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Central (Vertex) Defects
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O-Z Closure
Indications: Circular or elliptical defects.
Technique: Two curvilinear incisions are made from the opposite ends of the
defect. For circular defects, the placement of the incision can be determined
according to the areas of maximum tissue laxity, scar position and neurovascular
structures. In the case of elliptical defects, the incisions commence at the opposite poles. The incision is made through the galea, and the ap undermined
widely in the sub- galeal plane. Similar to rotation aps, the length of the incisions will have to be generous (around 4–6 times the size of the defect). The
primary defect is sutured rst, followed by the margins of the curvilinear incisions (Fig.5.8a–i).
Tips: It is important to appreciate the difference in length (outer greater than
inner) and thickness (raised ap thinner than native lateral margins) of the two ap
margins and this would have to be accommodated in the suturing technique.
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a
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5 Scalp Reconstruction
c
b
Fig. 5.8 O-Z closure. (a) Markings for excision and ap incision, (b) Excision defect and wide
subgaleal undermining, (c) Initial closure of primary defect, (d) Final closure, (e) Markings of
excision and planned ap, (f) Excision defect, (g) Flaps raised in a sub galeal plane with wide
undermining, (h) Initial closure of primary defect, (i) Final closure
hi
Central (Vertex) Defects
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d
f
e
g
Fig. 5.8 (continued)
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5 Scalp Reconstruction
Multiple Rotation Flap (Pin Wheel Flap)
Indications: Circular defects in the vertex.
Technique: The curvilinear incisions are equally spaced around the margins of
the ap. It is vitally important that they all follow the same pattern and do not compromise the blood supply of the adjacent aps. The lengths of the aps will have to
be generous (around 2–3 times the size of the defect). The incision is made through
the galea and the ap undermined widely in the sub-galeal plane. The primary defect
is sutured rst, followed by the margins of the curvilinear incisions (Fig.5.9a–k).
Tips: The orientation of the aps should be designed to recruit tissue laxity
most efciently. With the use of multiple aps, the amount of movement of each
individual ap component is decreased and minimises tension. The number of
aps should be kept to the minimum to maintain a broad vascular base and minimise scarring. It is important to appreciate the difference in length of the ap margins (outer greater than inner), and this would have to be accommodated in the
suturing technique.
ab
Central (Vertex) Defects
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c
d
e
f
Fig. 5.9 Multiple rotation (Pin wheel) ap. (a) Markings for excision and aps, (b) Excision
defect and falps raised, (c) Closure of primary defect, (d) Final closure, (e) Markings for excision,
(f) Flap markings, (g) Excision defect, (h) Flap incisions, (i) Flaps raised with subgaleal undermining, (j) Closure of primary defect, (k) Final closure
86
gh
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5 Scalp Reconstruction
i
j
k
Fig. 5.9 (continued)
Central (Vertex) Defects
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Multiple Rhomboid Flaps
Indication: Medium-sized defect vertex. This is useful for hexagonal defects or
defects which could be converted to a hexagon.
Technique: The margins of the ap are converted to a hexagon, with equal sides.
Three limberg ap are marked out from the corners of alternate facets, making sure
that the length of the limbs are equal to that of each facet and the secondary limbs
are parallel to the relevant facet. It is mandatory that the aps are all oriented in the
same direction to maintain the vascularity of the aps. The aps are raised in the
sub-galeal plane, and the surrounding tissue is undermined geneorously. The secondary defects are closed intially, which decreases the tension and aids precise
approximation of the ap margins (Fig.5.10a–d).
Tips: It might be easier to place the sutures across the leading edges of the sec-
ondary defects before tying them. Time spent in designing the appropriate position
of the individual aps to take into account relative tissue laxity will make closure
easier, without tension. It is a complicated ap to design and execute and similar
defect can often be addressed with other aps (pin wheel/O-Z).
88
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ab
c
Fig. 5.10 Multiple Rhomboid aps. (a) Defect following excision and ap markings, (b) aps
raised with wide subgaleal undermining, (c) Initial closure of secondary defect, (d) Final closure
d
Central (Vertex) Defects
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Skin Graft (Full Thickness)
Indication: Medium/large scalp defects, when atleast the periosteum is preserved
at the base of the defect.
Technique: A suitable template is made of the defect, which is transferred to the
donar site to harvest the graft. The graft is sutured to the defect, with additional
“long” sutures that can be used for “tying” over the bolus. If possible, the graft can
be “quilted” to the base, to decrease the risk of heamatoma and dead space. A nonadherent dressing is laid over the sutured graft, over which a cotton wool ball/
sponge soaked in proavin or a suitable antibiotic ointment is paced. The tie-over
bolus sutures are now used to hold the dressing in place. Alternatively the dressing
could be held in place with skin staples (Fig.5.11a–i).
Tips: The defect created can often be made smaller, by undermining around the
periphery and using a “purse string” suture (Fig.5.11a, b). The skin of the scalp is
among the thickest in the body, and the native defect margins can be shelved to
make the junction with the skin graft smoother. It is easier to suture from the graft
to the native skin, which prevents displacement of the graft, when the suture is
pulled through. Meticulous haemostasis is paramount, and the space between the
skin graft and the defect can be ushed with saline on a blunt needle, prior to placement of the last few sutures to make sure there is no haematoma beneath the
skin graft.
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ab
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c
d
Fig. 5.11 Full thickness skin graft. (a) Defect following excision and purse string sutures to
reduce size of defect, (b) Purse string sutures, (c) Skin graft sutured into place, (d) Non adherent
and bolus dressing placed over graft, (e) Tie over bolus sutures and dressing is situ, (f) Dressing
sutured in place, (g) Excision defect with intact pericranium, (h) Skin graft sutured in defect, (i)
Dressing stapled in place
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