Dermatosurgery – Tricks of the Trade DOI: 10.1111/ddg.12422
The transverse parietooccipital transposition flap for the closure of extensive frontoparietal scalp defects Eva Maria Valesky, Roland Kaufmann, Markus Meissner Department of Dermatology, Venereology, and Allergology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
Introduction In recent years, there has been an increase in the number of extensive scalp defects, showing involvement of all scalp layers and bone exposure, thus posing a challenge to dermatosurgeons. Among other reasons, this hike may likely be attributed to the extensive actinic damage seen in recent decades, but also to the substantially older age of our patients. Provided an exact knowledge of the anatomy, a number of flap techniques have proven useful in the closure of large defects, for example, advancement-rotation flaps, transposition flaps, or a combination thereof. Another more time-consuming alternative is a two-stage procedure involving trepanation of the skull (external tabula) to induce granulation, followed by full or split-skin grafting [1]. In rare cases, especially for benign tumors, using an expander technique may also be considered. To our knowledge, closure of an extensive frontoparietal scalp defect using a transverse parietooccipital transposition flap, with simultaneous closure of the do-
nor site by split-skin grafting, has only rarely been described [2, 3]. The following example serves to illustrate the principle and feasibility of this flap technique.
Technique An 83-year-old patient with dementia presented with an ulcerated squamous cell carcinoma, 10 × 12 cm in size, on the left frontoparietal scalp (Figure 1a). Employing micrographic surgery, the tumor was removed using local tumescent anesthesia (Figure 1b); osseous involvement had previously been ruled out by cranial CT scan. For defect closure under general anesthesia, the patient was placed in an abdominal position. Figure 2 depicts the vascular supply of the scalp and the marked flap. First, the flap was excised, preserving the left occipital and left posterior auricular arteries (Figure 3a). The right temporal, right posterior auricular, and right occipital arteries were severed (Figure 2). The transverse transposition flap was then mobilized while preserving the pericranium at the donor
Figure 1 Squamous cell carcinoma of the scalp and surgical defect (pictures in supine position). Large ulcerated frontoparietal squamous cell carcinoma (a); Following micrographic surgery, the skull bone is exposed and the pericranium is missing (b).
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© 2015 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2015/1302
Dermatosurgery – Tricks of the Trade
Figure 2 Graphic illustration of the arterial supply of the scalp, showing the marked flap and the primary defect.
Figure 3 Closure using a transverse parietooccipital transposition scalp flap (pictures in abdominal position with the head turned sideways). Excised parietooccipital transposition flap (a). Status post mobilization of the flap, preserving the pericranium (b). Transposition of the flap into the primary defect, resulting in a large dog-ear (c). Closure of the donor site with a split-skin graft (d). Two weeks post-op. Frontal view: no signs of flap necrosis; the dog-ear has already shrunk (e).
© 2015 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2015/1302
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Dermatosurgery – Tricks of the Trade
site (Figure 3b). This was followed by double-layered suturing of the flap into the primary defect (Figure 3c), resulting in a typical large dog-ear, which was left in place to ensure blood supply to the flap. Finally, the donor site was closed with a split-skin graft taken from the thigh (Figure 3d). After two weeks, the flap showed good perfusion and no signs of necrosis; the split-skin graft had already healed and the dog-ear had shrunk to half its original size (Figure 3e).
quick implementation, thus expanding the dermatosurgical armamentarium with respect to large and otherwise difficult-to-close defects with missing pericranium. However, especially in elderly patients, this procedure is associated with a greater surgery and anesthesia risk. Conflict of Interest None.
Discussion The transverse parietooccipital transposition flap represents a very good method for closing extensive frontal or frontoparietal defects with missing pericranium. This holds especially true in cases where patient age, preexisting conditions, or the patient’s wish dictate a one-stage procedure, in order to avoid a time-consuming two-stage procedure that includes skull trepanation, waiting for granulation to set in, and skin grafting. Even for osseous defects involving the dura mater, this method is an adequate option. Alternative, more c omplex flap techniques, such as the one described by O rticochea, may be aesthetically somewhat superior to the procedure described herein, but fail to provide an equally simple, safe, and fast defect closure [4]. Blood supply from the occipital and posterior auricular arteries ensures adequate perfusion and minimizes the risk of flap necroses. The resulting dog-ear must not be removed for aesthetic reasons during the initial flap procedure. Only if it persists 10–12 weeks after surgery, a respective repair procedure may be performed. However, in most cases, this will not be necessary due to spontaneous regression [5]. The transverse parietooccipital transposition flap is characterized by great flap stability as well as its simple and
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Correspondence to Priv.-Doz. Dr. med. Markus Meissner Department of Dermatology, Venereology, and Allergology University Hospital Johann Wolfgang Goethe-University Theodor-Stern-Kai 7 D-60590 Frankfurt am Main Germany E-mail: [email protected]
References 1 2
3 4 5
Meissner M, Kaufmann R. Surgical wounds of the scalp. ethods of closure. Hautarzt 2011; 62(5): 354–61. M García del Campo JA, García de Marcos JA, del Castillo Pardo de Vera JL et al. Local flap reconstruction of large scalp defects. Med Oral Patol Oral Cir Bucal 2008; 13(10): E666–70. Gelbke H. Wiederherstellende und plastische Chirurgie. Band III, Kopf, Hals, Thieme, Stuttgart, 1964: 251–3. Orticochea M. New three-flap reconstruction technique. Br J Plast Surg 1971; 24(2): 184–8. Lee KS, Kim NG, Jang PY et al. Statistical analysis of surgical dog-ear regression. Dermatol Surg 2008; 34(8): 1070–6.
© 2015 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2015/1302
The transverse parietooccipital transposition flap for the closure of extensive frontoparietal scalp defects Eva Maria Valesky, Roland Kaufmann, Markus Meissner Department of Dermatology, Venereology, and Allergology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
Introduction In recent years, there has been an increase in the number of extensive scalp defects, showing involvement of all scalp layers and bone exposure, thus posing a challenge to dermatosurgeons. Among other reasons, this hike may likely be attributed to the extensive actinic damage seen in recent decades, but also to the substantially older age of our patients. Provided an exact knowledge of the anatomy, a number of flap techniques have proven useful in the closure of large defects, for example, advancement-rotation flaps, transposition flaps, or a combination thereof. Another more time-consuming alternative is a two-stage procedure involving trepanation of the skull (external tabula) to induce granulation, followed by full or split-skin grafting [1]. In rare cases, especially for benign tumors, using an expander technique may also be considered. To our knowledge, closure of an extensive frontoparietal scalp defect using a transverse parietooccipital transposition flap, with simultaneous closure of the do-
nor site by split-skin grafting, has only rarely been described [2, 3]. The following example serves to illustrate the principle and feasibility of this flap technique.
Technique An 83-year-old patient with dementia presented with an ulcerated squamous cell carcinoma, 10 × 12 cm in size, on the left frontoparietal scalp (Figure 1a). Employing micrographic surgery, the tumor was removed using local tumescent anesthesia (Figure 1b); osseous involvement had previously been ruled out by cranial CT scan. For defect closure under general anesthesia, the patient was placed in an abdominal position. Figure 2 depicts the vascular supply of the scalp and the marked flap. First, the flap was excised, preserving the left occipital and left posterior auricular arteries (Figure 3a). The right temporal, right posterior auricular, and right occipital arteries were severed (Figure 2). The transverse transposition flap was then mobilized while preserving the pericranium at the donor
Figure 1 Squamous cell carcinoma of the scalp and surgical defect (pictures in supine position). Large ulcerated frontoparietal squamous cell carcinoma (a); Following micrographic surgery, the skull bone is exposed and the pericranium is missing (b).
172
© 2015 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2015/1302
Dermatosurgery – Tricks of the Trade
Figure 2 Graphic illustration of the arterial supply of the scalp, showing the marked flap and the primary defect.
Figure 3 Closure using a transverse parietooccipital transposition scalp flap (pictures in abdominal position with the head turned sideways). Excised parietooccipital transposition flap (a). Status post mobilization of the flap, preserving the pericranium (b). Transposition of the flap into the primary defect, resulting in a large dog-ear (c). Closure of the donor site with a split-skin graft (d). Two weeks post-op. Frontal view: no signs of flap necrosis; the dog-ear has already shrunk (e).
© 2015 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2015/1302
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Dermatosurgery – Tricks of the Trade
site (Figure 3b). This was followed by double-layered suturing of the flap into the primary defect (Figure 3c), resulting in a typical large dog-ear, which was left in place to ensure blood supply to the flap. Finally, the donor site was closed with a split-skin graft taken from the thigh (Figure 3d). After two weeks, the flap showed good perfusion and no signs of necrosis; the split-skin graft had already healed and the dog-ear had shrunk to half its original size (Figure 3e).
quick implementation, thus expanding the dermatosurgical armamentarium with respect to large and otherwise difficult-to-close defects with missing pericranium. However, especially in elderly patients, this procedure is associated with a greater surgery and anesthesia risk. Conflict of Interest None.
Discussion The transverse parietooccipital transposition flap represents a very good method for closing extensive frontal or frontoparietal defects with missing pericranium. This holds especially true in cases where patient age, preexisting conditions, or the patient’s wish dictate a one-stage procedure, in order to avoid a time-consuming two-stage procedure that includes skull trepanation, waiting for granulation to set in, and skin grafting. Even for osseous defects involving the dura mater, this method is an adequate option. Alternative, more c omplex flap techniques, such as the one described by O rticochea, may be aesthetically somewhat superior to the procedure described herein, but fail to provide an equally simple, safe, and fast defect closure [4]. Blood supply from the occipital and posterior auricular arteries ensures adequate perfusion and minimizes the risk of flap necroses. The resulting dog-ear must not be removed for aesthetic reasons during the initial flap procedure. Only if it persists 10–12 weeks after surgery, a respective repair procedure may be performed. However, in most cases, this will not be necessary due to spontaneous regression [5]. The transverse parietooccipital transposition flap is characterized by great flap stability as well as its simple and
174
Correspondence to Priv.-Doz. Dr. med. Markus Meissner Department of Dermatology, Venereology, and Allergology University Hospital Johann Wolfgang Goethe-University Theodor-Stern-Kai 7 D-60590 Frankfurt am Main Germany E-mail: [email protected]
References 1 2
3 4 5
Meissner M, Kaufmann R. Surgical wounds of the scalp. ethods of closure. Hautarzt 2011; 62(5): 354–61. M García del Campo JA, García de Marcos JA, del Castillo Pardo de Vera JL et al. Local flap reconstruction of large scalp defects. Med Oral Patol Oral Cir Bucal 2008; 13(10): E666–70. Gelbke H. Wiederherstellende und plastische Chirurgie. Band III, Kopf, Hals, Thieme, Stuttgart, 1964: 251–3. Orticochea M. New three-flap reconstruction technique. Br J Plast Surg 1971; 24(2): 184–8. Lee KS, Kim NG, Jang PY et al. Statistical analysis of surgical dog-ear regression. Dermatol Surg 2008; 34(8): 1070–6.
© 2015 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2015/1302
