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Brawley et al. Plast Aesthet Res 2022;9:6 https://dx.doi.org/10.20517/2347-9264.2021.107 Page 5 of 14

overall complication rates of local flaps at 24.1% in their retrospective review of scalp defects. On review of
the literature, there is no high-powered study that documents each specific complication and associated
rates for local flaps.

When approaching scalp defects with locoregional flaps as a reconstructive option, decision making is
dependent on the defect size and location. These factors can narrow the choices, with the understanding
that other reconstructive options may also be successful. Therefore, the proceeding sections will begin with
a picture of a defect to initiate the reconstructive thought process for the reader.

Vertex scalp defects
The vertex is the most inelastic portion of the scalp due to the confluence of the galea without an
accompanying muscle layer [Figure 4]. Due to the biomechanics, increased undermining must be
performed for either primary or local flap closure. Small defects under 2-3 cm in diameter should be closed
primarily.

The triple rhombic flap, also known as a multiple Limberg flap, is a three pedicled transposition flap
primarily used to close to medium-sized defects on the vertex of the scalp where laxity is scarce [32,33] .
Derivatives of this flap include the rotational pinwheel and multiple O-to-Z flaps. The author has found the
triple rhombic flap to be more effective than the derivatives due to better distal flap tip vascularity and less
opportunity for central dehiscence. The triple rhombic flap is designed to close an approximate hexagonal
defect . Perpendicular lines are drawn from 3 equidistant locations around the defect, extending away
[32]
from the defect to a length of approximately of one side of the hexagon. Once that length has been reached,
60-degree angles are drawn in a clockwise (or counterclockwise) fashion using this same distance. After
scalp undermining and incisions, the flaps are rotated in the same direction to fill the defect [Figure 5].

2
Closure of larger defects up to 72 cm have been reported with modified quadruple rhombic flaps . A
[34]
benefit of multiple rhombic flaps in this location is that rotating tissue into itself will recreate the natural
[2]
“whorl” hair pattern seen at the vertex by recruiting tissue 360 degrees around the defect . This pattern can
also be recreated with a spiral rotational flap; however, this is more suitable for smaller defects .
[35]
Additionally, should a patient already have alopecia at the vertex, the triple rhombic flap has been
successfully used for the sole purpose of cosmesis and hair restoration . Because of the central design of
[36]
this flap and the apical nature of the vertex itself, its high success rate and versatility with all defect sizes, the
triple rhombic flap should be highly considered for any solitary vertex defect in a non-radiated scalp.

Other flap choices for larger defects of the vertex include double opposing rotational flaps with or without
skin graft supplementation centrally. Still larger defects may require free flap coverage or tissue expansion.

Anterior scalp and forehead defects
Due to this cosmetically sensitive location, extensive communication with the patient should occur
regarding reconstructive expectations [Figure 6]. Smaller defects under 1-2 cm in diameter can be closed
primarily with appropriate undermining. The hairline and brow position must always be considered
preoperatively. More extensive undermining should be performed posteriorly as not to disrupt these
structures.

Double opposing rectangular advancement flaps, also known as H-flaps, can be used for anterior scalp and
forehead defects greater than 2 cm. A major advantage of this flap is that the incisions are parallel and can
camouflage with resting skin tension lines of the forehead. Its parallel orientation also optimizes brow and