1. The scalp and forehead have a complex anatomy consisting of layers of skin, subcutaneous tissue, fascia, and muscle overlying the skull. The scalp receives its blood supply from branches of the external carotid artery and drains venously into a network that connects to the internal jugular vein. 2. Injuries or defects of the scalp and forehead can often be reconstructed using local flaps such as rotation, transposition, or advancement flaps. For larger defects, regional flaps from the temporal region, glabella, or forehead can be mobilized. 3. Microsurgical reconstruction with free flaps or face transplantation are options for very large scalp or forehead defects that cannot

1. SCALP RECONSTRUCTION
BY:DR.AMIT KUMAR CHOUDHARY

2. Introduction
• The scalp and forehead are a very specialized and unique
component of the upper most part of the head and neck.
• It is dome-shaped and covers the cranium and the underlying
brain.

3. Anatomy
• The scalp and forehead is proportionally
greater in children than in adults.
• Anteriorly - Superior orbital rims
• Posteriorly - Nuchal line
• Laterally- from each frontal process of the
zygoma and zygomatic arch anteriorly, the
ear centrally and mastoid process
posteriorly.

4. • The forehead is extending between the
side-burns laterally and the supraorbital
ridges and glabella inferiorly.
• Superiorly, the boundary between the
forehead and scalp depends on the
hairline which is variable with age and
gender.

5. Scalp
• S - skin,
• C - subcutaneous tissue,
• A - aponeurotic layer,
• L - loose areolar tissue,
• P - pericranium

6. Galea aponeurotica
• Connects the occipitalis muscles
posteriorly and the frontalis muscles
anteriorly.
• Temporoparietal fascia is an extension
of the galea
• Anterolaterally, the SMAS of the
face.

7. Frontalis muscles
• Originate from the galea and insert into the dermis of the brow.
• FUNCTION
• Blend with the procerus and corrugator supercilii muscles as
well as the upper aspects of the orbicularis oculi muscles.

8. Corrugator supercilii muscles
• Arise from the frontal bone near the superomedial orbital rim
and then pass superolaterally through the fibers of the
orbicularis oculi and the frontalis muscles before inserting into
the medial eyebrow skin. The
• Brow depressor pulling the brow medially and inferiorly
producing vertical glabella wrinkles.

9. Procerus muscle
• Thin muscle that inserts into the glabella and lower mid
forehead.
• It is a brow depressor forming horizontal nasal root creases.

10. occipitalis muscles
• Origin from the superior nuchal line and
mastoid and insert into the galea.

11. Auricular muscles
origin from the temporalis fascia
and mastoid bone and insert
into of the perichondrium of the
external ear

12. loose areolar layer
• Very thin over the vertex that
becomes thicker laterally
where it joints the
temporoparietal fascia.
• It is at this level of loose
areolar tissue that scalping
injuries occur.

13. Pericranium
• The deepest layer of the scalp is the pericranium or periosteum
of the cranium.
• This is a well vascularized layer firmly adherent to the skull in
the region of the cranial sutures.

14. The temporal region of the scalp
• The temporal region of the scalp
has additional specialized layers
and attributes .
• The hair-bearing skin typically is
the last to lose its hair in cases of
male pattern baldness.
• The temporoparietal fascia
(TPF) is an extension of the
galea and is closely applied to
the skin and the hair follicles
and has a rich blood supply
which passes on its deep surface.
• Anteriorly, the frontal branch of
the facial nerve passes in this
layer

15. Deep temporal fascia
• Thick and fuses with
the periosteum
superiorly above the
temporalis muscle.
• Inferiorly it splits into
superficial and deep
layers.
• The superficial layer
attaches to the anterior
aspect of the
zygomaticarch, and the
deeper layer fuses with
medial aspect of the
zygomatic arch.

16. • Dissection deep to this layer
avoids injury to the frontal
branch of the facial nerve as
it passes over the zygomatic
arch within the fascia

17. Temporalis muscle
• Large strong fan shaped muscle of
• Origin- temporal fascia and skull
• Insertion- coronoid process of the
mandible.
• Blood supply - deep temporal
branches of the internal maxillary
artery.

18. Blood supply

19. venous drainage
1. venous drainage of the scalp is by veins that parallel and accompany the main
arteries.
2.Through diploë of the cranium to the dural sinuses by emissary veins.
3.The supratrochlear and supraorbital veins drain into the ophthalmic vein.
4.Laterally, the venous drainage passes through the parotid gland and joins the
maxillary vein to form the retromandibular vein.
5.The post-auricular veins join the posterior division of the retromandibular vein to
form the external jugular vein.
6.The occipital veins drain into the deep cervical vertebral venous plexus

20. Lymphatics
• Scalp lymphatics are located in the subdermal and
subcutaneous layers.
• There are no lymph nodes in the scalp region.
• Pre- and post-auricular lymph nodes,
• Upper cervical and occipital nodes.

21. Innervation
• Motor innervation to the muscles of the forehead - temporal branch of the facial
nerve .
• Corrugator muscles - temporal branch of the facial nerve
• Procerus muscle is - deep buccal branch of the facial nerve.
• Occipitalis muscle - posterior auricular branch of the facial nerve.

22. • Temporalis muscle is innervated by two branches from the
third or mandibular division of the trigeminal nerve.

23. The sensory nerve
• Anterior scalp and forehead -
supratrochlear and supraorbital nerves
which originate from the ophthalmic
or first division of the trigeminal
nerve.
• The lateral orbit, temple, and scalp -
zygomaticofacial and
zygomaticotemporal nerves which are
branches of the maxillary or second
division of the trigeminal nerve.
• The pre-auricular scalp –
auriculotemporal nerve which is a
branch of the mandibular or third
division of the trigeminal nerve.

25. Disorders of the scalp and
forehead

27. Patient selection
1. The defect
2. The surrounding tissues
3. Patient factors

28. Treatment/surgical technique

29. A. Reconstructive options – scalp and
forehead: common options
• 1. Closure by secondary intention
• 2. Vacuum-assisted closure (VAC)
• 3. Primary closure – maximum of 2–3 cm in diameter
Scalp reduction techniques.
• 4. Tissue expansion
• 5. Skin grafts

30. B. Reconstructive options – scalp: local and
regional flap reconstruction
Local flaps- Rotation,
Transposition,
Advancement
Small pin wheel flaps – 1.two-flap “yingyang”
2.three-flap “Isle-of-Man”

36. Development of the three-flap technique. It is preferable to cut flaps 1 and 2 at an angle as shown.
The secondary defect that results after juxtaposition of flaps 1 and 2 is smaller than the primary one

37. B, The three flaps have been mobilized. Parallel incisions have been made in the aponeurosis of the large flap (3)
transverse to the longitudinal axis of the skull. Flaps 1 and 2 are sutured in juxtaposition but without tension
because their pedicles are narrow.

39. Four-flap technique,

40. JURI FLAP

41. Component separation of the scalp
• Use of separate galeal flaps.
• This is most commonly used in the frontal area, where the.
galea and attached frontalis muscle is often used to repair
frontal sinus and anterior cranial defects.

42. Reconstructive options – forehead: local
and regional flap reconstruction

43. Temporal subunit
• VY
• Extended VY,
• Double extended VY flap

46. Suprabrow and glabella subunits
Double opposing VY flaps

47. • Larger defects of the medial
suprabrow area require a
vertically oriented transposition
flap, which can be raised from
the adjacent glabella. This
glabella flap is based on the
terminal branches of the angular
vessels

49. Central
• Larger vertically oriented
defects are repaired by
bilateral forehead (+/− and
scalp) flap mobilization, with
galeal scoring and back cut

50. Lateral

51. • Microsurgical reconstruction with
free flaps
• FACE TRANSPLANTATION

52. THANK YOU