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Egypt. J. Plast. Reconstr. Surgg., Vol. 23, No. 1, 1999: 35 - 40

Treatment of Burn Alopecia with Temporo-Parieto-Occipital Flap

MOHAMAD OSAMA KOTB, M.D.
The Department of Plastic Ahined Maher Teaching Hospital, Cairo.

ABSTRACT

Fifteen cases suffering from burn alopecia were treated by a temporo-paricto-occipital flap for recreation of the frontal hairline. Flap delay for 10 day was used in 11 cases to augment their blood supply. There were 3 minor post operative necrosis of the distal 1-2 cm of the flap and the remaining 12 cases had complete flap survival. The results were discussed and it was concluded that using the temporo-paricto-occipital flap is a simple, quick and safe procedure to recreate the anterior hairline in patients with burn alopecia.

INTRODUCTION

Fifteen cases suffering from burn alopecia were treated by a temporo-paricto-occipital flap for recreation of the frontal hairline. Flap delay for 10 day was used in 11 cases to augment their blood supply. There were 3 minor post operative necrosis of the distal 1-2 cm of the flap and the remaining 12 cases had complete flap survival. The results were discussed and it was concluded that using the temporo-paricto-occipital flap is a simple, quick and safe procedure to recreate the anterior hairline in patients with burn alopecia.

PATIENTS AND METHODS

During the last 2 years, the temporo-parietooccipital flap procedure was used in fifteen patients with postburn alopecia. Nine patients were males and six were females. Their ages range from 4 to 40 years. The cause of the bum was flame in 10 patients, scald in 3 and chemical in 2 patients. In 4 of the patients the flap was raised directly without delay, while the other 11 patients the flap raising was delayed for 10 days. In 1 patient the flap was raised bilaterally.

Operative techniques:
The temporo-paricto-occipital flap is based on the posterior branch of the superficial ternporal vessels and their patency can be assessed by doppler ultrasonography. The flap is outlined preoperatively as is the area of hairless frontal scalp to be excised.The plane of dissection is between the galea and the skull pericranium. The haemostasis is best achieved by using Allis forceps or scalp clips rather than cautery to ensure viability of the flap edges [8]. A delay is frequently recommended, following the flap raising, it is sutured again to its bedwhere it will be raised after 10 days and then rotated into the recipient's bed after excision of the burned area. A subgaleal drain is left for 24 hours to decrease the risk of haematoma. A dog ear will usually occur at the pedicle base point of rotation. It is adjacent to the vascular supply of the flap and should be allowed to remain after the procedure is completed. It will flatten with time and if necessary can be surgically revised after I year [9].The donor site is closed directly without tension after wide undermining of the edges. A non pressure dressing is applied, as pressure may compromise blood supply of the flap. The patient is allowed to shampoo on the second day and the sutures are removed after 10- 12 days [1].

RESULT

In this study no total flap loss had occurred in 16 flaps raised. There were 3 cases in which post operative necrosis at the distal 1-2 cm of the flap, 2 had occurred with undelayed flaps and I condition with a delayed flap but all 3 were healed by secondary intention. No wound infection or haematoma were seen in our patients. Table (1) illustrates the data of 15 casesThe length of the flap ranged from 14-20 em, while the flap's width ranged from 2.5-3 em. Flaps measuring 14 to 15 cm never developed distal necrosis, in contrast to those 16 to 20 em in length. The donor site healed by primary intention in all patients. Minor alopecia appeared in 3 donor sites post operatively.

Table (1): Results of the teinporo-paricto-occipital flap in 15 patients with burn alopecia.

Case No. Sex

Age (years)

 Flap size (cm) Delay Flap complications Donor site complications
1 Female 15 16 x 3 cm -    
2 Female 40 17 x 3 - Necrosis of distal 2 cm  
3 Male 5 15 x 2.5R
15 x 2.5L		 -
+		 Necrosis of distal 1 cm (R. side )  
4 Male 6 17 x 2.5 +    
5 Male 20 16 x 3 -   Mild alopecia
6 Female 4 14 x 2.5 +    
7 Female 22 20 x 3 + Necrosis of distal 1.5 cm Mild alopecia
8 Male 30 16 x 2.5 +    
9 Male 14 15 x 3 +    
10 Female 20 17 x 2.5 +    
11 Male 10 16 x 3 +    
12 Female 8 15 x 2.5 +    
13 Female 14 15 x 2.5 +    
14 Male 21 16 x 3 +   Mild alopecia
15 Male 10 15 x 2.5 +    
Table (1): Results of the teinporo-paricto-occipital flap in 15 patients with burn alopecia.
Fig(1): a-Pre and b- Post operative photographs of case No. 3 Fig(1): a-Pre and b- Post operative photographs of case No. 3
Fig(1): a-Pre and b- Post operative photographs of case No. 3
Fig(2): a-Pre and b- Post operative photographs of case No. 4 Fig(2): a-Pre and b- Post operative photographs of case No. 4
Fig(2): a-Pre and b- Post operative photographs of case No. 4
Fig(3): a-Pre and b- Post operative photographs of case No. 6 Fig(3): a-Pre and b- Post operative photographs of case No. 6
Fig(3): a-Pre and b- Post operative photographs of case No. 6
Fig(4): a-Pre and b- Post operative photographs of case No. 8 Fig(4): a-Pre and b- Post operative photographs of case No. 8
Fig(4): a-Pre and b- Post operative photographs of case No. 8
Fig(5): a-Pre and b- Post operative photographs of case No. 10 Fig(5): a-Pre and b- Post operative photographs of case No. 10
Fig(5): a-Pre and b- Post operative photographs of case No. 10
Fig(6): a-Pre and b- Post operative photographs of case No. 13 Fig(6): a-Pre and b- Post operative photographs of case No. 13
Fig(6): a-Pre and b- Post operative photographs of case No. 13

DISCUSSION

Scalp flaps have been used to reconstruct the anterior hairline. Dardour et al. [11 used one stage preauricular random flap for male baldness without a delay and they stated that risk factors were tobacco consumption, anxiousness, thin flaps and haematoma formation. Rizetto and Ellenbogen [10] reported 62 undelayed temporo-parieto-occipital flaps for male baldness with adequate hair growth in all patients.In the present study, 15 cases suffering from burn alopecia were treated by temporo-parietooccipital flap to recreate anterior hairline. Threecases had necrosis at 1-2 cin of the flap distalend, two of them with undelayed flaps and one with a delayed flap. The other twelve cases had complete viable flaps with accepted post operative results. The advantages of the temporoparieto-occipital flap procedure are:

  1. Easy quick operation and short hospital stay.
  2. High hair density and aesthetic frontal hairline.
  3. The 2 stages of the operation can be done within 10 days.
  4. Direct closure of the donor site.
  5. In severe alopecia it could be the first stage procedure, allowing a quick pleasant aspect, that would be completed afterwards by scalp reduction, punch grafts or tissue expansion [11].

The disadvantages of the temporo-parietooccipitalflap procedure are:

  1. Posterior direction of hair growth.
  2. Dog ear usually occurs at the pediele base[12].
  3. Delay procedure causes scarring of the flap edges which may lead to difficult closure of the donor site.
  4. Alopecia might occur at the donor site if closure is under significant tension.
  5. Necrosis at the distal end of the flap, especially if its length is more than 17 em, which can be repaired by fusiform graft and the final result is obtained before 6 months.

In conclusion, the results achieved in this study point out that temporo-paricto-occipital flap with one delay is a simple, quick and safe procedure for recreation of the anterior hairline in bum alopecia.

REFERENCE

  1. Dardour J.C., Pugash E. and Aziza R.: The onestage preauricular nap for male pattern baldness: Long term results and risk factors. Plast. Reconstr. Surg., 81: 907, 1988.
  2. Nataf J.: Surgical treatment for frontal baldness. The long temporal vertical flap. Plast. Reconstr.Surg., 74: 628, 1984.
  3. Smith J.W. and Aston S.J.: Treatment of baldness with the use of flaps-Grabb and Smith's plastic surgery-4th edition-Little, Brown and Company, p: 635, 1991.
  4. Unger W.: Treatment of bladness. Grabb and Smith's plastic surgery-5th edition- lippincottRaven publishers, Philadelphia, p: 569, 1997.
  5. Argenta L.C.: Controlled tissue expansion in reconstructive surgery. Brit. J. Plast. Surg., 37: 520, 1984.
  6. Frechet R: Scalp extension. J. Dermatol. Surg.Oncol., 19: 616, 1993.
  7. Juri J.: Use of parieto-occipital flaps in the surgical treatment of baldness. Plast. Reconstr. Surg., 55:456,1975.
  8. Mathes S. and Nahai F.: Scalp flap. Reconstructive surgery, Principles, Anatomy and Technique-churchill livingstone. Vol. 1, 333, 1997.
  9. Huang T.T., Larson D.L. and Lewis S.R.: Burn alopecia. Plast. Reconstr. Surg., 60: 763, 1977.
  10. Rizatto-Stubel A., Ellenbogen R.: Male baldness: Immediate single stage rotation of very long arterialized temporo-parieto- occipital flaps. Plast. Reonstr. Surg., 77: 215, 1986.
  11. Paul Buhrer D., Huang T.T., Yee H.W & Blackwell S1: Treatment of burn alopecia with tissue expanders in children. Plast. Reconstr. Surg., 81: 512, 1988.
  12. Lesavoy M.A., Dubrow T.J., Schwartz RJ, Wackym P.A., Eisenhauer D.M. and McGuire M.: Management of large scalp defects with local pedicle flaps. Plast. Reconstr. Surg., 91: 783, 1993,