Case 2 Excision of Scalp Tumor with Advancement Rotation Flap

Surgical excision of tumors in the non-hair-bearing areas of the scalp requires coverage of the surgical defect with tissues that resemble the normal tissues in the area for a satisfactory esthetic appearance. Although split-thickness skin graft can be used to cover such surgical defects, its esthetic appearance is unacceptable. Advancement rotation scalp flaps provide a very satisfactory method of closure of such surgical defects. The defect is covered with the adjacent scalp while the donor site deformity is transferred posteriorly in the hair-bearing area of the scalp which may be either closed primarily or, on occasion, covered with a split-thickness skin graft. Alternatively, large defects of the non-hair-bearing area of the scalp or forehead can be repaired with a radial forearm microvascular free flap.

When surgical excision of a scalp tumor requires excision of the underlying periosteum, then bare bones of the calvaria are exposed. Scalp flaps or microvascular free flaps are the ideal method of coverage of such surgical defects.

The patient shown in Figure 4-5A had a recurrent basal cell carcinoma involving the midline frontal area of the scalp. A local excision was performed for biopsy purposes elsewhere prior to presentation. The intended extent of surgical excision and the outline of the rotation advancement flap are shown in Figure 4—5A. Even though the anticipated surgical defect is relatively small, a large area of the scalp has to be ele-

Figure 4-4. A A pigmented basal cell carcinoma of the scalp. B The defect of surgical excision was reconstructed with a split-thickness skin graft and resulted in an acceptable appearance 6 months postoperatively.

vated because of its inelasticity and consequent inability to provide sufficient mobilization and coverage. The blood supply of this scalp flap is through both the superficial temporal as well as the occipital artery. The flap is advanced anteriorly and rotated inferiorly to cover the surgical defect. Meticulous attention should be paid in the outline of the flap by appropriate measuring of the surgical defect and the rotated scalp flap, keeping the pivot point in mind. A measurement can be taken using 4 x 8 inch gauze, holding one end at the pivot near the external ear and the other extended to the apex of the surgical defect inferomedially. Using that length as a radius, the scalp flap is outlined all the way up to the parieto-occipital region. Thus, if proper measurements are taken, the flap will satisfactorily rotate and cover the surgical defect.

The flap is reflected laterally showing its proximal mobilization up to the vascular pedicle near the pinna. The flap is now rotated both anteriorly and inferiorly to cover the surgical defect (Figure 4-5B and C). The anterior end of the scalp flap should be adequate to match the lower border of the surgical defect.

The postoperative appearance of the patient approximately 7 months following surgery is shown in Figure 4-5D. There is excellent coverage of the surgical defect near the hairline without any significant functional or esthetic deformity.

Advancement rotation scalp flaps are very satisfactory for most defects of the anterior scalp. However, if these defects are of significant size, then primary closure of the donor site is not possible and a split-thickness skin graft would be necessary in the occipital region.

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