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Lateral Defects
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a
c
b
d
Fig. 5.17 Unilateral advancement ap. (a) Defect follwoing excision and ap markings, (b) Flap
raised in the sub galeal plane, (c) Sutured in situ, (d) Markings for excision and ap, (e) Defect
following excision, (f) Flap raised in sub galeal plane, (g) Flap sutured with dog ear in situ, (h)
Final closure with correction of dog ear
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5 Scalp Reconstruction
Bilateral Advancement Flap
Indication: Medium-sized defects lateral and vertex of scalp.
Technique: Two parallel incisions are made from the margins of the defect. The
length of the ap is ideally no more than 3 times the width. One ap is initially raised
and assessed to see if it is adequate, before the second ap is raised. The aps are
raised in the sub-galeal plane, and the surrounding tissue is widely undermined. The
ap is advanced into the defect and closed in layers. If the differing lengths of the ap
margins are not accommodated during closure, the resulting dog ears are excised as
Burrow’s triangles at the base or along the margins of the ap (Fig.5.18a–f).
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. It
might be easier to place the all the sutures along the leading edge of the ap and
defect margins, before tying them. The length of the two aps can differ according
to the relative tissue laxity and position of the resulting scar.
ab
Lateral Defects
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c
e f
Fig. 5.18 Bilateral advancement aps. (a) Defect following excision and ap markings, (b) Flaps
raised in sub galeal plane, (c) Final closure, (d) Markings for excision and aps, (e) Defect following excision and aps raised, (f) Final closure
d
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5 Scalp Reconstruction
Rotation/Transposition Flaps
Rotation aps can be used to cover a variety of lateral defects. The orientation is
based on relative tissue laxity and large aps, these are best designed to include a
named vascular pedicle. The length to size of the defect ratio is similar to that used
to reconstruct vertex defects (1:6) (Fig.5.19a–k). In this patient, an intradiploic
dermoid was excised and an additional pericranial ap utilised to cover the
bony defect.
Lateral Defects
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a
c
b
d
ef
Fig. 5.19 Rotation/transposition ap. (a) Markings for excision and ap, (b) Excision of lesion,
(c) Defect following excision, (d) Flap raised in sub galeal palne with wide underming of surrounding tissues. Pericranial ap to cover the bone defect, (e) Transposition ap sutured in situ, (f)
Early post operaive result, (g) Markings for excision and ap, (h) Excision defect, (i) Flap raised,
(j) Flap mobilised into defect, (k) Final closure
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5 Scalp Reconstruction
g
h
k
j
Fig. 5.19 (continued)
Suggested Algorithm
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Suggested Algorithm
Central (Vertex) Defects
Small
1. Primary closure.
2. Healing by secondary intention.
Medium
1. Rotation/transposition ap.
2. O-Z closure.
3. Unilateral/bilateral advancement ap.
4. Multiple rotation (pin wheel) ap.
5. Multiple Limberg ap.
6. Skin graft.
7. ReCell®.
Large
1. Skin graft.
2. Skin graft with Integra®.
3. Skin graft with pericranial ap.
4. Multiple rotation ap.
5. Rotation/transposition ap with skin graft to secondary defect.
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Lateral Defects
Small
1. Primary closure.
Medium
1. Unilateral/bilateral advancement ap.
2. Rotation/transposition ap.
3. O-Z closure.
4. Skin graft.
Large
1. Rotation/transposition ap with skin graft to secondary defect.
2. Skin graft.
3. Skin graft with Integra®.
Forehead Reconstruction
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Subunits andAnatomical Considerations
The forehead can be divided into central, paramedian and lateral (temple) subunits
(Fig.6.1). In addition, the subunits can be further divided into upper and lower segments for the purposes of reconstruction.
Fig. 6.1 Forehead:
Subunits
6
© Springer Nature Switzerland AG 2024
V. Ilankovan et al., Local Flaps in Facial Reconstruction,
https://doi.org/10.1007/978-3-031-49464-2_6
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6 Forehead Reconstruction
The supra-orbital and supra-trochlear nerves traverse the bony orbital margins,
pierce the overlying muscles and run in the subcutaneous plane, just above the frontalis/galea up to the vertex (Fig.6.2). If attempting to preserve the sensation of the
forehead, horizontal incisions and undermining should be limited to the subcutaneous plane. In case of central vertical incisions, undermining can be undertaken in
the plane deep to frontalis/galea.
In the central forehead, the frontalis muscle is often separated in the lower part
before they join together to form a raphae. This along with the creases created by
the “corrugator supercilli” offer the possibility of utilising vertical scars in this area.
In the para median and lateral subunits, the RSTLs lie horizontally and offer good
camouage to scars (Fig.6.3).
The temporal branch of the facial nerve runs on the deep surface of the frontalis/
galea and therefore incisions and dissections should be above this plane. It is also
important that any transection of the frontalis is repaired to restore continuity of the
muscle, so as to avoid drooping of the eyebrow.
Zygomaticotemporal nerve
Subunits andAnatomical Considerations
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Fig. 6.2 Nerve supply of forehead
Fig. 6.3 Orientation of
RSTL’s in the forehead
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Supra-trochlear nerve
Supra-orbital nerve (V1)
Infra-trochlear nerve (V1)
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