Scalp reconstruction: an algorithmic approach and systematic review

Management of Immobile Scalp Skin Tumors and Analysis of Skin Graft Survival on Burred Calvaria

Background

Surgeons face challenges associated with adherent cutaneous scalp malignancy. Traditional general anesthetic excision involves periosteal removal and burring of the outer table of the calvaria for deep margin clarity and tissue reconstruction. Research on this practice is limited, and graft survival in burr-treated bones is underexplored. This study aimed to assess the clinical margin accuracy for immobile scalp malignancies, identify deep-invading malignancy types, and evaluate graft survival in burr-treated calvariae. It compares split-thickness grafts (STSGs) and full-thickness grafts (FTSGs).

Methods

Twelve fixed scalp malignancies were excised under anesthesia, allowing immediate STSG or FTSG for defect reconstruction. Postsurgery, graft take, malignancy type, and margin clearance were evaluated.

Results

Histopathological diagnosis identified seven squamous cell carcinomas, two melanomas, one basal cell carcinoma, one adenocarcinoma, and one metastatic squamous cell carcinoma. Deep margins ranged from 0 to 0.9 mm, and peripheral margins ranged from 0 to 15 mm. The graft take was 100% in eight cases, with total failure in two cases, and 75%-90% in two cases. The five STSGs had 100% take and 90% take. The three FTSGs had 100%, 75%, and two failed.

Conclusions

Clinical examination effectively gauges the tumor fixation depth, but large lesions may require imaging. Most deep-invading tumors were SCCs. STSGs performed better on burr-treated Calvaria than FTSGs.

Integra® Dermal Regeneration Template in Complex Scalp Reconstruction

Background/Objectives: The need for surgical reconstruction of scalp defects following the excision of cutaneous skin cancers is an increasingly common procedure. Particular challenges arise when considering options for reconstruction of large defects not amenable to local skin flap coverage. The use of skin grafts poses the risk of donor site morbidity. This paper investigates the emerging use of Integra®, a synthetic acellular dermal regeneration template, as an alternative or adjunct to skin grafting in scalp reconstruction. Methods: The study presents a retrospective analysis of 101 patients who underwent Integra®-based reconstruction of scalp defects. Demographics, procedure details, complications, need for further surgery, and time to healing were evaluated. Results: The overall success rate of the one-stage Integra®-only procedure was 95%, with a minor complication rate of 30.7%. Anticoagulation medication was identified as an independent risk factor for post-operative infection, while previous head and neck radiotherapy and increased defect depth were associated with the requirement for a second-stage skin graft. Conclusions: These findings support the consideration of Integra® as a safe and viable alternative for both partial and full thickness scalp defects in a select cohort of complex highly co-morbid patients, reducing complications and the need for additional procedures.

Linear Scalp Incision in Brain Tumor Surgery: Intraoperative and Postoperative Considerations

BACKGROUND

Although the linear scalp incision is commonly used in neurosurgical practice, a systematic study elucidating its pros and cons in a specific surgical setting is lacking. Herein, we analyzed our experience with linear scalp incision in brain tumor surgery and the impact on intraoperative variables and postoperative complications.

METHODS

Patients undergoing brain tumor surgery (January 2014-December 2021) at 2 neurosurgical departments were included and divided into 2 groups: linear or flap scalp incision. Patients' demographics characteristics, surgical variables, and wound-related complications were analyzed.

RESULTS

More than a total of 1036 craniotomies, linear incision (mean length 6cm) was adopted in 282 procedures (27.2%). Mean maximum diameter of the craniotomy was 5.25 cm, with no statistical difference between the 2 groups. In emergency surgery (36 cases), the linear and flap incisions were used indifferently. Linear incision was predominant in supratentorial and suboccipital lesions. Flap incision was significantly more frequent among meningiomas (P < 0.01). Neuronavigation, operative microscope, and subgaleal drain were more frequently used in the flap scalp incision group (P = 0.01). Overall complication rate was comparable to flap scalp opening (P = 0.40).

CONCLUSIONS

The use of the linear incision was broadly applied for the removal of supratentorial and suboccipital tumors granting adequate surgical exposure with a low rate of postoperative complications. Tumors skull base localization resulted the only factor hindering the use of the linear incision. The choice of 1 incision over another didn't show to have any impact on intraoperative and postoperative variables, and it remains mainly based on surgeon expertise/preference.

Surgical Management for Hair Restoration: A Review of Contemporary Techniques

BACKGROUND

Hair loss can cause psychological distress for patients, regardless of the etiology or extent of the defect. Many conservative and pharmacological approaches are successful in management, but refractory or severe cases often mandate surgical treatment. Surgical techniques have been refined over the course of a century, and we aim to review the most contemporary strategies.

METHODS

A review of the literature was performed using the databases PubMed, Web of Science, and Embase, in May 2020. Articles were included if they discussed techniques used within the past 10 years, in search of more contemporary strategies and the most widely used approaches.

RESULTS

The use of local flaps, scalp reduction surgery, and hair transplantation techniques are all used for various indications. Modern hair transplantation can be further divided into follicular unit excision and follicular unit transplantation, each with its own advantages. Local flaps are most often used for post-traumatic and reconstructive indication, while hair transplantation can be used for smaller cosmetic lesions or in combination with a variety of other reconstructive techniques.

CONCLUSION

Hair loss continues to be a challenging pathology for both patients and physicians, regardless of etiology. When conservative treatment is inadequate, there exist multiple surgical techniques that can feasibly restore hair, though the exact degree of success may vary between patients. The proper technique is dependent upon etiology, patient specific factors, as well as surgeon experience and comfort.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Concomitant Reconstruction of Multiple Scalp Defects With One Rotational Flap

The cornerstones of scalp reconstruction are provisions of adequate skin paired with a satisfactory cosmetic outcome without hairline distortion. Several techniques have been described over the years to reconstruct sizable defects. Currently, an individualized approach, based on the patient's medical status and needs, the defect characteristics, and the local tissue quality and availability, should be considered for an optimal outcome. The reconstruction of multiple scalp defects, by means of a well-planned rotational flap, is proposed as a viable option with many advantages. It enables concurrent reconstruction of the defects, obviates further surgical incisions, and elaborates surgical maneuvers, minimizing operative time and complications risk. A satisfactory esthetic outcome can be achieved.

Spectrum of malignant scalp tumours and its impact on management-a tertiary care cancer centre experience

BACKGROUND

Tumours on the scalp are diverse and often exhibit site- and histology-specific characteristics. Reconstructing the scalp after oncological resection has always been challenging because of its unique anatomy.

METHODOLOGY

A retrospective review of patients with malignant scalp tumour operated on at a single institution over 10 years was performed. Data were collected and analysed regarding the scalp tumour profile, treatment, and the outcome of these procedures.

RESULTS

Of the 66 patients in our study, 33 (50%) had SCC. In addition to this, 21% were sarcomas, 17% were appendageal carcinomas, 11% were BCCs, and 1% was neuroendocrine carcinoma. Cortical erosion was observed in 6 patients in the CT imaging, all with SCC histology. Among the eight patients with pathological nodal involvement, three had angiosarcoma, three had SCC, one had appendageal carcinoma, and one had neuroendocrine carcinoma. The mean surgical defect size was 67.4 cm2. The surgical defect was reconstructed with local flaps in 58% of patients and primary closure in 27%. Local and systemic recurrence was noted in 25% of patients. Tumour size more than 6 cm, tumour histology (SCC & sarcoma), unplanned margin-positive excision, and residual disease in re-excision had higher recurrence, even though the p-value was not significant.

CONCLUSION

Scalp tumours are heterogeneous in their clinical profiles. Often, its tumour biology and microscopic extent are underestimated. High suspicion, histological diagnosis, and clear surgical margins are all requirements in successfully treating scalp tumours. In order to minimize morbidity and restore an aesthetic and functional outcome, it is critical to use the simplest scalp reconstruction whenever possible.

Reconstruction of Moderately and Severely Atrophic Scalp-A Multicentric Experience in Surgical Treatment of Patients Irradiated for Tinea Capitis in Childhood and Surgical Algorithm

Background and Objectives: Before the introduction of griseofluvin, the use of X-ray radiation was the treatment of choice for tinea capitis. More than half a century later various types of tumors have been found to be associated with childhood irradiation due to tinea capitis, most commonly cancers of the head and neck, as well as brain tumors. The often unusually aggressive and recurrent nature of these tumors necessitates the need for repeated surgeries, while the atrophic skin with an impaired vascular supply due to radiation often poses an additional challenge for defect reconstruction. We present our experience in the surgical treatment of such patients. Materials and Methods: This is a retrospective cohort study. In this study, 37 patients treated for acquired defects of the scalp with a history of irradiation therapy due to tinea capitis in childhood were included in this study, 24 male and 13 female patients. The mean age at the first appointment was 60.6 ± 7.8, with the youngest included patient being 46 and the oldest being 75 years old. Patients' characteristics, surgical treatment, and complications were analyzed and a reconstructive algorithm was developed. Results: Local flaps were used for reconstruction in 34 patients, direct sutures were used in 10 patients and 20 patients received split-thickness skin grafts for coverage of both primary and secondary defects for reconstruction of flap donor sites. One regional flap and one dermal substitute covered by an autologous skin graft were also used for reconstruction. Complications occurred in 43.2% of patients and were significantly associated with the presence of comorbidities (p = 0.001), aseptic bone necrosis (p = 0.001), as well as skin atrophy in frontal, occipital, and parietal region (p = 0.001, p = 0.042 and p = 0.001, respectively). A significant correlation between major complications and moderate skin atrophy was found only in the parietal region (p = 0.026). Conclusions: Unfortunately, many protocols developed for scalp reconstruction are not applicable in the setting of severe or diffuse scalp skin atrophy associated with high tumor recurrence rate and radiation-induced vascular impairment, such as in tinea capitis patients in Serbia. An algorithm has been developed based on the authors' experience in managing these patients.

A novel treatment approach for traumatic scalp defects with exposed calvaria denuded of pericranium by combined application of low-temperature plasma and negative pressure wound therapy: A case series

Background and Aims

Traumatic scalp defects with an exposed calvaria denuded of the pericranium are challenging to manage. In such cases, adjunctive therapies, such as milling the outer calvarial cortex and applying negative pressure wound therapy (NPWT), can promote granulation tissue. This case series describes the successful management of traumatic scalp defects after cortical craniectomy using a combination of low-temperature plasma (LTP) and NPWT.

Methods

This is a retrospective single-surgeon case series. Three patients with traumatic scalp wound defects underwent cortical calvarial bone removal after LTP combined with NPWT. LTP was applied to the diploic space of the calvaria weekly or twice weekly using BioPlasmaJet BPJ1 (BIOPlasma System: Model-BioPlasmaJet System). Subsequently, NPWT was applied with a continuous pressure of 110 mmHg until good granulation tissue formation was achieved for skin graft placement.

Results

Two males and one female were included, and the mean follow-up duration was 7 (range 3-12) months. In addition, the average time to achieve good granulation tissue formation was 4 (2-6) weeks; all patients achieved successful split-thickness skin grafting within 3 weeks after placement without signs of calvarial infection.

Conclusions

The combination of LTP and NPWT is a safe and effective treatment modality for scalp defects with exposed calvaria denuded of the pericranium resulting from trauma. Combining these two therapies may provide a synergistic effect that enhances granulation tissue formation and prevents local infections without complications.

A staged approach for complex scalp defects using titanium mesh and anterolateral thigh flaps: Two case reports

INTRODUCTION AND IMPORTANCE

Scalp tumors are diverse, with the characteristics of individual tumors depending on the cell lineage. Invasive squamous cell carcinoma and sarcomas of the scalp are a variety of uncommon, aggressive neoplasms of the head and neck. Resecting large invasive tumors causes extensive full-thickness scalp defects, and repairing these defects remains challenging.

CASE PRESENTATION

The authors present two successful cases using a staged approach with titanium mesh and free tissue transfer (anterolateral thigh flap) technique.

CLINICAL DISCUSSION

Complex scalp defects are challenging to manage when insufficient local tissue is available. This frequently necessitates the use of microvascular free tissue transfer for reconstruction. The availability of microsurgery in developing countries such as ours has enabled functional and aesthetic reconstruction for patients presenting with such complex defects.

CONCLUSION

Free flaps are safe and reliable when scalp defects are significant and require both scalp and calvarial reconstructions. The ALT-free tissue transfer shows predictable results in both clinical cases.

Pedicled Latissimus Dorsi Flap for Extensive Scalp Reconstruction in Acute Burns

Extensive full-thickness head and neck burn defects represent some of the greatest challenges because of the exposure of burned calvaria and lack of good local reconstructive options. This study reports the use of a pedicled latissimus dorsi (LD) muscle flap to cover a large full-thickness scalp burn defect measuring 20 × 15 cm, including 15 × 13.7 cm of bone exposure and extending from the posterior neck to the mastoid and vertex of the scalp. The authors discuss the technique to safely maximize the reach, which includes distal dissection to the iliac crest and thoracolumbar fascia, dissection of the pedicle to the axillary vessels, tunnel creation through the pectoralis major muscle, re-attachment of the LD origin to the pectoralis major and teres major, and undermining of the neck skin and subcutaneous tissue to avoid damage of the accessory nerve. This case highlights the reach of a pedicled LD muscle flap for extensive scalp reconstruction for defects all the way to the vertex and beyond. The size and reliability of the LD muscle makes it a valuable alternative for large scalp defects for cases of complex scalp reconstruction in patients deemed not ideal candidates for free flap reconstruction.

Negative Pressure Wound Therapy (NPWT) after Hybrid Reconstruction of Occipital Pressure Sore Using Local Flap and Skin Graft

Background and objectives: Pressure sores are a common medical burden among patients, particularly those who are bedridden or frail. Surgical management of occipital pressure sores poses unique challenges due to limited elasticity and the spherical shape of the scalp. This study aims to evaluate the efficacy and safety of a novel reconstruction method utilizing a local transpositional flap and split-thickness skin graft with negative pressure wound therapy (NPWT) for occipital pressure sore treatment. Material and methods: A retrospective analysis was performed on patients with occipital pressure sores who underwent hybrid reconstructions using a local flap and split-thickness skin graft in conjunction with NPWT. Surgical outcomes, including flap survival rate, graft take percentage, and complications, were assessed. A comparative analysis was performed between the NPWT group and the conventional dressing group. Results: The NPWT group (n = 24) demonstrated a significantly higher mean graft take percentage at postoperative day 14 compared with the conventional dressing group (n = 22) (98.2% vs. 81.2%, p < 0.05). No significant difference in flap survival rate was observed between the two groups. Conclusions: As the aging population continues to grow, occipital pressure sores have gained significant attention as a crucial medical condition. The innovative surgical method incorporating NPWT offers an efficient and safe treatment option for patients with occipital pressure sores, potentially establishing itself as the future gold standard for managing this condition.

Reconstruction of Scalp and Forehead Defects: Options and Strategies

Background Aesthetic reconstruction of scalp and forehead defects with local flaps and minimal donor site morbidity is the primary goal of coverage. While selecting the coverage technique, essential factors such as size, location, and components of a defect, hair-bearing or non-hair-bearing nature of skin, status of the exposed skull, need for radiation, patient condition, availability of local tissue, and the potential for hairline distortion should be kept in mind. Materials and methods This is a retrospective analysis in which 54 patients who underwent soft tissue reconstruction of the scalp and forehead defects were included. The defect size was categorized into four groups: small: <4 cm2, medium: 4-50 cm2, large: 50-200 cm2, and very large: >200 cm2. Reconstruction of all defects was done according to the defect's size, location, and depth. All patients were regularly followed at intervals of two weeks, six weeks, and three months, respectively. The outcome was evaluated in terms of flap survival, flap coverage scale, the requirement of secondary treatment, postoperative complications, and final aesthetic appearance. Results In 54 consecutively treated patients with scalp and forehead defects, the male-to-female ratio was 2:1, and the overall mean age of participants was 34.8 years, ranging from 0.5 to 66 years. The most common etiology of the defect was trauma (16; 29.6%), and the most common location of the defect was combined (16; 29.6%). Rotation flap and primary closure were the most commonly performed procedure, each 12 (22.2%) in number. Out of 12 primary closure cases, two patients developed wound dehiscence because of infection. All cases of skin grafting healed well. All cases of transposition flap with skin grafting at the donor site went uneventful, and the dog ear at the base was revised later. One case of the bipedicle flap in which partial graft loss occurred at the donor area was managed with regrafting. Two cases of single rotation flap, one double rotation flap, and one free latissimus dorsi muscle flap developed distal necrosis. The excellent aesthetic outcome was found in all cases of primary closure and single and double rotation flaps. Conclusions Local flaps have an architecture similar to the recipient site, and low donor site morbidity results in an aesthetically more pleasant outcome. In our experience, scalp defects up to 50 cm2 were covered with the local scalp flaps with primary closure of the donor area. Defects ranging from 50 to 200 cm2 required local scalp flap with skin grafting at the donor area. Free tissue transfers are usually needed when the defect is very large, devoid of the periosteum, or with the calvarial defect.

Scalp Reconstruction Using the Latissimus Dorsi Free Flap: A 12-Year Experience

BACKGROUND

Complex scalp defects are regularly reconstructed using microvascular tissue transfer. The latissimus dorsi free flap is one of the workhorse flaps used in scalp reconstruction. These cases necessitate, particularly in the elderly, a close cooperation between plastic surgeons and neurosurgeons. The purpose of this study was to evaluate the suitability of the latissimus dorsi free flap for complex scalp reconstructions and to analyze potential risk factors.

METHODS

A retrospective study identified 43 patients undergoing complex scalp reconstruction using a latissimus dorsi free flap at our department between 2010 and 2022.

RESULTS

The mean patient age was 61 ± 18 years. Defects were mostly caused by oncologic tumor resections (n = 23; 55%), exposure to a cranioplasty (n = 10; 23%) or infection (n = 4; 9%). The most frequent recipient vessels were the superficial temporal artery (n = 28; 65%), external carotid artery (n = 12; 28%) and the venae comitantes (n = 28; 65%), external jugular vein (n = 6; 14%). The reconstructive success rate was 97.7%. There was one total flap loss (2%). Partial flap loss occurred in five cases (12%). Follow-up was 8 ± 12 months. Major complications were seen in 13 cases, resulting in a revision rate of 26%. Multivariate logistic regression identified active tobacco use as the only risk factor for major complications (odds ratio 8.9; p = 0.04).

CONCLUSION

Reconstruction of complex scalp defects using the latissimus dorsi free flap yielded high success rates. Among the potential risk factors, active tobacco use seems to affect the outcome of complex scalp reconstructions.

Exophytic Squamous Cell Carcinoma of the Scalp: A Case Report

Squamous cell carcinoma (SCC) is the second-most common clinical presentation of non-melanoma skin cancer. Despite its prevalence, the rate of growth and development of SCC lesions is low. We present a case report of an exophytic SCC of the midline scalp. Over approximately 18 months, the exophytic portion of this lesion grew to a size of 8.5 x 7 cm due to the fact that the patient did not seek medical attention. The patient suffered from many predisposing factors including active smoking status, type II diabetes, and significant previous sun exposure. In addition to these predisposing factors, the patient did not have comprehensive health insurance to cover outpatient medical care. This case highlights the importance of early intervention in the management of head and neck skin cancers and the negative impact of delayed treatment.

Dermal Substitutes and Skin Grafts in the Reconstruction of Post-Traumatic Total Scalp Avulsion: A Case Series

Although scalp defects can vary in size and thickness, scalp avulsion represents a rare occurrence. This type of lesion may have different origins, but it is usually related to long hair being caught in agricultural machinery. The management of full-thickness scalp defects poses a challenge to the head and neck surgeon due to the possible involvement of neurovascular structures and scar retraction, which can affect the esthetic restoration of the area. Several algorithms for the choice of scalp reconstruction have been proposed in the literature and different techniques are available for extensive scalp defect reconstruction (local soft tissue flap, microvascular free flap, and skin graft combined with dermal substitutes), based upon the scalp defect type. Here we describe six cases of patients with total scalp avulsion, which required a combined reconstruction with a split-thickness skin graft (STSG) and Integra® matrix immediately after the trauma.

The 1-2-3 cm Advancement Flap Rule in Scalp Reconstruction

Background Defects of the scalp are surgically challenging for several reasons: anatomical convexity limits tissue displacement, resistance to advancement is different at different points on the scalp, and there is also interindividual variation. For many patients, the idea of undergoing an advanced surgery such as a free flap is not preferred. Hence, a simple technique with a favorable outcome is needed. We hereby introduce our new technique: the 1-2-3 scalp advancement rule. Objectives The objective of this study is to discover a novel way to reconstruct scalp defects secondary to trauma or cancer, without having the patient undergo a big procedure. Material and Methods A total of nine cadaveric heads were used to test the idea of achieving greater advancement and increased scalp mobility to cover a 4×8 cm-sized defect using our proposed 1-2-3 scalp rule. Three steps performed were advancement flap, galeal scoring, and removal of the outer table of the skull. The measurement of advancement was recorded after each step, and the results were analyzed. Results The mobility of the scalp was calculated from the sagittal midline with identical arcs of rotation. With zero tension, we found that the total distance of advancement with a flap had a mean of 9.78 mm, while the advancement for the same flap after galeal scoring had a mean of 20.5 mm, and after removing the outer table, the mean advancement was 30.2 mm. Conclusion To create a tension-free closure necessary for optimal outcome for scalp defects, our study showed that increased distances were possible using galeal scoring and outer table removal, increasing the distance of advancement by 10.63 mm and 20.42 mm, respectively.

An algorithmic approach of reconstruction for cranioplasty failure: A case series

RATIONALE

Cranioplasty is a surgical procedure used to repair cranial defects for both cosmetic and functional reasons. The complication rate of cranioplasty is between 10% and 50%. The failure of cranioplasty is associated with various factors, including etiologies, types of material, and the timing of cranioplasty. In this study, a case series of managing cranioplasty complications at a single institution.

PATIENT CONCERNS

Eighteen patients were identified who underwent craniofacial defect reconstruction due to the failure of their initial cranioplasty between January 2010 and May 2020. Five men (27.78%) and thirteen women (72.22%) were included. The mean age was 39.61 years old. The average follow-up duration was 5.94 years.

DIAGNOSES

The indication for initial cranioplasty included previous decompressive craniectomy (77.78%, n = 14), traumatic cranial defects (16.67%, n = 3), and congenital cranial deformity (5.56%, n = 1). The reported complications were infection (50%, n = 9), implant exposure (50%, n = 9), wound dehiscence (22.22%, n = 4) and cranial deformity (11.11%, n = 2).

INTERVENTIONS

More than half of the materials used for initial cranioplasty were synthetic [titanium mesh: 44.44%, n = 8; polymethyl metacrylate: 5.56%, n = 1; titanium mesh and polymethyl metacrylate: 5.56%, n = 1], while 44.44% of the patients received autologous bone graft.

OUTCOMES

Of all reconstructive procedures for cranioplasty failure, 55.56% was local flap with or without skin graft (n = 10), 16.67% was free flap (n = 3), 11.11% was skin graft only (n = 2), 5.56% was regional flap (n = 1). The free flap survival rate was 100% (3/3), and implant removal with sebsquent second cranioplasty was performed on 27.78% (n = 5) of the patients.

LESSONS

Management of cranioplasty failure can be challenging due to infection, refractory implant exposure, and wound dehiscence. The principles of management are based on adequate infection control and reconstructive ladder. Meanwhile, collaboration with plastic surgery and neurosurgery should be strengthened in order to achieve the best clinical outcomes.

Modified Keystone Perforator Island Flap Techniques for Small- to Moderate-Sized Scalp and Forehead Defect Coverage: A Retrospective Observational Study

We aimed to demonstrate the effective application of keystone perforator island flap (KPIF) in scalp and forehead reconstruction by demonstrating the authors' experience with modified KPIF reconstruction for small- to moderate-sized scalp and forehead defects. Twelve patients who underwent modified KPIF reconstruction of the scalp and forehead from September 2020 to July 2022 were enrolled in this study. In addition, we retrospectively reviewed and evaluated the patient's medical records and clinical photographs. All defects (size range, 2 cm × 2 cm to 3 cm × 7 cm) were successfully covered using four modified KPIF techniques (hemi-KPIF, Sydney Melanoma Unit Modification KPIF, omega variation closure KPIF, and modified type II KPIF) with ancillary procedures (additional skin grafts and local flaps). All flaps (size range, 3.5 cm × 4 cm to 7 cm × 16 cm) fully survived, and only one patient developed marginal maceration that healed with conservative management. Furthermore, through the final scar evaluation with the patient satisfaction survey and Harris 4-stage scale, all patients were satisfied with their favorable outcomes at the average final follow-up period of 7.66 ± 2.14 months. The study showed that the KPIF technique with appropriate modifications is an excellent reconstructive modality for covering scalp and forehead defects.

Staggered Setting of Latissimus Dorsi and Serratus Anterior Flaps for the Treatment of Scalp Avulsions: A Retrospective Study

Although the incidence of scalp avulsion has decreased in recent years, it remains a major concern among plastic surgeons. We therefore aimed to introduce an improved free flap technique for repairing scalp avulsion with less tissue from the donor site. This method can achieve maximum primary closure of the donor site and improve its appearance and function as well as reduce the donor-site morbidity by ensuring that a smaller free flap can completely cover the scalp defect. Eight patients with scalp avulsion who had undergone staggered placement of the free flaps were evaluated. Data on the age, cause of scalp avulsion, scalp defect size, degree of avulsion, postoperative complications, and follow-up duration were analyzed. The postoperative evaluation criteria were donor-site sensation, latissimus dorsi muscle strength, upper extremity function, and quality of life. Patients' mean age was 38.7 years. The main cause of scalp avulsion was occupation-related accidents. The mean scalp defect size and postoperative follow-up duration were 26 cm × 20.4 cm and 41.5 months, respectively. One patient developed flap congestion postoperatively. The wounds at the recipient site healed well in all patients. There was no significant difference in the sensation between the surgical and nonsurgical sides. However, the latissimus dorsi muscle strength significantly differed between both sides. The mental component score, which was used to assess quality of life, did not significantly differ between the patients and healthy population, whereas the physical component score significantly differed between the two groups. None of the included patients had severe upper extremity functional limitation. Staggered placement of free flaps achieved maximum primary closure of the donor site and greater scalp avulsion defect coverage with less tissue excised from the donor site. Importantly, donor-site appearance improved and some donor-site functions were preserved postoperatively.

Reconstruction of necrotizing soft tissue infection in the auricle and temporal region: a case report

A 43-year-old female patient had a necrotizing soft tissue infection in the temporal region. Because of the necrotic temporoparietal fascia, auricular reconstruction was attempted using the temporalis muscle flap; the flap was successfully placed. The use of the temporalis muscle flap was considered a treatment option for salvaging the auricle.

Delayed axial flaps for coverage of a fourth degree scalp burn

Although free tissue transfers may be required to cover wounds of the head and neck with bone involvement and exposure, options lower on the reconstructive ladder should still be considered during the planning process. We present a case of an elderly gentleman with a history of cardiovascular comorbidity and neck radiotherapy, who sustained a deep flame burn injury to his scalp. Two delayed axial flaps, based on the superficial temporal and supraorbital arteries respectively, were used to obtain durable coverage of this complex wound.

Reconstruction of Scalp with Local Axial Flaps

The scalp is a unique part of the human body and various etiological factors, such as tumour extirpation, infection, burns, or trauma, can lead to scalp defects. Primary closure, skin grafting, local flaps, tissue expansion or free tissue transfer are modalities available for scalp reconstruction. In this article, the authors share their institutional experience using various local flaps concerning the size, location, depth of defect and the quality of surrounding tissue. From September 2017 to January 2020, 54 patients underwent scalp reconstruction with local flaps for a sizeable defect size of 5-150 cm2 in the Department of Plastic Surgery, SMS Medical College, Jaipur. Patients were identified by age, sex, cause of the scalp defect; the location, size, and depth of the defect; condition of surrounding tissue and the type of reconstruction done. The most common cause of scalp defect was excision of malignant tumour (50%). 30 patients had a large sized defect (40-90 cm2) and in 28 patients had 90-150 cm2 defects. Surgical reconstruction was done using local flaps, transposition flap was the most used in 36 patients (66.7%) followed by rotation advancement flap in 11 patients (20.4%). The recovery was relatively quick. Minor complications happened in 5 patients (9.3%) that were managed conservatively. In the present era of microsurgical reconstruction, local options as axial flaps provide a simpler and safer method of scalp reconstruction. A carefully planned scalp flap gives healthy, robust, hair-bearing tissue coverage and requires a shorter healing time for the patients.

An Algorithm for Reconstruction of Electrical Injuries of the Scalp

BACKGROUND

Electrical injuries of the scalp are a frequent occurrence in developing countries. Burns can be contact or conductive and result in extensive tissue damage. The authors present their experience with treatment of scalp and calvarial electrical injuries and propose a management algorithm.

METHODS

This was a retrospective cohort study comprising all patients with electrical injuries of the scalp treated at the authors' center between January of 2010 and December of 2016. Noncontrast computed tomography scans were obtained to assess viability of the calvarium in patients who presented more than 2 weeks after injury. Single-stage débridement and reconstruction were performed. All nonviable soft tissue and bone was removed. Soft-tissue reconstruction was performed with skin grafts, local scalp flaps, pedicled trapezius flaps, and free flaps (anterolateral thigh, latissimus dorsi, and scapular). Cranioplasty was performed in a delayed manner with autologous bone grafts.

RESULTS

Over a 7-year period, a total of 52 patients underwent scalp reconstruction for high-voltage (44 patients) and low-voltage (eight patients) electrical injury. All patients underwent successful soft-tissue reconstruction. Osteomyelitis with draining sinuses developed in three patients; these patients underwent flap re-elevation and bone débridement, which resulted in a healed wound and stable reconstruction. Cranioplasty was performed with split calvarial grafts in two patients and split rib grafts in four patients. One patient underwent scalp tissue expansion for hair restoration.

CONCLUSION

The authors propose an algorithm for reconstruction of electrical injuries of the scalp. Thorough débridement of the calvarium is the most important determinant of a successful outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Systematic Review of Syndrome of the Trephined and Reconstructive Implications

Syndrome of the trephined (SoT) is a severe complication following decompressive craniectomy resulting in neurological decline which can progress to aphasia, catatonia, and even death. While cranioplasty can reverse neurological symptoms of SoT, awareness of SoT is poor outside of the neurosurgery community. The authors performed a systematic review of the literature on SoT with a focus on reconstructive implications. Search terms "syndrome of the trephined" and "sunken flap syndrome" were applied to PubMed to identify primary studies through October 2021. Full-text review yielded 11 articles discussing SoT and reconstructive techniques or implications with 56 patients undergoing cranial reconstruction. Average age of the patients was 41.8±9.5 years. Sixty-three percent of the patients were male. The most common indication for craniectomy was traumatic brain injury (43%), followed by tumor resection (23%), intracerebral hemorrhage (11%), and aneurysmal subarachnoid hemorrhage (2%). Patients most commonly suffered from motor deficits (52%), decreased wakefulness (30%), depression or anxiety (21%), speech deficits (16%), headache (16%), and cognitive difficulties (2%). Time until presentation of symptoms following decompression was 4.4±8.9 months. Patients typically underwent cranioplasty with polyetheretherketone (48%), titanium mesh (21%), split thickness calvarial bone (16%), full thickness calvarial bone (14%), or split thickness rib graft (4%). Eight percent of patients required free tissue transfer for soft tissue coverage. Traumatic Brain Injury (TBI) was a risk factor for development of SoT when adjusting for age and sex (odds ratio: 8.2, 95% confidence interval: 1.2-8.9). No difference significant difference was observed between length until initial improvement of neurological symptoms following autologous versus allograft reconstruction (P=0.47). SoT can be a neurologically devastating complication of decompressive craniectomy which can resolve following urgent cranioplasty. Familiarity with this syndrome and its reconstructive implications is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.

Dufourmentel Flap for Scalp Reconstruction

Transposition flaps are useful for reconstruction of many skin defects. Limberg described a rhomboid rotation flap in 1946. Dufourmentel described an improved version of the Limberg flap in 1962. The Dufourmentel flap is also a quadrangular rhomboid flap which can be used in any area of the body except for the central face, the fingers, and the volar hand. The design of the Dufourmentel flap creates a wider base for this random flap, thus making it more reliable. Where tissue loss is significant, or where skin and soft tissue elasticity is limited, double opposing Dufourmentel flaps are useful. A variation of the Dufourmentel flap is described where a circular defect is converted to a square. The line of greatest extensibility is marked through the circular defect or lesion. A square is marked around the circle with one corner of the square tilted 10–20 degrees counterclockwise from the line of greatest extensibility. After marking corners A, B, C, and D, lines are marked extending BD and CD. The first incision, DE, will bisect the angle created by extending BD and CD. The second incision, EF, is roughly perpendicular to CD extended, but the angle at E is opened up a bit to create a wider base for the flap. Point D will rotate to point B, E rotates to C, and F translates to D. The invisible line DF should be approximately parallel to the line of greatest extensibility. When the defect is relatively large or where the surrounding tissues have limited elasticity, the above-described ideal variation of the Dufourmentel flap may not be possible because the flap may not rotate and advance all the way around without tension. In this case, double opposing Dufourmentel type flaps have been found to be useful by meeting each other at the halfway point.

Marjolin Ulcers of the Scalp Post Trauma and of the Neck Post Radiation, Diagnosis, and Reconstruction

What are potential causes of Marjolin ulcer and how do they present?How are MU diagnosed?What are differential diagnoses for MU, and what can help differentiate them?What are the appropriate treatments for MU?

Outcomes of Cranioplasty Strategies for High-Risk Complex Cranial Defects: A 10-Year Experience

INTRODUCTION

Although the literature contains reports of the risks and complications of calvarial vault reconstruction for acquired defects, there are few publications addressing the specific patient population who require such reconstructions in cases preceded by prior infection, radiation, massive associated soft tissue trauma, and so on. We define such clinical presentations as a hostile environment for large surface area reconstruction. Our objective is to compare the safety and efficacy of autologous bone and alloplastic reconstruction in hostile cranial defects.

METHODS

An institutional review board-approved retrospective review of patients who underwent cranioplasty of a hostile site at the University of Alabama at Birmingham between January 2008 and December 2018 was performed. The patients were stratified into 3 groups based on the type of implant used: autogenous (bone), alloplastic (polyetheretherketone [PEEK], titanium, polymethyl methacrylate), or mixed (combination of bone and prosthetic). The primary outcome metric was a complication in the year after cranioplasty, identified by implant failure, necrosis, or infection. Statistical analysis included t tests and χ2 tests where appropriate using SPSS.

RESULTS

There were 55 total cases in this period: 27 autogenous, 23 alloplastic, and 5 mixed. The purely autogenous group had the highest complication rate (44%), and the alloplastic group had the lowest complication rate (38%), which was not statistically different between the 3 groups (P = 0.121). When stratified by specific material used for reconstruction (27 bone, 14 PEEK, 10 titanium, and 5 polymethyl methacrylate), overall complication rate was statistically significant (P = 0.009, χ2 test), with PEEK implants having the lowest complication rate (21%).

CONCLUSIONS

This analysis interestingly found that in the setting of hostile cranial defects, cranioplasties would benefit from the use of prosthetic implants instead of autologous bone grafts, not only for avoidance of donor site morbidity but also for a decrease in overall complications.

Current trends in craniofacial reconstruction

Reconstruction of the head and neck continues to pose a variety of difficult functional and aesthetic challenges to the plastic surgeon. While the surgical treatment for midfacial and skull base tumours continues to advance, the three-dimensional reconstruction predicaments continue to increase in complexity. Reconstructive strategies of the head and neck require the restoration of intricate skeletal architecture and large volumes of both internal and external soft tissue envelopes that can withstand adjuvant therapies. Vascularized bone grafts in combination with microsurgical techniques is the current trend of most reconstruction and has replaced local and pedicle flaps as the preferred modality for large defects. This article will focus on concise areas of difficulty in craniofacial reconstruction, including mandibular, midfacial, scalp and base of skull reconstruction. As our goals now move from flap survival to refinement, more complex and innovative reconstructions are executed. The problems with each modality are examined, and the frontiers of head and neck reconstruction are explored. With the potential combination of virtual surgery and tissue engineered biotechnology, we may someday be able to expand our reconstructive capabilities beyond free tissue transfer.

Expanded scalp flap combined with laser hair removal to reconstruct facial defects around the hairline

BACKGROUND

Congenital and acquired facial lesions around the hairline can bring huge physical and psychological trauma to patients. At present, reconstruction of this area remains a challenge. In this study, we present an alternative technique to reconstruct the aesthetic units using an expanded scalp flap combined with laser hair removal.

METHODS

We retrospectively reviewed 25 cases of facial lesions around the hairline reconstructed with this surgical technique between May 2014 and May 2020. Expander was implanted under the scalp as designed before the operation. After the expander was fully expanded, the lesion was removed and the scalp flap was transferred. Laser hair removal was performed on the transplanted skin flap 2 weeks after flap transfer.

RESULTS

There were ten cases of postburn scar, nine cases of congenital nevus, four cases of traumatic scar, one case of haemangioma, and one case of nevus sebaceous. The median times of laser treatment was 3 (range, 1-8). The median follow-up time was 11 months, ranging from 1 to 27 months. The colour and texture of expanded flaps were similar to adjacent tissue in all cases. The direction of reserved hair in transferred flaps was consistent with the direction of hair in the recipient area or contralateral hair. There were no complications, such as infection, blistering, discolouration, and ulceration. All patients were satisfied with the appearance of the reconstructed hairline and the surgical outcomes.

CONCLUSIONS

The expanded scalp flap combined with laser hair removal is a feasible and effective technique to reconstruct both sides of the hairline simultaneously from a single donor site with a good colour match and a similar texture and thickness.

Secondary Intention Healing Over Exposed Bone on the Scalp, Forehead, and Temple Following Mohs Micrographic Surgery

BACKGROUND

Removal of skin cancers on the scalp, forehead, and temple can result in surgical defects with exposed bone. In such cases, reconstruction becomes challenging due to limited vascularity for flap or graft repair.

OBJECTIVE

Demonstrate the usefulness of secondary intention healing of scalp, forehead, and temple defects over exposed bone.

METHODS/MATERIALS

A retrospective case series of 41 patients who had Mohs Micrographic Surgery with post-surgical scalp, forehead, or temple defects involving exposed bone. These patients then underwent secondary intention healing.

RESULTS

90% of patients successfully healed. Average time to complete granulation was 92 days, and average time to full re-epithelialization was 186 days. Visual analog scale assessment of final scar quality resulted in 57% being good, 35% being fair, and 8% being poor. No patient had infection or other serious complication. Mean follow-up duration was 272 days.

CONCLUSION

This case series shows the viability of secondary intention healing of scalp wounds over exposed bone. Study power was not adequate to predict time to complete healing based on defect size, or allow association of patient factors with the risk of nonhealing. Managing patient expectations, and emphasizing the importance of early occlusive wound care is paramount for healing success.

Reconstruction of the Defect at Temporal Hairline by a Scalp Keystone Island Flap: Clinical Experience on 14 Cases

BACKGROUND

The reconstructions of defects at the temporal hairline always require more complicated designs and higher surgical skills to acquire better aesthetic results. By taking advantage of the unique anatomy of the temporal region, the authors designed a scalp keystone island flap pedicled by superficial temporal fascia to repair defects on the temporal hairline.

METHODS

The authors retrospectively analyzed the clinical data of 14 patients who had lesions adjacent to the temporal hairline between April 2018 and June 2020. Patients were diagnosed with basal cell carcinoma, squamous-cell carcinoma, or seborrheic keratosis. These lesions were resected and reconstructed by scalp keystone island flaps. The defects ranged from 2.0 cm × 1.5 cm to 3.0 cm× 3.5 cm.

RESULTS

All patients were satisfied with postoperative morphology and reported no recurrence at the 6 to 24 months follow-up. Flaps in two patients were partially necrosed but eventually healed by dressing changes. The rest had the first intention of healing.

CONCLUSIONS

The scalp keystone island flap is a very useful method to repair small or medium defects at the temporal hairline. This flap can be flexibly designed and easily performed with a high survival rate and good aesthetic results. It provides another surgical option for complicated reconstruction.

Successful management of complex scalp wounds with exposed calvarial bones by customized Negative pressure wound therapy (NPWT): Case series and review of the literature

Scalp wounds with exposed calvarial bones continue to be a challenge especially when no local flap options are available and no microvascular flaps can be performed. Our prospective study looked at 19 patients (14 males) where customized negative pressure wound treatment was used till the complex scalp wounds, mostly from animal bites, were covered with healthy granulation and grafted. Scalp wounds ranged from 6 × 4 cm to 17 × 11 cm in size whereas the area of exposed bone ranged from 1 × 2 cm to 10 × 10 cm. No major complication was seen, and wounds were rapidly healed.

Laser speckle imaging to evaluate scalp flap blood flow during closure in neurosurgical procedures

Background:

To measure the degree of relative ischemia caused by skin closure, we explored the potential utility of intraoperative surface blood flow measurement with laser speckle imaging (LSI).

Methods:

Prospective observational study of eight subjects that underwent intraoperative LSI during elective cranial neurosurgical procedures at the time of skin closure.

Results:

Seven 1st time incisions, with closure techniques including sutures (n = 3), staples (n = 3), and one after galeal sutures. When compared to the control region, there was a mean 63.7% reduction in flow across all seven subjects (range 18.7–95.32%). Comparing by closure type, a higher flow reduction in the three subjects with suture closure (80.7% reduction) compared to staples (61.9% reduction, P = 0.0379). One subject had a complex wound where tightening and loosening of sutures were performed to ensure adequate perfusion. Suturing resulted in significantly more local decreased flow compared to staples (P < 0.0001).

Conclusion:

These findings demonstrate the relative feasibility of using LSI for preoperative vascular flow assessment in planning complex incision closure. These data also provide preliminary support for the hypothesis that skin closure itself causes relative ischemia compared to deep approximation or cautery of the skin edge and that the relative ischemia from staples closure is generally less than from suture closure.

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach

BACKGROUND

 Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp.

METHODS

 In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described.

SUMMARY

 Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction.

CONCLUSION

 We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

Utility of Dermal Wound Matrices Compared with Local-Tissue Rearrangement and Free Flap Reconstruction for Oncologic Scalp Wounds: A Multidisciplinary Dual Matched-Pair Analysis

BACKGROUND

Local tissue rearrangement, free flap reconstruction, and Bilayer Wound Matrix represent reconstructive modalities for coverage of scalp defects; however, preferred indications are less clear. The authors aimed to evaluate the efficacy of these interventions.

METHODS

A retrospective review (2008 to 2019) was performed of subjects requiring soft-tissue reconstruction of oncologic scalp wounds. Subjects were dual matched into two comparative cohorts based on age and wound size/wound age: (1) local tissue rearrangement versus Bilayer Wound Matrix, and (2) free flap reconstruction versus Bilayer Wound Matrix. Ninety-day wound coverage, reoperation rates, hospital length of stay, operative time, and wound complications were compared.

RESULTS

In total, 361 subjects were included. Following matching, 126 subjects constituted the local tissue rearrangement versus Bilayer Wound Matrix cohort, and 56 constituted the free flap reconstruction versus Bilayer Wound Matrix cohort. Local tissue rearrangement/Bilayer Wound Matrix median defect size was 35 ± 42.5 cm2. Local tissue rearrangement provided significantly better wound coverage at 90 days (95.2 percent) compared to Bilayer Wound Matrix (84.1 percent) (p < 0.040), although reoperation rates (7.9 percent versus 15.9 percent) did not differ (p < 0.271). Median defect size in the free flap reconstruction/Bilayer Wound Matrix cohort was 100 ± 101.1 cm2. Ninety-day success (free flap reconstruction, 92.9 percent; Bilayer Wound Matrix, 96.4 percent; p < 1.00) and reoperation rates (14.3 percent versus 3.6 percent; p < 0.352) were similar between groups. Free flap reconstruction had significantly greater operative time (418 minutes versus 100 minutes; p < 0.001) and length of stay (3 days versus 0.5 days; p < 0.001).

CONCLUSIONS

Local tissue rearrangement may be more reliable for smaller wounds (<100 cm2) when compared to Bilayer Wound Matrix. Bilayer Wound Matrix may have comparable efficacy to free flap reconstruction for larger defects (150 to 250 cm2), and may be more cost-effective, given greater operative time and length of stay associated with free flap reconstruction. Free flap reconstruction is preferentially used in complicated large defects in the setting of radiation therapy, and for large defects that have failed Bilayer Wound Matrix.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Efficacy of Local Flaps in the Treatment of Traumatic Scalp Defects

BACKGROUND

 Scalp defects represent a therapeutic challenge. The aim of this study is to present our experience with local and regional flaps in the treatment of trauma-induced scalp defects. Furthermore, a comparison with other surgical techniques was performed.

METHODS

 A retrospective evaluation of patient records was performed. Only patients who underwent surgery using local flaps between January 2010 and September 2020 due to traumatic scalp defects were included in the study.

RESULTS

 In all, 10 cases were identified (3 females, 7 males, average age at surgery of 46.5 years [range: 18-82 years]). Six patients underwent surgery due to tissue defects and four due to scar keloids. Three patients experienced minor postoperative complications, one of which required additional surgery. The mean defect size was 35.75 cm² (range: 4-79 cm²) among the four patients where the defect size could be determined retrospectively. The mean inpatient follow-up was 12.4 days (range: 2-34 days).

CONCLUSIONS

 Local flaps can be widely used. In carefully selected cases, they have the fewest disadvantages of all surgical techniques. In our experience, large angiosomes of the main scalp arteries allow the treatment of defects larger than 30 cm² with local flaps. Our experience also suggests that the dimensions of flap length to flap width can exceed a ratio of 2:1 in the scalp.

Use of xenografts and allografts in scalp reconstruction

PURPOSE OF REVIEW

Scalp reconstruction requires a full array of reconstructive options given the complex anatomy and protection of vital structures. Not all patients qualify for advanced reconstructive options and therefore rely on short, effective procedures with minimal morbidity. This review aims to focus on xenografts and allografts to achieve an adequate reconstruction while minimizing morbidity.

RECENT FINDINGS

Although bovine xenografts have been used for many decades, there have been recent advances in porcine xenografts to aid in scalp defects. Similarly, new allogenic materials have emerged as additional tools in the armamentarium to promote wound healing.

SUMMARY

Both xenografts and allografts offer viable options for complex scalp reconstruction.

Stepwise Reconstruction of a Large, Self-Inflicted Calvarial Defect

BACKGROUND AND IMPORTANCE

Scalp expansion ensures that tissue similar in color, texture, thickness, and most importantly, hair-bearing quality, is available to resurface the scalp. It is a critical option for reconstruction of large calvarial defects.

CLINICAL PRESENTATION

Over 6 months, a 55-year-old male patient excoriated his scalp into a full-thickness scalp and calvarial wound resulting in dural violation and meningitis. The patient presented with altered mental status and methicillin-susceptible staphylococcus aureus (MSSA) bacteremia, cranial osteomyelitis, and an intracranial abscess secondary to the large scalp defect. The patient underwent immediate debridement and dural coverage with a scalp rotational flap. Several months later he began delayed stepwise cranioplasty with multiple scalp tissue expanders given the deficiency of soft tissue.

CONCLUSIONS

This case is presented to highlight the unusual mechanism of injury and the complex reconstructive approach in surgical management.

Integra as Firstline Treatment for Scalp Reconstruction in Elderly Patients

PURPOSE

Large scalp defects pose a reconstructive problem especially in elderly patients. The purpose of the study is to describe our experience of oncologic scalp reconstruction using a dermal matrix (Integra).

MATERIAL AND METHODS

We conducted a retrospective cohort study (January 2007 to March 2021) of patients who had undergone scalp tumor excision and reconstruction using Integra and a split-thickness skin graft (STSG). The primary end point was Integra and STSG success (defined by ≥75% percent take) and the secondary end point was postoperative complications. Both end points were assessed by the surgeon during follow-up. Demographic data, tumor characteristics, average defect size, time between stages and full-thickness scalp defects were characterized using descriptive statistics. Univariate and multivariate logistic regression models were used to evaluate the association between variables and end points.

RESULTS

The sample included 70 patients with a mean (SD) age of 83.3 (7.0) years, 75.7% men and 92.9% with comorbidities. Mean (SD) defect area was 23 (17.0) cm² and the mean (SD) first-to-second phase interval was 30.6 (8.4) days. Sixty-four patients (91.4%) underwent outpatient surgery. Integra and STSG success rates were 87.1% (95% CI: 77.69 to 93.74%) and 100%, respectively. The complications rate was 18.6% (95% CI: 9 to 28%). Mean (SD) follow-up was 18 (16.7) months. Univariate and multivariate logistic regression analysis showed no association between variables and the primary and secondary end points.

CONCLUSIONS

Reconstruction of oncologic scalp defects using Integra can be performed under sedation and local anesthesia. Integra should be considered as firstline treatment for the reconstruction of scalp defects in elderly patients with comorbidities, given the low postoperative major complications rate and Integra and STSG take success.

Decision-Making in Adult Cranial Vault Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Define and classify different types of cranial defects 2. Compare both autologous and alloplastic options for reconstruction 3. Develop an optimal approach for cranial vault reconstruction in various clinical scenarios.

SUMMARY

Defects of the cranium result from various causes, including traumatic loss, neurosurgical intervention, skull tumors, and infection. Cranial vault reconstruction aims to restore both the structural integrity and surface morphology of the skull. To ensure a successful outcome, the choice of appropriate cranioplasty reconstruction will vary primarily based on the cause, location, and size of the defect. Other relevant factors that must be considered include adequacy of soft-tissue coverage, presence of infection, and previous or planned radiation therapy. This article presents an algorithm for the reconstruction of various cranial defects using both autologous and alloplastic techniques, with a comparison of their advantages and disadvantages.

Osteoradionecrosis and microvascular free flap failure managed with negative pressure wound therapy: A case report

A 56-year-old female with a history of meningioma status post subtotal resection (Simpson grade IV) and extensive radiation therapy presented with osteoradionecrosis (O.R.N.) managed previously with a microvascular free flap (MVFF). The evaluation revealed worsening O.R.N. and a scalp defect of 15 × 10 cm. The patient underwent MVFF reconstruction utilizing a free latissimus muscle flap covered by meshed split-thickness skin graft (STSG). Her surgery was complicated by delayed free flap failure and Serratia marcescens growth, which occurred sometime after discharge from the hospital. This was managed with removal of the free muscle flap and skin graft, serial debridement's, antibiotics, and replacements of a synthetic dural matrix and negative pressure wound therapy (NPWT). Once a clean wound bed was again obtained, the patient underwent fasciocutaneous anterolateral thigh (A.L.T.) MVFF reconstruction, which was complicated by left hypoglossal nerve injury, dehiscence of the flap inset, and dehiscence of the neck access incision requiring revision surgery. On the last follow-up 2 weeks after her surgery, the patient had 100% flap viability and a 2 × 1.5 cm on the left parietal aspect of the flap healing be secondary intent. We demonstrate that NPWT is successful in managing open calvarial wounds due to O.R.N.

Management of Scalp Injuries

Soft tissue wounds in the scalp are a common occurrence after trauma or resection of a malignancy. The reconstructive surgeon should strive to use the simplest reconstructive technique while optimizing aesthetic outcomes. In general, large defects with infection, previous irradiation (or require postoperative radiation), or with calvarial defects usually require reconstruction with vascularized tissue (ie, microvascular free tissue transfer). Smaller defects greater than 3 cm that are not amenable to primary closure can be treated with local flap reconstruction. In all cases, the reconstruction method will need be tailored to the patient's health status, desires, and aesthetic considerations.

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.

Scalp Reconstruction after Mohs Cancer Excision: Lessons Learned from More Than 900 Consecutive Cases

BACKGROUND

Scalp reconstruction has evolved over time. Given the large surface area, location, and high likelihood of sun exposure, the scalp is particularly prone to sun damage and skin cancer. Resection of scalp cancers often leaves a large defect that can be challenging for reconstruction. The authors present objective data and recommendations based on more than 10 years of consecutive scalp reconstructions performed by the senior author (J.F.T.). In addition, the authors describe each method of reconstruction and delineate an algorithm based on the senior author's approach and the cases assessed.

METHODS

The authors conducted a retrospective review of patients who underwent scalp reconstruction after Mohs cancer excision over a 10-year period. Each case was evaluated for key patient characteristics, defect location, defect size, defect composition, reconstructive modality, and complications.

RESULTS

The senior author (J.F.T.) performed 913 scalp reconstruction procedures. Defects most commonly involved the forehead or vertex of the scalp, with a wide range of sizes. A significant majority of the patients' defects were repaired with the use of adjacent tissue transfer or Integra dermal regeneration templates. There were 94 complications (12.5 percent) noted, ranging from graft loss to cancer recurrence.

CONCLUSIONS

Reconstruction of scalp defects after Mohs cancer excision presents the plastic surgeon with numerous patient and defect preoperative variables to consider. Each defect should be evaluated, and a plan based on composition of the defect and the needs of the patient should be developed. Scalp reconstruction is safe to perform in an outpatient setting, even in elderly patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Bilayer wound matrix-based cutaneous scalp reconstruction: A multidisciplinary case control analysis of factors associated with reconstructive success and failure

BACKGROUND

Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp.

METHODS

A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes.

RESULTS

In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm², and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 - 26.7, and p<0.012). Additionally, subjects who underwent preoperative radiation were more likely to suffer from reconstructive failure (p<0.040) as well as those who require postoperative inpatient admission (p<0.034).

CONCLUSION

BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure.