British Journal of Plastic Surgery (2005) 58, 676 680 Repair of scalp defect using a superficial temporal fascia pedicle VY advancement scalp flap * Kiyoshi Onishi a, *, Yu Maruyama b, Akiteru Hayashi b, Kohei Inami c a Department of Plastic and Reconstructive Surgery, Toho University Ohashi Hospital, 2-17-6 Ohashi, Meguro-ku, Tokyo 153-8515, Japan b Department of Plastic and Reconstructive Surgery, Toho University Hospital, 6-11-1 Omorinishi, Ota-ku, Tokyo 143-8541, Japan c Department of Plastic and Reconstructive Surgery, Tokyo-Rinkai Hospital, 1-4-2 Rinkaicho, Edogawa-ku, Tokyo 134-0086, Japan Received 23 February 2004; accepted 11 January 2005 KEYWORDS Scalp defect; VY advancement flap; Scalp flap; Superficial temporal artery; Superficial temporal fascia Summary Repair of scalp defects using a superficial temporal fascia pedicle VY advancement scalp flap, which is supplied by superficial temporal vessels, is reported. This method has been used in seven cases of scalp defects, and enables us to provide primary closure of the defects with hair-bearing scalp skin. This method is simple, easy, and reliable. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. In the repair of scalp defects, restoration of hair is an important problem. The size of the defect, which can allow primary closure, is restricted. Although there are many reports of flaps based on the superficial temporal artery, most are pedicle flaps or island flaps. We have applied a superficial temporal fascia pedicle VY advancement scalp flap based on the superficial temporal vessels to repair scalp defects, and obtained good results both in closing the defects, and restoring the scalp hair. We * This article was presented at the 21st Annual Meeting of Japan Society of Cranio-Maxillo-Facial Surgery, November 6, 2003, Tokyo, Japan. * Corresponding author. Tel.: C81 3 3468 1251; fax: C81 3 3468 1264. E-mail address: prsoni@m9.dion.ne.jp (K. Onishi). describe the operative procedure and clinical cases in which the surgery was performed. Operative procedure A Doppler probe is used to trace the course of the superficial temporal artery preoperatively. A triangular flap adjoining the defect is designed such that it intersects perpendicularly to the direction of hair flow and includes the parietal branch of the superficial temporal artery. The design of the flap allows a rotation transfer of a fan shaped flap centering on the upper part of the anterior auricle (Fig. 1(a)). The distal border of the flap is incised to the periosteum, then subgaleal undermining of the flap is carried out toward the proximal side of S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.01.009
Superficial temporal facia pedicle VY advancement scalp flap 677 Figure 1 (a) Defect and design of the superficial temporal fascia pedicle VY advancement scalp flap based on the superficial temporal vessels. (b) The flap is elevated and transferred to the defect. (c) Immediately after the operation. The flap donor site is closed in a VY fashion. the pedicle. Then a skin incision, which stops at the subcutaneous fat layer, is made in the proximal side of the flap. Undermining in the subcutaneous fat tissue is advanced proximally taking care not to injure the hair follicles. By these dissections, the nutrient vessel of the flap is preserved and included in the pedicle because the superficial temporal artery runs in the superficial temporal fascia, which consists of temporoparietal fascia and galea aponeurosis. Pedicle dissection toward the proximal side is then made under direct vision at the anterior and posterior sides of the superficial temporal fascia taking care not to injure the superficial temporal artery until the flap can reach the defect without tension. The flap is then elevated and transferred to the defect (Fig. 1(b)). Suction drain is placed under the flap and the skin is closed by suture in two layers. The donor site is closed in VY advancement fashion employing subgaleal undermining (Fig. 1(c)). The suction drain is removed after 3 4 days depending on the volume of drainage. Case reports The surgical repair outlined above has been used in seven cases of scalp defects (Table 1). Three cases for were basal cell carcinoma, two were seborrhoeic keratosis, and the remaining two were proliferating pilomatrixoma and squamous cell carcinoma. The size of the defects ranged from 35!40 to 100!150 mm 2. They were followed for 3 months to 2 years and 3 months postoperatively. All flaps survived completely with none of them showing even partial necrosis or baldness. The postoperative scar was inconspicuous because of the suture line lay at right angles to the direction of hair flow. Case 2 A 62-year-old woman was sent to our hospital with a suspected malignant scalp skin tumour. Excision of Table 1 Clinical cases Case no. Age Sex Diagnosis Defect size Follow up Complications (mm 2 ) 1 63 M Basal cell carcinoma 50!60 2 years 3 months None 2 62 F Proliferating pilomatrixoma 100!150 2 years 3 months None 3 72 M Seborrhoeic keratosis 40!40 1 year 5 months None 4 60 M Basal cell carcinoma 45!50 1 year 3 months None 5 62 M Basal cell carcinoma 35!40 1 year 1 month None 6 48 M Seborrhoeic keratosis 40!45 8 months None 7 51 M Squamous carcinoma 75!80 3 months None
678 K. Onishi et al. was closed in VY advancement fashion (Fig. 2(b)). Postoperative course was uneventful and the flap survived completely without any partial necrosis. Postoperative pathological examination showed that the tumour was a proliferating pilomatrixoma. There has been no tumour recurrence 27 months postoperatively (Fig. 2(c)). Case 4 A 60-year-old man was referred to our hospital with a basal cell carcinoma of the right temporal region. The tumour was excised with a 5 mm margin of surrounding tissue including the periosteum. To allow restoration of the frontal hairline, an additional excision for anterior side was performed, leaving a 45!50 mm 2 soft tissue defect (Fig. 3(a)). The superficial temporal fascia pedicle VY advancement scalp flap based on the superficial temporal vessels was elevated and transferred to cover the defect in the same manner. The donor site was closed primarily in VY advancement fashion. The flap survived completely and there was no tumour recurrence at 1 year and 3 months after the operation. There was no baldness and the operative suture line was inconspicuous. Furthermore, the frontal hairline was well reconstructed from a cosmetic viewpoint (Fig. 3(b)). Discussion Figure 2 (a) Defect and design of the superficial temporal fascia pedicle VY advancement scalp flap. (b) Immediately after the operation. (c) Two years after the operation. The result is excellent. She does not need a wig. the tumour with margin of 5 mm was performed and the result of an intraoperative pathological diagnosis showed a pilomatorical carcinoma. An additional wide excision with margin of 25 mm including periosteum gave a defect of 100! 150 mm 2 (Fig. 2(a)). The superficial temporal fascia pedicle VY advancement scalp flap based on the superficial temporal vessels was elevated and transferred to cover the defect. The donor site Various methods for the repair of scalp defects have been reported. Direct closure and local flaps such as the Limberg flap have been used for small defects, and combinations of scalp flaps, combinations of scalp flaps and skin grafting, free flaps, and skin grafting have been selected for large defects. However, from aesthetic consideration, reconstruction using a hair-bearing scalp flap without concomitant skin grafting is desirable. The tissue expander is advantageous for this purpose, but onestage reconstruction is impossible, and two-stage surgery may impose restrictions and mental distress during the interval between the stages. Recent anatomical studies have clarified the structure and vasculature of the temporal region. 1 5 The superficial temporal artery runs anteriorly to the auricle, appears in the superficial layer above the posterior end of the zygomatic arch, runs in the superficial temporal fascia, and divides into the frontal and parietal branches. It runs in a shallower layer in more peripheral regions and is located mostly in the subcutaneous fat layer in the midline region. The scalp is rich in vascular
Superficial temporal facia pedicle VY advancement scalp flap 679 communications, many of which are across the midline. Even the unilateral superficial temporal artery is reported to be able to supply the entire scalp due to the blood flow through its abundant communications. 6 Superficial temporal fascia, on the other hand, originates in the galea aponeurosis, runs toward the auricle, and joins the frontal muscle anteriorly, occipital muscle posteriorly, and superficial musculoaponeurotic system (SMAS) of the face inferiorly. It adheres tightly to the scalp by sandwiching adipose tissue immediately below hair follicles. The flap using superficial temporal fascia including superficial temporal artery as the nutrient vessel can be elevated relatively easily and safely by undermining the deep layer of the flap under the galea aponeurotica and the superficial layer of the flap in the subcutaneous fat tissue. This flap, generally called the temporoparietal flap, is useful for various reconstruction procedures including the treatment of microtia as a pedicle flap and other applications as a free flap. 7,8 Various reconstruction procedures using scalp flaps with superficial temporal artery as the nutrient vessel have also been reported as a vascular island flap including eyebrow reconstruction and as a pedicle flap. 9 In 1988, Marks et al. 10 reported reconstruction of facial burn scars using a temporal island scalp flap, and Borah et al. 11 also reported reconstruction of the forehead including the hairline with temporal island scalp flap in 1990. The VY advancement flap is a useful reconstructive procedure and has been applied to reconstruction of small scalp defects. 12,13 In 1999, Gruber et al. 14 reported reconstruction of damaged forehead with bilateral fasciocutaneous temporal VY advancement island flaps based on superficial temporal artery, and Davis 15 also reported reconstruction of sideburns using an arterial VY hair-bearing scalp flap. However, in all these reports, vascular island flaps with superficial temporal artery as the nutrient vessel were used. Our method used a flap in which superficial temporal fascia is coupled with a skin paddle, and it is a pedicle flap elevated with superficial temporal fascia as the pedicle rather than a vascular island flap having superficial temporal artery as the pedicle. In 1997, Gunji et al. 16 reported reconstruction using a scalp flap with a pedicle consisting of the superficial temporal Figure 3 (a) Defect and design of the superficial temporal fascia pedicle VY advancement scalp flap. (b) One year and 3 months after the operation. The frontal hairline is well reconstructed.
680 artery and part of the superficial temporal fascia. They considered that superficial temporal vein must be included in the pedicle when a flap larger than 50!70 mm 2 was prepared in consideration of the venous drainage and that inclusion of superficial temporal fascia would allow elevation of a flap for a defect as large as 80!60 mm 2. The flap reported in this paper included a large part of superficial temporal fascia in the pedicle, and it remained continuous with the lower layers at the proximal site of the pedicle, so that it received a stable blood supply not only from superficial temporal artery but also middle temporal artery and deep temporal artery. With this flap, no problem with the venous drainage was observed, and even defects as large as 100!150 mm 2 could be reconstructed satisfactorily. This method can be performed by a simple procedure, provides a stable blood supply, and allows designing of the flap in consideration of the direction of the hair flow. Since, the postoperative suture line is perpendicular to the direction of hair flow, the scar is inconspicuous, and reconstruction of the hairline is also possible. In addition, the use of VY advancement fashion allows donor site closure primarily. Since, this method makes onestage reconstruction of relatively large defects possible, it is considered to be very useful for the repair of scalp defects. References 1. Abul-Hassan HS, Ascher GD, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77:17 28. K. Onishi et al. 2. Hata Y, Yano K, Matsuka K, Ito O, Hosokawa K. An anatomic study of the temporal region in fresh cadavers. J Jpn Cranio- Max-Fac Surg 1989;5:1 10. 3. Nakajima H, Imanishi N, Minabe T. The arterial anatomy of the temporal region and the vascular basis of various temporal flaps. Br J Plast Surg 1995;48:439 50. 4. Houseman ND, Taylor GI, Pan W-R. The angiosomes of the head and neck: anatomic study and clinical applications. Plast Reconstr Surg 2000;105:2287 313. 5. Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C. The fascial planes of the temporal and face: an enbloc anatomical study and a plea for consistency. Br J Plast Surg 2003;56:623 9. 6. Har-Shai Y, Fukuta K, Collares MV, et al. The vascular anatomy of the galeal flap in the interparietal and midline regions. Plast Reconstr Surg 1992;89:64 9. 7. Byrd HS. The use of subcutaneous axial fascial flaps in reconstruction of the head. Ann Plast Surg 1980;7:191 8. 8. Brent B, Byrd HS. Secondary ear reconstruction with cartilage grafts covered by axial, random, and free flaps of temporoparietal fascia. Plast Reconstr Surg 1983;72:141 51. 9. Lesavoy MA, Dubrow TJ, Schwartz RJ, Wackym PA, Eisenhauer DM, McGuire M. Management of large scalp defects with local pedicle flaps. Plast Reconstr Surg 1993; 91:783 90. 10. Marks MW, Friedman RJ, Thornton JW, Argenta LC. The temporal island scalp flap for management of facial burn scars. Plast Reconstr Surg 1988;82:257 61. 11. Borah GL, Chick LR. Island scalp flap for superior forehead reconstruction. Plast Reconstr Surg 1990;85:606 10. 12. Sakai S, Soeda S, Terayama I. Subcutaneous pedicle flaps for scalp defects. Br J Plast Surg 1988;41:255 61. 13. Pribaz JJ, Chester CH, Barrall DT. The extended V Y flap. Plast Reconstr Surg 1992;90:275 80. 14. Gruber S, Papp C, Maurer H. Reconstruction of damaged forehead with bilateral fasciocutaneous temporal V Yadvancement island flaps. Br J Plast Surg 1999;52:74 5. 15. Davis WH. Sideburn reconstruction with an arterial V Y hairbearing scalp flap after the excision of basal cell carcinoma. Plast Reconstr Surg 2000;106:94 7. 16. Gunji H, Sanbe N, Tateshita T, Yoza S, Ono I. Reconstruction of scalp defect with hair-bearing skin flap pedicled by superficial temporal arterial and venous system. J Jpn Plast Reconstr Surg 1997;17:514 25.