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 FIG. 9-05. The scalp flap was inset into the left forehead to create a hairline and anastomosed to the recipient left temporal vessels.
 FIG. 9-06. Seven months later, an identical procedure was performed, transplanting another strip of scalp between twins. The donor flap is outlined on the left superficial temporal vessels.
 FIG. 9-07. Donor flap is isolated.
 FIG. 9-08. Flap is transplanted to recipient's right frontal area, anastomosed to the right superficial temporal vessels.
 FIG. 9-09. Despite the uncomplicated success of the two previous procedures, the recipient twin had a large nonhair-bearing area (7 x 22 cm) remaining behind the previously transplanted scalp flaps, plus a low anterior hairline. The donor twin had residual alopecia along the left temporal donor scar.
Six years later, a third scalp transplant between these identical twins was performed to reconstruct remaining areas of traumatic alopecia. Before this third scalp transplant, scalp expansion was done in both twins. (From Valauri, F.A., Buncke, H.J., Alpert, B.S., Lineaweaver, W.C., and Argenta, L.C.: Microvascular transplantation of expanded scalp flaps between identical twins. Plast. Reconstr. Surg. 85:432, 1990. )
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 FIG. 9-10. Recipient twin's scalp is expanded with two expanders before the third transplant, one in the forehead to raise the hairline and one in the occipital area to permit advancement of the posterior scalp.
 FIG. 9-11. A. Diagram of expander placement in the recipient patient. B. Subsequent flaps transposed.
 FIG. 9-12. Elevation of flaps in recipient after removal of expanders.
 FIG. 9-13. Interpolation of anterior flaps and advancement of occipital flap.
 FIG. 9-14. A. Diagram of expander placement in the donor twin. Correction of left frontal bald area. B. Donor flap No. 3 outlined over remaining expander.
 FIG. 9-15. Expanded occipital scalp of donor twin.
 FIG. 9-16. Donor twin prone on operating table, occipital artery revealed by Doppler out over expander.
 FIG. 9-17. Scalp flap at recipient site. Note the recipient scalp defect. The occipital vein was fibrotic, possibly secondary to multiple previous surgeries and recent expander compression. A small superficial vein in the island was connected by a long vein graft to a proximal vein.
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