Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Double Scalping Flap: A Versatile Technique in Scalp Reconstruction Othon Papadopoulos, MD, PhD,*Þ Dimitrios Karypidis, MD,*þ Margarita Moustaki, MD,* Chrisostomos Chrisostomidis, MD,* Champsas Grigorios, MD,* Kostopoulos Epaminondas, MD,* and Marios Frangoulis, MD, PhD* Abstract: Scalp reconstruction is a challenging area in plastic surgery. The susceptibility of potentially exposed brain tissue is almost always a concern along with the provision of adequate soft tissue coverage in cases of full-thickness defects. The applied reconstructive strategy also affects efficiency in malignant disease treatment providing both local control of the disease and vigorous monitoring for recurrence or metastasis. The general condition of the patients presenting with malignant lesions of the scalp is often impaired because of old age or concomitant disease. Therefore, de- manding, long-lasting, or multistage procedures may often be un- desirable. The double scalping flap comprises a 1-stage procedure, which can be used in most full-thickness defects of the vertex of the scalp. Some of the primary advantages of the double scalping flap procedure are its versatility and arc of rotation, its minimal donor site morbidity, being relatively simple, and being a short technique. Disadvantages that may be considered are the loss of hair-bearing skin at the occipital region and the poor color and texture match between scalp skin and the split-thickness skin graft that is used on the donor site. We present 2 patients with exemplary case of neglected malignancy of the scalp and their successful treatment using the double scalping flap. Comparison and contrast of alter- native reconstructive procedures are also included to further in- vestigate scalp reconstruction. Key Words: Scalp, flap, double scalping flap, scalp reconstruction, sarcoma, squamous cell carcinoma (J Craniofac Surg 2009;20: 1484Y1491) D espite the fact that numerous techniques have been described for the management of scalp defects, scalp reconstruction remains a challenge for the plastic surgeon. Complexity in the reconstruction of such defects is primarily due to the surgical anatomy of the region that requires sophisticated procedures for aesthetic and functional restoration. Reconstruction mainly concerns defects after tumor resection, trauma, or congenital deformity. There are several techniques available in the reconstructive armamentarium, which should be tailored to meet the individual requirements of the patient, depending on the location, size, and depth of the defect. 1,2 The best replacement for scalp tissue is autologous scalp tissue. 2 Therefore, local flaps, with or without concurrent skin grafts, still remain the method of choice for the reconstruction of scalp defects, especially after tumor resection and when not amendable to primary closure. Most of these defects can be reconstructed using local tissue rearrangements that allow for coverage over the calvaria, restore the hair, and achieve good aesthetic results. 2 We report 2 patients who underwent resection of their neglected malignant tumor with immediate reconstruction of the subsequent large full- thickness defect using the 1-stage double scalping rotation advancement flap based on the superficial temporalis vessels bilaterally. This successful reconstruction of the scalp requires careful preoperative planning and intraoperative precision to achieve coverage of the calvaria while preserving vascularity. Avoiding disruption of the regional anatomy includes attention to native hair patterns and hair lines. Although local flaps are usually preferred, when local tissue rearrangements are inadequate for reconstruction, alternative techniques should be considered such as secondary intention healing for split-thickness defects, skin grafting, tissue expansion, and free tissue transfer. 1Y3 HISTORIC REVIEW The reconstruction of facial defects using flaps has been practiced since ancient times (circa 600 BC) when Sushruta of Varanasi-India 4 described in writings the use of a forehead flap, which is probably among the first applications of plastic surgery. These attempts, however, were not successful. The use of local flaps for facial reconstruction was described and well accepted during World War I, when surgeons faced the challenge of treating severe traumatic midface defects. 5 In 1942, during World War II, Converse 6 applied the 2-stage anterior scalping flap, originally for nasal reconstruction. It was a variation of the Bup and down[ flap of Gillies. 7 In the late 1970s, the scalping flap gained popularity and found applications in cheek, eyebrow, and orbital roof restoration successfully and later in nasopharynx, tonsils, and floor of the mouth reconstruction. 8,9 In 1964, Frezieres et al 10 presented the use of rotation flap for scalp defect reconstruction. In 1967, Orticochea 11Y13 described the 4-flap reconstruction technique, a more elaborate flap to achieve closure for larger defects of the occipital region of the scalp. A year later, he suggested the use of a 3-flap technique, providing enhanced CLINICAL NOTE 1484 The Journal of Craniofacial Surgery & Volume 20, Number 5, September 2009 From the *Plastic Surgery Department, BAndreas Syggros[ Hospital for Skin and Venereal Diseases; †2nd Department of Propedeutic Surgery, Faculty of Medicine, University of Athens, BLaiko[ General Hospital, Athens, Greece; and ‡Cardiff University Medical School, United Kingdom. Received January 16, 2009. Accepted for publication March 17, 2009. Address correspondence and reprint requests to Dimitrios Karypidis, MD, Plastic Surgery Department, BAndreas Syggros[ Hospital for Skin and Venereal Diseases, Cardiff University Medical School, United Kingdom; E-mail: karypidisd@cardiff.ac.uk Copyright * 2009 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3181b09ade