Case and Research Letter
Double Hatchet Flap For The Reconstruction Of Scalp Defects
Reconstrucción de defecto en cuero cabelludo mediante doble colgajo en hacha
A. Varela-Veiga
, O. Suárez-Magdalena, Ó. Suárez-Amor, B. Monteagudo
Corresponding author
Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, Spain
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Varela-Veiga, O. Suárez-Magdalena, Ó. Suárez-Amor, B. Monteagudo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Varela-Veiga" "email" => array:1 [ 0 => "ana.varela.veiga@sergas.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "O." "apellidos" => "Suárez-Magdalena" ] 2 => array:2 [ "nombre" => "Ó." "apellidos" => "Suárez-Amor" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Monteagudo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reconstrucción de defecto en cuero cabelludo mediante doble colgajo en hacha" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1632 "Ancho" => 2250 "Tamanyo" => 536289 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Immediate postoperative result. B, Final outcome 2 months after the operation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The scalp is a relatively common site for skin tumors. The lack of cutaneous elasticity and the high frequency of actinic damage can limit the choice of reconstruction techniques, particularly in medium-sized or large defects. One of the most widely used flaps is the double hatchet flap, which is a good option with excellent cosmetic results.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 62-year-old patient with a past history of hypertension and diabetes mellitus. He was referred to our outpatient clinic for a basal cell carcinoma measuring 3.4<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>cm in the right parietal region (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). After histological confirmation by biopsy, surgical excision under local anesthesia and sedation was scheduled.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The resulting surgical defect measured approximately 4.2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>5.7<span class="elsevierStyleHsp" style=""></span>cm; the periosteum was intact. A bilateral hatchet flap was designed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B); the length of each flap was 1.5 times the diameter of the defect and the pedicle was a third of the length of the flap. Dissection was performed in the subgaleal plane (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C), and the defect was closed by tissue planes, with placement of a drain posteriorly (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The drain was removed the following day. The cosmetic result was excellent, with a minimal residual scar (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B), and there were no signs of recurrence after a year of follow-up.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Tumors are not uncommon on the scalp, and can sometimes be large lesions that require laborious surgical techniques.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The options for reconstruction include closure by second-intention, which is possible when the periosteum is preserved.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> This is an acceptable option in small defects and in patients of advanced age or with comorbidities, although healing time is prolonged and the scar is depressed and alopecic. Another possibility is a graft, which usually achieves a poorer cosmetic result than a plasty, and leaves an area of alopecia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Several flaps may be considered. Advancement, rotation, and transposition flaps are usually good options in defects that require special anatomical modifications. Specifically, advancement and transposition plasties are used less frequently, although they may be considered to be an option for reconstruction, depending on the size and site of the defect. The anatomical convexity makes rotation flaps and combined rotation-advancement flaps the most useful alternatives. These include the double hatchet flap and the O-Z flap, which is widely used for the reconstruction of scalp defects.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Free vascularized flaps are technically more complex and require hospital admission. Also, they are more expensive in the short and medium term.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It must be noted that when the defect includes the periosteum, leaving the cortical or even spongy bone exposed, the only reconstructive options are local plasties and free vascularized flaps, as a graft in this situation would have no vascular bed from which to draw nutrients and establish its blood supply, and would thus be lost.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The double hatchet flap, first described by Emmet in 1977, is a particularly useful option for the reconstruction of small and medium-sized scalp defects.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3</span></a> It is a triangular plasty with a random vascular pattern that allows a double movement of rotation and advancement, facilitated by a tension-releasing design at its base, enabling closure of larger-diameter defects.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> This procedure can be performed in a single operation, on an ambulatory basis under local anesthesia, except for large defects that may require sedation and a short hospital admission.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">When designing the flap, the reference measurement after the circular excision of a lesion is the diameter of the defect; the length of the flap must be 1.5 times the diameter of the defect and the vascular pedicle must be at least a third of the length of the flap. Dissection is performed in the subgaleal plane, which will provoke less hemorrhage and preserve the supragaleal vascular bed. The disadvantage of this plane of dissection is the limited elasticity of the tissue, requiring broader release to achieve greater mobility of the plasty and thus distribute the tension across the surgical wound, avoiding complications such as dehiscence. Closure is performed by tissue planes, with a V-Y suture.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Close follow-up is required in the immediate postoperative period, with regular wound care.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The cosmetic result of the double hatchet flap can be excellent, as tissue of similar characteristics is used, with preservation of hair, texture, and thickness,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> rapid healing, and minimal scarring and comorbidity. Possible complications include flap necrosis, dehiscence, and the formation of hypertrophic scars.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2,4,5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">For all these reasons, the double hatchet flap is one of the best techniques for its simplicity of design, speed of performance, ease of postoperative care, and excellent result in the medium and long term.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Varela-Veiga A, Suárez-Magdalena O, Suárez-Amor Ó, Monteagudo B. Reconstrucción de defecto en cuero cabelludo mediante doble colgajo en hacha. Actas Dermosifiliogr. 2017;108:878–880.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 922 "Ancho" => 2834 "Tamanyo" => 479062 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Lesion to be excised (basal cell carcinoma). B, Design of the double hatchet flap. C, Dissection of the flap in the subgaleal plane.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1632 "Ancho" => 2250 "Tamanyo" => 536289 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Immediate postoperative result. B, Final outcome 2 months after the operation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The double hatchet flap as a potential alternative closure technique for scalp defects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Schultheis" 1 => "R. Kaufmann" 2 => "M. 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Moore" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archfacial.2010.27" "Revista" => array:6 [ "tituloSerie" => "Arch Facial Plast Surg" "fecha" => "2010" "volumen" => "12" "paginaInicial" => "198" "paginaFinal" => "201" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20479437" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cirugía del cuero cabelludo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Redondo-Bellón" 1 => "P. Redondo-Bellón" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "edicion" => "2nd ed." "titulo" => "Atlas Práctico de Cirugía Dermatológica" "fecha" => "2014" "editorial" => "Grupo Aula Médica" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010800000009/v1_201711021004/S1578219017302627/v1_201711021004/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010800000009/v1_201711021004/S1578219017302627/v1_201711021004/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017302627?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 8 | 18 |
| 2024 October | 184 | 66 | 250 |
| 2024 September | 193 | 43 | 236 |
| 2024 August | 245 | 87 | 332 |
| 2024 July | 163 | 45 | 208 |
| 2024 June | 144 | 44 | 188 |
| 2024 May | 150 | 37 | 187 |
| 2024 April | 107 | 33 | 140 |
| 2024 March | 138 | 36 | 174 |
| 2024 February | 114 | 45 | 159 |
| 2024 January | 158 | 42 | 200 |
| 2023 December | 141 | 29 | 170 |
| 2023 November | 131 | 43 | 174 |
| 2023 October | 159 | 43 | 202 |
| 2023 September | 184 | 40 | 224 |
| 2023 August | 118 | 28 | 146 |
| 2023 July | 145 | 40 | 185 |
| 2023 June | 103 | 32 | 135 |
| 2023 May | 160 | 35 | 195 |
| 2023 April | 145 | 33 | 178 |
| 2023 March | 139 | 39 | 178 |
| 2023 February | 103 | 25 | 128 |
| 2023 January | 109 | 53 | 162 |
| 2022 December | 116 | 40 | 156 |
| 2022 November | 84 | 23 | 107 |
| 2022 October | 71 | 33 | 104 |
| 2022 September | 96 | 56 | 152 |
| 2022 August | 79 | 33 | 112 |
| 2022 July | 63 | 51 | 114 |
| 2022 June | 47 | 44 | 91 |
| 2022 May | 145 | 32 | 177 |
| 2022 April | 159 | 60 | 219 |
| 2022 March | 190 | 60 | 250 |
| 2022 February | 162 | 45 | 207 |
| 2022 January | 189 | 49 | 238 |
| 2021 December | 140 | 55 | 195 |
| 2021 November | 128 | 56 | 184 |
| 2021 October | 138 | 68 | 206 |
| 2021 September | 95 | 47 | 142 |
| 2021 August | 96 | 56 | 152 |
| 2021 July | 84 | 43 | 127 |
| 2021 June | 150 | 62 | 212 |
| 2021 May | 108 | 57 | 165 |
| 2021 April | 301 | 92 | 393 |
| 2021 March | 193 | 43 | 236 |
| 2021 February | 142 | 40 | 182 |
| 2021 January | 84 | 30 | 114 |
| 2020 December | 81 | 30 | 111 |
| 2020 November | 62 | 23 | 85 |
| 2020 October | 64 | 15 | 79 |
| 2020 September | 61 | 27 | 88 |
| 2020 August | 39 | 31 | 70 |
| 2020 July | 57 | 17 | 74 |
| 2020 June | 34 | 35 | 69 |
| 2020 May | 27 | 14 | 41 |
| 2020 April | 32 | 16 | 48 |
| 2020 March | 24 | 22 | 46 |
| 2020 February | 4 | 1 | 5 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 10 | 0 | 10 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 10 | 0 | 10 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 4 | 0 | 4 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 4 | 0 | 4 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 6 | 0 | 6 |
| 2018 April | 0 | 1 | 1 |
| 2018 February | 23 | 4 | 27 |
| 2018 January | 56 | 6 | 62 |
| 2017 December | 33 | 13 | 46 |
| 2017 November | 72 | 36 | 108 |
| 2017 October | 3 | 6 | 9 |
| 2017 September | 5 | 8 | 13 |
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