Ortichochea three flap scalp reconstruction of 9.5 cm defect on vertex by Dr Ali Mujtaba at BCC, PIMS hospital, Islamabad, Pakistan

1. SCALP
RECONSTRUCTION
DR ALI MUJTABA
PGR MS
BURN & RECONSTRUCTIVE SURGERY
SZABMU,PIMS

2. CASE HISTORY
 Mohammad Arslan 16 Y/o Male ,Resident of ISB, Presented
in BCC ER on 15th .july.2022 with H/O High Transmission
electric Current, accidently while playing outside near
electricity pole, with entry wound on scalp and exit wound on
Right foot with associated wounds on B/L upper limbs, with
delay of approximate 96 hours.

3. ON DAY OF ADMISSION
 Patient admitted in ward and
management started as per
BCC protocols
 Patient labeled as a case of
High voltage Electric burn
(HVEB) with 7th degree scalp
burn wound
 Hb 11.7,Tlc 11000,Cr 2.6,
CKMB 937, LDH 3167,
Myoglobinuria
First Day Of Admission

4.  Non healing post burn wound
closure surgery planed ,after
series of OR visits for wound
debridement and preparation for
surgery.
1st week 3rd week
AFTER FOUR WEEKS

5. PRE OP WORKUP
 Hb 13.7
 Tlc 4000
 Hct 41
 Plt 199
 Na 137
 K 4.0
 Cr 0.6
 Total biliroubin 0.6
 Pus C/S NG
4th week

6. WOUND DIMENSIONS
 Ruler Method technique used to
calculate the wound area
Length 9.0 cm
Width 4.5 cm
Depth 8mm (0.8cm)
 Wound covers the Frontal ,B/L
Parietal and Occipital regions

7. DOPPLER ULTRASOUND
 Vascular hand held Doppler
ultrasound used for marking
Temporal, supratrochlear ,
supraorbital and occipital vessels
(5 & 8 MHz frequency probes)

8. LAYERS OF SCALP

9. PRINCIPLES OF SCALP RECONSTRUCTION
 Replace tissue with like tissue.
Use adjacent scalp for reconstruction if possible
 Consider tissue expansion

10. SURGICAL OPTIONS
 Small defects (2 cm2 )
Primary closure after
undermining
 Moderate defects (2-25 cm2 )
V-Y flaps
V-Y-S flaps
Subcutaneous pedicled flaps
Rotation advancement flaps
 Large defects (above
25 cm2 )
Temporo-parietal-occipital
flaps
Large rotation advancement
flaps
Orticochea flaps

11. ORTICOCHEA FLAPS
 Two flaps for reconstructing the defect, each based off the superficial
temporal vessels
 One large flap based off the occipitals to fill the donor defect
Orticochea three
flaps technique

12. CAUTION
 Avoid infected scalp.
 Local anesthetic with dilute epinephrine decreases
intraoperative skin edge bleeding.
 Minimize the use of hemostatic clips and electrocautery on
cut edges of the scalp
 Score the galea perpendicular to the direction of desired
tissue gain.
 Healing by secondary intention provides acceptable aesthetic
results and will not cause significant contractures.

13. MARKING OF INCISION SITE
Anterior Incision
20cm horizontal
Incision given 13cm
above nasal bridge
parallel to the
coronal suture

14. MARKING OF INCISION SITE
Posterior Incision
22cm horizontal Incision
given 9cm superior to
occipital notch parallel
to lamb-doid suture

15. SCORING OF GALEA
Scoring in 1 cm increments will gain 1.67 mm for each relaxing incision

16. APPROXIMATION OF THE GALEA &
CLOSING

17. GOALS OF SCALP RECONSTRUCTION
 Tension-free closure of
defect
 Maintenance of motor
and sensory function
when possible
 Maintenance of brow
symmetry
 Maintenance of hairline
 Protection of
cranium/dura/brain

18. POST OP PRESENTAION OF SCALP

19. SECOND POST OP DAY

20. NINTH POST OP DAY

21. OR TEAM
PROF DR TARIQ IQBAL
DR REHAN
DR HASSAN
DR ALI MUJTABA
DR IBRAHIM
DR KAMAL
MR ZUBAIR
MR QASIM

22. Thank you