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Case 3: Bilateral rotation flaps on scalp

Authors: Mari Irgens Bøkset, M.D., Magnus Balslev Avnstorp, M.D.

A 77-year-old female patient was referred to our department of plastic surgery with a squamous cell carcinoma localized to the vertex of the scalp, confirmed by punch biopsy. Initially, the plan was to excise the tumor and reconstruct using a split thickness skin graft. However, this would have resulted in a bald area, thus not ideal for this female patient.

Before and after

Pre-Operative Considerations

There is sparse skin-excess in the scalp region, therefore rotation flaps are a good option when considering local skin flap reconstruction. Due to the large size of the excision defect, we decided to design two ooposing rotation flaps, also known as a Yin-Yang flap.


Step 1: Pre-operative markings and flap design

Design of double rotation (Yin Yang) flap. The lenght of the rotation flaps are 2x the lenght of the defect.


Step 2: Elevation of flaps

Flaps are elevated in the plane of the fascia galea aponeurotica, to avoid bleeding and keep a safe blood supply.


Step 3: Flap assessment

Assesment of flap size by dragging of flaps.
In case the defect cannot be closed, you must further lenghten the rotation flap or further undermine around the defect.
Slight scoring of the aponeurotic galea fascia might also be performed.


Step 5: Closing of defect

The flaps have been adapted nicely withour tension, to keep the blood supply.

Post-Operative Plan

The patient was seen for follow-up and removal of sutures 10 days post-surgery. In case of high tension the sutures may be removed after 14-21 days.


  • The tumor was excised to the level galea aponeurotica, and the flaps were harvested at the same level, providing a well-demarcated excision and flap elevation. Blood perfusion to the flaps were considered when designing the flaps, which should rely on the periferal branches of the maxillary arteries, lateral to the scalp.


  • The flaps should be designed sufficient in size in order to cover the defect.