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Page 2 of 14 Brawley et al. Plast Aesthet Res 2022;9:6 https://dx.doi.org/10.20517/2347-9264.2021.107

Figure 1. The reconstructive ladder algorithm representing increasing complexity with each additional step.

[9]
the increasing complexity of repair . Therefore, when approaching reconstruction, the safest, then simplest,
then most aesthetically pleasing option should be chosen dependent on each patient.

BRIEF ANATOMIC OVERVIEW
The skin has the greatest thickness on the scalp, ranging from 3 mm to 8 mm. The layers of the scalp listed
from superficial to deep include the skin, subcutaneous tissue, the galea, loose areolar tissue, and
periosteum. The complexity increases for the temporal scalp with the addition of the temporalis muscle and
accompanying deep and superficial temporalis fascia. The galea gives the scalp its inelastic properties, and
Raposio et al. found that full-thickness galeotomies 1cm apart gave an average of 1.67 mm of extra flap
[10]
length per galeotomy. Careful attention must be given while performing linear galeotomies as the
vascularity of the flap lies in the layer just beyond where the galea is being incised.

The arterial supply of the scalp from an anterior to posterior orientation includes the supratrochlear artery,
supraorbital artery, the anterior and posterior branches of the superficial temporal artery, the posterior
auricular artery, and the occipital artery [Figure 2]. The frontalis muscle is innervated by the frontal branch
of the facial nerve, the occipitalis by the posterior auricular branch of the facial nerve, and the temporalis by
the anterior division of the mandibular nerve (V3). Sensation of the scalp is supplied by terminal branches
of the trigeminal nerves, as well as the greater and lesser occipital nerves.