The document discusses scalp anatomy and reconstruction of scalp defects using flap procedures. It describes the layers of the scalp, blood supply, nerve supply and causes of scalp defects. Various reconstruction options are summarized including primary closure, skin grafting, local flaps such as rotation and transposition flaps, regional flaps such as trapezius flaps, and free tissue transfer including latissimus dorsi flaps. Factors to consider for reconstruction include the location and size of the defect, surrounding tissues, and preservation of the native hairline.

1. SCALP Defects
Reconstrucion with Flap Procedure
Oleh: dr. T. Bima Fasha. TS
Pembimbing :
dr. Teuku Yose Mahmuddin Akbar, Sp. BS

2. EXTENT OF SCALP
 Anteriorly : supraorbital rims
 Posteriorly : the nuchal line.
 Laterally: from the frontal process of the zygoma to
the prominence of the mastoid process.

3. LAYERS
 S is skin
 C is subcutaneous tissue
 A is aponeurotic layer
 L is loose areolar tissue
 P is pericranium

4. IMPORTANT POINTS OF GALEA
 Septa jaringan ikat di dalam lapisan subkutan terhubung dengan kuat
lapisan muskuloaponeurotik di bawahnya
 Galea aponeurotica : lapisan muskuloaponeurotik yang terbentang dari
otot frontalis anterior ke oksipitalis
Ke lateral galea berlanjut sebagai fasia temporoparietal.
 Galea is highly vascularized
 Subgaleal fascia : loose areolar layer beneath the galea
tipis di atas verteks
lebih tebal di daerah temporoparietal.
kaya akan vaskularisasi dan dapat meningkat
sebagai lapisan independen

5. PERICRANIUM
 periosteal layer of the calvaria.
 Thick collagenous layer with a rich blood supply
Melekat kuat pada tengkorak di daerah sutura.
 Pericranial flaps

6. TEMPOROPARIETAL REGION
 four distinct fascial layers
 Superficial temporal fascia:
lapisan paling superfisial
Lapisan ini merupakan
perpanjangan langsung dari
galea
diterapkan erat pada kulit di atasnya

7.  Jauh ke fasia temporal superfisial adalah fasia subgaleal.
 Terkandung dalam lapisan yang mudah dibedah ini adalah temporal
superfisial arteri dan cabang frontal saraf wajah.
 Di bawah fasia subgaleal adalah bantalan lemak temporal
superfisial. Banyak vena perforasi besar mengalir melalui lapisan ini
 Temporal fat pad : terhubung dengan bantalan lemak bukal dari
midface.

8. DEEP TEMPORAL FASCIA.
 Di bawah bantalan lemak temporal superfisial
 lapisan fasia tebal yang mengelilingi temporalis.
 Fasia temporal yang dalam superior menyatu dengan pericanium
 Secara inferior, itu terbagi menjadi dua lapisan pada tingkat jahitan
frontozygomatic.
 Bagian superfisial fasia temporal dalam melekat pada batas lateral
arkus zigomatikus
 Lapisan dalam menyatu dengan aspek medial lengkung

9.  Reflection of the superficial portion of the deep temporal fascia : Protects
facial nerve branches from injury.
 Temporalis Blood Supply : two deep temporal branches of the internal
maxillary artery: the middle and deep temporal

10. BLOOD SUPPLY OF SCALP
Internal carotid External carotid
Supraorbital Superficial temporal
Supratrochlear Posterior Auricular
Occipital

11. NERVE SUPPLY MOTOR
Muscle Nerve supply
Frontalis Frontal br. Of Facial
Occipitalis Posterior auricular
T
emporalis Posterior and Anterior branches of
Deep temporal Nerve
{branch of Trigeminal N }

12. SENSORY NERVE SUPPLY
Supratrochlear Medial forhead
Supraorbital
Superficial Central forhead
Deep Remaining Frontoparietal
region
Zygomaticotemporal of Skin lateral to temporal crest
Maxillary division of
Trigeminal N
Auriculotemporal of Trigeminal
N Lateral scalp
Greater and lesser occipital N Posterior scalp

13. CAUSES OF SCALP DEFECTS
 Trauma
 Burns
 Neoplastic
 Dermatological conditions
 Congenital

14. FACTORS CONSIDERED FOR
 Location
SCALP DEFECTS
 Structures involved & exposed
 Sorrounding tissue
 Wound size
 Contour
 Previous treatment taken
 Hairline

15. SECONDARY INTENTION
 the defect is less than 1 cm in diameter and without bone
exposure.

16. NPWT
 Can help to reduce size, make healthy granulation tissue over the floor
 Molnar et al
the use of the NPWT in conjunction with skin grafts for full-thickness
lesions of the scalp.
They combined decortication of the outer surface of the skull with
immediate skin grafting in four patients with successful graft take.

17. PRIMARY CLOSURE
 If <3 cm
 Galea scoring :- method of decreasing tension on wound margins
avoid injury to major vessel
1 mm gain in each incision, keep 1 cm gap
 Obtain meticulous hemostasis following galeotomy to prevent hematoma

 Chances of distal flap vascular
compromise

18. TISSUE EXPANSION
 Rapid intraop Tissue expansion and
closure :
3-4 cycles of inflation and deflation of the
expander for 3–5 minutes are performed.

19. STAGED TISSUE EXPANSION TECHNIQUES
 subcutaneous or subgaleal position
 Expansion begins at 2 weeks following placement.
 The device is expanded on a weekly or biweekly basis until the tissue
requirements of the defect are met.
 Expansion should be continued until the expanded flap
20% larger than the size of the defect
is approximately
 tissue expansion produces a delay phenomenon
 Defects up to 50% of the scalp can be reconstructed.
 decreased hair follicle density.

20. Austad advocates against tissue expansion in acute injuries because

of the risk of contamination and implant exposure.
Disadvantage : 2 stage procedure

Complications :

Hematoma
implant exposure
infection
flap necrosis
Alopecia
wide scars.
Pressure from the






expander can deform the cranial vault.


21. SKIN GRAFTING
 prerequisite for skin grafting
 adequately vascularized wound bed.
 Preservation of the cranial periosteum or the underlying subcutaneous
tissue of the scalp
 Drill holes upto diploic spaces and NPWT F/B interval STSG
 Crane principle

22. LOCAL FLAPS
Rotation flap
Transposition flap
Gillies tripod flap
Juri flap
Orticochea flap
Bipedicled flap
T
emporoparietal flap
Frontooccipital flap
O to T , Y to T flap
Cervical fascial advancement









flap


23. ROTATION FLAP

24. TRANSPOSITION FLAP
 Based on principle of triangulating the defect
 Right angled triangle made
 Donor site Covered with STSG

25. PINWHEEL FLAP

26. PIN WHEEL FLAP

27. ORTICOCHEA FLAP
 two anterior ones that are placed in the front part of the defect and a
transverse flap that is placed in the back.
 The posterior transverse flap is situated at the nape of the neck and has its
pedicle located in the retroauricular region.
 This pedicle should be placed on the side opposite the raw surface to be
reconstructed.

28.  When a large scalp flap is rotated, the dissection should be
subgaleal
 T
emptation to revise the dog-ear should be resisted . It will
flatten with time

29. JURI - TEMPOROPARIETO-
FLAP OCCIPITAL FLAP
If defect size <25 cm length as this flap can be taken upto 25 cm
Based on Parietal br . Of STA
Delay needed

30. TEMPORO-PARIETO-OCCIPITO-PARIETAL
 If more than 25 cm of flap is needed in length
 Upto 30-32 cm length possible
FLAP


31. BIPEDICLED FLAP

32. FRONTALIS MYOCUTANEOUS FLAP

33. GALEAL FLAP
 Based on STA
 galeal flap is commonly based on a named scalp vessel or combination of
vessels.
 Flap length can often cross the midline
 Can be elevated with frontalis muscle of the forehead to reconstruct the
anterior cranial base.
 Can be taken with bone [vascularized cranial bone for reconstruction about
the orbit and facial skeleton ]
 Subgaleal areolar tissue can be raised with the underlying periosteum as a
turnover flap to provide vascularized coverage for denuded calvaria

34. DEEP TEMPORAL FASCIA FLAP
 The temporalis fascia is a direct lateral extension of the scalp
periosteum.
 This structure obtains its blood supply from the middle temporal
artery, a branch of the superficial temporal artery.
 Thus, a composite flap of superficial temporal fascia and
temporalis fascia can be isolated on the same vascular leash.

35. TEMPORALIS MUSCLE
 Origin : the temporalis fossa
 It passes under the
zygomatic arch
 Insertion :coronoid process
of the mandible.
 Blood Supply : DTA
 Always need grafting for
cover

36. COMPONENT SEPERATION
 Galeal frontalis flaps
 Osteogaleal flaps
 T
emporoparietal fascial flaps

37. REGIONAL FLAP
 Trapezius flap : type 2
 For occipital defects
 blood supply :- transverse cervical
dorsal scapular
occipital arteries
 Pattern :
Transverse flap : upper fibres [A/w shoulder drop]

Vertical flap : middle and lower fibres
8-10 cm donor defect can be closed primarily

39. LD FLAP [PEDICLED /FREE]
 By passage of the muscle through the axilla,
defects in the orbit and temporal bone can be
repaired.

40. OTHER REGIONAL FLAPS
 Splenius capitis for occiput
 Pectoralis major flap for mastoid and temporal region

41. FREE TISSUE TRANSFER
 LD [Flap of choice for large
 RFF
 ALT
 Omental Flap with STSG
defects]
 Free temporo-occipital scalp flap for free hair
baring tissue transfer

42. CHECKLIST
Named vessel included?
Native hairline preserved ?
I.
II.
III. Mode of
IV. Inherent
occipital
injury?
inelasticity of galea and mobile parietal and
region [neck]
V. Donor site : less sensitive cosmetically?

43. Thanks