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bearing structures of the facial skeleton. A.
Projection of the midface is created by
reconstructing the zygomatic arches,
starting from the stable part of the
temporal bone. B. The zygomas are fixed
to the arches and to the frontal bone to
create the final projection of the midface.
C. The width of the midface is
reconstructed by repositioning the central
midface (orbits and nose) to its correct
position, in relation to the zygomas and
frontal bone. Concomitantly, canthopexy is
fixed, and the frontal bone and sinus
fractures are treated. (This procedure is
independent of the occlusion.) D. The
posterior vertical height of the face is
reconstructed by positioning and fixing the
condylar fractures. E. Intermaxillary
fixation is applied, and the mandible is
reconstructed. F. Finally, the Le Fort I-level
fractures are positioned to natural
occlusion. (Modified from Guyuron B,
Eriksson E, Persing JA. Plastic Surgery:
Indications and Practice. Vol. 1. 2009:633;
Booth PW, Schendel SA, Hausamen JE.
Maxillofacial Surgery. 2nd ed. 2007;Vol.
1:38.)
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Systematic approaches either from “top down” or “bottom
up”
Traditionally, a “bottom-up” approach by achieving
anatomic reconstruction of the mandible is performed
to provide a stable base. This provides the base to
reconstruct the midface and up.
A “top-down” approach can also be used and
sometimes can be helpful in presence of condylar
fracture. This would avoid opening and fixating the
condylar fractures (high ankylosis rate).
Working from known (ie, stable) area to unknown area and
from inside to outside makes proper reduction more
manageable and achievable.
Some degrees of malreduction above the dentition may be
tolerated if functional occlusion, vertical facial height, and
projection can be achieved.
QUESTIONS YOU WILL BE ASKED
1. The bones comprising the orbit.
Maxilla, zygoma, sphenoid, palatine, ethmoid, lacrimal, and
frontal (see Fig. 20-3).
2. Facial nerve branches.
(“Two zebras bit my cat”) temporal, zygomatic, buccal, marginal
mandibular, and cervical.
3. Patterns of Le Fort fractures.
See Figure 20-5. Le Fort I is horizontal maxillary fracture. Le
Fort II is pyramidal maxillary fracture. Le Fort III is craniofacial
disjunction. All involve pterygoid plates.
4. The ZMC “tetrapod.”
The zygoma has a quadrilateral shape. It articulates with
maxilla, frontal, sphenoid, and temporal bones.
5. The facial buttresses and their importance.
See Figure 20-4. Four transverse and four vertical paired
structural units of thicker bone lend strength and stability and
project the soft tissue envelope of face.
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1.
2.
3.
4.
5.
6.
6. How to diagnose a CSF leak?
Send fluid for β-transferrin.
Recommended Readings
Fraioli RE, Branstetter BF IV, Deleyiannis FW. Facial fractures: beyond Le Fort.
Otolaryngol Clin North Am. 2008;41(1):51‐76. vi.
Haug RH, Buchbinder D. Incisions for access to craniomaxillofacial fractures.
Atlas Oral Maxillofac Surg Clin North Am. 1993;1(2):1‐29.
Sargent LA. Nasoethmoid orbital fractures: diagnosis and treatment. Plast
Reconstr Surg. 2007;120(7 Suppl 2):16S‐31S.
Sharabi SE, Koshy JC, Thornton JF, Hollier LH Jr. Facial fractures. Plast
Reconstr Surg. 2011;127(2):25e‐34e.
Yavuzer R, Sari A, Kelly CP, et al. Management of frontal sinus fractures. Plast
Reconstr Surg. 2005;115(6):79e‐93e. discussion 94e-95e.
Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg.
1998;101(3):840‐851. doi: 10.1097/00006534-199803000-00041
*
Denotes common in-service examination topics.
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21
Scalp and Calvarial
Reconstruction
Alexandra O. Luby
SCALP RECONSTRUCTION
ANATOMY
Anatomic Layers of the Scalp—Acronym Scalp (Fig. 21-1)
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Figure 21-1 Anatomic layers of the
forehead and scalp. (From Head. In:
Dalley AF II, Agur AMR. Moore’s Clinically
Oriented Anatomy. 9th ed. Wolters Kluwer;
2023:839-999. Figure 8.15.)
Skin.
Connective tissue
Hair follicles, sweat glands, and fat cells
Connective tissue fibers between the galea and skin
Aponeurotic layer or galea aponeurotica: a fibrous tissue
layer that is continuous with the frontalis and occipitalis and
temporoparietal (TP) fascia.
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*Loose areolar tissue: this layer allows the scalp to
move on the cranium and is the most common plane of
scalp avulsion injuries.
Pericranium/periosteum: a thick collagenous layer with firm
attachments to the skull.
Scalp Vascular Supply (Fig. 21-2)
Figure 21-2 Arterial supply to the scalp
and face. (From Head. In: Dalley AF II,
Agur AMR. Moore’s Clinically Oriented
Anatomy. 9th ed. Wolters Kluwer;
2023:839-999. Figure 8.24.)
Internal Carotid Artery Branches
Supraorbital artery
Supratrochlear artery
External Carotid Artery Branches
Superficial temporal artery.
Postauricular artery.
Occipital artery.
Extensive interconnections are present between
branches and across the midline. These anastomoses
allow potential replantation of a scalp based on a single
artery and vein.
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Scalp Innervation (Fig. 21-3)
Motor
Frontalis: frontal branch of CN VII
Occipitalis: posterior auricular branch of CN VII
Temporalis: deep temporal nerve of CN V
Sensation
Forehead and anterior scalp supplied by supratrochlear
and supraorbital nerves (V1)
Supraorbital nerve
Superficial division: supplies skin of the forehead
and anterior hairline
Deep division: innervates frontoparietal scalp
Temporal region supplied by zygomaticotemporal nerve
(V2) and auriculotemporal nerve (V3)
Posterior scalp supplied by greater and lesser occipital
nerves (both are spinal nerves from C2/C3)
Ear and postauricular area supplied by great auricular
nerve (cervical plexus from C2/C3)
Figure 21-3 Sensory innervation to the
scalp and face. (From Head. In: Dalley AF II,
Agur AMR. Moore’s Clinically Oriented
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Anatomy. 9th ed. Wolters Kluwer; 2023:839-
999. Figure 8.20.)
SCALP RECONSTRUCTIVE LADDER
(FIG. 21-4)
Figure 21-4 Reconstruction of scalp
defects.
Primary closure is an excellent option for defects <3 cm in
diameter.
Facilitated by wide undermining in the avascular subgaleal
plane.
Scoring the galea allows additional advancement but may
decrease the skin’s blood supply.
Split-Thickness Skin Grafting (STSG)
Indication: patients who are not candidates for extensive
procedures and cosmesis are of low importance.
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Design: can be placed directly on subcutaneous tissue,
galea, or pericranium. If calvarial bone is exposed,
STSG is contraindicated. If bare calvarium is present,
the outer table can be burred and the STSG placed on
the diploe.
Alternatively, Integra (a bilaminate bovine collagen
construct) can be placed at the index procedure. At a
second operation 2-3 weeks later to allow for
neovascularization of the Integra, a thin STSG
(approximately 8/1000 of an inch) can be placed
Disadvantages: no hair follicles, contour deformities,
susceptible to trauma.
Local Flaps
Indication: coverage of defects between 3 cm and up to
30% defects of the scalp
Design: rotation flaps: designed 4-6× as long as the defect
is wide
Double-opposing rotation flaps (yin-yang) are also
useful.
Orticochea three-flap and four-flap techniques are
based on axial blood supply and can cover 30%.
Local flaps provide superior cosmesis as hair-bearing
skin is brought into the defect.
Flaps should be raised in the subgaleal plane, which
keeps the pericranium as a “lifeboat” for STSG should
the donor site break down.
Galeal scoring can increase flap movement.
Disadvantage: STSG of the secondary defect may be
necessary in order to cover the primary defect.
Local rotation and advancement flaps often create a dog
ear at the base. Do not excise the dog ear as flap
compromise may result. The majority of these will flatten
out over time.
Local axial flaps can be used for specific indications.
Galeal flaps can be based on one or multiple axial vessels.
The flap is thin and pliable with minimal donor site
morbidity.
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They are particularly useful for three-dimensional (3D)
intracranial defects.
TP fascia flaps are based on the superficial temporal
vessels and can carry vascularized calvarium. TP fascial
flaps are useful for 3D defects or, if bone is included, for
periorbital or facial bony defects.
Temporalis muscle flaps are based on the deep temporal
arteries. Temporalis flaps have limited use as rotation flaps
for anterior scalp and periorbital defects.
“Crane” flaps are interpolated flaps used to transfer soft
tissue to the recipient site. Once vascularization occurs
from the recipient site, the flap is raised in a more
superficial plane, leaving adequate soft tissue at the
recipient site. The flap is then replaced into the original
donor site.
Tissue expansion is often used in secondary scalp
reconstruction and can replace hair-bearing skin with hairbearing skin.
Tissue expansion requires a staged approach with 2-3
months between operations.
Tissue expansion goal is to generate flaps that are 50%
wider and longer than the defect.
Multiple rounds of tissue expansion may be required for
large defects.
*Up to 50% defects can be reconstructed with tissue
expansion before getting alopecia.
Tissue expanders (TEs) are placed via incisions at the flap
margin, often at the junction of normal scalp and skin graft.
Dissection in the subgaleal plane should be just large
enough to allow TEs insertion.
Important not to have any sharp folds when placing TE.
A separate incision allows placement of a remote filling
port over stable bone.
Hematoma, infection, and implant exposure are the most
common complications of expansion. In children, pressurerelated deformation of the cranial vault may occur.
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