unpad

1. Forehead & Scalp
Reconstruction
Pembimbing : dr. Ali Sundoro, SpBP-RE(K)
Graciella W.

2. Unique Challenges of forehead & scalp
• Visibility  defects difficult to conceal
• Cosmesis is vital & function is specialized
• Anatomically have a complex 3D anatomy
Neligan P, Novak C. Head and neck. Flaps and Reconstructive Surgery. Wei, Fu Chan. 2009.
Wells M, Skytta C. Scalp and forehead reconstruction. Plastic Surgery – Volume 3 . Neligan. 2013.

3. Guiding principles
• Like replaced with like
• Reconstruction should not interfere with treatment of the patient’s main
condition
• Choose option with best likelihood of success
Neligan P, Novak C. Head and neck. Flaps and Reconstructive Surgery. Wei, Fu Chan. 2009.

4. Reconstructive Plan
• Relevant anatomy
• Defect analysis
• Knowledge of various reconstructive options
• Tailored to meet requirements of patient & wound
Wells M, Skytta C. Scalp and forehead reconstruction. Plastic Surgery – Volume 3 . Neligan. 2013.

5. Anatomy
• Scalp & forehead : from supraorbital rims  nuchal line (AP), frontal
process of zygoma – prominence of mastoid process (laterally)
• SCALP : Skin, subCutaneous tissue, Aponeurotic layer, Loose areolar tissue,
Pericranium
• Skin & Subcutaneous : hair follicles, sweat glands, fat, connective tissue
septa
• Galea aponeurotica : musculoaponeurotic layer : highly vascularized
Wells M, Skytta C. Scalp and forehead reconstruction. Plastic Surgery – Volume 3 . Neligan. 2013.

6. Scalp Anatomy

7. Blood Supply
Anatomy
1. Superficial temporal a & v
2. Transverse facial a & v
3. Facial a & v
4. Submental a
5. Superior thyroid a & v
6. Transverse cervical a & v
7. Internal mammary artery
perforators
8. Internal carotid system :
supratrochlear & dorsal nasal a
Wells M, Skytta C. Scalp and forehead reconstruction. Plastic Surgery – Volume 3 . Neligan. 2013.

8. Blood supply anatomy
Wells M, Skytta C. Scalp and forehead reconstruction. Plastic Surgery – Volume 3 . Neligan. 2013.

9. Aesthetic subunits

10. Diagnosis/patient presentation
• Relevant medical factors (hx smoking, CAD, DM, immunosuppression,
radiation)
• Etiology : malignant tumor, trauma, etc
• Previous operative reports (scarred wound bed, remaining blood supply)
• Palpation for metastatic disease (fixation of tumor)
• CT scan/MRI can’t reliably demonstrate extent of tumor invasion into bone

11. Patient
Selection

12. Reconstructive Options

13. Closure by Secondary Intention
• Small, noncosmetically critical defects
• < 1 cm diameter & without bone exposure
• Relies on cicatrical wound contracture
• Need for vascularized tissue underlying defect
• Appropriate daily dressing changes & compliant patient
• @ scalp = alopecia

14. Vacuum-Assisted Closure
• Noninvasive active therapy
• Removes chronic edema, increases local blood flow, enhance granulation
formation & wound healing, lower bacterial counts
• Secondary intention/combined with skin graft (wound contours)
• Care on viable periosteum (pressures >capillary closing pressure  ischemic
necrosis of pericranium & graft loss)

15. Primary closure
• Larger defects (>3 cm)
• Ideally on RSTL
• Care on meticulous hemostasis following galeotomy  prevent hematoma
formation

16. Tissue expansion
• Immediate intraop tissue expansion can be performed
• Partial inflation at time of insertion to prevent seroma  expansion begins @ 2
weeks, weekly/biweekly
• Expansion until +/- 20% larger than size of defect
• Disadvantage : time & multiple procedures
• Complications : hematoma, implant exposure, infection, flap necrosis, alopecia, wide
scars

17. Skin Graft
• When medical condition precludes larger, more complex
procedures
• May be indicated after tumor resection/risk of recurrence is
high
• Requires adequately vascularized wound bed
• Multiple drill holes can be made in outer cortex to diploic layer
• Long-term stability tends to be problematic
• Advantage: technical simplicity
• Disadvantage: mismatch of color, texture, contour, alopecia,
unstable in hostile wound environments

18. Local flaps
• Small – medium sized defects
• Transposition, advancement, rotation
• If a named vessel can be included in the flap, surviving length is often
improved (superficial temporal, occipital, supraorbital)
• Small peripheral defects  can be closed with 1 flap. Larger defects (vertex
>50 cm2)  multiple flaps

19. Ortichoea
Three-flap
Technique

20. Juri Flap
• Flaps as long as 28 cm based on a 4-cm
pedicle
• Bilateral flaps for larger defects
• Anterior scalp incision should be beveled =
allow hair grow through incision
• Disadvantages : risk of flap necrosis, donor
site alopecia, sharp frontal hairline, direction
of hair growth is different

21. Scalp Reduction Technique

22. Large rotation flap
• Dissection should be subgaleal, preserving underlying periosteum
• Large dog-ear is often formed, do not revise dog ear (often narrow vascular
pedicle  distal necrosis)
• Avoid excessive tension
• Small rotation flaps fewer applications (depend on local adjacent tissue laxity)
• Drain post op, may use temporary halo device

24. Regional flaps
• Regional flap options are somewhat
limited
• Doesn’t allow reconstruction of vertex
defects
• Most common : trapezius muscle flap
• Pectoralis major  can reach temporal
& mastoid region

25. Microsurgical reconstruction
• Extensive & complex defects involving exposed vital structures not amenable to
local/regional techniques
• Popular muscle flaps : latissimus dorsi, serratus anterior, rectus abdominis
• Fasciocutaneous : radial forearm flap, scapular flap, anterior lateral thigh flap
• Beasley et al. proposed algorithm for Unfavorable wound environment
• Scapular flap for forehead defect >50 cm2
• Large scalp defects (200-600 cm2) = single LD w/ skin graft
• Massive defects (>600 cm2) = bilateral free LD Flap

26. Microsurgical Reconstruction
• Preferred recipient for
• Upper 1/3 : Superficial temporal artery & vein
• Lower branches : external carotid system (facial, superior thyroid, transverse cervical)
• Recipient vein close proximity to recipient artery

27. Microsurgical Reconstruction
• Skin-grafted latissimus is the workhorse of scalp reconstruction  long pedicle, often
allows primary anastomosis in the neck
• Allows muscle to be split into distinct muscle flaps for complex 3D defects
• Aesthetic result : local flaps > muscle flaps w/ skin graft >
fasciocutaneous/myocutaneous

28. Microsurgical Reconstruction
• Fasciocutaneous flaps for forehead defects
• Common options : scapular, parascapular, radial forearm, ALT
• ALT increasing popularity – long vascular pedicle w/ suitable vessel diameter
for anastomosis, thickness can be adjusted by removing deep fascia &
subcutaneous fat
• Potential disadvantages : long duration, anesthetic risk for patient, technically
demanding, risk flap failure

29. Replantation
• For complete & near complete avulsions of scalp
• Cleavage usually subgaleal, starting in supraorbital & neck areas
• Two teams (one for recipient vessel, other for amputated)
• One superficial temporal artery capable of ensuring entire scalp
• Microvascular clamps on draining veins to prevent blood loss
• Contraindications: Hemodynamic instability of patient & severely macerated
amputated part w/ multiple segmental injuries

30. Mario Cherubino, Dominic Taibi, Stefano Scamoni, Francesca Maggiulli, Danilo Di Giovanna, Rita
Dibartolo, Matteo Izzo, Igor Pellegatta, Luigi Valdatta, "A New Algorithm for The Surgical Management
of Defects of the Scalp", International Scholarly Research Notices, vol. 2013, Article
ID 916071, 5 pages, 2013. https://doi.org/10.5402/2013/916071

31. Post Operative

32. Postoperative Care
• Secondary intention : several weeks of twice-daily dressing
• Skin grafts : immobilization with tie over dressing/wound VAC
• Tissue expanders : drained for 3-5 days post Op. Expansion initiated 2 weeks after
procedure
• Regional skin, fascial, or muscle flaps : protected from direct pressure for 7-10 days
post op
• Free tissue transfer & replants : require close monitoring to detect perioperative
thrombosis

33. Potential Complications
• Secondary intention  may not occur / cosmetically unacceptable /alopecia
• VAC w/ skin grafting  can destroy underlying bed if excessive pressure
• Wound dehiscence & infection
• Tissue expansion : most complications relatively minor, infection
• Skin graft failure : avascular bed/infection/hematoma/seroma/shear
• Flap complications : seroma/hematoma/necrosis/infection/inadequate coverage
• Failure for free tissue transfer : generally <5%. Complications higher @ prior
irradiation, anesthesia >10 h, age >70, pre-existing conditions

34. Secondary Procedures
• Dog-ear deformities, revision should be delayed min. 6 weeks
• STSG : mismatch of color & texture w/ surrounding tissue
• Widened scars : Closure under excessive tension  Re-excision with layered
closure , or Z-plasty/W-plasty procedures
• Alopecia : may result from excessive tension, vascular insult, skin grafts
• Mobile structures displaced (e.g. eyebrows, eyelids)

35. Secondary Procedures
• Hairlines : can be displaced if flap planning not optimal
• Malignant tumors  require careful monitoring for post op, need regular
follow-up & education for further intervention
• Temporal region : frontal-branch injuries = brow ptosis  may require
secondary brow suspension
• Destroy underlying calvarium  secondary cranioplasty procedures (requires
well-vascularized full thickness coverage over bony defect prior to recon)

36. References
1. Neligan P, Novak C. Head and neck. Flaps and Reconstructive Surgery. Wei, Fu Chan. 2009.
2. Wells M, Skytta C. Scalp and forehead reconstruction. Plastic Surgery – Volume 3 . Neligan. 2013.