
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FIGURE 2. Blood supply to the posterior scalping flap: the superficial temporal artery, the supratrochlear artery, and the supraorbital artery. GENDEN ET AL
FIGURE 3. The gracilis muscle sutured into place. Anteriorly, the gracilis is sutured to the orbicularis oris at the lateral commissure. Posteriorly, the gracilis is sutured to the temporalis fascia. The anterior branch of the obturator nerve has been anastomosed with the stump of the facial nerve. The vascular pedicle has been anastomosed with the facial artery and facial vein. 73
RAISING OF THE POSTERIOR SCALPING FLAP The patient's mid-face defect is first measured. The area of non-hair-bearing posterior neck skin that will be transferred to the face is marked. A vertical midline incision is made from the vertex to the posterior mid-neck. The length of the incision can be extended in a caudal direction to obtain greater distal flap length. Likewise, the anterior extent of the incision will enhance the arc of rotation of the flap. A second, postauricular incision is then made, parallel to the midline incision, along the anterior border of the trapezius muscle (Fig 4). The postauricular incision should not be carried any further superiorly than the superior attachment of the helix, to avoid transection of the parietal branch of the superficial temporal artery. The postauricular incision is continued caudally to the same level as the previous midline incision (approximately 8 to 10 cm below the earlobe). The 2 vertical incisions are then connected horizontally at the base of the neck. Next, the flap is elevated, including skin, subcutaneous fat, and the fascia overlying the trapezius and splenius muscles. This dissection is carried to the level of the superior nuchal line, which marks the superior insertion of the paired occipital muscles and the beginning of the scalp. The junction between the occipital muscle and galea aponeurotica is incised, and the dissection continues deep to the galea, in the loose areolar connective tissue layer of the scalp, where perforating occipital and posterior auricular vessels are encountered and divided. The flap, pedicled superiorly, is then rotated anteriorly, over the ear, and sutured into the recipient site (Fig 5). The vertical midline incision can be extended farther superiorly to achieve greater arc of rotation of the flap into the mid-face.
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FIGURE 5. Stage 1 of the posterior scalping flap. The flap is rotated anteriorly and sutured into place for approximately 3 weeks. The inferior portion of the donor site is skin grafted.
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FIGURE 4. Raising of the posterior scalping flap and rotation anteriorly.
74
FIGURE 6. Stage 2 of the posterior scalping flap. The flap has been transected and returned to its donor site. The remainder of the donor site has been skin grafted. MID-FACE RECONSTRUCTION
A split-thickness skin graft is used to resurface that portion of the donor site that will ultimately remain denuded as a result of the borrowed skin flap. Between 3 and 4 weeks' postoperatively, the pedicle is transected, and that portion of the flap that is not used in the reconstruction is returned to its anatomic site (Fig 6). In cases in which the donor-site scar is poorly camouflaged, tissue expanders followed by serial excision may be used to restore the posterior scalp.
CONCLUSION While microvascular free tissue transfer offers the advantage of a single-staged procedure, donor-site tissue is often cosmetically unsuitable for reconstruction of mid-face cutaneous defects. Available techniques for the reconstruction of cutaneous mid-face defects include cervicofacial advancement flaps, tissue-expansion techniques, forehead flaps, and the submental island flap. 2 The anterior scalping flap provides adequate facial skin coverage; however, the donor-site defect is difficult to conceal. In contrast, the posterior scalping flap avoids the disfigurement of a forehead scar while providing tissue of similar color and texture to that of native facial skin. Introduced over 20 years ago, is the posterior scalping flap should be reconsidered as a reconstructive technique for patients with midface cutaneous defects. The combination of a posterior scalping flap with an innervated gracilis free flap provides both cosmetic as well as functional mid-facial restoration.
REFERENCES 1. Cheney ML, McKenna MJ, Megerian CA, et al: Early temporalis muscle transposition for the management of facial paralysis. Laryngoscope 105:993-1000, 1995 2. Strelzow VV, Friedman WH, Katsantonis GP: Reconstruction of the paralyzed face with the polypropylene mesh template. Arch Otolaryngo1109:140-144, 1983
GENDEN ET AL
3. Spector GJ, Matsuba HM, Killeen TE: Fascial pulley: Crosscommissure lip reanimation for inferior division facial nerve paralysis. Laryngoscope 96:102-105,1986 4. Aviv JE, Urken ML: Management of the paralyzed face with microneurovascular free muscle transfer. Arch Otolaryngol Head Neck Surg 118:909-912, 1992 5. Fine NA, Pribaz JJ, Orgill DP: Use of the innervated platysma flap in facial reanimation. Ann Plast Surg 34:326-330, 1995 6. Guelinckx PJ, Sinsel NK: Muscle transplantation for reconstruction of a smile after facial paralysis past, present, and future. Microsurgery 17:391-401, 1996 7. Harii K, Ohmori K, Torii S: Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 57:133-143, 1976 8. Jiang H, Guo ET, Ji ZL, et al: One-stage microneurovascular free abductor hallucis muscle transplantation for reanimation of facial paralysis. Plast Reconstr Surg 96:78-85,1995 9. Wei W, Zuoliang Q, Xiaxi L: Free split and segmental latissimus dorsi muscle transfer in one stage for facial reanimation. Plast Reconstr Surg 103:473-480, 1999 10. Gillies H: Plastic Surgery of the Face. London, UK, Oxford University Press, 1920 11. Converse JM: A new forehead flap for nasal reconstruction. Proc R Soc Med 35:811-812, 1942 12. Gillies H: The Development and Scope of Plastic Surgery. Northwest University Medical School Press, 1935 13. Converse JM, McCarthy JG: The scalping forehead flap revisited. Clin Plast Surg 8:413-434, 1981 14. Urken MC, Sullivan M, Biller H: Free flaps. Muscle and musculoteneous flaps: Gracilis, Urken MC (ed): Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York, NY, Raven, pp 139-148 15. Washio H: Retroauricular-temporal flap. Plast Reconstr Surg 43:162166, 1969 16. Arena S: The posterior scalping flap. Laryngoscope 87:98-104, 1977 17. Harii K: Microneurovascular free muscle transplantation, in Rubin LR (ed): The Paralyzed Face. St. Louis, MO, Mosby-Year Book, pp 178-200 18. Martin D, Pascal JF, Baudet J, et ah The submental island flap: A new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconst Surg 92:867-873, 1993
75
il
THE COMBINATION OF POSTERIOR SCALPING FLAP AND GRACILIS FREE FLAP FOR MID-FACE RECONSTRUCTION ERIC M. GENDEN, MD, DAVID MANDELL, MD, MARK L. URKEN, MD
A variety of donor sites have been reported for the restoration of mid-face cutaneous defects; however, the limited availability of tissue of similar color and texture to that of native facial skin greatly limits reconstructive options. Similarly, resection of the underlying mimetic musculature during the primary ablation compounds this reconstructive challenge, resulting in both a cosmetic and a functional deformity. The combination of the posterior scalping flap for cutaneous resurfacing, and microvascular transfer and reinnervation of the gracilis free flap for dynamic facial reanimation, offers a reconstructive alternative for extensive soft tissue defects of the mid-face.
Reconstruction of extensive soft tissue mid-facial defects requires reconstruction of both the underlying mimetic musculature as well as the cutaneous defect. Cervicofacial, 1 submental, 2 and forehead flaps 3 serve as options for resurfacing of such cutaneous defects; however, these options fail to address the functional deficit associated with a concomitant facial-nerve paralysis. A number of methods have been described to establish static facial symmetry 4-6 and dynamic facial motion 7-12 after facialnerve injury, yet there are few reconstructive options that offer a solution for both deficits. While the gracilis and latissimus dorsi free flaps may be reinnervated and transferred with a skin paddle, the skin color and texture dramatically contrast with that of the native facial skin. The complex defect involving both the facial musculature and the overlying skin may be optimally reconstructed with a combination of the innervated gracilis free flap and the posterior scalping flap. During World War I, surgeons commonly faced the dilemma of mid-face reconstruction following traumatic injury. During this time, surgeons popularized the use of pedicled, local skin flaps as a reliable means of reconstructing mid-facial cutaneous defects. 13 By the end of the Second World War, Converse 13 described the anterior scalping flap, a variation on the "up-and-down" flap described earlier by GillesJ °,12 This 2-staged scalp flap is composed of the forehead skin providing a well-vascularized cutaneous skin paddle, which matches the color and texture of the facial skin. The significant donor-site defect is difficult to conceal, resulting in limited popularity. 14 In 1969, Washio 15introduced the retroauricular-temporal
From the Department of Otolaryngology, Head and Neck Surgery, Mount Sinai Medical Center, New York, NY. Address reprint requests to Eric M. Genden, MD, Assistant Professor, Department of Otolaryngology, Box 1189, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029. Copyright © 2000 by W.B. Saunders Company 1043-1810/00/1102-0002510.00/0 doi:10.1053/otot.2000.8228
72
scalping flap. Arena 16 later extended the donor site to include the posterior scalp and nape-of-neck skin. Reported in 1977 by Arena, the posterior scalping flap accomplishes many of the objectives of the anterior scalping flap without the disfigurement of a forehead scar. Unlike the anterior forehead flap, the nape-of-neck donor site is easily camouflaged, particularly in women with long hair. The selection of an appropriate technique for the management of a facial-nerve deficit depends on the mimetic musculature available, and whether there is access to the main trunk or branches of the ipsilateral facial nerve. In conditions in which both the proximal and distal branches of the facial nerve are available, immediate nerve grafting offers the optimal solution for reanimation. When the main branch of the facial nerve is not accessible, a cross-facial nerve graft or a host of adynamic facial sling techniques may be used. The resection of the facial nerve with its facial musculature, however, presents a challenging reconstructive dilemma. In 1976, Harii et al 7 first described the microvascular transfer of a segment of gracilis muscle for dynamic facial reanimation. This original description entailed an anastomosis between the anterior branch of the obturator nerve with the deep temporal nerve, followed by suturing one end of the gracilis segment to the lateral oral commissure and the opposite end to the temporal fascia. Several refinements have been made to establish synchronous mimetic movement to the face, including using the facial stump as the donor nerve and performing cross-facial sural nerve grafts. This article addresses the pertinent anatomy and method of harvesting the posterior scalping flap, as well as highlighting the role of the reinnervated gracilis free flap for facial reanimation.
APPLICABLE ANATOMY The scalp is composed of 5 layers (Fig 1). The skin is most superficial, followed by the deeper layers including the
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 11, NO 2 (JUN), 2000: PP 72-75
d.//
/:/j "/
/
/
j/"
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/
¢
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/ } /
d/ 4 ": .' .~""
.
_._'.,2
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' ......
L : --"
, ,, ' ,
~
.
'
:
"------- Skin "'
~
Subcutaneous
:---:--~'~
tissue
Galeaaponeurotica
vJ
Cranium FIGURE 1. The 5 layers of the scalp including (from superficial to deep) the skin, subcutaneous tissue, galea aponeurotica, periosteum, and cranium. The epicranium is composed of the most superficial 3 layers.
subcutaneous tissue, galea aponeurotica, loose connective tissue, and the periosteum of the skull. The galea is continuous anteriorly with the paired frontalis muscles and posteriorly with the paired occipital muscles. The epicranium is composed of the skin, subcutaneous tissue, and galea aponeurotica, which are tightly adherent to one another, acting as a single unit. The loose areolar connective tissue layer represents the relatively avascular plane in which the posterior scalping flap is raised. Most nerves and blood vessels to the scalp enter and traverse superficial to the galea aponeurotica. The nutrient blood supply to the posterior scalping flap is the superficial temporal, supraorbital, and supratrochlear arteries (Fig 2). The occipital and postauricular arteries are transected during flap harvest. The veins of the scalp run parallel to the arteries, and are in communication with the cranial venous sinuses via a complex network of emissary veins.
description of the technique may be found elsewhere¢6 Once the appropriate segment of gracilis muscle has been harvested with its accompanying vascular pedicle and motor nerve, the vascular and neural anastomoses are completed. Reinnervated muscle will tend to maintain its bulk, atrophying only minimally, so that the cosmetic augmentation can be appropriately assessed intraoperatively. Although choosing the correct length and width of muscle for harvest plays an important role in functional and cosmetic results, Harii 17found that the recipient nerve had the greatest impact on the final result. The stump of the facial nerve offers the most consistent results; however, the 2-staged cross-facial nerve graft offers a satisfactory alternative. Determining the appropriate length of the muscle is estimated by suturing one end to the orbicularis oris at the lateral commissure, and the other end to the temporal fascia under tension (Fig 3). Ideally, the tension on the orbicularis otis should expose the second molar. The muscle will later relax, ultimately yielding an optimal result. The width of the muscle is largely dependent on the amount of bulk necessary to achieve the desired cosmetic result. If only a minimal amount of bulk is desired, a nerve stimulator can be used intraoperatively to select a small portion of the active muscle innervated by a single or double nerve fascicle. Otherwise, a segment 3 cm in width is sufficient.17 Once the microneural and microvascular anastomoses have been completed, the posterior scalping flap may be harvested and rotated anteriorly.
OPERATIVE TECHNIQUE INSET OF T H E G R A C I L I S FREE FLAP
The operative technique of harvesting the gracilis free flap is beyond the scope of this article; however, a complete ,-4
' '-"
i"';
"
.._
i Supratrochlear
~....%
,,;
",
a.
, S u p r a o r b i t a l a.
Facial n..,
Facial a. &
d
Post auricula
S !
Gracilis flap al t e m p o r a l a. Occlpltal
a.
~ :4 o
FIGURE 2. Blood supply to the posterior scalping flap: the superficial temporal artery, the supratrochlear artery, and the supraorbital artery. GENDEN ET AL
FIGURE 3. The gracilis muscle sutured into place. Anteriorly, the gracilis is sutured to the orbicularis oris at the lateral commissure. Posteriorly, the gracilis is sutured to the temporalis fascia. The anterior branch of the obturator nerve has been anastomosed with the stump of the facial nerve. The vascular pedicle has been anastomosed with the facial artery and facial vein. 73
RAISING OF THE POSTERIOR SCALPING FLAP The patient's mid-face defect is first measured. The area of non-hair-bearing posterior neck skin that will be transferred to the face is marked. A vertical midline incision is made from the vertex to the posterior mid-neck. The length of the incision can be extended in a caudal direction to obtain greater distal flap length. Likewise, the anterior extent of the incision will enhance the arc of rotation of the flap. A second, postauricular incision is then made, parallel to the midline incision, along the anterior border of the trapezius muscle (Fig 4). The postauricular incision should not be carried any further superiorly than the superior attachment of the helix, to avoid transection of the parietal branch of the superficial temporal artery. The postauricular incision is continued caudally to the same level as the previous midline incision (approximately 8 to 10 cm below the earlobe). The 2 vertical incisions are then connected horizontally at the base of the neck. Next, the flap is elevated, including skin, subcutaneous fat, and the fascia overlying the trapezius and splenius muscles. This dissection is carried to the level of the superior nuchal line, which marks the superior insertion of the paired occipital muscles and the beginning of the scalp. The junction between the occipital muscle and galea aponeurotica is incised, and the dissection continues deep to the galea, in the loose areolar connective tissue layer of the scalp, where perforating occipital and posterior auricular vessels are encountered and divided. The flap, pedicled superiorly, is then rotated anteriorly, over the ear, and sutured into the recipient site (Fig 5). The vertical midline incision can be extended farther superiorly to achieve greater arc of rotation of the flap into the mid-face.
~
"~v ~
~
J
]"7
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FIGURE 5. Stage 1 of the posterior scalping flap. The flap is rotated anteriorly and sutured into place for approximately 3 weeks. The inferior portion of the donor site is skin grafted.
dL
,÷ j'
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Split-thickness skin graft
¢
FIGURE 4. Raising of the posterior scalping flap and rotation anteriorly.
74
FIGURE 6. Stage 2 of the posterior scalping flap. The flap has been transected and returned to its donor site. The remainder of the donor site has been skin grafted. MID-FACE RECONSTRUCTION
A split-thickness skin graft is used to resurface that portion of the donor site that will ultimately remain denuded as a result of the borrowed skin flap. Between 3 and 4 weeks' postoperatively, the pedicle is transected, and that portion of the flap that is not used in the reconstruction is returned to its anatomic site (Fig 6). In cases in which the donor-site scar is poorly camouflaged, tissue expanders followed by serial excision may be used to restore the posterior scalp.
CONCLUSION While microvascular free tissue transfer offers the advantage of a single-staged procedure, donor-site tissue is often cosmetically unsuitable for reconstruction of mid-face cutaneous defects. Available techniques for the reconstruction of cutaneous mid-face defects include cervicofacial advancement flaps, tissue-expansion techniques, forehead flaps, and the submental island flap. 2 The anterior scalping flap provides adequate facial skin coverage; however, the donor-site defect is difficult to conceal. In contrast, the posterior scalping flap avoids the disfigurement of a forehead scar while providing tissue of similar color and texture to that of native facial skin. Introduced over 20 years ago, is the posterior scalping flap should be reconsidered as a reconstructive technique for patients with midface cutaneous defects. The combination of a posterior scalping flap with an innervated gracilis free flap provides both cosmetic as well as functional mid-facial restoration.
REFERENCES 1. Cheney ML, McKenna MJ, Megerian CA, et al: Early temporalis muscle transposition for the management of facial paralysis. Laryngoscope 105:993-1000, 1995 2. Strelzow VV, Friedman WH, Katsantonis GP: Reconstruction of the paralyzed face with the polypropylene mesh template. Arch Otolaryngo1109:140-144, 1983
GENDEN ET AL
3. Spector GJ, Matsuba HM, Killeen TE: Fascial pulley: Crosscommissure lip reanimation for inferior division facial nerve paralysis. Laryngoscope 96:102-105,1986 4. Aviv JE, Urken ML: Management of the paralyzed face with microneurovascular free muscle transfer. Arch Otolaryngol Head Neck Surg 118:909-912, 1992 5. Fine NA, Pribaz JJ, Orgill DP: Use of the innervated platysma flap in facial reanimation. Ann Plast Surg 34:326-330, 1995 6. Guelinckx PJ, Sinsel NK: Muscle transplantation for reconstruction of a smile after facial paralysis past, present, and future. Microsurgery 17:391-401, 1996 7. Harii K, Ohmori K, Torii S: Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 57:133-143, 1976 8. Jiang H, Guo ET, Ji ZL, et al: One-stage microneurovascular free abductor hallucis muscle transplantation for reanimation of facial paralysis. Plast Reconstr Surg 96:78-85,1995 9. Wei W, Zuoliang Q, Xiaxi L: Free split and segmental latissimus dorsi muscle transfer in one stage for facial reanimation. Plast Reconstr Surg 103:473-480, 1999 10. Gillies H: Plastic Surgery of the Face. London, UK, Oxford University Press, 1920 11. Converse JM: A new forehead flap for nasal reconstruction. Proc R Soc Med 35:811-812, 1942 12. Gillies H: The Development and Scope of Plastic Surgery. Northwest University Medical School Press, 1935 13. Converse JM, McCarthy JG: The scalping forehead flap revisited. Clin Plast Surg 8:413-434, 1981 14. Urken MC, Sullivan M, Biller H: Free flaps. Muscle and musculoteneous flaps: Gracilis, Urken MC (ed): Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York, NY, Raven, pp 139-148 15. Washio H: Retroauricular-temporal flap. Plast Reconstr Surg 43:162166, 1969 16. Arena S: The posterior scalping flap. Laryngoscope 87:98-104, 1977 17. Harii K: Microneurovascular free muscle transplantation, in Rubin LR (ed): The Paralyzed Face. St. Louis, MO, Mosby-Year Book, pp 178-200 18. Martin D, Pascal JF, Baudet J, et ah The submental island flap: A new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconst Surg 92:867-873, 1993
75