Grabb’s Encyclopedia of Flaps Head and Neck

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located on a projection of line AC. Line CD must be at least 50% longer than AC. Midway between A and D, a
point is designated, which becomes the center for an arc drawn from B to D that completes the outline for the
flap (Fig. 1.5B). This flap offers primary closure of the secondary defect by distributing tension over a wide and
linear area.
OPERATIVE TECHNIQUE
Preoperative shaving of the hair is unnecessary. As opposed to most skin incisions, scalp incisions should be
beveled at an angle parallel to the hair shafts to avoid a linear hairless scar. As shown in Figure 1.6 a traditional
vertical incision ab will interrupt the hair follicles in segment c. The resulting hairless scar becomes an artificial
“part” that may be unsatisfactory to the patient.
As the incision is continued through the galea, the avascular subaponeurotic layer affords quick and easy
separation by blunt dissection. Although bleeding from the wound margin is frequently profuse, it can be
controlled readily by pressure and plastic clips without the need for ties or cautery. Definitive hemostasis is
accomplished later with closure of the wound. Relaxing or “gridiron” incisions in the rigid galea are used
frequently but will permit only 1 mm of extension for each incision. Scalp expanders may be used to good
advantage to facilitate scalp closure in larger defects. The lack of elasticity in the scalp will create a buckling
effect or dog-ear at the base of a flap with rotation greater than 30 degrees. Smaller redundancies will diminish
with time, but larger ones may require secondary excision. Closure of the scalp should be performed in two
layers beginning with suture of the galea aponeurotica followed by closure of the integument.
FIGURE 1.5 A-D: Design and transfer of the rotation flap.
Forehead Rotation Flap
The entire forehead is available as an arterialized flap based on the superficial temporal artery to reconstruct
forehead defects involving up to 40% of the surface area. As illustrated in Figure 1.7A, the superior border of a
forehead rotation flap is developed in the hair-bearing scalp and traverses the frontal scalp to the preauricular
crease (5).
Elevation of the flap is accomplished easily down to the supraorbital rim, resulting in a “free-swinging” extensile
segment of tissue. After mobilization is complete, back-cutting of the base is permissible but rarely necessary.
Once the flap has been rotated to the desired position, the hairline on the distal margin of the flap is aligned with
and sutured to the temporal hairline on the lateral margin of the defect (Fig. 1.7B).

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FIGURE 1.6 A: Effect of a vertical incision through oblique hair shafts. B: The incision should be beveled at an
angle parallel to the hair shafts when there is hair on both sides of the incision. When dealing with a wound in
which there is hair on one side and no hair on the other side (such as a direct brow lift or an anterior incision for
face lift), the incision should be beveled in the opposite direction. This cuts the hair shafts and leaves the follicles
intact. C: The hairless skin then is brought over the cut hair shafts. When the wound heals, the hair shafts grow
out through the overlying intact skin and help disguise the incision.
FIGURE 1.7 A: Incision for forehead rotation flap. B: Reestablishment of temporal hairline and closure of original
defect. C: Completion of wound closure.

FIGURE 1.8 A: Unsightly split-thickness skin graft of forehead. An area as large as 40% of the forehead can be
reconstructed with a forehead rotation flap. B: Outline of forehead rotation flap within the scalp and area of
excision. C: Final result. (From Worthen, ref. 5, with permission.)
The forehead defect is closed without tension, often with a suture line oriented transversely, to minimize the only
portion of scar that will be visible on the exposed forehead. The secondary frontal scalp defect extends across
the entire width of the frontal scalp but is relatively narrow and amenable to primary closure by relaxation and
advancement of the scalp posterior to the defect (Fig. 1.7C). The effectiveness of this flap is shown in Figure
1.8.
CLINICAL RESULTS
Because of the great vascularity of the forehead rotation flap, necrosis and infection rarely pose a
significant problem. The only disadvantages encountered are lateral displacement of a prominent widow's
peak, which is easily minimized by hair-styling, and temporary asymmetry of the forehead furrows when
these are deep and prominent.
SUMMARY
The basic principles involved in transposition and rotation flaps are described and can be applied to scalp
defects. The rotation flap can be used effectively to close large forehead defects. Cosmetic results are
excellent.
References
1. Corso PF. Variations of the arterial, venous and capillary circulation of the soft tissues of the head by
decades, as demonstrated by the methacrylate injection technique, and their applications to the construction
of flaps and pedicles. Plast Reconstr Surg 1961;27:160.
2. Galvao MSL. A postauricular flap based on the contralateral superficial temporal vessels. Plast Reconstr
Surg 1981;68:891.
3. Miller GDH, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular
anastomoses. Plast Reconstr Surg 1976;58:133.
4. Nahai F, Hurteau J, Vasconez L. Replantation of an entire scalp and ear by microvascular anastomoses of
only one artery and one vein. Br J Plast Surg 1978;31:339.

5. Worthen EF. Repair of forehead defects by rotation of local flaps. Plast Reconstr Surg 1976;57:204.

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Chapter 2
Multiple Pinwheel Scalp Flaps
T. R. VECCHIONE
The removal of scalp lesions with primary closure can tax the imagination and ingenuity of the surgeon. Lesions
greater than 3.0 cm in diameter sometimes require extensive mobilization of surrounding tissues and/or elaborate
flap designs for closure. The literature is filled with variations of transposition and rotation flaps for these
situations (1, 2, 3).
This is not a new method, but a practical variation on a well-established theme. This application is a multi-flap
closure, and it takes on a pinwheel or camera-shutter configuration.
INDICATIONS
This method takes advantage of a full 360° of mobilization of the surrounding tissues. Excision and linear
closure move tissue in only two directions. There is essentially no elasticity of the scalp, and complete
mobilization of flaps of surrounding tissue is necessary even for short tissue advancement. If the lesion is
simply removed and closed in a straight line, a significant amount of normal tissue must be removed.
FIGURE 2.1 The inscription of the four arcs can be geometrically constructed using the technique
described in the text.
The advantages of this pinwheel method are as follows:
1. Minimal undermining
2. Ease in design
3. No excessive excision of normal tissue (apart from minimal recontouring of small dog-ears)
4. The distribution of tension over four radiating suture lines instead of one.
ANATOMY
The multiflap closure in a pinwheel fashion can be used anywhere on the scalp, since the mobility and blood
supply are relatively uniform (see Chapter 1).

FLAP DESIGN AND DIMENSIONS
Limberg's extensive studies of transposed triangular flaps have been used for many years in the closure of 60°
rhomboid defects (1, 4, 5). The use of multiple Limberg flaps for closure has been described (2). This basic
principle is the point around which many variations have been built. This presentation is one of those variations.
The two coordinated movements, a lateral movement and a rotation, are the basics of this plastic surgical
principle. The “standing cones” or dog-ears at the flap bases have to be trimmed, but these are not large
because four flaps are rotated, thus dissipating the cervical distortion at the flap base.
In constructing the spiral arms of the pinwheel, what is needed is a simple, yet accurate, geometric method that
does not require tedious calculations or complex templates. Most spirals, including the spiral of Archimedes and
the logarithmic spiral, require construction using a polar-coordinate system. However, the curve of an involute of
a circle is easily constructed and seems ideal for a practical solution to the pinwheel flap arms.
FIGURE 2.2 An infiltrating squamous cell carcinoma was excised resulting in a 4.5- to 3.8-cm defect to
periosteum. The four rotational flaps close the lesion without excessive overhang. The apices of all the flaps are
held at the midpoint by one subcuticular suture. The minor change in direction of hair follicles has not been a
significant problem.
This is most easily done by unwinding a thread wrapped around a cylinder of a diameter that is approximately
twice the diameter of the excised lesion. If a marking pencil tip is placed in a loop at the distal end of the string as
the taut string is unwound from the cylinder, the curve of an involute of a circle is produced that is ideal for
producing the arms of the pinwheel flap. By repeating the procedure four times starting at 0°, 90°, 180°, and 270°
on the excised circle, the four arms are created (Fig. 2.1). Once the principle of flap design is mastered, free-
hand flap construction can be equally effective. The diameter of twice the excised lesion diameter was chosen
because a smaller diameter produced too small a flap pedicle and a diameter greater than twice the excised
diameter produced too small an arc for proper rotation.
CLINICAL RESULTS
The rounded edges, broad base, and smaller arc of rotation make this method relatively free of
complications. Edge necrosis has been encountered only in a very small percentage of cases. The
vascularity of the scalp, along with the integrity, inelasticity, and thickness of the tissue, accounts for the
clinical success of this procedure (Fig. 2.2).

SUMMARY
A pinwheel variation in design of multiflap closure in the inelastic scalp tissue is presented.
References
1. Limberg AA. Design of local flaps. In: Gibson T, ed. Modern trends in plastic surgery, 2d Ed. London:
Butterworth, 1966.
2. Lister GD, Gibson T. Closure of rhomboid skin defects: the flaps of Limberg and Dufourmental. Br J Plast
Surg 1972;25:300.
3. Brobyn T, Cramor L, Hulnick S, Rodsi M. Facial resurfacing with the Limberg flap. Clin Plast Surg
1976;3:481.
4. Limberg AA. Mathematical principles of local plastic procedures on the surface of the human body.
Leningrad: Medgis, 1946.
5. Jervis W, Salyer KE, Vargas-Busquets MA, Atkins RW. Further applications of the Limberg and
Dufourmentel flaps. Plast Reconstr Surg 1974;54:335.

Chapter 3
“Banana Peel” Scalp, Forehead, and Nape of Neck Flaps
M. ORTICOCHEA
The forehead and the nape of the neck have a surgical unity with the rest of the scalp, thus enabling
reconstructive procedures to be carried out from one area to the other without separation between them (1, 2, 3,
4).
ANATOMY
The cutaneous covering of the skull (Fig. 3.1) includes not only the hair-bearing skin, but also the forehead and
the nape of the neck. The scalp itself is composed of (1) the hairy skin that covers the skull, (2) the
subcutaneous adipose cellular tissue, (3) the underlying epicranial aponeurosis, (4) the subaponeurotic layer of
loose connective tissue, and (5) the pericranium (external periosteum).
The location of vascular pedicles of the cutaneous covering of the skull is divided into three groups on the basis
of which vessels they contain (Fig. 3.2).
Anterior Orbital Pedicle
The anterior orbital pedicle is made up of arteries and veins that reach the skin of the forehead from the orbital
cavity and are collateral branches of the ophthalmic vessels. In the middle, they consist of the supraorbital
vessels, the most important elements of this group. These vessels reach the forehead via the supraorbital
foramen or supraorbital notch of the middle part of the supraorbital border. The notch is easily palpable. This
pedicle also includes the supratrochlear vessels that reach the skin on the forehead through the medial part of
the supraorbital border. When planning scalp flaps, one should take advantage of the fact that the vessels in this
group are located in the central and medial part of the supraorbital border (Fig. 3.2A).
FIGURE 3.1 Schematic representation of the external limits of the cutaneous covering of the skull. A: Anterior
view. B: Lateral view. C: Posterior view. (From Orticochea, ref. 1, with permission.)
Lateral Pedicle
The lateral pedicle contains the superficial temporal vessels, terminal branches of the external carotid vessels,
that reach the scalp after passing in front of the external ear (Fig. 3.2). In front of the superior pole of the ear,
they divide into two branches: the frontal branch that proceeds forward, anastomosing with the supraorbital
vessels, and the parietal branch that runs upward and backward and ends by anastomosing with the terminal
branches of the occipital and posterior auricular arteries.
The superficial temporal vessels are the most important vascular elements to reach the cutaneous covering of
the skull because (1) they are the longest vessels of the scalp and thus irrigate a large area of it, and (2) their

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easy mobilization allows them to be included in a variety of flaps (see Fig. 3.6).
The posterior auricular vessels, collateral branches of the external carotid vessels, reach the scalp just behind
the external ear (Fig. 3.2B). These vessels pass the mastoid process of the temporal bone, branching through
the scalp in back and above the external ear. They anastomose with the parietal branch of the superficial
temporal vessels and with the occipital vessels. The posterior auricular pedicle is less important than the
superficial temporal one, because it is of smaller caliber and has shorter branches that are mobilized with
difficulty during surgery, since they are firmly attached in the mastoid auricular region.
FIGURE 3.2 A,B: Schematic representation of the circulation of the cutaneous coating of the skull: (1)
supraorbital and supratrochlear vessels; (2) superficial temporal vessels; (3) posterior auricular vessels; (4)
lateral and medial branches of occipital vessels; (5) multiple perforating vessels, which are collateral branches of
the occipital, vertebral, and superficial cervical arteries. (From Orticochea, ref. 1, with permission.)
Posterior Pedicle
The posterior vessels are made up of two groups. The upper group (Fig. 3.2B) corresponds to the two lateral
and medial branches of the occipital vessels. These vessels, after running a horizontal trajectory under the
insertion of the trapezius and splenius muscles, come to the surface, crossing the trapezius muscle and rising to
the scalp at a point above the superior nuchal line. The lower group (Fig. 3.2B) contains multiple perforating
vessels that supply the skin that covers the neck muscles. These vessels reach the skin on the nape of the neck
after running through the trapezius and splenius muscles. These multiple perforating vessels are collateral
branches of (1) the occipital artery, (2) the posterior branches of the vertebral artery, and (3) the superficial
cervical artery. They are of small caliber and short length. Thus, the skin on the nape of the neck has little
circulatory autonomy in comparison with the scalp.
When a dissection is carried caudally, the scalp vessels course into a deeper layer—a fact of importance in the
raising of scalp flaps. On reaching the external limits of the forehead and of the scalp dissection, the epicranial
aponeurosis thins and disappears, and these vascular elements leave the cutaneous covering and pass to a
deeper plane. The supraorbital and supratrochlear vessels follow the supraorbital margin and then enter the
orbital cavity. The superficial temporal vessels reach the parotid region and go deeper, entering the parotid
gland.
The posterior auricular vessels enter the scalp in a cephalic direction at the retroauricular space, and the
occipital vessels enter the scalp under the insertions of the trapezius muscle. This is important to the surgeon,
since a careful dissection with a blunt instrument must be made when lifting and dissecting the flaps of the scalp
caudally in order not to damage the vessels where they pass from the forehead and the scalp to a deeper level,
where they are firmly attached (Fig. 3.3).

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FIGURE 3.3 Constitution of the osteomuscular sphere of the skull. Left. Lateral view: (A) osseous structures:
frontal, parietal, and occipital bones; (B) temporal muscle covered by the temporal fascia; (C)
sternocleidomastoid muscle; (D) trapezius muscle. Right. Posterior view: (A) occipital bone; (C)
sternocleidomastoid muscle; (D) trapezius muscle. (From Orticochea, ref. 1, with permission.)
Considering the cutaneous covering of the skull as a unity, there are five possible zones of raw surface to be
reconstructed and, therefore, five different applications of the three-flap technique: (1) forehead, (2) right
temporal region, (3) left temporal region, (4) central region of the skull, and (5) nape of the neck.
FLAP DESIGN AND DIMENSIONS
To repair a very large defect of the cutaneous covering of the skull, we mobilize the entirety of what is left of the
scalp, forehead, and nape of the neck, including these structures within three flaps. Each flap must have its own
vascular pedicle as far as possible to ensure circulation. An exact knowledge of the anatomy of the cutaneous
covering of the skull and the possible distribution of the vascular pedicles is extremely important in carrying out
this operation.
Three-Flap Technique for a Central Scalp Defect
In cases of large defects in the central part of the scalp (Fig. 3.4), the rest of the cutaneous covering of the skull
can be used to form three flaps—two anterior ones that are placed in the front part of the defect and a transverse
flap that is placed in the back. In this way, we take advantage of two important aspects of the anatomy of the
forehead, scalp, and nape of the
neck: First, the secondary defect from the two anterior flaps can be covered with small split-thickness skin grafts
(Fig. 3.5) that give the forehead an anatomic continuity. Second, the posterior transverse flap (3 in Fig. 3.2B)
placed in back and under the central defect allows us to use the abundant skin of the nape of the neck (Figs. 3.6
and 3.7).

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FIGURE 3.4 After surgical extirpation of a large tumor, a broad surface in the central scalp remains to be
reconstructed. The diameter of the raw surface is 24 cm, and its area is 452 cm2. The pathologic specimen,
when it contracted, was 18 cm in diameter. The diameter of the section of occipital bone that was removed was
10 cm. (From Orticochea, ref. 3, with permission.)
FIGURE 3.5 Final result of surgery. It was necessary to place a small skin graft in the region adjoining the
forehead. From an aesthetic viewpoint, this gives a very good result. (From Orticochea, ref. 3, with permission.)
The posterior transverse flap is situated at the nape of the neck and has its pedicle located in the retroauricular
region, through which the occipital or posterior auricular vessels enter. This pedicle should be placed on the side
opposite the raw surface to be reconstructed. Flap dimensions vary, depending on the size both of the patient's
head and of the raw surface to be reconstructed.
The anteroposterior midline of the scalp is a place where vascular territories converge from both sides of the
skull. It constitutes a physiologic barrier that limits the frontiers of these territories. This is why caution is
necessary and why the posterior transverse flap should not be made too long.
Since the circulation in the skin of the nape of the neck is less than that in the scalp, and since this flap crosses
the midline, necrosis at the end of the flap can occur. To avoid this, the surgeon should design the flap with a
wide pedicle (Fig. 3.5D).
OPERATIVE TECHNIQUE
The epicranial aponeurosis is thick, resistant, and not very elastic. This is why the surgeon must make multiple
shallow longitudinal incisions parallel to the longer axis in the epicranial aponeurosis of each of the flaps to
facilitate their increased width (Fig. 3.6), making it possible for these multiple flaps to cover large defects. When
doing this, the surgeon must be very careful not to section or damage the vessels that are very closely attached
to the epicranial aponeurosis. The veins are of large caliber and have thin walls and thus can be easily
damaged. When incising the epicranial aponeurosis, it is easier to interrupt

the venous circulation than the arterial circulation. Damaging the veins produces greater and more serious
circulatory disturbances than damaging the arteries.
FIGURE 3.6 A-I: Schematic development of the three-flap technique. (From Orticochea, ref. 3, with permission.)
The vessels in the flap pedicles are very vulnerable for two reasons: (1) the epicranial aponeurosis becomes thin
and disappears, and (2) the vessels pass from a superficial plane (scalp) to a deeper plane.
FIGURE 3.7 The three flaps are stretched out. The epicranial aponeurosis has been divided with multiple
shallow longitudinal incisions. The dotted line shows the zone of occipital bone that was removed. Inside the
circle is that area that corresponds to the dura mater. (From Orticochea, ref. 3, with permission.)
Three-Flap Technique for a Central Scalp Defect
The incision (Fig. 3.5C) that separates the two anterior flaps along the midline should be oblique, so that when
the flaps are rotated and slid back, they will fit up against the posterior transverse flap (3 in Fig. 3.2B) when it is
moved up and forward.

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The anterior flaps should be carefully undermined with blunt instruments, and great caution should be used
when dissecting their pedicles, because the superficial temporal vessels and the posterior auricular vessels pass
deeply and can be easily damaged.
FIGURE 3.8 The surgeon must move the cutaneous covering of the skull with the same facility with which a boy
peels a banana. (From Orticochea, ref. 3, with permission.)
The anterior flaps (1 and 2 in Fig. 3.2) and the posterior transverse flap (3 in Fig. 3.2B), once mobilized, should
be interpolated and sutured without being submitted to exaggerated tension. When extensive surfaces of the
scalp are being reconstructed, it will be necessary to cover small raw zones with free skin grafts.
SUMMARY
Large defects of the scalp can be closed using a three-flap technique that peels the skin off the skull as one
would peel a banana (Fig. 3.8). This takes advantage of the excess skin that can be mobilized from the
neck. The epicranial aponeurosis is also incised parallel to the vessels to allow many defects to be closed
primarily. If the defect is large, however, a skin graft will be required.
References
1. Orticochea M. Flaps of the cutaneous covering of the skull. In: Grabb WC, Myers MB, eds., Skin flaps.
Boston: Little, Brown, 1975:155-183.
2. Orticochea M. Four-flap scalp reconstruction technique. Br J Plast Surg 1967;20:159.
3. Orticochea M. New three-flap scalp reconstruction technique. Br J Plast Surg 1971;24:184.
4. Orticochea M. A pneumatic cranial tourniquet to control haemorrhage during operations on the scalp. Br J
Plast Surg 1977;30:223.

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Chapter 4
Temporoparieto-Occipital and Temporoparieto-Occipitoparietal
Scalp Flaps
T. R. VECCHIONE
EDITORIAL COMMENT
The following four chapters (Chapters 4-7) describe a series of techniques for restoration or transfer of hair-
bearing skin about the scalp. These flaps have found their greatest usefulness in treating acquired
baldness. They are most helpful with the adjunctive insertion of microvascular grafts, as well as the use of
additional free multiple and single hair-bearing grafts.
In the treatment of frontal or frontoparietal alopecias, the temporoparieto-occipital flap is the method of choice,
since it provides enough hair to cover the alopecic area up to the contralateral region (1, 2, 3, 4, 5, 6). The flap
can be extended if necessary as the temporoparieto-occipitoparietal scalp flap (7, 8, 9).
INDICATIONS
These flaps have the valuable advantage that the donor area is closed by approximation of its edges, at the
expense of a large retroauricular advancement flap.
FIGURE 4.1 Schematic representation of the temporoparieto-occipital flap. A: Design of the anterior implant
line and recipient area. B: Flap design. C: Flap transposition and closure of the donor area with a large
advancement flap (arrows). D: Flap in its final position and sutured to the recipient site. (From Juri et al., ref.
6, with permission.)
When the alopecia affects the frontal area (Figs. 4.1 and 4.2), only one flap will be required to close the
defect. If the alopecia also involves the parietal region, a second flap from the contralateral zone is placed
behind the first one a month later.
When a large area of central alopecia cannot be covered completely, an extended flap (Figs. 4.3 and 4.4)
can be used not only to cover part of the defect, but also to help camouflage the remaining defect with an
appropriate hairstyle.
ANATOMY
Both flaps are based on the superficial temporal vessels. The temporoparieto-occipitoparietal scalp flap, called

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the encircling flap, is made possible by the wide anastomotic net of the temporal vessels with the ipsilateral
occipital ones and of the latter with the contralateral occipital vessels.
FLAP DESIGN AND DIMENSIONS
Temporoparieto-Occipital Scalp Flap
The glabrous surface to be resected is marked, taking the measurements of the flap to be designed (Fig. 4.1A).
The flap base will be determined by the pulse of the superficial temporal artery, which is either palpated or
marked using a Doppler probe 2 to 3 cm over the zygomatic arch. Then two points are marked, one on each side
of the base point at a distance of 2 cm. These will indicate the width of the flap (4 cm), from which two parallel
lines are drawn in an upper direction, along the parietal region, and down the occipital area (Fig. 4.1B). Although
the viability of this flap is supported by its temporal pedicle, it is best to do one or two delays, especially if it is
noted that the flap will suffer a slight torsion in the base during its transposition.
FIGURE 4.2 A: Preoperative view. Design of the glabrous surface, which is going to be resected. (The arrow
shows the direction of the flap.) B: Preoperative view. The extension of the glabrous surface that reaches the
contralateral temporal region is observed. C: Design of the temporoparieto-occipital flap that is going to be
transferred. (continued)
FIGURE 4.2 Continued. D: Intraoperative view. Closure in two layers without tension in the donor site. E:
Appearance of the flap after a week. F: Postoperative frontal view 5 years later. (From Juri et al., ref. 6, with
permission.)

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Temporoparieto-Occipitoparietal Scalp Flap
When the glabrous surface that extends from one temporal zone to the contralateral one is more than 25 cm
long, the temporoparieto-occipital flap does not have enough length to reach the opposite hair-bearing region. In
this case, a larger flap that will reach the contralateral parietal zone is required. Therefore, we employ the
temporoparieto-occipitoparietal flap that is 30 to 32 cm long and 4 cm wide. The design of this flap is based on
that of the preceeding flap, and it uses the remaining hair-bearing regions of the parietal, occipital, and
contralateral parietal regions (Fig. 4.3B and C).
FIGURE 4.3 Schematic representation of the temporoparieto-occipitoparietal flap. A: Extensive frontoparieto-
occipital alopecia. B: Lateral view of the donor site and flap design. C: Superior and posterior views of the flap
design. D: Raising of the flap, closure of the donor site, and resection of the frontal glabrous surface. E: Flap in
its new position. F: Final appearance of the flap. (From Juri et al., ref. 6, with permission.)
OPERATIVE TECHNIQUE
Temporoparieto-Occipital Scalp Flap
Once the flap is raised and before suturing it to the recipient site, a large retroauricular flap up to the base of the
neck is made to take advantage of the elasticity of this region and to allow closure of the donor area without
tension (Fig. 4.1C). Subsequently, the anterior edge of the flap is sutured to the frontal skin in only one layer.
The skin of the forehead is brought over a de-epithelialized surface of 2 mm in the anterior
edge of the flap so as to avoid an uneven suture line. Then the remaining glabrous area is resected, and the
posterior edge of the flap is sutured (Fig. 4.1D).

FIGURE 4.4 A, B: Preoperative views. Preparation of the flap and the recipient site. C: Intraoperative view.
Preparation of the frontal recipient site. D: Intraoperative view. Final suture of the flap in its new position. E, F:
Postoperative frontal and lateral views 1½ years later. (From Juri et al., ref. 6, with permission.)
Temporoparieto-Occipitoparietal Scalp Flap
Because of the great extension of this flap, we prefer to do two delays. The first delay includes both edges of the
flap up to the contralateral occipital region, and the second delay, done a week later, involves the end of the flap
(contralateral parietal region). A week later, the flap is raised from its bed and closure is done with a large
advancement flap that contours all the donor area (Fig. 4.3D). The glabrous recipient zone is resected (Fig.
4.3D), and the flap is placed in its new position (frontal region), where it is sutured in only one dermal plane. In
this manner, hair that was of little aesthetic value is transferred to the frontal region, which is aesthetically more
important. This hair hides the remaining central alopecia.
SUMMARY
Both the temporoparieto-occipital flap and its extended counterpart, the temporoparieto-occipitoparietal flap,
can be effectively used to treat frontal and parietal alopecia in both male and female patients.
References
1. Juri J. Use of parieto-occipital flaps in the surgical treatment of baldness. Plast Reconstr Surg
1975;55:456.
2. Juri J, Juri C, de Antueno J, Gonzalez Otharan A. Surgical treatment of baldness. In: Sisson G, Tardy M,
eds., Plastic and reconstructive surgery of the head and neck. (Proceedings of the Second International
Symposium). New York: Grune & Stratton, 1977;221.

3. Juri J, Juri C, Arufe H. Use of rotation scalp flaps for the treatment of occipital baldness. Plast Reconstr
Surg 1978;61:23.
4. Juri J. Use of pedicled flaps in the surgical treatment of alopecias. In: Unger WP, ed., Hair transplantation.
New York: Marcel Dekker, 1979;143.
5. Juri C, Juri J, Colnago A. Monopedicled transposition flap for the treatment of scalp alopecias. Ann Plast
Surg 1980;4:349.
6. Juri J, Juri C, Colnago A. Reconstruction of scalp hemicircumference. Ann Plast Surg 1980;4:304.
7. Juri J, Juri C. Aesthetic aspects of reconstructive scalp surgery. Clin Plast Surg 1981;8:243.
8. Juri J, Juri C. Two new methods for treating baldness: temporoparieto-occipitoparietal pedicled flap and
temporoparieto-occipital free flap. Ann Plast Surg 1981;6:38.
9. Juri J, Juri C. Use of flaps in the surgical treatment of baldness. In: Vallis CP, ed., Hair transplantation for
the treatment of male pattern baldness. Springfield, Ill.: Charles C. Thomas, 1982;545-556.

Chapter 5
Diagonal Frontoparieto-Occipital Scalp Flaps
J. JURI
EDITORIAL COMMENT
The oblique flap does not ensure the inclusion of a known arterial pedicle or a way to extend it beyond its
known blood supply. Consequently, the need for increasing care and delays is clear.
When alopecia affects the scalp hemicircumference, the only monopedicled flap that allows reconstruction of this
region is a diagonal flap on a frontal pedicle (1, 2, 3).
ANATOMY
The diagonal frontoparieto-occipital scalp flap, which we call a diagonal flap, receives its blood supply from the
frontal vessels. The area of convergence of the frontal branch of the superficial temporal artery and the
supraorbital branches, because of their numerous connections with the contralateral vessels, allows the design
of this flap across the midline (Fig. 5.1B and C). A second delay is performed at the end of the flap because of
the perforating vessels in the occipital region.
FIGURE 5.1 Schematic representation of the diagonal flap. A: Alopecia and frontal implant line. B,C: Flap
design. D: Raising of the flap. E: Closure of the donor site and final suture of the flap. F: Posterior view of the
flap in its final position. (From Juri et al., ref. 2, with permission.)
FLAP DESIGN AND DIMENSIONS
This flap has a width of 3.5 to 4 cm, and its base is located in the frontal area next to the beginning of the
alopecia (Fig. 5.1B). It extends over all the cranial vault, crossing the midline, and up to the hair-bearing
retroauricular region (Fig. 5.1C). A flap is obtained with a length of 30 to 32 cm.
OPERATIVE TECHNIQUE
We do two delays. The first involves the flap edges, and the other, a week later, includes the last 3 cm at the end
of the flap. A week after the second delay, the flap is raised from its bed and transposed to the recipient zone

that has been designed to reconstruct the alopecic hemicircumference (Fig. 5.1D), an area of great aesthetic
value. The donor site is closed by approximation of its edges (Fig. 5.1E), hiding the extensive alopecic surface in
its central portion (Fig. 5.1F). Partial successive resections of the residual alopecic area can be performed at
later stages.
FIGURE 5.2 A: Preoperative view of the alopecic surface and of preparation of the flap. B: Preoperative anterior
view. C: Preoperative view of the distal end of the flap. D: The hair-bearing implant line to be reconstructed is
observed. E: Postoperative view 1 week later. F: Postoperative view 3 years later. G: Preoperative posterior
view. H: Postoperative posterior view after 1 month. (From Juri et al., ref. 2, with permission.)
SUMMARY
The diagonal frontoparieto-occipital flap can be used to reconstruct the hairline from the frontal to the
occipital region along one side of the scalp (Fig. 5.2).

References
1. Juri C, Juri J, Colnago A. Monopedicled transposition flap for the treatment of scalp alopecias. Ann Plast
Surg 1980;4:349.
2. Juri J, Juri C, Colnago A. Reconstruction of scalp hemicircumference. Ann Plast Surg 1980;4:304.
3. Juri J, Juri C. Aesthetic aspects of reconstructive scalp surgery. Clin Plast Surg 1981;8:243.

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Chapter 6
Temporoparietal (Superficial Temporal Artery) Fascial Flap
H. S. BYRD
EDITORIAL COMMENT
Detailed studies of the temporoparietal area have resulted in some controversy over the number of layers.
For clinical purposes, the author's description and guidelines are accurate and clinically safe.
The superficial temporal artery fascial flap is derived by dissecting the scalp away from its underlying
subcutaneous fascia and the contained axial (superficial temporal) vessels, thereby creating a vascularized
fascia that can be transferred about a single vascular pedicle.
INDICATIONS
This flap is useful in reconstructing defects of the forehead, eyebrow, eyelid, and ear (1, 2, 3, 4) (see also
Chapter 96). It also has been used to provide a vascular cover for bone grafts where an adequate soft-
tissue bed does not exist.
ANATOMY
The temporoparietalis is a thin sheet arising from the temporal fascia above and anterior to the ear. It is divided
into three parts that spread out like a fan over the temporal fascia. There is a temporal part anteriorly, a parietal
part superiorly, and a triangular part between. The temporoparietalis inserts into the lateral border of the galea
aponeurotica. The auricularis anterior and superior are recognized as small but inconstant muscle bellies that
contribute to this layer.1
The key to the anatomy of the temporoparietal fascial flap is an understanding of the relationship of the
superficial temporal vessels to the layers of the scalp (Fig. 6.1). The specific fascia carried by the superficial
temporal vessels is the temporoparietalis fascia with its upper galeal aponeurotic extension. The
temporoparietalis fascia must be distinguished from the denser and anatomically deeper temporalis fascia, which
invests the temporalis muscle. Confusion arises at the level of zygoma, where both the temporalis and
temporoparietalis fasciae attach.
At the level of the ear, the vessels are found deep to the subdermal fat and on the surface of the
temporoparietalis fascia. At a level approximately 10 cm above the crus helix, the vessels take a more superficial
course, penetrating the subdermal fat and eventually entering the subdermal plexus. While there is some
variance in the level at which the axial vessels become contiguous with the subdermal plexus, generally this
occurs 12 cm above the crus helix. At this level, a subdermal dissection violates the blood supply and thereby
describes the limit of the fascial vascular domain.

FIGURE 6.1 A: Relationship of temporoparietal fascial flap to the layers of the scalp. Cross section of temporal
scalp in the area between 10 and 12 cm above the crus helix. At the 10-cm point, the vessels are still on the
surface of the temporoparietal fascia, but by the 12-cm point, the vessels have entered the more superficial
subdermal plexus. B: Frontal and parietal branches of the superficial temporal artery and vein lying on the
temporoparietal fascia. C: Layers of tissue in the temporal region. D: Arc of anterior rotation of the
temporoparietal fascial flap. E: Posterior extension of the flap.
FLAP DESIGN AND DIMENSIONS
The courses of the frontal branch, parietal branch, and posterior ramifications of the superficial temporal artery
are identified with the Doppler probe. The axis of rotation is taken at a point in the preauricular fold anterior to
the crus helix and overlying the tubercle of the zygomatic process of the temporal bone. A flap of sufficient length
to reach the defect is obtained by measuring from the axis along the underlying vessels. If a flap length of more
than 10 cm is required, the flap is extended by following the posterior branches of the temporal artery that
communicate with the occipital vessels (Figs. 6.1, 6.2, 6.3, 6.4).
OPERATIVE TECHNIQUE
An incision is made over the course of the superficial temporal vessels, just to the level of the dermis. The

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dissection is then carefully deepened through the subdermal fat in a plane that leaves the temporal vessels
exposed on the surface of the temporoparietalis fascia. The subdermal fat remains on the skin. Numerous small
perforating branches from the main axial vessels to the subdermal plexus must be divided and cauterized. Care
should be taken not to interrupt the course of the primary vessels, either by a plane of dissection that is carried
too deep or by imprecise cauterization.
FIGURE 6.2 A: Nine-year-old boy with right microtia and a very low-lying hairline. B: Reconstruction with a rib
cartilage graft. A temporoparietal fascial flap has been elevated. C: The flap is used to surface the upper half of
the framework. D: A skin graft from the medial surface of the arm supplied cover to the fascial flap. E: The result
1 year postoperatively.
FIGURE 6.3 A: A large basal cell epithelioma was chemosurgically excised, resulting in exposed frontal bone
and loss of the left eyebrow. B: An extended temporoparietal flap carrying an island of hair-bearing skin from the
parieto-occipital area to serve as eyebrow and a segment of temporal scalp skin to replace sideburn was rotated

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into the defect. C: The result 4 months postoperatively. Note that the extended flap allows one to carry an island
of skin from the posterior parieto-occipital scalp, affording hair growth in an upward and outward direction when
transferred to the brow.
FIGURE 6.4 A: Chemosurgical excision of a recurrent basal cell epithelioma resulted in total full-thickness loss
of the lower eyelid and the medial 25% of the upper eyelid. B: Design of the incisions used to elevate the flap.
C: Reconstruction consisted of replacement of lining and support with a septal cartilage-mucosa graft. D: The
graft was vascularized by an extended temporoparietal fascial flap. E: A supraclavicular full-thickness skin graft
has been applied. F: The result 1½ years postoperatively demonstrates good central support with a well-defined
lid. A small lateral symblepharon exists where the lining graft was folded onto itself in the area of the lateral
fornix.
A superior extension of the flap, requiring a transition in the plane of dissection through the subdermal fat to the
base of the hair follicles, is now avoided. When greater flap lengths are required, dissection is carried posteriorly
(Fig. 6.1E), following the anastomotic arc between the occipital and superficial temporal vessels in a plane deep
to the subdermal fat.
The posterior dissection is begun at approximately 5 cm above the ear and is continued to approximately 10 cm
above the ear, creating a base 5 cm wide. The extended portion of the flap generally widens from this point in
order to maximize the contribution of the vascular arcade. Scalp elevation sufficient to provide the necessary
width and length is accomplished, and the subcutaneous fascia (galea and temporoparietalis fascia) is divided
distally and along its lateral margins. Elevation of the fascia in a plane superficial to the pericranium and anterior
to the fascia of the temporalis muscle is achieved. Division of the temporoparietalis fascia near the posterior
base of the pedicle should hug the cartilaginous margin of the crus helix in order to avoid injury to the primary
vessels. The branch to the ear will be divided with this back cut, and careful hemostasis to avoid injury to the
main vessels is mandatory.
A subcutaneous plane of dissection from the axis of the flap to the defect is accomplished. The fascial flap is

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then tunneled into position, and the desired covering grafts are applied. The flap also may be lined with
appropriate grafts, if needed. The donor scalp wound is closed, and suction catheters are employed.
CLINICAL RESULTS
Twenty-three superficial temporal artery fascial flaps have been used. Five of these flaps were of the
extended variety. One flap was used as a free microvascular transfer. No total flap loss has occurred,
although three partial losses were seen when attempts were made to extend the flap in a superior direction
beyond the 12-cm limit. Flaps extended posteriorly have remained viable with lengths of 16 to 18 cm. While
greater flap lengths may be possible, the predictable clinical limits of this extended flap have not been
determined.
Donor wounds have generally been acceptable. Neither scalp loss nor alopecia has occurred when the
subdermal fat was preserved with the skin.
SUMMARY
The temporoparietal fascial flap can be used to provide thin, vascularized tissue to the forehead, eyebrow,
eyelid, and ear. This flap can support underlying cartilage grafts and an overlying skin graft.
References
1. Ohmori S. Reconstruction of microtia using the Silastic frame. Clin Plast Surg 1978;5:379.
2. Tanzer RC. Total reconstruction of the auricle: a 10-year report. Plast Reconstr Surg 1967;40:547.
3. Tettmeier RE, Gooding RA. The use of a fascial flap in ear reconstruction. Plast Reconstr Surg
1977;60:406.
4. Byrd HS. The use of subcutaneous axial fascial flaps in reconstruction of the head. Ann Plast Surg
1980;4:191.

Chapter 7
Microvascular Free Transfer of Temporo-Occipital Scalp Flaps
K. OHMORI
EDITORIAL COMMENT
The application of methods of scalp reduction, as well as the use of expanders, has facilitated the treatment
of large areas of alopecia. There is still a place for microvascular transfer of hair-bearing tissue, however,
even though the risk and magnitude of the procedure are increased.
I have developed four types of microsurgical scalp flaps, viz., free temporo-occipital, free occipitotemporal, free
temporo-occipitoparietal, and free occipito-occipital flaps (1, 2) (Fig. 7.1).
INDICATIONS
The temporo-occipital scalp flap has been employed in the treatment of cicatricial alopecia (Juri type I) and
male pattern baldness (Juri type II) with excellent results, especially in producing an anterior hairline with
natural hair direction (3). Advantages of microsurgical free temporo-occipital scalp flaps include the one-
stage creation of a frontotemporal hairline with natural hair direction, the achievement of a minimal and
inconspicuous donor scar, and only a short period of hospitalization.
ANATOMY
The superficial temporal artery arises from a branch of the external carotid artery and turns beneath the parotid
gland. This artery then runs superficially, approximately 1 cm below the level of the ear tragus. Subsequently, it
routinely gives off four branches: the zygomatic branch, a branch to the auricle, an anterior branch, and a
posterior branch. There are many variations in the positions of these branches. The zygomatic artery becomes a
branch of the anterior branch when the latter leaves the superficial temporal artery at a more proximal point.
However, even the size of the auricular branch, which is usually located just over the small mimic muscle of the
auricle, varies.
The main trunk of the superficial temporal artery usually makes a wide curve between the level of the ear tragus
and 2 cm above it. After giving off its anterior branch, it then runs toward the top of the head, where it provides a
posterior branch. Along the latter it gives off a branch posteriorly, that is usually not evident in the angiography of
the external carotid artery, but is easier to see when it is dissected out clinically. This branch is located about the
distance of two to three fingerbreadths from the hairline, just over the auricle. This small branch and the posterior
branch of the superficial temporal artery may have multiple anastomoses between them and the posterior
auricular artery and the occipital artery itself. The arterial supply of the free temporo-occipital flap is based on
these two branches (Fig. 7.2).
Routinely, the vein runs posterior and superior to the superficial temporal artery, but it can often be seen
wrapped around the artery, especially at the level of the tragus. Then it usually receives two tributaries that are
accompanied by the anterior and posterior branches of the superficial temporal artery. A tributary from the auricle
joins either the posterior part of the superficial temporal vein or its common trunk. There are venae comitantes
accompanying the superficial temporal artery, but they are usually quite small in caliber. The main drainage of

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the free temporo-occipital flap appears to be the posterior tributary of the superficial temporal vein.
FLAP DESIGN AND DIMENSIONS
Since the scalp tissue is well vascularized by a tight network of vessels, one can design the flap in almost all
directions and for more than 20 cm in length, as long as the flap is more than 4 cm
in width and has a good vascular pedicle. Despite this advantage, closure of the donor defect becomes difficult
to achieve without leaving a visible area of alopecia. To overcome this problem, the inferior border of the free
temporo-occipital flap is designed almost parallel to the parieto-occipital hairline, and the distance between the
latter and the inferior border of the flap should remain less than 6 cm. Extensive undermining of the neck can
then be done to slide the inferior margin of the scalp defect upward. The superior border of the flap is also
designed parallel to the inferior border, and the width of the flap kept less than 5 cm.
FIGURE 7.1 Four types of microsurgical scalp flaps.
After the distal two-thirds of the flap are marked, its central axis is bent approximately 90° where the pulsating
path of the posterior branch of the superficial temporal artery can be felt. This point should be located about 2
cm above the origin of the small posterior branch that originates from the posterior branch of the superficial
temporal artery.
The design is then completed about 1 to 2 cm above the hairline, bringing both parallel lines together at this
point. With such a plan, this free flap can be employed easily in the treatment of baldness (Fig. 7.3).
FIGURE 7.2 The branches of the external carotid artery to the scalp. A small branch of the superficial temporal
artery (STA) can be easily identified along with the posterior branch and preserved with the flap.

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OPERATIVE TECHNIQUE
Donor Site
Because of the numerous variations seen in the pedicle of the flap, dissection of the pedicle vessels should be
carried out before raising the flap completely. All the arterial and venous branches should be dissected out first,
while keeping intact the posterior branch of the superficial temporal artery and the small branch arising from it,
together with the posterior tributary of the superficial temporal vein.
To perform this operative procedure more easily, it is better to include all the superficial temporal fascia with
these vessels, that are raised together en bloc from the deep temporal fascia to provide a pedicle for the free
flap. All the vessels that do not supply the flap are coagulated or ligated. Then the remaining portion of the flap is
raised from the pericranium by incising both sides, so that the galea is left attached to the flap (Fig. 7.4).
FIGURE 7.3 Design of the free temporo-occipital flap.
FIGURE 7.4 The temporo-occipital scalp flap raised on its pedicle.

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FIGURE 7.5 The donor and recipient sites can be designed so that a natural anterior hairline can be formed.
FIGURE 7.6 A: A patient with cicatricial alopecia. B: Postoperative appearance. C: Minimal donor deformity.

FIGURE 7.7 A: Male pattern baldness. B: Postoperative appearance.
Recipient Site
To give a natural direction to the anterior hairline, the superficial temporal vessels on the opposite side are
exposed (Fig. 7.5). In cases of temporofrontal alopecia, the recipient vessels can be prepared as proximally as
possible, to produce the sideburn and the temporofrontal hairline in one piece. However, when the flap is used in
cases of baldness, the hair-bearing portion of the flap should be started at the frontotemporal junction. The
recipient vessels are therefore prepared inside the scalp, about 2 cm above the hairline of the auricle. In some
cases, however, the caliber of the superficial temporal vein may be too small, necessitating a more proximal
dissection and the use of a vein graft. In all my patients, one artery and one vein were anastomosed.
CLINICAL RESULTS
Sixty-eight free scalp flaps have been performed in the Tokyo Metropolitan Police Hospital, and 39 free
temporo-occipital flap transfers have been done in the Juri Clinic of Plastic Surgery, Buenos Aires,
Argentina. In this combined series of 107 free scalp flap transfers, only two flaps underwent necrosis.
SUMMARY
The microsurgical transfer of a temporo-occipital scalp flap has been described as a treatment for baldness.
Both cicatricial alopecia (Juri type I) and male pattern baldness (Juri type II) can be treated with this flap.
However, such a procedure should be restricted to selected patients (Figs. 7.6 and 7.7).
References
1. Ohmori K. Free scalp flap. Plast Reconstr Surg 1980;65:42.
2. Ohmori K. Free scalp flap surgery. Ann Plast Surg 1980;5:17.
3. Juri J, Juri C. Aesthetic aspects of reconstructive scalp surgery. Clin Plast Surg 1981;8:243.

Chapter 8
Galea Frontalis Myofascial Flap for Cribriform and Paracribriform
Areas
H. COSTA
A. CEREJO
EDITORIAL COMMENT
This chapter and the one following (Chapter 9) demonstrate a reliable and accessible method of covering
defects in the cribriform area, which may prevent cerebrospinal fluid leaks.
The galea frontalis flap (1, 2, 3, 4, 5) is highly vascularized and versatile. The flap may be used on either a wide
or narrow pedicle for a variety of craniofacial problems.
INDICATIONS
Reconstructions using this flap are primarily applicable for defects of the cribriform and paracribriform areas,
orbital roof, and frontal sinus. The flap also can be used for defects after various craniofacial-defect
corrections, maxillofacial injuries (such as Le Fort II and III fractures), cerebrospinal fluid (CSF) leaks, and
tumor ablation of the anterior cranial fossa (3, 4, 5).
ANATOMY
The occipitofrontalis is a broad, musculofibrous layer that covers the dome of the skull from the nuchal lines to
the eyebrows. The two frontal bellies are thin, quadrilateral, and adherent to the superficial fascia, with no bony
attachments; the medial fibers are continuous with those of the procerus. The fibers are directed upward to join
the galea aponeurotica in front of the coronal suture. Between the bellies, there is a variable interval occupied by
an extension of the galea aponeurotica.
The galea flap is anteriorly based on the supratrochlear and supraorbital vessels, allowing transfer from an
extracranial to an intracranial position, thus creating a vascularized myofascial barrier between cranial, orbital,
and nasal cavities. In some cases, repair of an anterior cranial-base bone defect has been performed with split
calvarial bone grafts harvested from the frontal craniotomy bone (Fig. 8.1) and covered with the flap.
FLAP DESIGN AND DIMENSIONS
The flap is raised from the deep aspect of the bicoronal flap, which is frequently used in craniofacial surgery (see
Fig. 8.1). It may be based on either or both supraorbital and supratrochlear vessels and has a trapezoidal or
rectangular shape. The larger trapezoidal flaps can cover all the anterior to cranial fossa. The pedicle width can
range between 2 and 10 cm, and a flap length of 6 to 7 cm easily reaches the greater wings of the sphenoid
bones, providing a vascularized myofascial barrier between cranial, orbital, and nasal cavities.
OPERATIVE TECHNIQUE
The operative approach has several stages: (a) a bicoronal flap and a bifrontal craniotomy are used for the
surgical approach to the anterior fossa; (b) the bony defect is explored through an extradural approach; (c) the

dural tear is defined through an intradural approach and prepared; (d) the galeal flap is used to reinforce the
dural repair; and (e) if required, the bony defect is corrected using an inner- or outer-table calvarial bone graft.
The galeal flap is raised from the deep aspect of the bicoronal flap (see Fig. 8.1C). Two longitudinal myogaleal
incisions are taken about 6 to 8 cm apart until the subcutaneous tissue is visualized. By sharp knife dissection,
the myofascial flap is carefully raised, including the supraorbital and supratrochlear vessels. After careful
hemostasis, the muscle flap is ready for transfer to the anterior cranial base, normally through a slit-type bone
window created in the frontal bone flap (Fig. 8.1D).
If the anterior fossa cranial bone defect is small, a galeal frontalis myofascial flap is raised from the deep aspect
of the bicoronal flap and transferred (see above text). If the anterior cranial-base bone defect is larger (more than
5 mm wide), however, a split-thickness bone graft is harvested from the frontal craniotomy bone flap. After
careful modeling of the bone graft, fixation is usually possible by finger pressure. Then the frontalis myofascial
flap is carried out as described (see Fig. 8.1A-D). Although an outer-table cranial bone graft has been used,
contour defect of the frontal bone has not been a problem. The transverse dural incision is closed with
continuous nonabsorbable suture: transcutaneous intradural and extradural drains are inserted; the frontal-bone
flap is repositioned and fixed; and all wounds are closed.
FIGURE 8.1 A-D: Diagram of anatomic relationships of the myofascial frontalis galeal flap, with and without
calvarial split-bone grafts, for treatment of anterior fossa cerebrospinal fluid leaks.
CLINICAL RESULTS
The procedure was used with complete success in 12 patients with anterior fossa CSF leaks after trauma.
In all patients, an intracranial-intradural approach was used, with transfer of a myofascial frontalis galeal
vascularized flap. Repair of skull-base defects with calvarial bone grafts also was performed in seven of
these patients. Follow-up has been between 6 months and 6.5 years. In all patients, neither recurrence of
CSF leakage nor postoperative meningitis or its recurrence were observed.

SUMMARY
The galea frontalis myofascial flap is easy and quick to elevate, provides adequate size for nasal-cranial
separation in most cases, and leaves an inconspicuous donor defect. It also can be used successfully after
resection of skull-base tumors and frontofacial advancements.
References
1. Schramm VL, Myers EN, Maroon JC. Anterior skull base surgery for benign and malignant disease.
Laryngoscope 1979;89:1077.
2. Ousterhout DK, Tessier P. Closure of large cribriform defects with a forehead flap. J Maxillofac Surg
1981;9:7.
3. Jackson IT, Adham MN, Marsh WR. Use of the galeal frontalis myofascial flap in craniofacial surgery.
Plast Reconstr Surg 1986;77:905.
4. Costa H, Cerejo A, Baptista A, et al. The galea frontalis myofascial flap in anterior fossa CSF leaks. Br J
Plast Surg 1993;46:503.
5. Rinehart CG, Jackson IT, Potparic Z, et al. Management of locally aggressive sinus disease using
craniofacial exposure and the galeal frontalis fascia-muscle flap. Plast Reconstr Surg 1993;92:1219.

Chapter 9
Galeal Frontalis Myofascial Flap
I. T. JACKSON
Z. POTPARIC
The galeal frontalis myofascial flap is a distally based flap that contains the deep subcutaneous tissues of the
forehead. It is usually elevated from the coronal flap by subcutaneous dissection, thereby creating a vascularized
myofasciodisposal flap that is either placed intracranially, or used for coverage of the orbits or the nose or both.
Recently, as a result of careful injection studies, the pericranium also has been included, as to do so increases
the vascularity of the flap.
INDICATIONS
The goals in intracranial reconstruction with the galeal frontalis flap are to provide separation between the
nasopharynx and brain, to obliterate dead space, to prevent cerebrospinal fluid (CSF) leakage (particularly
if the dura is lacerated), and to provide vascularized coverage for bone grafts. The flap is used for
reconstruction of defects after resection of anterior skull-base malignancies, trauma involving the anterior
cranial fossa, and when a Le Fort III advancement is combined with frontal advancement. In the case of an
old CSF leak, the flap is used in precisely the same way. Together with a skin graft, it also can be used as a
vascularized soft-tissue bed for coverage of the orbits and the nose. Finally, it is an excellent material for
packing the frontal sinus following trauma. In this situation, bone can be packed on top of it to fill this area
completely (1). The flap should not be taken from a previously irradiated area or from an area to be
irradiated.
ANATOMY
The key to the anatomy of the galeal frontalis myofascial flap is an understanding of the layers of the forehead
skin and the scalp. These are histologically composed of the following five layers: (a) skin, (b) subcutaneous
tissue, (c) frontalis muscle and its aponeurotic extension, (d) subgaleal fascia, and (e) cranial periosteum.
The subcutaneous fat tissue as well as the subgaleal loose connective tissue are called the subgaleal fascia;
these layers vary considerably in thickness in different areas of the forehead as well as in different persons. The
subgaleal fascia consists of several well-vascularized parallel connective tissue sheets that glide over one
another. Histologically, three superimposed layers may be distinguished: a well-vascularized superficial layer
underlying the galea frontalis muscle, a middle relatively avascular layer, and a deep loose areolar layer
overlying the cranial periosteum. The layers that were originally included in the galeal frontalis myofascial flap
are (a) partial-thickness subcutaneous fat, (b) galeal frontalis muscle, and (c) superficial layers of subgaleal
fascia (2). As mentioned, the pericranium has now been added (3).
The blood supply to the galeal frontalis flap is entirely from the supratrochlear and supraorbital vessels (Fig. 9.1).
Both divide into larger superficial and smaller deep branches, either within or shortly after exiting from the orbit
around the supraorbital rim. Deep branches have a short axial course in the cranial direction, traveling just on top
of the periosteum and within the layers of the subgaleal fascia. As the larger superficial branches exit from the
orbit, they first pierce the orbicularis oculi and corrugator muscles. For a short distance, they travel within the
substance of these muscles and the frontalis muscle. They then pierce the frontalis muscle and become
superficial to it and to the galea, coursing within the subcutaneous fat.

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As they course toward the crown of the scalp, they become more superficial, travelling just below the dermis and
hair follicles. Only a few anastomoses between the paired vessels cross the midline. At the level of
subcutaneous tissue, dissection of the flap violates the axial blood supply and determines distal flap viability.
Continuous axial vessels within the flap may range from 3 to 7 cm (4). The supraorbital artery provides the major
blood supply, as the supratrochlear artery is transected more proximal to the flap because of its more superficial
course. Volumes of galeal frontalis flaps, with sizes in the 9- × 14-cm range, vary from 15 to 30 cc (3).
Supratrochlear and supraorbital nerves provide sensory supply to the forehead and anterior scalp. Their course
is similar, but not identical, to the course of the blood vessels. Harvest of the galeal frontalis flap unavoidably
results in the transection of these nerves. The loss of sensation occurs approximately at the same level as the
loss of the axial blood supply to the flap.
FLAP DESIGN AND DIMENSIONS
The flap is designed with its base at the level of the supraorbital rim, including the mid-forehead area, 1.0 to 1.5
cm lateral to the supraorbital notch on both sides. Extending the lateral border of the flap toward the
frontotemporal ridge allows inclusion of well-vascularized lateral forehead tissue and provides additional axial
length to the supraorbital vessels. The width of the flap base is 8 to 10 cm. A unilaterally based flap
should be avoided because it causes asymmetry of the frontalis muscle and a noticeable deformity of the
forehead (5).
FIGURE 9.1 Vascular anatomy of the galeal frontalis myofascial flap. A: Intact scalp shows numerous
anastomoses between the temporal and supraorbital and supratrochlear vessels; blood supply is far superior in
the scalp. B: Galea dissected from the full-thickness scalp with wire placed to show where most of the blood
supply is in the galeal frontalis area. (This has been shown to be extended if the pericranium is included in the
flap.)
The extent of distal random extension of the flap depends on the available axial blood supply. About 50% of the
axial length may be added as a random portion to provide for a well-vascularized flap. A distal flap portion larger
than that should be considered a nonvascularized graft and should not be used for coverage of bone grafts or
exposed areas.

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To compensate for vascular and volume shortcomings of the galeal frontalis myofascial flap, consideration
should be given to using the composite galeal frontalis pericranial flap. By including the pericranium and intact
subgaleal fascia within the flap, a significant increase in blood supply and volume is achieved. The volume of this
flap is about 50% greater than that of the galeal frontalis flap.
OPERATIVE TECHNIQUE
Most frequently, the coronal flap dissected in the subgaleal plane is used to approach the anterior cranial fossa.
Occasionally, a midline incision is made in the frontal area; this is related to excision of tumor or skin resection in
hypertelorism. The flap is dissected carefully from the skin by subcutaneous dissection just below the hair
follicles in the hair-bearing scalp and just below the dermis in the forehead. The dissection includes most of the
subcutaneous fat in the flap but also leaves some fat tissue on the skin side. Dissection through the
subcutaneous tissue, instead of the top of the galeal and frontalis muscle, provides additional vessel length and
supplies more volume. Care is taken not to injure the hair follicles superiorly or to go too deeply and miss the
frontalis muscle. The flap is taken based on where the supratrochlear and supraorbital vessels enter its base.
Transillumination of the flap or use of the handheld Doppler may help to estimate continuous axial blood supply
(2) (Figs. 9.2 and 9.3). Harvesting of the composite galeal frontalis pericranial flap requires elevation of the
coronal flap in the subpericranial plane, followed by elevation of the composite flap in the subcutaneous plane.
CLINICAL RESULTS
We have used more than 500 flaps in the past 12 years. They were used for cranial-base reconstruction,
frontal sinus obliteration, soft-tissue augmentation, or soft-tissue cover with an overlying skin graft. There
was no problem with intracranial infection in any of the cases in which the flap was used intracranially.
Breakdown of forehead skin, with underlying necrosis of the frontal bone, occurred in two patients. In one,
the flap necrosed completely and, although there was no resulting infection, a free rectus abdominis flap
was used to fill the intracranial dead space that occurred (6). Both patients received preoperative and
postoperative irradiation.
Frontal contour irregularities, sensory deficit, and frontalis muscle dysfunction occurred in 75% of the
patients. Those who had a wide flap based bilaterally in the forehead presented with weakness of eyebrow
movement. Flaps based unilaterally caused eyebrow weakness on the affected side and
asymmetric deformity of the forehead that was more conspicuous than the bilateral deformity. A narrow flap
based in the midline is more likely to preserve frontalis muscle function.

FIGURE 9.2. A: Removal of ethmoid sinuses and their contents together with sphenoid sinus and clivus.
The frontal and maxillary sinuses also had their contents resected. B: Galeal frontalis flap elevated. Note
that this flap is very thick and includes a generous portion of tissue removed with the galea; this is taken
down to the hair roots and is especially thick at the supraorbital region.
FIGURE 9.3 A: CT scan shows mucocele of left frontal sinus, with erosion of sinus floor and displacement
of left globe. B: Removal of anterior wall of frontal sinus with removal of the mucocele. Note the contents of
the orbit seen through the orbital roof on the left. (continued)

FIGURE 9.3 Continued. C: Narrow, one-sided galeal frontalis flap elevated on supraorbital vessels. D: The
flap has been used to pack into the frontal sinus. E: Supraorbital rim replaced and held in place with
microplates.
All patients developed hypesthesia or anesthesia of the forehead. None of the patients had any problems
related to sensory deficit. Half of the patients did not notice this to be a problem until they were asked
specifically about it and examined for sensory deficit (5).
SUMMARY
The galeal frontalis myofascial flap provides vascularized tissue for reconstruction of the anterior cranial
fossa. It is the flap of choice wherever there is intracranial/nasopharyngeal connection and concern about
infection ascending from the nasopharynx into the extradural area and from there into the meninges or
brain.
References
1. Rinhart GC, Jackson IT, Potparic Z, et al. Management of aggressive sinus disease using craniofacial
exposure and the galeal frontalis fascia-muscle flap. Plast Reconstr Surg 1993;92:1219.
2. Jackson IT, Adham MN, Marsh WR. Use of the galeal frontalis myofascial flap in craniofascial surgery.
Plast Reconstr Surg 1986;77:905.
3. Potparic Z, Fukuta K, Colen LB, et al. Galeo-pericranial flaps in the forehead: a study of blood supply and
volumes. Br J Plast Surg 1996;49:519.
4. Fukuta K, Potparic Z, Sugihara T, et al. A cadaver investigation of blood supply to the galeal frontalis flap.
Plast Reconstr Surg 1994;94:794.
5. Fukuta K, Avery C, Jackson IT. Long-term complications of the galeal frontalis myofascial flap in
craniofacial surgery. Eur J Plast Surg 1993;16:174.

6. Jackson IT, Webster HR. Craniofacial tumors. Clin Plast Surg 1994;21:633.

Chapter 10
Microvascular Free Transfer of Omentum
Y. IKUTA
If the scalp has been avulsed, the obvious first choice is replantation, when feasible (1). If the injury is old or
results from other defects such as tumor excision or burns, other methods must be sought (2).
If the periosteum is still intact, split-thickness skin grafts can readily survive but do not provide stable coverage
(3). Ulcerations are frequent, especially when the area is covered with a wig. The situation is even worse if a
split-thickness skin graft is applied to a skull that has been decorticated of its outer table. Full-thickness skin
grafts are more stable but do not take well, and the available donor sites are often not adequate (4).
The availability of local and distant flaps is limited. Instead, free vascularized skin, muscle, or omental flaps can
be used with good results (5, 6, 7, 8).
INDICATIONS
There are several advantages to the vascularized omental flap. It can be used, in association with a skin
graft, to treat large defects. It can be easily shaped to any desired size, and it can be used to improve the
circulation of a suitable recipient site. It is generally used when there is an extensive tissue defect, the
surface of the defect is irregular in shape or narrow and deep, the circulation is poor, or infection is present.
However, since the omental tissue must be obtained by abdominal laparotomy, consideration must be given
to the fact that its original function will decrease, with the risk of causing panperitonitis (9). The possibility of
employing other procedures, such as a skin flap, a musculocutaneous flap, or a muscle flap with skin graft,
must be seriously considered.
ANATOMY
The greater omentum is attached to the greater curvature of the stomach and transverse colon and covers most
of the colon, ileum, and jejunum. It consists of a double layer of fused peritoneum, with the blood supply
interposed between the two layers. There are five major variations in the routes of omental vessels (10). Usually,
the right and left gastroepiploic arteries form an arterial arch along the greater curvature of the stomach, with the
omentum nourished by three large branches that arise from the arch. As shown in Fig. 10.1, the right, middle,
and left omental vessels that arise from the gastroepiploic arch form vascular arcades near the lower end of the
omental apron. The accessory omental vessel is located on the right end of the omentum.
OPERATIVE TECHNIQUE
Donor Site
The greater curvature of the stomach is exposed by an upper midline abdominal incision, and the right and left
gastroepiploic arteries and omental arcades are confirmed. The numerous vessels that enter the greater
curvature from the gastroepiploic arch are ligated into several groups. The omentum is then detached from the
greater curvature and transverse colon. After selecting which of the two gastroepiploic arteries to anastomose to
the artery of the recipient site, the other artery is ligated and cut. Finally, the artery selected for use is severed. In
most cases, the right gastroepiploic artery is used, because the left gastroepiploic artery is slightly smaller. If the
length of the normal omentum is not sufficient, a lengthening procedure may be used (11).

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It is advisable to introduce heparinized saline solution into the artery to be anastomosed and to confirm outflow
from veins on the same side. This also makes it possible to ascertain whether the ligatures are secure, that there
is no impairment of circulation within the omentum itself, and that lengthening has been properly achieved.
Recipient Site
The choice of arteries to be used at the recipient site depends on the extent and degree of avulsion. In the
forehead, the supraorbital or supratrochlear vessels can be chosen. In the temporal region, the superficial
temporal or posterior auricular vessels can be selected. In the occipital region, the occipital vessels can be used.
A split-thickness skin graft is then placed over the omentum and secured by the compression provided by the
tieover method (Fig. 10.2).
SUMMARY
Vascularized omental transplantation should be considered in cases of extensive loss of skin, subcutaneous
tissue, and periosteum of the skull and when replantation by microvascular anastomosis of vessels or other
composite grafts may be inadequate. Indications must be sufficient to justify an abdominal laparotomy and
removal of the omentum.
FIGURE 10.1 The routes of omental vessels. The right and left gastroepiploic arteries form an arterial arch
along the greater curvature of the stomach. There are three large omental vessel units. The right, middle,
and left omental vessels form vascular arcades near the lower end of the omental apron. The accessory
omental vessel is located on the right end of the omentum.

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FIGURE 10.2 A, B: A 5-year-old girl was attacked by a dog and had her scalp bitten off. Outer cortex of
skull was removed to induce ingrowth of granulation tissue, and it was initially covered with an unstable
meshed split-thickness skin graft. C, D: Three months postoperatively, the omentum provides a satisfactory
cushion and the condition of the overlying skin graft is good. (From Ikuta, ref. 7, with permission.)
References
1. Miller GDH, Anstee J, Snell JA. Successful replantation of an avulsed scalp by microvascular
anastomoses. Plast Reconstr Surg 1976;58:133.
2. Koss N, Robinson MC, Krizek TJ. Scalping injury. Plast Reconstr Surg 1975;55:439.
3. Lu MM. Successful replacement of avulsed scalp. Plast Reconstr Surg 1969;43:231.
4. Nummi P, Arppe A. Replacement of the avulsed scalp. Scand J Plast Reconstr Surg 1971;5:67.
5. Harii K, Ohmori K, Ohmori S. Transplantation with free scalp flaps. Plast Reconstr Surg 1974;53:410.
6. McLean DH, Buncke HJ. Autotransplant of omentum to a large scalp defect, with microsurgical
revascularization. Plast Reconstr Surg 1972;49:268.
7. Ikuta Y. Autotransplant of omentum to cover large denudation of the scalp. Plast Reconstr Surg
1975;55:490.
8. Banzet P, LeQuang C. Free transplant of the greater omentum into the vault of the skull: three cases with

vascular microanastomosis. Chirurgie 1976;102:457.
9. Hakelius L. Fatal complication after use of the greater omentum for reconstruction of the chest wall. Plast
Reconstr Surg 1978;62:796.
10. Ninghsia Medical College, Department of Anatomy. Types of greater omentum arterial distribution and
their clinical significance. Chin Med J 1978;4:127.
11. Alday ES, Goldsmith HS. Surgical technique for omental lengthening based on arterial anatomy. Surg
Gynecol Obstet 1972;135:103.

Chapter 11
Tissue Expansion in Forehead and Scalp Reconstruction
L. C. ARGENTA
EDITORIAL COMMENT
In the discussion following Radovan's pioneering article (1982) (1) on tissue expansion, Grabb stated, “I
predict that over the next 5 years, the technique of tissue expansion will be of equal importance to the
impact of microsurgery techniques in muscle flaps. Heaven only knows the principle of skin expansion has
been staring us in the face.”
The skin of the forehead and scalp differs considerably in color, texture, thickness, and hair-bearing qualities
from tissue elsewhere on the body. Reconstruction of defects of this area is best accomplished with the use of
similar tissue. Expansion of facial and scalp tissues is a relatively painless, well-tolerated procedure that can be
accomplished over a period of several months (2).
Tissue expanders are available in multiple sizes and shapes from various manufacturers; custom prostheses can
be produced if necessary. All prostheses presently available require periodic percutaneous injection of saline.
INDICATIONS
Because visits are required at 2- to 3-week intervals, skin expansion should be carried out only on reliable
individuals who will conform to the required schedule and will modulate their activities appropriately during
the expansion process. Expansion of facial and scalp tissues, in most cases, can be done only in well-
healed injuries. Although the procedure has been used in subacute trauma, there is insufficient experience
at this time to recommend this.
There is no tissue on the body that can cosmetically reproduce the qualities of the scalp. Expansion is
particularly useful in individuals who have lost full-thickness hair-bearing tissue of the scalp secondary to
burns or trauma.
PLANNING AND DESIGN
Careful planning is necessary so that the tissue to be expanded is compatible in physical nature to the area
where tissue is needed. All incisions should take into account previous scars or should be at the margin of the
tissue to be advanced. In the scalp, the prosthesis is placed beneath the galea.
The largest prosthesis that will fit comfortably into the pocket is selected. It must be adequate enough to develop
the necessary expansion without being so large as to develop folds that may precipitate extrusion.
OPERATIVE TECHNIQUE
In prostheses with distant inflation reservoirs, the reservoirs should be placed away from the prostheses by at
least 2 inches. The prosthesis is placed beneath the galea, with the reservoir over the mastoid.
A minimal amount of saline is placed in the prosthesis at the time of surgery. Inflation is then begun 2 or 3 weeks
after

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the procedure. The patient returns to the office at weekly or biweekly intervals for inflation. Meticulously sterile
procedures are required. The inflation is then carried out to the point of pain until the overlying tissue becomes
tense. If excessive pain or tension develops, some fluid can be removed.
FIGURE 11.1 A,B: A 34-year-old woman who had undergone frontal craniotomy for a meningioma with loss of
the forehead skull secondary to infection. A previous attempt at cranioplasty had been abandoned because of
the extreme tightness of the skin. An expander was placed in the right temporal area and expanded to 300 cc.
The patient's forehead flap was then taken down, and a large methyl methacrylate cranioplasty was used to
close the defect. The expanded skin allowed an adequate amount of tissue for closure over the cranioplasty.
The scalp may be difficult to expand initially. Approximately 2 weeks after expansion commences, the resistance
of the galea seems to diminish and expansion proceeds more rapidly. The overlying skin becomes loose, and the
prosthesis can be felt moving within the underlying pocket. The overlying tissue characteristically becomes
ruberous and remains so until the prosthesis has been removed. Some pressure discomfort is usually described
after inflation, but this rapidly subsides after the overlying tissue softens.
If insufficient scalp is generated to cover the entire defect, the expanded tissue may be advanced as far forward
as possible, leaving the prosthesis beneath the flap. Within several weeks, reexpansion can be accomplished.
The hair follicles are more distantly separated from one another than in normal skin, but the result is usually
more than adequate for cosmetic improvement.
FIGURE 11.2 A: A newborn with a large defect of the skull with exposed brain. Large flaps were developed on
either side, one based anteriorly and the other posteriorly. Both closed over the brain. B: The patient at age 6.

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The flaps have been dissected from the brain, a reinforced silicone sheet was tented from the edges of the
cranium over the brain, and the scalp was expanded over a period of 8 weeks. C: Intraoperative photograph of
split-rib cranioplasty within the expanded scalp. Bone graft consolidation was achieved in 6 weeks.
CLINICAL RESULTS
Skin of the face, neck, and scalp has been successfully expanded in patients as young as 3 and as old as
57 years of age. In head and neck reconstruction, the development of a capsule adjacent to the prosthesis
more than compensates for the loss of tissue. Furthermore, the dense vascular network within the capsule
and adjacent to it makes the expanded tissue extremely robust for the development of flaps. Several
patients have successfully undergone bone grafting to reconstruct facial bones or cranium within the
capsule. All have gone on to rapid consolidation of the bone graft. Also, synthetic prostheses may be placed
beneath expanded tissue (Figs. 11.1 and 11.2).
Provided that there is sufficient underlying supportive structure, there will be minimal or no contracture of
expanded skin. Frequently, dog-ears that have resulted from the rotation of flaps necessitate resection
months later.
Infection occurs less commonly in the head and neck than elsewhere in the body, partly because of the
dense vascular network in this area. Perioperative antibiotics are employed, but long-term antibiotics are
not. The development of late infection complications has almost always been secondary to breaks in
inflation technique, with contamination of the injection reservoir, or the development of an intraoral
communication.
Erosion of the prostheses through the suture line may occur if inflation is begun prematurely or if the
prostheses are inflated at an excessively rapid rate. It is critical that the surgeon be judicious in the
expansion process. Once extrusion has occurred, the prosthesis should be removed within 48 hours;
however, the expanded tissue can still be rotated. The inflation reservoir is constructed of a harder and less
flexible silicone and is particularly prone to extrusion if improperly situated.
In almost all cases, the overlying skin is slightly ruberous and occasionally mottled during the expansion
process. This may persist for several days after removal of the prostheses, but it quickly subsides.
SUMMARY
Tissue expansion can be used effectively to reconstruct scalp and forehead defects.
References
1. Radovan C. Breast reconstruction after mastectomy using a temporary expander. Plast Reconstr Surg
1982;69:195.
2. Argenta LC, Watanabe MJ, Grabb WC. The use of tissue expansion in head and neck reconstruction. Ann
Plast Surg 1983;11:31.

Chapter 12
Transposed (Mcgregor) Flap in Eyelid Reconstruction
I. A. McGREGOR
EDITORIAL COMMENT
In the editor's view, this flap, which is simpler and less involved, has supplanted the more extensive
Mustardé-type flap, which was the standard for lower lid reconstruction.
This flap consists of an inferiorly based transposed flap raised on the skin area below and lateral to the outer
canthus, and it is moved medially to close V-shaped full-thickness defects of the lower eyelid. Transfer of the flap
leaves a triangular secondary defect laterally, and this is closed using a Z-plasty.
INDICATIONS
The reconstruction that uses this flap is primarily applicable to full-thickness defects of the lower eyelid that
can be created in the form of a V, although, as discussed later, the principle also can be applied to
comparable defects of the upper eyelid (1, 2). This flap can be used for defects of up to two-thirds of the
breadth of the lower lid, canthus to canthus, but defects greater in breadth are unsuitable. The technique is
one of the triad of reconstructions used to treat full-thickness V-shaped defects of increasing breadth (Fig.
12.1). With the narrow V, the defect can be closed directly; where the defect is broader and direct closure
would be under tension, reduction of tension can be provided by dividing the slip of the lateral canthal
ligament to the lower eyelid—lateral canthotomy. It is when the defect is still too broad for lateral
canthotomy alone that the transposed flap has to be advanced medially to bring together the two limbs of
the V and close the defect.
The method is easiest to carry out technically when an element of tarsal plate is present on both sides of
the defect. The presence of the plate provides a good base for suturing the two margins of the V together,
and while the method can be used for defects that abut on one or the other canthus, the absence of tarsal
plate on one side of the defect makes secure closure of the defect more difficult.
FLAP DESIGN AND DIMENSIONS
Before raising the flap, the lines along which the various incisions will be made are drawn out on the skin. With
the V-shaped defect outlined on the eyelid, the line that indicates the upper border of the transposed flap
extends laterally from the outer canthus, continuing the upward curve of the margin of the lower eyelid, to just
short of the temple hairline. The upward curve is required to provide an adequate vertical height of the
reconstructed eyelid segment and to avoid ectropion.
From the lateral extremity of this line, a further line is drawn in a generally downward direction parallel to the
lateral limb of the V on the eyelid, the angle between the two lines being approximately 60°. The effect is to
outline a flap with the overall shape of a parallelogram. As already indicated, transfer of the flap medially leaves
a triangular defect that is closed by a Z-plasty. This is designed at this stage, before any skin incisions are made,
constructed around the lateral part of the line representing the upper margin of the flap. This acts as the common
limb of the Z, it and the line representing the lateral margin of the flap together forming one of the Z-plasty flaps.

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Design of the Z-plasty is completed with the drawing of a line that runs upward and laterally from the upper
margin of the flap, outlining the second Z-plasty flap.
OPERATIVE TECHNIQUE: LOWER EYELID DEFECTS
With the V excision of the full thickness of the eyelid completed, the flap, as outlined, is raised at the face lift level
lateral to the orbicularis oculi. When the orbicularis is reached, the plane of elevation becomes deep to the
muscle, the muscle being advanced as part of the flap. In the process of elevating the flap, the slip of the lateral
canthal ligament to the lower eyelid is divided. This division can be carried out as a formal step, but the ligament
can just as effectively be felt as a resistance to medial flap advancement and be divided.
With a skin hook to gently pull the flap medially, sites of resistance to advancement can be identified with the
finger and divided with scissors. In the process, much of the lower border of orbicularis is divided, as well as the
orbital septum, neither structure being divided as a formal, visualized step, but rather felt as a focus of resistance
to medial advancement. The amount of tissue that must be divided in this way depends very much on the
breadth of the V and the amount of flap advancement required to
approximate its two limbs. A broad V necessitates more extensive soft-tissue division; a narrow V, less. Division
must be continued until the flap can be advanced to close the defect with a minimum of tension. The extent of
mobilization required also depends to some extent on the preexisting laxity of the eyelids and local tissues
generally. When the amount of soft-tissue division is considerable, the flap may ultimately appear to be attached
inferiorly by little more than the skin and immediately subcutaneous tissues superficially and the conjunctiva
deeply. There should be no particular concern about this. In contrast to the cheek rotation flap used in lower
eyelid reconstruction, with its recognized vulnerability to necrosis, the ratio of length to breadth and the relative
smallness of the transposed flap make it safe.