An Algorithm for Oncologic Scalp Reconstruction

Abstract

Sir: We read with interest your article about oncologic reconstruction of the scalp.1 We agree that an algorithm is necessary to facilitate the surgical planning after radical oncologic excision. Radical surgical resection is the most important curative action, and every surgeon has to perform it every time. Many techniques are available today to reconstruct the scalp. We think that where there are full-thickness bone defects or dura defects, microsurgical flaps are necessary, but when there is a soft-tissue defect of the scalp, there is the possibility of covering the loss of substance using a dermal regeneration template, such as Integra (Integra LifeSciences, Plainsboro, N.J.).2 Our experience suggests that in cancer patients there is the possibility of tumor recurrence, and mobilization of local flaps (or the use of free flaps) may compromise the possibility of controlling the local tumor recurrence. We have operated on 32 patients with scalp defects (mean surface area, 70.1 cm2) using Integra directly over the bone, under local anesthesia. The tumor excision included the periosteum in all cases, and adequate débridement of the scalp wound down to bleeding bone was performed by drilling of the outer table of the cortex. The artificial dermis was grafted as in a classic full-thickness skin graft and a compressive tied-over dressing was placed on the Integra for 5 days. If clear surgical margins were found, a second operation was performed at an average period of 21 to 22 days after artificial dermis implantation. The silicone layer was removed, and ultrathin autografts, taken usually from the thigh with a dermatome, were applied to the neodermis. There was full graft take in all cases. We obtained good outcomes from aesthetic and oncologic points of view, with a mean follow-up of 12 months. In eight cases, we noted a recurrence very early under the skin graft or under the Integra. Using Integra and skin grafts, we provide durable coverage of the scalp, thicker than direct skin grafting on the skull or on granulation tissue, reducing the likelihood of intraoperative or postoperative complications. This technique allows early detection of local tumor recurrence and therefore early tumor removal, with additional resections to obtain clear surgical margins before the final reconstruction is performed with split-thickness skin grafts over the dermal substitute. Our experience suggests that the use of a dermal regeneration template may be considered a successful option for scalp reconstruction after tumor excision. Bartolo Corradino, M.D. Sara Di Lorenzo, M.D. Dipartimento di Discipline Chirurgiche ed Oncologiche Sezione di Chirurgia Plastica Università degli Studi di Palermo Palermo, Italy