Complex Scalp Research Articles

Reconstruction of Full-Thickness Calvarial Defect

The reconstruction of scalp defects presents a clinical challenge. Free tissue transfer has played an increasingly important role in the reconstruction of complex scalp defects. In many cases, patient medical comorbidities along with the length of the operative procedures incurs significant patient risk. Artificial dermis, used extensively in burn reconstruction, has emerged as a reconstructive option for the coverage of many complex posttraumatic and postoncologic defects; however, none have described its use for the reconstruction of full-thickness calvarial defects with exposed dura.We report a clinical case of an elderly, medically compromised patient with a full-thickness scalp defect, who underwent successful reconstruction with artificial dermis.The use of artificial dermis and subsequent skin grafting, as was performed in this case, provides a less invasive, less intensive, and satisfactory means of soft tissue reconstruction for full-thickness calvarial defects.

Scalp and calvarial reconstruction.

Over the past several decades, an improved understanding of the blood supply of local flaps, increased experience with tissue expansion, and the development of techniques for microsurgical transfer of distant flaps have greatly contributed to the ability of plastic surgeons to repair scalp defects. This article will review basic anatomy, principles, and pearls of reconstruction for simple to complex scalp defects. Included will be anatomic considerations, indications and contraindications for reconstruction, and an overview of reconstructive options.

Management of a Complex Scalp Defect

Received for publication November 27, 2007; accepted January 7, 2008. Disclosure:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. Editorial Board Plastic and Reconstructive Surgery Editorial Office, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, HD1.544, Dallas, Texas 75390-8820, [email protected]

Coverage of scalp defects following contact electrical burns to the head: A clinical series

Fifteen patients with various scalp defects resulting from contact electrical burns to the head, were reconstructed between the periods of January 1989 and October 2004 in our burns unit. The incidence of scalp burns in our patient population was 2.99% for electrical injuries and 0.95% for all burns during the study period. We present here a clinical series of fifteen patients with large, complex scalp defects following contact electrical burns to the head treated successfully by the application of local and free flaps. In this series, four free flaps, one pedicled flap and 10 local flaps were used for the reconstructions with no major postoperative complications seen. The average size of the defect was 89.45 cm 2 for cases in whom local flaps were applied, 193 cm 2 for free flaps and 143 cm 2 for one case treated with distant flap. Four cases required craniectomies because of the delay in reporting to our burns unit. Early surgical attempt to cover the defect with a well-vascularized tissue provides excellent healing, osteogenesis, short hospital staying, low rate of infection and requires no surgical debridement of the bone in the early phase.

Artificial Dermis as an Alternative for Coverage of Complex Scalp Defects following Excision of Malignant Tumors

Artificial dermis has been used successfully for coverage of full-thickness wounds with a well-vascularized surgical bed. However, the use of artificial dermis in the reconstruction of partial- and full-thickness scalp defects has not been well documented. Seven patients (six men and one woman; mean age, 70 +/- 14 years) with partial-thickness (three patients) and full-thickness (four patients) soft-tissue defects of the scalp (mean defect area, 97 +/- 58 cm) following resection of recurrent malignant tumors and/or previous failed reconstructions underwent staged scalp reconstruction with a bilaminate skin substitute (Integra). After adequate debridement of scalp wounds, including burring the outer table of the calvaria down to bleeding bone for full-thickness defects, Integra was scored and applied unexpanded. A split-thickness skin graft (0.011 +/- 0.0 inch in thickness) was placed on the operative site at postoperative day 36 +/- 15 after removal of the silicone layer of the artificial dermis. Two patients required repeated applications of artificial dermis to compensate for contour deficits before skin grafting. Clinically, all reconstructed areas showed well-vascularized neodermis before skin grafting. There was a 100 percent take of the skin grafts, with no infections or other complications noted. All reconstructive procedures were performed in less than 3 hours of combined operative time, with the last stage performed on an outpatient basis. Artificial dermis can be used successfully for reconstruction of complex scalp defects following oncologic resection, offering minimal donor-site morbidity, expedient operative time, and when needed, temporary quality closure until final pathologic results are known. Integra skin may offer another option for definitive management of extensive full-thickness scalp defects.

Complex scalp defects from cicatricial pemphigoid and ionizing radiation

RC is a 59-year-old lady with cicatricial pemphigoid for more than 15 years. The entire scalp was involved eventually resulted in extensive alopecia as well as a difficult chronic exudative wound management problem (Fig. 1). Periodic scalp biopsy followed by imaging studies detected a moderately differentiated squamous cell carcinoma invading the full thickness of the dermis and extending through the skull bone into meninges near the sagital sinus which makes surgical resection impossible. The treatment included synchronous chemo-radiation consisting of 54 gray, 30 fractions over 43 days using photon tangents and 6 MeV electrons on lateral sides of the scalp combined with weekly cisplatin. Despite successful adjuvant therapy there was no healing on the scalp and furthermore there were large areas of exposed skull bone. The patient was referred to the burns unit after failure of conservative treatment. She was admitted for inpatient wound management with Vacuum-Assisted Closure (V.A.C.TM System, Kinetic Concepts Inc., San Antonio, TX) for a total period of 1 month (Fig. 2). The dressings were changed every 3 days under general anaesthesia in the operating theatre. The wound was irrigated with aqueous

Reconstruction of complex scalp defects: the "Banana Peel" revisited.

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

Reconstruction of Extensive Scalp Defects with Rectus Free Flaps

This review represents the largest reported series involving reconstruction of complex scalp and calvarial defects with rectus abdominis free flaps. Sixteen patients presented with extensive (up to 300 cm2) scalp and calvarial defects requiring free tissue transfer for closure. All of the 11 patients who underwent a rectus abdominis free flap had a technically successful microvascular transfer. The defects encountered involved a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiated fields, and infection. In our institutions, the rectus abdominis muscle has evolved as a uniquely superior donor choice for restoring extensive scalp defects for several reasons: (1) accessibility, which eliminates intraoperative patient repositioning and allows for a simultaneous two-team approach; (2) minimal donor-site morbidity; (3) vascular reliability; and (4) the ability to supply abundant, easily contoured tissue.

Anatomic and Physiologic Bases of Posterior Tibial Nerve Somatosensory Evoked Potentials

Following stimulation of the posterior tibial nerve, lumbar electrodes record a response that is the composite of two signals, one (PV) corresponding to the afferent volley in the cauda equina and gracile tract, and another (N22) generated postsynaptically in the gray matter of the lumbar cord. Subcortical structures generate two distinct, widely distributed signals, recordable from scalp electrodes using a noncephalic reference, P31 and N34. P31 is most likely generated by the afferent volley in the caudal medial lemnicus. N34 probably reflects subcortical postsynaptic activity in brain stem and/or thalamus, respectively. The "primary" cortical response, P38/N38, has a complex scalp distribution reflecting the location of the leg area on the mesial aspect of the postcentral gyrus, within the interhemispheric fissure. It is most likely a composite waveform with multiple cortical generators.

Single-stage repair of complex scalp and cranial defects with the free radial forearm flap.

The free radial forearm flap provides a reliable single-stage method to cover difficult scalp and forehead defects where other local methods are unsuitable. Six patients have been successfully reconstructed utilizing seven free radial forearm flaps. A description of our surgical technique along with illustrative cases demonstrate the indications and advantages of this flap. Cranial soft-tissue deficits are primarily cutaneous; therefore, a more predictable reconstruction can be obtained utilizing a cutaneous flap with similar characteristics. Restoration of bony defects should be considered separately utilizing autogenous bone and/or alloplastic materials and not merely obliterated with a bulky soft-tissue flap. Therefore, if the local factors of a cranial wound require the utilization of a distant tissue transfer, we prefer the thin coverage of a well-vascularized free fasciocutaneous radial forearm flap over two-stage distant pedicle flaps or skin-grafted free flaps.

Electroencephalogram correlates of higher cortical functions.

By means of two-stage, nonlinear multivariate pattern recognition, electroencephalograms (EEG's) were analyzed during performance of verbal and spatial tasks. Complex scalp distributions of theta-, beta-, and, to a lesser extent, alpha-band spectral intensities discriminated between the two members of a pair of tasks, such as writing sentences and Koh's block design. Small EEG asymmetries were probably attributable to limb movements and other uncontrolled noncognitive aspects of tasks. Significant EEG differences beteeen cognitive tasks were eliminated when controls for inter-task differences in efferent activity, stimulus characteristics, and performance-related factors were introduced. Each controlled task was associated with an approximately 10 percent reduction, as compared with visual fixation, in the magnitude of alpha- and beta-band spectral intensity. This effect occurred bilaterally and was approximately the same over occipital, parietal, and central regions, with some minor difference over the frontal region in the beta band. With these controls, no evidence for lateralization of different cognitive functions was found in the EEG.