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for example&#44; it is particularly appropriate for use on the limbs and after excision of the pulp of a finger or toe&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> For lesions in the craniofacial territory&#44; it is useful for repairs of the frontal and temporal regions&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The double-flap technique&#44; with 2 flaps arranged one on either side of a given defect&#44; is a reliable method for the repair of small and moderate-sized defects of the scalp&#46; We consider it a good reconstruction technique for these cases&#44; particularly when evaluating the possibility for coverage by means of local options&#44; when it is not possible to use skin grafts &#40;for example&#44; oncologic surgery that requires deperiostization&#44; which will not leave an adequate receptor bed&#41; or other more complex options&#44; such as microvascular free flaps&#46; The minimal morbidity associated with the hatchet flap means that the procedure can be performed as ambulatory surgery or&#44; when used for large defects&#44; with only a single day of hospital admission&#46; The ease of its design&#44; the speed of its performance&#44; the simple postoperative follow-up&#44; and patient comfort &#40;rapid healing&#44; ease of wound care&#44; and the absence of a donor site and of distant sequelae&#41; make the double hatchet flap an ideal option&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Descriptions</span><p id="par0020" class="elsevierStylePara elsevierViewall">Between November 2008 and January 2011 we used the double hatchet flap to repair 20 scalp defects after oncologic surgery&#46; In all cases the tumor was excised with adequate resection margins&#44; and immediate postoncologic-surgery repair was performed&#46; There were no significant complications &#40;partial or total flap necrosis of arterial or venous etiology&#44; hematomas&#44; wound dehiscence&#41; in any of the patients during the immediate or late postoperative periods&#46; The underlying periostium was systematically preserved when oncologic surgery did not require its excision&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The majority of patients treated were men over 70 years of age &#40;mean age&#44; 76 years&#41; with scalp lesions of 3 to 7<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;mean&#44; 4<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46; The lesions were clinically and histopathologically compatible with squamous cell carcinoma and most were located on the vertex or parietal region of the cranium &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After excision of the lesion&#44; with or without resection of the periostium&#44; depending on oncologic requirements&#44; the random-pattern double hatchet flaps were fashioned on either side of the lesion&#59; the length of each flap was approximately 1&#46;5 times the diameter of the initial defect and the width of the skin pedicle was equivalent to the radius of the defect&#46; Dissection of the flap was performed in the subgaleal plane&#44; preserving the rich supragaleal vascular network &#40;and maintaining the periostium intact to facilitate reconstruction if necrosis of the flap should occur&#41;&#46; The flaps were rotated and advanced&#44; with release of the adjacent tissues along the same plane&#46; The site of apposition of the 2 flaps&#44; in the midline of the area of the defect to be repaired&#44; was closed by tissue planes&#44; and the donor areas of the flaps in V-to-Y fashion &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In large repairs&#44; we favor leaving a drain for the first 24 hours&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The results 1 month after the operation show that a stable repair is achieved&#44; with a cosmetic result that we have not been able to better using other reconstruction techniques in defects of these sizes &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The double hatchet flap enables small or moderate-sized defects of the scalp to be covered in a single surgical session&#44; providing tissue of the same characteristics as the area of the defect&#44; with minimal morbidity of the donor site&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">With regard to the general surgical technique for reconstructions with this type of flap&#44; the excision of the skin lesions must be performed with a circular incision with adequate margins&#46; To design the 2 flaps&#44; the size of the defect left by the excision is measured &#40;the maximum length of each flap is equivalent to 1&#46;5 times the diameter of the defect&#44; and the width of the pedicle of each flap is equivalent to 0&#46;5 times that diameter&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The dissection of the flap must be performed in the deep subcutaneous plane&#44; preserving the vascularization from the subdermal plexus&#44; after which the flaps are rotated until their advancement borders meet&#44; and the distal area of the defect is closed in V-to-Y fashion&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">When using this technique on the scalp&#44; the plane of dissection is modified and is typically subgaleal in order to preserve the supragaleal vascularization&#46; This form of dissection&#44; with preservation of the galea aponeurotica&#44; means that the flap is less elastic and that there is a greater need for advancement and rotation&#44; as well as extensive release of the surrounding skin in order to distribute the tension of closure of the wound&#46; The appearance of any deformity in the immediate postoperative period is uncommon&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> If deformity develops&#44; it usually resolves in less than 2 months without the need for further surgery&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In small defects&#44; the excision and reconstruction can be performed as ambulatory surgery under local anesthesia&#46; In moderate or large defects&#44; we recommend performing the operation under local anesthesia and sedation&#44; or even under general anesthesia in selected patients&#46; In such cases&#44; hospital admission is required for postoperative monitoring &#40;usually for 24 hours&#41;&#46; Patients are seen every week for the first 3 weeks&#44; until removal of the sutures&#44; and then every 3 months as part of standard oncologic follow-up&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Because of the mixed movement component and the extensive coverage that reconstruction with this type of flap can offer&#44; we consider it to be ideal to cover scalp defects in general and those of the central area in particular&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Its constant and sufficient vascular supply together with the adaptability of the design of the flap&#44; allowing the hairline to be preserved&#44; provides an excellent cosmetic result with tissue of the same characteristics as the defect in terms of thickness&#44; texture&#44; and hair&#46; Furthermore&#44; compared to other options&#44; such as skin grafts or microvascular free flaps&#44; this technique offers the advantage of more stable coverage and a saving in terms of days of hospital stay &#40;in addition to the advantage that this represents in elderly patients&#41;&#44; postoperative follow-up&#44; and ease of outpatient wound care&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; the use of the double hatchet flap is proposed as a valuable technique for the reconstruction of scalp defects&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are a number of approaches for the repair of scalp defects&#44; including local&#44; regional&#44; and distant options&#46; The use of a local double triangular hatchet flap has numerous advantages due to its mixed rotational and advancement components&#44; its large size&#44; and the possibility of maintaining the cosmetic appearance of the hairline as the flap has similar characteristics to those of the area to be reconstructed&#46; We present our experience with a series of skin tumors of the scalp&#46; After oncologic excision&#44; immediate repair of the defect was performed using this double flap&#46; The surgical technique and the advantages of this type of reconstruction are discussed&#46; We believe that the hatchet flap is an ideal option for the reconstruction of moderate-sized scalp defects&#46;</p>"
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Case Reports
Versatility of Hatchet Flaps for the Repair of Scalp Defects
Versatilidad de colgajos en hacha en defectos del cuero cabelludo
M. Fernández-Calderóna,
Corresponding author
drfernandezcalderon@gmail.com

Corresponding author.
, C. Casado-Sánchezb, E. Cabrera-Sánchezb, C. Casado-Pérezb
a Servicio de Cirugía Plástica y Quemados, Hospital Universitario La Paz, Madrid, Spain
b Servicio de Cirugía Plástica y Quemados, Hospital Universitario Reina Sofía, Córdoba, Spain
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for example&#44; it is particularly appropriate for use on the limbs and after excision of the pulp of a finger or toe&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> For lesions in the craniofacial territory&#44; it is useful for repairs of the frontal and temporal regions&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The double-flap technique&#44; with 2 flaps arranged one on either side of a given defect&#44; is a reliable method for the repair of small and moderate-sized defects of the scalp&#46; We consider it a good reconstruction technique for these cases&#44; particularly when evaluating the possibility for coverage by means of local options&#44; when it is not possible to use skin grafts &#40;for example&#44; oncologic surgery that requires deperiostization&#44; which will not leave an adequate receptor bed&#41; or other more complex options&#44; such as microvascular free flaps&#46; The minimal morbidity associated with the hatchet flap means that the procedure can be performed as ambulatory surgery or&#44; when used for large defects&#44; with only a single day of hospital admission&#46; The ease of its design&#44; the speed of its performance&#44; the simple postoperative follow-up&#44; and patient comfort &#40;rapid healing&#44; ease of wound care&#44; and the absence of a donor site and of distant sequelae&#41; make the double hatchet flap an ideal option&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Descriptions</span><p id="par0020" class="elsevierStylePara elsevierViewall">Between November 2008 and January 2011 we used the double hatchet flap to repair 20 scalp defects after oncologic surgery&#46; In all cases the tumor was excised with adequate resection margins&#44; and immediate postoncologic-surgery repair was performed&#46; There were no significant complications &#40;partial or total flap necrosis of arterial or venous etiology&#44; hematomas&#44; wound dehiscence&#41; in any of the patients during the immediate or late postoperative periods&#46; The underlying periostium was systematically preserved when oncologic surgery did not require its excision&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The majority of patients treated were men over 70 years of age &#40;mean age&#44; 76 years&#41; with scalp lesions of 3 to 7<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;mean&#44; 4<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46; The lesions were clinically and histopathologically compatible with squamous cell carcinoma and most were located on the vertex or parietal region of the cranium &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After excision of the lesion&#44; with or without resection of the periostium&#44; depending on oncologic requirements&#44; the random-pattern double hatchet flaps were fashioned on either side of the lesion&#59; the length of each flap was approximately 1&#46;5 times the diameter of the initial defect and the width of the skin pedicle was equivalent to the radius of the defect&#46; Dissection of the flap was performed in the subgaleal plane&#44; preserving the rich supragaleal vascular network &#40;and maintaining the periostium intact to facilitate reconstruction if necrosis of the flap should occur&#41;&#46; The flaps were rotated and advanced&#44; with release of the adjacent tissues along the same plane&#46; The site of apposition of the 2 flaps&#44; in the midline of the area of the defect to be repaired&#44; was closed by tissue planes&#44; and the donor areas of the flaps in V-to-Y fashion &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In large repairs&#44; we favor leaving a drain for the first 24 hours&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The results 1 month after the operation show that a stable repair is achieved&#44; with a cosmetic result that we have not been able to better using other reconstruction techniques in defects of these sizes &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The double hatchet flap enables small or moderate-sized defects of the scalp to be covered in a single surgical session&#44; providing tissue of the same characteristics as the area of the defect&#44; with minimal morbidity of the donor site&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">With regard to the general surgical technique for reconstructions with this type of flap&#44; the excision of the skin lesions must be performed with a circular incision with adequate margins&#46; To design the 2 flaps&#44; the size of the defect left by the excision is measured &#40;the maximum length of each flap is equivalent to 1&#46;5 times the diameter of the defect&#44; and the width of the pedicle of each flap is equivalent to 0&#46;5 times that diameter&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The dissection of the flap must be performed in the deep subcutaneous plane&#44; preserving the vascularization from the subdermal plexus&#44; after which the flaps are rotated until their advancement borders meet&#44; and the distal area of the defect is closed in V-to-Y fashion&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">When using this technique on the scalp&#44; the plane of dissection is modified and is typically subgaleal in order to preserve the supragaleal vascularization&#46; This form of dissection&#44; with preservation of the galea aponeurotica&#44; means that the flap is less elastic and that there is a greater need for advancement and rotation&#44; as well as extensive release of the surrounding skin in order to distribute the tension of closure of the wound&#46; The appearance of any deformity in the immediate postoperative period is uncommon&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> If deformity develops&#44; it usually resolves in less than 2 months without the need for further surgery&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In small defects&#44; the excision and reconstruction can be performed as ambulatory surgery under local anesthesia&#46; In moderate or large defects&#44; we recommend performing the operation under local anesthesia and sedation&#44; or even under general anesthesia in selected patients&#46; In such cases&#44; hospital admission is required for postoperative monitoring &#40;usually for 24 hours&#41;&#46; Patients are seen every week for the first 3 weeks&#44; until removal of the sutures&#44; and then every 3 months as part of standard oncologic follow-up&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Because of the mixed movement component and the extensive coverage that reconstruction with this type of flap can offer&#44; we consider it to be ideal to cover scalp defects in general and those of the central area in particular&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Its constant and sufficient vascular supply together with the adaptability of the design of the flap&#44; allowing the hairline to be preserved&#44; provides an excellent cosmetic result with tissue of the same characteristics as the defect in terms of thickness&#44; texture&#44; and hair&#46; Furthermore&#44; compared to other options&#44; such as skin grafts or microvascular free flaps&#44; this technique offers the advantage of more stable coverage and a saving in terms of days of hospital stay &#40;in addition to the advantage that this represents in elderly patients&#41;&#44; postoperative follow-up&#44; and ease of outpatient wound care&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; the use of the double hatchet flap is proposed as a valuable technique for the reconstruction of scalp defects&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are a number of approaches for the repair of scalp defects&#44; including local&#44; regional&#44; and distant options&#46; The use of a local double triangular hatchet flap has numerous advantages due to its mixed rotational and advancement components&#44; its large size&#44; and the possibility of maintaining the cosmetic appearance of the hairline as the flap has similar characteristics to those of the area to be reconstructed&#46; We present our experience with a series of skin tumors of the scalp&#46; After oncologic excision&#44; immediate repair of the defect was performed using this double flap&#46; The surgical technique and the advantages of this type of reconstruction are discussed&#46; We believe that the hatchet flap is an ideal option for the reconstruction of moderate-sized scalp defects&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los defectos localizados a nivel del cuero cabelludo pueden reconstruirse mediante diversas opciones terap&#233;uticas&#44; de car&#225;cter local&#44; regional o a distancia&#46; El empleo de un doble colgajo local triangular en hacha aporta m&#250;ltiples ventajas en la cobertura de estos defectos&#44; debido a su componente mixto&#44; tanto rotatorio como de avance&#44; sus considerables dimensiones y la posibilidad de mantener la est&#233;tica de la l&#237;nea capilar&#44; aportando similares caracter&#237;sticas al territorio a reconstruir&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presentamos nuestra experiencia en una serie de tumores cut&#225;neos en el cuero cabelludo&#44; en los que tras su ex&#233;resis oncol&#243;gica se realiz&#243; la reconstrucci&#243;n inmediata del defecto resultante mediante este doble colgajo&#44; discuti&#233;ndose la t&#233;cnica quir&#250;rgica y las ventajas de este tipo de reconstrucci&#243;n&#44; para concluir su idoneidad como opci&#243;n reconstructiva en defectos moderados del cuero cabelludo&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Fern&#225;ndez-Calder&#243;n M&#44; Casado-S&#225;nchez C&#44; Cabrera-S&#225;nchez E&#44; Casado-P&#233;rez C&#46; Versatilidad de colgajos en hacha en defectos del cuero cabelludo&#46; Actas Dermosifiliogr&#46;2012&#59;103&#58;629-631&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Squamous cell carcinoma of 4<span class="elsevierStyleHsp" style=""></span>cm in diameter on the scalp&#46; The area of excision and the design of the hatchet flaps are outlined&#46;</p>"
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ISSN: 15782190
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