| Objective: Reconstruction of scalp defects caused by tumor resection or trauma is very challenging.Plastic surgeons are always faced with the dilemma when some defects are not eligible for simple primary closure.The main goal for surgical repair of scalp defect includes the restoration of hair growth and normal scalp anatomy.Through literature review,there are many operative options in dealing scalp defects,such as random flap,local advancement and rotation flaps.Sometimes,skin grafting or free flaps have also been reported of its application after extended tumor resection.Practically,the optimal method of choice depends initially on the surgeon's preference.A majority of the surgeons prefer to use local flap rather than skin graft or free flap for scalp defects repair.Previously,V-Y island flap has been proven to be a useful local or regional flap to cover various defects of the body parts.Here for a better aesthetic result,we made some refinements to the flap through Doppler assisted pre-operative design and show advantages of this modified technique for scalp reconstruction as compared to the traditional V-Y advancement flap.The aim of this study is to investigate the technique of modified unilateral pedicled V-Y advancement flap for the reconstruction of scalp defect.Methods:Part 1: Dissection of the superficial temporal artery(STA)and vein of 3 adult cadavers(6 sides)to confirm the location and branches of main scalp arteries and the concomitant vascular condition,to improve the anatomical basis of the V-Y scalp flap pedicled for repairing cranial scalp defect.We observed the location and branches of superficial temporal vessels and the concomitant vascular condition after pour different color latex into STA and STV.The superficial temporal,postauricular and occipital arteriovenous line and traffic anastomosis were observed.Part 2: According to the location of individual scalp defect,the main branches of the superficial temporal,posterior auricular or occipital artery were identified,traced and marked respectively on the temporal,parietal or occipital region of the scalp aided by a Doppler ultrasound device.All Doppler ultrosound examination were performed by experienced vascular technician using a high end scanner equipped with 3.5 MHz probe.Our modified unilateral pedicled V-Y advancement flaps are based on those anatomic studies and Doppler ultrasound examination.Part 3: A retrospective review was performed in a series of 25 patients who had had a modified unilateral pedicled V-Y advancement flap to restore scalp defect from May 2013 to January 2017.16 males and 9 females aged24 to 78 years old(mean age 58 years)were recruited in this study.These patients suffered from basal cell carcinoma,seborrhoeic keratosis,squamous cell carcinoma or trauma on the scalp.All of them underwent pre-operative Doppler scanning to identify the scalp arteries and then individually designed.The flap size ranged from 33×50 mm to 68×105 mm.Patients were followed for an average of 12 months postoperatively(ranged from 6 to 37 months).Results:Part 1: In the anatomical specimens,we found that the main branch of scalp vessels have many branches,those branches have a lot of traffic branches with other arteries in the observation of the STA,those branches supply an area approximately three-fourth of parietal soft tissue.The observation also found that there was no stable location relationship between the scalp veins and the arteries.This result are consistent with the current majority researches.Part 2: The hue of the ultrasonography provides useful information on the direction of underlying blood flow.The courses of the main vascular can be clearly seen and reliably marked through the Doppler monitor.The diameter of blood vessels at the root of zygomatic arch of STA was 1.8-3.0 mm,most of which were divided into frontal and parietal branches at the point 3.5-5.0 cm above zygomatic arch.16 cases of posterior auricular artery were examined.the length of trunk was 2.9-3.1 cm and the diameter was 0.9-1 mm.The location of the postauricular vein is generally located on the superficial side of the postauricular artery,most of which were closely associated.All 20 cases of occipital artery can clearly show that the occipital artery was generally tortuous up to the cranial apex under the upper line,and the superficial point of occipital artery is located at 1.0±0.1 cm below the external occipital protuberance and 3.5±0.2cm outside the midline.The diameter of occipital artery at this point was 2.15±0.26 mm.The ascending branch,initially located deep to the muscular fascia of the scalp became superficial,to be subcutaneous 2.5-4.2cm above the superior occipital line running on the surface of the glea aponeurosis.Part 3: Modified unilateral pedicled V-Y flap technique with fairly rapid recovery and acceptable re-orientation of hair follicles.No majorcomplications occurred,only 2 cases had a minor distal epidermal necrosis or obstruction of venous refluencevenous observed for the first 3 days of the surgery,and they both healed well,which leads to aesthetical outcome and patient satisfaction.Most importantly,no tumor recurrence at the original site during the follow-up period.Conclusions:The main arteries irrigating the scalp are STA with its frontal and parietal branches,the postauricular artery and the occipital artery,which attaches to external carotid artery,providing blood supply at the rear.We show that color Doppler-assisted perforators localization is a very simple,rapid and practical method.It is a routine practice of pre-operative Doppler mapping to identify potential vascular pedicle in the scalp defect patients,and to mark the routes of the arteries on the scalp can guide individual flap design and raising.The modified unilateral pedicled V-Y advancement flap is a simple but efficient technique,particularly suitable for the repair of small and medium size scalp defects with advantages including the safety of the procedure and overall aesthetic results like hairline preservation and less scarring when compared to other local flap techniques. |
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