Multiflap Closure of Scalp Defects: Revisiting the Orticochea Flap for Scalp Reconstruction

Abstract Reconstruction of the scalp following oncologic resection is a challenging undertaking owing to the variable elasticity of the soft tissue overlying the calvarium and the limited amount of tissue available for recruitment. Defect size, location, and skin characteristics heavily influence the reconstructive options available to the surgeon. Reconstruction options for scalp defects range from simple direct closure, to skin grafting, to adjacent tissue transfer with local flaps, and ultimately to free tissue transfer. Dermal regeneration templates have also gained popularity in the recent past. Often times a primary closure with multiple local flaps can be a prime choice in these scenarios. One such modality of multi-flap closure, the Orticochea flap, is an excellent option for scalp reconstruction as it decreases operative time, may provide hair-bearing skin, and potentially avoids the risks of general anesthesia in debilitated patients. We present an interesting case of a patient with a large scalp defect following melanoma excision that was successfully reconstructed with an Orticochea flap. A review of scalp reconstruction and uses of the Orticochea flap will follow the case presentation. CASE PRESENTATION A 61-year old Caucasian gentleman presented to the office with a two year history of a slowly enlarging hyperpigmented lesion of the occipital scalp. The patient reported a history of significant sun exposure. Examination of the scalp revealed a 2.5 cm ulcerated hyperpigmented lesion of the occipital scalp, along with a 1 cm focus of hyperpigmentation anteriorly and a smaller focus of irregular hyperpigmentation posteriorly. The remainder of the head and neck examination, including careful palpation of the neck for adenopathy, was unremarkable. A punch biopsy of the lesion was performed, revealing malignant melanoma with depth of invasion of at least 0.9 mm, and mitotic index of 1/mm2 , providing a preliminary tumor stage of at least T1b. A chest roentgenogram was negative, and a PET/CT was positive only for uptake at the primary site. Options were reviewed with the patient, and the patient elected to proceed with wide local excision of the primary lesion along with a sentinel lymph node biopsy. The patient was taken to the operating room, and sentinel node biopsy was negative for metastatic spread. Following excision of the primary cancer, there was an approximately 100 cm2 cutaneous defect down to the calvarium . In order to repair the defect