Full-thickness Scalp Research Articles

Removal of the Outer Table of the Skull for Reconstruction of Full-Thickness Scalp Defects with a Dermal Regeneration Template

The reconstruction of large defects of the scalp after wide excisional surgery of cutaneous malignancies is challenging. When the pericranium must be resected due to safety considerations, the exposed bone complicates reconstructive approaches. The objective was to develop an improved technique for reconstructive surgery of full-thickness scalp defects. Full-thickness scalp defects of up to 126 cm(2) in size with exposure of denuded bone were treated by partial removal of the outer table of the skull. The diploic space exposed by this treatment showed petechial bleeding and was covered with a dermal regeneration template (Integra, Integra Lifesciences Corp., Plainsboro, NJ). After transformation of the template by vascularization and by proliferation of fibroblasts, an ultrathin skin graft was transplanted onto the neodermis. Thirteen patients with cutaneous malignancies of the scalp were treated using this technique. The defects were transplanted within a median postoperative time period of 29 days (+/- 4 days) and showed good cosmetic results and stable scars. After a follow-up period of 6 months, no local recurrences were observed. This reconstructive procedure allows closure and rapid healing of large scalp defects in which the pericranium had to be resected.

Reconstruction of Extensive Scalp Defects with Free Tissue Transfer

Whole layer scalp defects may be caused by tumor excision, infection, burn injury or traumatic amputation of scalp. Adequate coverage of bared scalp bone with durable skin and soft tissue is necessary when reconstructing such kind of defect. When the defects are extensive, free tissue transfer is a good option for reconstruction. In our experience of 12 patients with 13 large scalp defects underwent 13 microsurgical free flaps, with one of them was bi-paddle flap. The average area of full thickness scalp defect was 105.5 cm^2. The anterolateral thigh perforator flap comprised majority of the free flaps harvested (7 cases, 57%), while the latissimus dorsi muscle, gracilis muscle and rectusw abdominis muscle flaps had two each. The survival rate of 13 flaps was 100%. Two long term complication were noted in patients reconstructead with free muscle flaps combined with skin grafts. Our experience showed that free tissue transfer can provide durable skin and soft tissue coverage for large scalp defect. Superficial temoral artery and vein are ideal recipient vessels for most cases.

Lambeaux locaux pour pertes de substance transfixiantes du scalp sur tumeurs évoluées. À propos d'une série de 21 patients

Subject The advanced tumors of the scalp can involve the calvarium, the dura and the cerebral tissue. The medium sized full thickness scalp defects secondary to the excision of such cutaneous malignancy can be successfully treated with local flaps coming from the remaining scalp if these flaps are large and including at least one major pedicle of the scalp. The cranioplasty can be done immediately or secondarily. Patients and methods From May 2001 to July 2006, 21 patients aged between 52 and 78 years old, suffering from advanced basal and squamous cell carcinomas with invasion of the calvarium in all cases, the dura in 1 case and the cerebral tissue in 2 cases have benefited from an excision of the scalp and calvarium with a margin between 1 and 3 cm. The secondary defects measured between 9 and 15 cm for the scalp and between 6 and 9 cm for the calvarium. In 1 case, the dura was resected and reconstructed with a fascia lata graft. The flaps used were: a single pedicled transposition flap based on one or two occipital pedicles in 10 cases — a bipedicled transposition flap based on the superficial temporal pedicles in 3 cases and on the frontal and occipital pedicles in 4 cases — a large rotation flap in 4 cases. These flaps were undermined under the galea without any galeotomies. Their donor sites were immediately grafted. The calvarium was reconstructed by a methylmetacrylate implant in 9 cases, simultaneously with these flaps in 4 cases and secondarily in 5 cases. Results There were no vascular problems in all these flaps — 3 cases of infection in the simultaneous reconstruction of the scalp and calvarium are reported. The two patients with cerebral invasion are deceased 1 year after the surgery. The other patients are still alive without any recurrence or metastasis with a mean follow-up of 36 months. Conclusion Such complex defects of the tumoral scalp can be reconstructed with large and axial local flaps of the remaining scalp with safety. The cranioplasty has to be delayed.

The use of artificial dermis for reconstruction of full thickness scalp burn involving the calvaria

The incidence of extensive full thickness scalp burn involving the calvaria is rare and can be very difficult to reconstruct, as the application of local or free tissue transfer is limited. Although wound closure can be achieved with bone debridement and immediate or delayed split-thickness autografting, the result may be problematic due to unstable skin graft surface. The use of artificial dermis that may provide stable thick coverage in the treatment scalp and skull burn has rarely been reported in literature. We encountered two patients who suffered from severe head burns involving the calvarium. Following debridement including the necrotic bone, the artificial dermis (Integra) was used for immediate wound coverage which was 15 cm × 10 cm in one case and 5 cm × 6 cm in another. Three weeks later, ultra-thin skin grafting was placed on the neodermis. Compared to split-thickness skin graft, this technique provides a thicker coverage for wound closure. Neither skin breakdown nor ulceration was noted in the 1-year follow-up. This paper reports the successful use of artificial dermis for reconstruction of severe scalp burn with calvarial bone involvement.

Aplasia cutis congenita of the scalp: Therapeutic modalities

Agenesis of scalp is an uncommon but well-recognized clinical entity. Congenital scalp and skull defects can be either obvious or occult; over 300 cases have been reported in literature. Aplasia cutis congenita (ACC) is recognized as a heterogeneous disorder, all characterized by focal absence of the epidermis, dermis and sometimes the calvarium and/or dura. We present a case of ACC in an infant whose mother was exposed to a teratogenic drug (Methimazole--an antithyroid drug) during pregnancy. This case report is presented to highlight the steps to successful management. Definitive full thickness scalp cover at the earliest avoids secondary infection, eschar formation and exsanguination.

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.

The use of a bovine collagen construct for reconstruction of full-thickness scalp defects in the elderly patient with cutaneous malignancy.

Full-thickness defects of the scalp following cancer resection are reconstructive challenges when bone is exposed. Local, regional, and/or free tissue transfer have all been described for reconstruction when the pericranium is exposed. We examined the surgical outcomes from 23 patients who underwent placement of bovine collagen constructs. Thereafter, delayed skin grafting was performed. The average age of the patients was 70 years. All patients had one of the following: melanoma (n = 13) squamous cell carcinoma (n = 5), angiosarcoma (n = 2), basal cell carcinoma (n = 1), spindle cell carcinoma (n = 1), or malignant pilar tumor (n = 1). The average defect size was 51 cm, with a range of 9 cm to 169 cm. Average time between bovine construct placement and skin grafting was 30 days. Histologic studies demonstrated persistence of the construct and infiltration of nascent fibroblasts. Six patients had delayed healing due to microabscesses in the constructs. All wounds eventually healed. In the elderly, this is a simple method to treat full-thickness scalp defects.

Reconstruction of complex cranial wounds with demineralized bone matrix and bilayer artificial skin.

Complex wounds involving loss of both cranium and scalp are difficult to reconstruct. Current solutions include both autogenous and alloplastic materials. Tissue engineering provides interesting alternatives for reconstruction of missing bone and soft tissue. Demineralized bone matrix and Integra, artificial bilayer skin substitute, have been used successfully to reconstruct bone and skin as isolated defects, but never in combination. This study investigates the possibility of using demineralized bone matrix in a gel carrier and Integra for combined cranial and scalp defects. The study was divided into two parts. In the first, demineralized bone matrix in the forms of Grafton Flex (n = 12) and Grafton putty (n = 12) was used to reconstruct 15-mm critical size cranial defects in female adult New Zealand White rabbits. In the control group (n = 6), the defect was left empty. The second part of the study investigated the use of Integra and Grafton Flex to reconstruct a 15-mm cranial defect with an overlying full-thickness scalp defect (n = 6). The first study revealed bony healing of the critical-size cranial defect with demineralized bone matrix. The second study demonstrated successful reconstitution of scalp and cranium with both demineralized bone matrix and Integra. We conclude that complex cranial defects involving bone and soft tissue may be successfully reconstructed with their tissue-engineered substrates, demineralized bone matrix (Grafton) and Integra artificial skin.

The Reverse Temporoparietal Fascia Flap

Case Report A 28-year-old man, after ejection from a motor vehicle, sustained a large, stellate laceration through all the layers of the temporoparietal scalp (Fig. 1). There was extensive contusion to the tissues; the initial therapeutic step chosen was debridement and rough approximation of the wound edges. Due to the extent of soft-tissue crush, progressive necrosis of the wound necessitated subsequent debridement of devitalized tissue. This debridement resulted in exposed calvarium (Fig. 2). After stabilization of the wound, the patient was returned to the operating room. After wound debridement, the fullthickness scalp loss measured 10 × 10 cm. There was an abutting 5 × 5 cm area of partial scalp loss down to the loose areolar tissue above the periosteum. A staged reconstruction was planned. The initial stage was the coverage of the calvarium, while preserving later reconstructive options. This coverage was performed through the use of what we term the “reverse temporoparietal fascia flap.” The reverse temporoparietal fascia flap was elevated from the level of the auricle while staying 1 cm caudal (inferior) to the temporal suture (Figs. 3 and 4). Through the surgical maneuver of turning the reverse temporoparietal fascia flap, the bare calvarium was covered. Because of the large size of the tissue deficit, flap dissection was accomplished through elevation of the wound edges. A split-thickness skin graft was applied on the flap's surface. There was complete healing of both the flap and graft (Fig. 5). Later reconstruction of the hair bearing scalp was accomplished by means of tissue expansion techniques.

Microvascular Reconstruction of a Full Thickness Scalp and Skull Defect following Herpes Zoster Infection

Herpes zoster is a common infection caused by reactivation of the varicella zoster virus. In most patients the disease runs a painful but benign course with complete recovery. A unique case of trigeminal ophthalmic herpes zoster presented to The Toronto Hospital, Toronto, Ontario. This patient had a unilateral full thickness defect of scalp and skull with secondary osteomyelitis and opacification of the eye. After appropriate medical therapy and surgical debridement, reconstruction was undertaken using a latissimus dorsi free flap and split thickness skin grafts. This achieved a satisfactory reconstruction with obliteration of the diseased tissue. On follow-up several months later, there was erosion through the central area of the skin graft. This appears to be secondary to trauma caused by the patient frequently scratching the area, and that the original defect likely had a factitious component of the same etiology.

Microvascular reconstruction of a full thickness scalp and skull defect following herpes zoster infection

Microvascular reconstruction of a full thickness scalp and skull defect following herpes zoster infection

Vascular Anatomy of the Galeal Occipitalis Flap: A Cadaver Study

The vascular anatomy of the galeal occipitalis flap was studied in 10 fresh cadavers by an intraarterial dye injection technique. The scalp flap was based posteriorly, incorporating both the occipital and posterior auricular arteries. A good transmidline anastomosis was demonstrated between the two occipital arteries in the full-thickness scalp flap. However, in the isolated galeal flap, although the axial distribution of the occipital artery was maintained, fewer transmidline connections were seen between the two occipital arteries. The posterior auricular artery was consistently visualized in all dissections, and it showed good connections with the ipsilateral occipital artery. However, there were very few anastomoses between the two posterior auricular arteries across the midline. The rich anastomotic network between the occipital artery and the posterior auricular artery extended well beyond the vertex. This study showed that a large flap can be raised if both the occipital artery and the posterior auricular artery are included in its base. The occipital artery is a vessel of satisfactory size and is potentially a good vascular source for a thin galeal free flap. It is recommended that the flap be raised at the subperiosteal level for ease of dissection and protection of the vessels, which are initially in the subgaleal plane and then arborize in the galea.

The Difficult Scalp And Skull Wound

Scalp and skull defects can be very difficult to reconstruct. Whereas small defects may require only primary closure, skin graft, or small rotation flaps, large defects involving full-thickness scalp can be much more problematic. These large defects may require free-tissue transfer for adequate soft-tissue coverage. The calvaria also may require reconstruction. If the underlying bone is not infected, it can be left in situ and covered with well-vascularized tissue. The bone should be removed only if it is infected. Calvarial reconstruction should then be delayed for 3 to 6 months. If the tissue has been irradiated, only selected defects are appropriate for coverage with local scalp flaps because adjacent tissues may have underlying damage. With a methodic, accurate assessment of the defect, successful reconstruction can be expected.

Management of Large Scalp Defects with Local Pedicle Flaps

Recent reports have emphasized free-flap reconstruction for large defects of the scalp and calvarium following resection of tumors, infection, or trauma. In most cases, however, a carefully planned local transposition or rotation flap may be equally effective, and the technical difficulties and donor-site problems associated with microsurgical tissue transfer are then avoided. We present 10 patients whose full-thickness scalp defects covered an average area of 241 cm2, or 27 percent, of the skull surface. Although this series included defects as large as 450 cm2, or 50 percent, of the skull surface area, each was easily managed with a local pedicle flap transfer. Four patients were reconstructed with parietal scalp transfer, four with an occipital scalp flap, and two with temporal scalp transfer. The technique and results are discussed.

Composite Reconstruction for Chest Wall and Scalp Using Multiple Ribs—Latissimus Dorsi Osteomyocutaneous Flaps as Pedicled and Free Flaps

A composite flap is presented based on the latissimus dorsi myocutaneous unit together with the underlying ninth to eleventh ribs. Three patients are presented. In two, a full-thickness chest-wall defect was present. In one, a full-thickness scalp and cranial defect was present. Use of the composite osteomyocutaneous latissimus dorsi free flap as a pedicled flap in two patients and as a free flap in one patient resulted in successful definitive reconstruction in all with no complications. This procedure necessitates no transplantation of soft tissue prior to bone grafting to maintain local vascularity, so the simultaneous one-stage reconstruction of an osseous-soft-tissue defect becomes possible easily.

Resurfacing denuded areas of the beard with full thickness scalp grafts

Reconstruction of a beard-bearing area, such as the upper lip, necessitates hair-bearing grafts no thicker than a full thickness skin graft, in order to allow for normal movement. In the normal scalp, however, most of the follicles reach into the subcutaneous fat. By preoperative epilation it seems possible to induce the catagen phase of the hair cycle during which the follicles migrate into the corium and thus will be transplanted as complete morphological units. The clinical results support this concept.

Freshwater Wound Infection Due to Aeromonas hydrophila

AEROMONAS hydrophila is a Gramnegative bacillus, member of the family Vibrionaceae, which is a common inhabitant of freshwater lakes and streams. 1-4 It is not commonly identified as an agent of human infection. Most reports have described gastroenteritis, septicemia, meningitis, pneumonia, or surgical wound infections, primarily in immunocompromised patients. 1,4-8 Infections of immunologically competent persons have been rare. We report a well-documented case of severe cellulitis in a previously healthy young man that derived from a laceration acquired during swimming. Aeromonas hydrophila was recovered in large numbers from the wound and was subsequently shown to be the major bacterial contaminant of the freshwater lake where the injury occurred. The clinical features of Aeromonas infections of freshwater traumatic wounds suggest a characteristic syndrome, indistinguishable from cellulitis caused by group A Streptococcus . Report of a Case A 22-year-old man sustained a full-thickness scalp laceration while diving in shallow water in Lake Mendota,