scalping flap PRACTICE - jrs.sagepub.com

PRACTICE JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 96 May 2003

Nasal reconstruction in the Yemen with the Converse
scalping flap

Kelvin W D Ramsey MA MB Garrick A Georgeu MSc FRCS John A Pereira MB FRCS
Naguib El-Muttardi MD FRCS

J R Soc Med 2003;96:230–232

Reconstruction of large nasal defects remains a surgical

challenge. For a good result, there is a need to match the

colour and texture of the nose, close or cover the donor site

well and maintain good function. The use of forehead tissue

for nasal reconstruction dates back to the Indian flap in

600BC,1 and modern techniques include the midline

forehead flap, the paramedian forehead flap, the Gilles

‘up-and-down flap’ and the McGregor transverse forehead

flap.2–5 The main drawback of these is that the flap is short

and under tension, so that perfusion may be compromised

in the area where it is most needed, at the nasal tip. An

alternative method, the scalping flap, was described by Jean

Marquise Converse, of the New York University School of

Medicine, in 1942.6 A pedicle of hair-bearing scalp is used

to move forehead skin onto the nose for extensive

reconstructions. This method is reliable and easy to

perform but many patients opt for a forehead flap rather

than spend time with a large hair-bearing pedicle while

awaiting the second-stage procedure. Working in the Figure 1 Operation technique. From original paper by Converse (see
Yemen, the senior author (N El-M) encountered numerous Ref. 6)

cases of advanced basal cell carcinoma of the nose. They

were beyond hope of cure by radiotherapy, even if it had main concerns were the length of time they would be in
been available, and multistage surgical procedures were too hospital and how quickly they could return to their families
costly. For social and economic reasons, patients wished to and work.
complete their treatment in a single hospital stay.

Therefore, after excision of the malignant lesion, the
Converse flap was used to provide soft-tissue cover. The Surgical technique

methods and two sample case histories are reported. In the first procedure a pattern of the nasal defect is made

and transferred as far laterally on the forehead as possible.

METHODS The design is made larger than the defect to allow for
natural skin retraction. The flap is raised superficial to

The patients were usually admitted from the outpatients frontalis, up to the level of the galea, where the dissection is

department. The carcinoma had often been present for two deepened to include the galea but leave the pericranium

years or more, during which various local remedies had (Figure 1).

been tried. Common reasons for finally attending the Once the flap is raised, the incision is extended from the

hospital were bleeding, repeated secondary infections, pain lateral border of the skin flap posteriorly with a coronal

and functional disruption of the nose. There was a strong incision from the tip of one auricle to the apex of the other,

preponderance of women, many of whom worked in the incorporating the contralateral superficial temporal vessels.

fields with headgear covering all but the nose. The patients’ To ensure adequate length for a long columella and thus a

good nasal tip, the flap is mobilized until the distal tip easily

230 Department of Plastic Surgery, St Thomas’ Hospital, London SE1 7EH, UK reaches the upper lip.7 The flap is then sutured down onto
Correspondence to: K W D Ramsey, The Garden House, Eyhurst Close, the nasal defect while the rest is folded in on itself without
Kingswood, Surrey KT20 6NR, UK

E-mail: [email protected] tension to mould the nasal tip, columella and alar rims. The

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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 96 May 2003

permanent forehead defect can be covered with a 3 weeks later, the flap was divided and returned to the
retroauricular full-thickness skin graft. The temporary scalp forehead and the patient was discharged. Although not
defect is covered with a split skin graft or a non-adherent cosmetically perfect the result was functionally excellent
dressing, and pressure bandages are applied for 24 hours. (Figure 3b).

The second-stage procedure is performed 2–3 weeks DISCUSSION
later, by which time the flap has acquired a host blood
supply. The pedicle is divided and inset, while the proximal In the Yemen the delay in presentation of basal cell
end of the flap, which is surplus to requirement, is returned carcinoma is probably due to a combination of ignorance of
to its original donor site on the forehead. Additional the potential seriousness of the lesion, misdiagnosis as
support or lining of the nose can be used in conjunction primary infection and treatment with antibiotics, misplaced
with the Converse flap and may include septal composite confidence in traditional remedies, fear of ‘western
grafts, bone or cartilage.4,7 medicine’, and inability to take time off work or pay for
medical attention. In most of the patients seen radiotherapy,
CASE HISTORIES even if available, would no longer have been an option.
Even for smaller lesions the required regimen, entailing
Case 1 multiple visits to the hospital, might not be economically
feasible. The choice is thus essentially limited to surgery.
A woman of 45 had a basal cell carcinoma involving both The use of tissue expanders in the forehead to create ‘extra
the soft tissue of the nose and the nasal skeleton itself skin’ for cover of the nasal defect has been well described
(Figure 2a). Admitted directly from the outpatients for such cases,8 but in this series was ruled out because of
department, she underwent the two stages of the Converse the high cost but also because of the required number of
scalping flap reconstruction during a 3-week inpatient stay. hospital visits and perceived higher infection rate. The
There were no postoperative complications. At the time of scalping flap is an acceptable compromise between excision
discharge she was tumour free and had a good functional of tumour, reconstruction, aesthetics and patients’ desire to
result (Figure 2b), enabling her to rejoin her family with its return to their work and families.
agricultural lifestyle.
The reliability and versatility of the Converse scalping
Case 2 flap can be explained in terms of the angiosomes involved.
In 1987 Taylor and Palmer introduced the concept of
A man aged 60 sought advice about a basal cell carcinoma dividing the body into angiosomes—three-dimensional
that had clearly been present for many months. It had anatomical blocks of tissue supplied by source arteries.9
invaded the entire distal tip of his nose and was starting to Houseman and Taylor used this new knowledge of
invade more laterally. The tumour was resected and a territories of the superficial temporal and ophthalmic
Converse scalping flap was raised (Figure 3a), the
temporary defect being covered with a split skin graft.

Figure 2 Case 1 (a) preoperative; (b) postoperative 231
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JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 96 May 2003

Figure 3 Case 2 (a) between stages; (b) postoperative

arteries to explain the differences in scalp and forehead Sixty years after it was first described, the Converse
flaps.10 They showed that, in the design of a flap, an scalping flap still has a place in subtotal nasal reconstruction.
adjacent vascular territory can safely be captured on the
branches of one angiosome but that perfusion difficulties can REFERENCES
arise when attempts are made on one or more successive
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length-to-breadth ratios. Whereas the Converse scalping
flap is based primarily on the superficial temporal vessels on 2 Tardy ME, Sykes J, Kron T. The precise midline forehead flap in
one side, avoids the ophthalmic territory on the same side reconstruction of the nose. Clin Plast Surg 1985;12:481
and links with the contralateral ophthalmic or superficial
temporal artery to produce a two-territory flap, McGre- 3 Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St Louis:
gor’s transverse forehead flap tries to capture three Mosby, 1994:57–91
additional territories in succession, often with poor tip
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defects, skin for the permanent defect can be taken from repairing the postexcisional defect. Br J Plast Surg 1963;16:318
the upper and lateral portion of the forehead, thus
minimizing the visible scar. The donor defect can be 6 Converse JM. New forehead flap for nasal reconstruction. Proc R Soc
covered with a full thickness skin graft from the retro- Med 1942;35:811
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colour and texture match. Most of the incision is behind the 7 Converse JM. Clinical applications of the scalping flap in
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two, the hair-bearing scalp skin is returned, leaving scars
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the head and neck. Sixty-Fifth Annual Meeting of the American Association of
Plastic Surgeons. Washington, DC: AAPS, 1986

9 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg
1987;40:113

10 Houseman ND, Taylor GI, Pan W-R. The angiosomes of the head and
neck: anatomic study and clinical applications. Plast Reconstr Surg
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