Reconstruction of a Marjolin Ulcer Defect of the Scalp Invading Brain and Causing Brain Abscess Formation Using Free Latissimus Dorsi Flap:

Surgical management of dissecting cellulitis of the scalp using free latissimus dorsi flap and meshed split-thickness skin graft: A case report

INTRODUCTION

Dissecting cellulitis of the scalp, or Hoffman disease, is described as an extremely rare condition. Clinically, it is represented by recurrent painful nodules, purulent drainage, interconnected sinus tracts and keloid formation, leading to scaring and cicatricial alopecia. Without a precise diagnosis and an adequate treatment, the repercussions consist of severe infectious complications along with psychological negative effects and serious aesthetic alterations. There is no standard treatment. In refractory cases, surgical management is reported.

PATIENT CONCERNS

We report a case of a 65-year-old Caucasian male patient, with a 5-year history of Hoffman disease, who presented with multiple abscesses and sinus tracts of the scalp and patches of alopecia. The lesions were non-responsive to medical treatment.

DIAGNOSIS

The diagnosis of DCS has been established on the basis of the clinical appearance and has been confirmed histopathologically.

INTERVENTIONS

The patient underwent wide excision of the scalp, followed by reconstruction using free latissimus dorsi flap and covered by meshed split-thickness skin graft.

OUTCOMES

Eighteen-month follow-up revealed complete remission of symptoms and lesions along with satisfactory cosmetic result.

CONCLUSION

The scope of this case report is to raise awareness of the following aspects: Hoffman disease has an extremely low occurrence rate, a difficult differential diagnosis and no standard therapeutical strategy. It also highlights the effectiveness of scalpectomy and free latissimus dorsi flap covered by meshed split-thickness skin graft in treating a very advanced stage of the disease together with providing a natural contouring of the scalp. Ultimately, it discusses the other treatment alternatives.

Characteristics of Marjolin's Ulcers in 21st Century: A Retrospective Study, Systematic Review, and Surgical Guideline Recommendation

Marjolin's ulcer is rare and aggressive malignancy. The objective was to conduct a review of Marjolin's ulcer cases to gain a better understanding and its management. A retrospective study of patients with Marjolin's ulcers at our hospital between 2010 and 2019 was conducted. For the systematic review, the electronic database of the National Library of Medicine was searched and articles published between 2000 and 2019 were included. A total of 14 patients were included in the retrospective study. Twelve patients were male. The mean age was 59.71 years. The latency period was 27.78 years. The most common malignancy was squamous cell carcinoma, and 71.43% had developed on the lower extremities. Well-differentiated squamous cell carcinomas occurred in 38.46% of the cases Rates of lymphovascular and perineural invasion were 30.77 and 23.08%, respectively. Results from the literature search yielded 80 case reports (91 cases) and 42 retrospective reviews (1216 cases). Most cases were male and the most common location was lower extremities. The latency period for the acute and chronic periods was 2.75 months and 20.75 years, respectively. The most common malignancy was squamous cell carcinoma (92.27% in the retrospective reviews) and 59.98% of the cases exhibited well-differentiation. Rates of regional lymph node involvement and distant metastases were 10.20 and 12.09%, respectively. Marjolin's ulcer in 21st century is not so rare. The most common is well differentiated squamous cell carcinoma. Early flap surgery or skin grafts for chronic ulcers or burn scars are recommended to reduce risk. Guideline for surgical management is established.

A review of 31 cases of Marjolin's ulcer on scalp: Is it necessary to preventively remove the scar?

We aimed to report the clinical features of squamous cell carcinoma (SCC) occurring on scalp scar tissue among a Chinese population, demonstrate its pathological progress, analyse the prognosis-related factors, and share our clinical experience of managing this rare disease in practice. A retrospective study was conducted at West China Hospital from January 2013 to January 2018 aiming to identify patients with a diagnosis of SCC or squamous atypical hyperplasia arising from scalp scars. Their medical records were reviewed, and related data were retrieved. Follow up was conducted, and informed consent was obtained by phone calls in June 2018. Of the 31 scalp Marjolin's ulcer (MU) patients, the average latency period and post-ulceration period were 42.9 years and 37.5 months, respectively. Among them, 30 patients (97%) were diagnosed with cancer more than 5 years after initial injury, and 25 patients (80.7%) experienced a pre-ulceration period longer than 20 years. A negative correlation between scalp MU's post-ulceration period and its pre-ulceration period was identified. Only burn scars caused post-ulceration periods of more than 24 months (7/19). Incomplete healing wounds experienced a significantly shorter latency period (P = 0.004) and longer post-ulceration period than others (P < 0.0001). However, the depth of tumour infiltration and complete tumour resection were the only two independent factors that significantly dictated patients' survival in this study. In conclusion, the scalp scaring tissue experienced a long-term stable period but would transform to malignancy rapidly and progressively once ulceration formed. The underlying malignant transformation mechanism remains unclear. Thus, we recommend scalp scarring tissue to be radically removed.