Closure of a scalp defect

Revisiting the Pericranial Flap for Scalp Reconstruction

ABSTRACT

Soft tissue deficits of the scalp due to trauma, infection, or tumor resection present a unique challenge to the reconstructive surgeon whose goal is to achieve excellent cosmesis in a hair bearing area without compromising coverage. While extensive undermining for large rotation flaps or free tissue transfer can provide necessary coverage, the pericranial flap is an excellent alternative for less ideal surgical candidates who cannot tolerate more extensive interventions or for patients who require long-term cancer surveillance. Elevation of the pericranial flap limits the need for back cuts through the skin and uses blunt dissection to preserve overlying hair follicles. Here we present a review of the anatomy and historical use of the pericranial flap for scalp coverage and we present 4 cases to demonstrate its current utility.

Rotation Flaps in Series: Simple Innovation for Complex Scalp Defects

A 42-year-old man presented with 2 full thickness defects in left parieto-temporal and right temporo-occipital regions with normal intervening scalp tissue. These 2 adjacent but discontinuous defects were covered in one stage with an innovative rotation flap design that provided 1 flap each for these 2 defects. This innovative flap design permitted one stage reconstruction with primary closure of the donor sites.

Treatment of Scalp Scars

The scalp presents many challenges to the reconstructive surgeon given its visible nature and the various considerations that must be given for optimal reconstruction. In this article, we review the anatomy of the scalp, the various options for reconstruction, and important considerations for improving the chances of optimal reconstruction of scalp defects.

Scalp reconstruction: an algorithmic approach and systematic review

IMPORTANCE

Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area.

OBJECTIVE

To review the current literature and describe a novel algorithm to help guide the reconstructive surgeon in determining the optimal reconstruction from a cosmetic and functional standpoint. Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, as well as the reconstructive ladder, are also discussed.

EVIDENCE REVIEW

A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence.

FINDINGS

Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer.

CONCLUSIONS AND RELEVANCE

Ideal reconstruction of scalp defects relies on a comprehensive understanding of scalp anatomy, a full consideration of the armamentarium of surgical techniques, and a detailed appraisal of patient factors and expectations. The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity.

LEVEL OF EVIDENCE

NA.

One stage reconstruction of skull exposed by burn injury using a tissue expansion technique

BACKGROUND

An area of the skull exposed by burn injury has been covered by various methods including local flap, skin graft, or free flap surgery. Each method has disadvantages, such as postoperative alopecia or donor site morbidities. Due to the risk of osteomyelitis in the injured skull during the expansion period, tissue expansion was excluded from primary reconstruction. However, successful primary reconstruction was possible in burned skull by tissue expansion.

METHODS

From January 2000 to 2011, tissue expansion surgery was performed on 10 patients who had sustained electrical burn injuries. In the 3 initial cases, removal of the injured part of the skull and a bone graft was performed. In the latter 7 cases, the injured skull tissue was preserved and covered with a scalp flap directly to obtain natural bone healing and bone remodeling.

RESULTS

The mean age of patients was 49.9±12.2 years, with 8 male and 2 female. The size of the burn wound was an average of 119.6±36.7 cm(2). The mean expansion duration was 65.5±5.6 days, and the inflation volume was an average of 615±197.6 mL. Mean defect size was 122.2±34.9 cm(2). The complications including infection, hematoma, and the exposure of the expander were observed in 4 cases. Nonetheless, only 1 case required revision.

CONCLUSIONS

Successful coverage was performed by tissue expansion surgery in burned skull primarily and no secondary reconstruction was needed. Although the risks of osteomyelitis during the expansion period were present, constant coverage of the injured skull and active wound treatment helped successful primary reconstruction of burned skull by tissue expansion.

Use of Urinary Bladder Matrix, a Bioactive, Acellular Scaffold, in Transplant Donor Scars and Androgenetic Alopecia: Initial Clinical Experience

Introduction:

Emerging regenerative medicine technologies have yet to be utilized in hair restoration surgery. Urinary bladder extracellular matrix (UBM) has shown promise in a wide variety of applications, inducing site-specific remodeling of injured tissue. This case series describes one clinician's experience in the first use of this regenerative material in hair restoration surgery.

Materials and Methods:

Twenty subjects underwent one of several protocols: (1) Treatment of 3-mm biopsies within donor site scars with UBM versus untreated controls, (2) Removal of a strip of donor site scar tissue and treatment of the site with UBM, (3) Soaking of occipital hair follicle grafts in a solution of UBM, or (4) Soaking of beard or temple hair follicle grafts.

Results:

At 6 months, hair was observed in biopsy sites that contained UBM, including donor scar areas that would not normally regrow hair, in contrast to the control biopsy sites. Similar results were observed for the strip excisions. UBM-soaked occipital, beard, and temple hair grafts consistently yielded higher than expected numbers of hair follicles.

Conclusions:

These cases provide anecdotal support for the hypothesized benefits of UBM regenerative technology in restoration therapy for men and women with androgenetic hair loss.

Scalp Reconstruction

The unique properties of the human scalp affect the surgeon's ability to reconstruct defects in this area. The scalp has a rich vascular supply, the ability to withstand wounds of greater tension than other regions, and often has hair that can camouflage resulting scars or asymmetries. Nevertheless, most of the scalp is relatively inelastic and is ideally reconstructed with hair-bearing skin. These properties compromise the ease of effective reconstruction. However, multiple reconstructive options exist. The selection depends on the size and thickness of the defect, its location on the scalp, limiting comorbidities of the patient, and the need for immediate or delayed reconstruction. These options are reviewed in a systematic manner, organized by the factors outlined previously.

Reconstruction of Complex Scalp Defects

OBJECTIVE

To demonstrate the use of multiple, large, local flaps in the reconstruction of large scalp defects.

METHODS

A retrospective review of 4 cases in which the "banana peel" method of scalp reconstruction, originally described by Orticochea, was used as a method for closure of moderately large to extensive scalp defects.

RESULTS

In all 4 cases, closure of the scalp defects was accomplished. Major morbidity included hair-bearing skin in the forehead in 1 patient, an inconsequential small flap dehiscence requiring closure in the same patient, and a partial loss of a small skin graft to a donor site defect in 1 patient.

CONCLUSIONS

While other techniques may be optimal for the management of most scalp defects, such as 1- to 2-flap rotation-advancement flaps in small to moderate-size defects and microvascular free tissue transfer and secondary tissue expansion for larger defects, we conclude that the multiple-flap reconstruction method as described by Orticochea may be useful in a small subset of patients. The latter includes older, severely debilitated patients who would be optimally treated with microvascular tissue transfer but cannot tolerate lengthy general anesthesia and young patients who will not accept a significant area of alopecia that might exist with other techniques, such as secondary intention, skin grafts, or free flaps.