The spiral flap: A novel approach to scalp closure in children

Abstract

Background: The spiral rotational advancement flap is a single-stage technique that has been described for the closure of nasal ala defects and in nipple reconstruction. Herein we present our experience using the spiral flap for closure of moderately sized defects of the scalp vertex in children. Compared to other scalp reconstructive approaches, such as a simple rotational flap or primary linear closure, the spiral flap design offers improved cosmesis through recreation of the natural whorl pattern within the hair-bearing scalp. Scar camouflage is especially important in the pediatric population, as increased skin elasticity and continued cranial growth impart a high risk of scar widening in children.

Methods: The electronic patient database at a single, urban, academic, tertiary pediatric otolaryngology and facial plastic surgery practice was queried to identify children who had undergone scalp reconstruction. The medical records of three children who had undergone spiral rotational advancement flap closure by a single surgeon were reviewed. Indications for scalp reconstruction in these patients were limited to the excision of benign, congenital lesions, such as infantile hemangioma unresponsive to propranolol and hypertrophic scarring and alopecia from aplasia cutis congenita A case example of a 15-month-old boy with scarring of the scalp, secondary to aplasia cutis congenita, is chosen for demonstration of the spiral flap design in step-by-step instructional video.

Results: A spiral rotational advancement flap was conceived for multi-layer repair in three pediatric patients. By reproducing the main elements of the logarithmic spiral flap design, the apex of the flap is rotated in on itself to complete a spiral closure pattern. There were no operative or post-operative complications. At various post-operative timepoints, the wounds appeared well-healed without evidence of flap necrosis, skin discoloration, or residual alopecia.

Conclusion: We report satisfactory results using the spiral rotational advancement flap to address moderately sized defects of the scalp vertex in three pediatric patients. Although this flap has primarily been used in the reconstruction of the nasal ala in adults, we feel that this technique is ideally suited for scalp reconstruction, particularly in young children with highly elastic tissues in areas with decreased pliability. This approach has the added advantage of simulating the natural hair whorl in a cosmetically sensitive region and may serve as an effective alternative to linear reconstruction methods. The technique described can be added to the armamentarium of the pediatric plastic surgeon.

Keywords: Alopecia; Aplasia cutis congenita; Infantile hemangioma; Pediatric facial plastic surgery; Scalp reconstruction; Spiral flap.