Forehead Scalp Flap Saha et al. THIEME 24 Original Article Triple-Plane Dissection of Combined Forehead and Scalp Flaps for Large Posttraumatic Forehead Defects Srinjoy Saha 1 1 Department of Plastic Surgery, Apollo Gleneagles Hospital, Kolkata, West Bengal, India Address for correspondence Srinjoy Saha, MBBS, MS, MRCS, MCh (Plast), Department of Plastic Surgery, Apollo Gleneagles Hospital, Day Care Building 2nd Floor, 58 Canal Circular Road, Kolkata 700054, West Bengal, India (e-mail: ss@medi.ac). Introduction Reconstruction of large (>20 cm 2 ) posttraumatic forehead defects, with esthetically pleasing results and without distorting the surrounding anatomical landmarks like eyebrow and hairline, is a significant surgical challenge. This study was aimed to determine the effectiveness of a triple-plane dissection technique of signifi- cantly-sized flaps, combining forehead, and scalp to cover large forehead defects. Materials and Methods A retrospective review from January 2009 to December 2019 revealed that 12 patients with large defects over the forehead were operated on. Significantly-sized rotation and advancement flaps, combining both the forehead and scalp tissues, were performed. Triple-plane dissection and careful galeal scoring recruited more tissues and increased the reach of these flaps while maintaining ade- quate flap vascularity. Results Large forehead posttraumatic defects in all 12 patients were covered in a single surgery with this combined flap. Eight patients were men and four were women (mean age, 58 years). Size of the defects ranged from 21 to 40 cm 2 (mean, 27 cm 2 ). Complications included deep marginal necrosis in one patient (8%), superficial necrosis in one patient (8%), and mild venous stasis in four patients (33%). Superficial necrosis and venous stasis resolved by itself. Good color and contour match, minimal alopecia, maintained positions of eyebrow, and hairline positions were found in most patients. Six months postoperatively, patient satisfaction measured on a visual analogue scale ranged between 3 and 9 out of 10 (mean, 7). Conclusion Primary forehead reconstruction with significant-sized flaps combining forehead and scalp tissues, with triple-plane dissection and galeal scoring, appears to be an effective option for covering large forehead defects. Abstract Keywords ► forehead reconstruction ► forehead anatomy ► scalp anatomy ► forehead flap ► reconstructive surgical procedures DOI https://doi.org/ 10.1055/s-0040-1713686 ISSN 2455-7420. ©2020 Medical and Surgical Update Society Introduction Posttraumatic large forehead defects are a reconstructive dilemma. Anatomic landmarks and esthetic subunits need special attention. 1 It is a challenge to match color, texture, and contour of the forehead skin while maintaining the defining anatomic landmarks, namely, eyebrows and hairline. 2 Forehead defects are classified according to their size, with <10 cm 2 being small, 10 to 20 cm 2 being moderate, and >20 cm 2 being large. 3 According to the reconstructive ladder described by Mathes and Nahai, defects over the forehead may be repaired by any of the following reconstructive procedures: healing by secondary intention, primary closure, skin grafting, local flaps, regional flaps, and free-tissue transfers. 4 In any reconstruction, an optimal approach is to replace “like tissues with like,” while being the simplest to perform. With increasing consciousness about esthetic outcomes, patients increasingly demand a normal-looking result with minimal scars. I intended to determine the effectiveness of a triple-plane dissection technique of significant-sized flaps, Int J Recent Surg Med Sci 2020;6:24–29 published online June 13, 2020