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New three-flap scalp reconstruction technique
NEW THREE-FLAP SCALP RECONSTRUCTION TECHNIQUE By MIGUELORTICOCHEA,M.D. Professor of Plastic Surgery, Medical School, Javeriana University, Bogotd, Colombia Former Student, Pasteur Hospital, Montevideo, Uruguay Head, Plastic Surgery Division at the National Cancer Institute, BogoM, Colombia
IN cases of not very large scalp loss in the frontal and occipital regions, we have reconstructed the defect by mobilising three large flaps that contain the whole remaining scalp. T h e technique of using only three large flaps instead of the original four-flap technique (Orticochea, 1967, 1969) has two advantages : the reconstruction becomes
FIG. I
Patient with benign tumour including the right superior eyelid, base of nose, two-thirds of the forehead and a portion of the temporal and parietal regions. T h e tumour covers the right eye.
easier and the blood supply of the flaps is better since their pedicles are wider. This technique is suitable for defects of the size shown in Figures 2 and" 6. T e c h n l q u e . - - T w o flaps (1 and 2 in Figure 3) are outlined along the superior border of the raw area. Their ends are cut at an angle and their width is equal to half that of the raw area, so that when mobilised and juxtaposed, they will automatically cover the raw surface. But when the width of the raw surface is larger than 12 cm., the width of the flaps should not exceed 6 cm. Each of these flaps should have its own vascular pedicle. When reconstructing scalp and forehead, the superficial temporal artery and vein are in the pedicle. When the reconstruction is carried out on the occipital region, their pedicles will carry the occipital and posterior auricular vessels of the external carotid. Behind flaps I and 2, a very large flap (3) is outlined which includes nearly the whole remaining scalp. The pedicle on the temporal region contains the posterior auricular and occipital vessels if the region to be reconstructed is located on the forehead I84
NEW THREE-FLAP SCALP RECONSTRUCTION TECHNIOUE
FIG. 2
Following excision, t h e raw surface is o n t h e right side of t h e midline.
Fit. 3 D e v e l o p m e n t of t h e surgical t e c h n i q u e . It is preferable to c u t flaps I a n d 2 at a n angle as s h o w n . T h e s e c o n d a r y defe~r (C) t h a t appears after j u x t a p o s ing flaps I a n d 2 is smaller t h a n t h e p r i m a r y one.
I85
I86
B R I T I S H J O U R N A L OF P L A S T I C S U R G E R Y
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NEW
THREE-FLAP
SCALP RECONSTRUCTION
TECHNIQUE
18 7
(Fig. 4). When the occipital region is to be reconstructed, the pedicle includes the superficial temporal vessels (Fig. 7). I f the scalp defect, either on the forehead or the occipital region, is symmetrically situated around the midline, the pedicle of the large flap may be placed on either side° If the area of reconstruction is lateral to the midline (Figs. i, 2, 4), it is preferable to place the pedicle on the opposite side. The vertex of the flap extends to the opposite temporal region. The three flaps are elevated by dissection in the loose areolar tissue lying between the pericranium and the galea aponeurotica. Great care has to be observed when approaching the base of the flaps to avoid injury to the vessels passing from the superficial
FIG. 6 Squamous cell cancer, radiated and relapsed, located in the occipital region. T h e r e is an alopecic area following radiotherapy. T h e t u m o u r has been resected and a portion of the occipital bone excised. T h e specimen, when retracted, measured 14 cm. long by 6 cm. wide. T h e surgical area to be reconstructed measured 16 cm. long by 8 cm. wide.
and external plane of the aponeurosis to a deeper plane in the paro~id regions in the case of the superficial temporal vessels, and the mastoid and occipital regions in the case of the posterior auricular and occipital vessels. Here the separation of the flaps has to be performed by blunt dissection. The aponeurosis is divided with incisions transverse to the longitudinal axis of the skull. Many parallel incisions are made x cm. apart. Great care is taken not to cut or injure veins and arteries. Uncomplicated post-operative healing depends principally on a good blood supply to the flaps. When the flaps are raised, numbers I and z are juxtaposed covering the primary raw surface (Figs. 3, c and 4, B). These two flaps are subjected to a homogeneous and balanced traction. Now, when the primary raw surface is almost completely covered, a smaller secondary defect is created which will be covered by the large flap (Fig. 3, c). Because of its size and large pedicle, this flap can be subjected to a greater degree of traction than flaps I and 2. This is the advantage of the new technique over that of the original four flaps.. By including half of the scalp in one giant flap, a better circulation is obtained.
188
B R I T I S H JOURNAL OF PLASTIC SURGERY
FIG. 7 Final result eight days after operation. It was not necessary to use a free skin graft. T h e forehead has been stretched and mobilised and looks larger. CONCLUSIONS
With this technique the whole scalp can be stretched to cover raw surfaces located at the frontal and occipital regions. The scalp is subjected to a distribution of regular pressures throughout its full extent and in all directions.
REFERENCES ORTICOCHEA, M. (1967). Four flap scalp reconstruction technique. British Journal of Plastic Surgery, 2o, 159-171. ORTICOCHEA, M. (1969). Application de la technique des quatre lambeaux dans la reconstruction du front et des regions pari6tales. AnnalesdeGhirurgiePlastique, I4, i53-i58.
IN cases of not very large scalp loss in the frontal and occipital regions, we have reconstructed the defect by mobilising three large flaps that contain the whole remaining scalp. T h e technique of using only three large flaps instead of the original four-flap technique (Orticochea, 1967, 1969) has two advantages : the reconstruction becomes
FIG. I
Patient with benign tumour including the right superior eyelid, base of nose, two-thirds of the forehead and a portion of the temporal and parietal regions. T h e tumour covers the right eye.
easier and the blood supply of the flaps is better since their pedicles are wider. This technique is suitable for defects of the size shown in Figures 2 and" 6. T e c h n l q u e . - - T w o flaps (1 and 2 in Figure 3) are outlined along the superior border of the raw area. Their ends are cut at an angle and their width is equal to half that of the raw area, so that when mobilised and juxtaposed, they will automatically cover the raw surface. But when the width of the raw surface is larger than 12 cm., the width of the flaps should not exceed 6 cm. Each of these flaps should have its own vascular pedicle. When reconstructing scalp and forehead, the superficial temporal artery and vein are in the pedicle. When the reconstruction is carried out on the occipital region, their pedicles will carry the occipital and posterior auricular vessels of the external carotid. Behind flaps I and 2, a very large flap (3) is outlined which includes nearly the whole remaining scalp. The pedicle on the temporal region contains the posterior auricular and occipital vessels if the region to be reconstructed is located on the forehead I84
NEW THREE-FLAP SCALP RECONSTRUCTION TECHNIOUE
FIG. 2
Following excision, t h e raw surface is o n t h e right side of t h e midline.
Fit. 3 D e v e l o p m e n t of t h e surgical t e c h n i q u e . It is preferable to c u t flaps I a n d 2 at a n angle as s h o w n . T h e s e c o n d a r y defe~r (C) t h a t appears after j u x t a p o s ing flaps I a n d 2 is smaller t h a n t h e p r i m a r y one.
I85
I86
B R I T I S H J O U R N A L OF P L A S T I C S U R G E R Y
- •~ . = ~
.
o
~.~
~__~
c~.~
,~ ~
NEW
THREE-FLAP
SCALP RECONSTRUCTION
TECHNIQUE
18 7
(Fig. 4). When the occipital region is to be reconstructed, the pedicle includes the superficial temporal vessels (Fig. 7). I f the scalp defect, either on the forehead or the occipital region, is symmetrically situated around the midline, the pedicle of the large flap may be placed on either side° If the area of reconstruction is lateral to the midline (Figs. i, 2, 4), it is preferable to place the pedicle on the opposite side. The vertex of the flap extends to the opposite temporal region. The three flaps are elevated by dissection in the loose areolar tissue lying between the pericranium and the galea aponeurotica. Great care has to be observed when approaching the base of the flaps to avoid injury to the vessels passing from the superficial
FIG. 6 Squamous cell cancer, radiated and relapsed, located in the occipital region. T h e r e is an alopecic area following radiotherapy. T h e t u m o u r has been resected and a portion of the occipital bone excised. T h e specimen, when retracted, measured 14 cm. long by 6 cm. wide. T h e surgical area to be reconstructed measured 16 cm. long by 8 cm. wide.
and external plane of the aponeurosis to a deeper plane in the paro~id regions in the case of the superficial temporal vessels, and the mastoid and occipital regions in the case of the posterior auricular and occipital vessels. Here the separation of the flaps has to be performed by blunt dissection. The aponeurosis is divided with incisions transverse to the longitudinal axis of the skull. Many parallel incisions are made x cm. apart. Great care is taken not to cut or injure veins and arteries. Uncomplicated post-operative healing depends principally on a good blood supply to the flaps. When the flaps are raised, numbers I and z are juxtaposed covering the primary raw surface (Figs. 3, c and 4, B). These two flaps are subjected to a homogeneous and balanced traction. Now, when the primary raw surface is almost completely covered, a smaller secondary defect is created which will be covered by the large flap (Fig. 3, c). Because of its size and large pedicle, this flap can be subjected to a greater degree of traction than flaps I and 2. This is the advantage of the new technique over that of the original four flaps.. By including half of the scalp in one giant flap, a better circulation is obtained.
188
B R I T I S H JOURNAL OF PLASTIC SURGERY
FIG. 7 Final result eight days after operation. It was not necessary to use a free skin graft. T h e forehead has been stretched and mobilised and looks larger. CONCLUSIONS
With this technique the whole scalp can be stretched to cover raw surfaces located at the frontal and occipital regions. The scalp is subjected to a distribution of regular pressures throughout its full extent and in all directions.
REFERENCES ORTICOCHEA, M. (1967). Four flap scalp reconstruction technique. British Journal of Plastic Surgery, 2o, 159-171. ORTICOCHEA, M. (1969). Application de la technique des quatre lambeaux dans la reconstruction du front et des regions pari6tales. AnnalesdeGhirurgiePlastique, I4, i53-i58.