Large Scalp Research Articles

Repair of a Large Posterior Scalp Defect.

Repair of a Large Posterior Scalp Defect.

OTHR-11 A CASE SERIES OF OUTER TABLE CALVARIAL DECORTICATION AS A VIABLE OPTION TO ACHIEVE SKULL COVER AFTER RESECTION OF LARGE SCALP TUMORS

Abstract A showcase of a scalp cover technique that offers a simple solution to a unique challenge posed by excision of late presenting large scalp tumors in a third-world setting through a case series of 2 patients with extensive scalp malignancy requiring wide local excision with striping of the pericranium. Outer table skull drilling resulted in granulation tissue formation allowing for defect cover by wound contraction. Unique circumstances in a third-world setting compounded by the COVID-19 pandemic restrictions allowed for observation of the natural history of the progression of the scalp defect coverage by wound contraction over a decorticated granulation tissue bed. An adequate granulation bed can be achieved within 4-6 weeks. Closure of the defect by wound contraction over the granulation bed is possible, albeit over a protracted period of months. These two cases proved that outer table decortication offers a good option to cover denuded large scalp defects after the excision of scalp tumors. Although less than ideal, total defect closure can be achieved without subsequent grating.

Reconstruction of Extensive Scalp and Skull Defects with Dural Exposure: Report of a Series of Cases and Literature Review.

Large scalp and calvarial defects pose significant challenges for reconstruction. Successful reconstruction necessitates soft tissue restoration capable of withstanding radiation following tumor resection. Free flaps allow preserving and maintaining the structural and functional status of the reconstructed area. This article presents our experience with microsurgical free tissue transfer for scalp and calvarial defects as well as a literature review on the subject. A retrospective study was conducted to retrieve the files of all the extensive scalp/forehead defects with dural exposure treated in the plastic surgery department of Hotel Dieu de France University Hospital from September 2006 to December 2023. Twelve free tissue transfers were performed in 11 patients between 2006 and 2023. In 3 cases, a 2-stage procedure was performed with the transfer of the free flap in the first stage and the ablative surgery in the second stage 1 week later. A muscular latissimus dorsi flap was used in 9 cases. In 3 patients, the defect involved the forehead and required cutaneous flaps: 2 radial forearm flaps and 1 parascapular flap. Complications included 1 flap venous thrombosis, 2 hematomas, 1 subdural hematoma, and 2 cases of distal flap necrosis. Free tissue transfer is indispensable for addressing large defects of the scalp and calvaria. A 2-stage operation is warranted for debilitated patients with a high risk of complications. The latissimus dorsi muscle flap is the flap of choice to cover extensive defects. Delayed cranioplasty is preferable in contaminated wounds.

‘Bucket Handle’ bipedicled flap for reconstruction of large scalp defects

Although advances in free flap surgery have allowed the reconstruction of a wide range of complex scalp defects, simpler local options continue to play a role. We describe how bipedicled or 'bucket handle' scalp flap with skin grafting of the donor site can be used to resurface large scalp defects of up to 15 cm x 20 cm. This retrospective case series of 11 patients describes flap outcomes, post-operative complications, pathology and patient-related outcomes collected via a questionnaire. Defect sizes ranged from 56 cm2 to 220 cm2. All 11 flaps survived with no readmissions or return to theatre. There were two minor post-operative infections. Pathologies requiring reconstruction were invasive squamous cell carcinoma involving the bone (45%), cranial bone necrosis after a cerebrovascular event (27%), trauma (9%) or cerebral malignancy (9%). Four patients (36%) underwent simultaneous cranial reconstruction with a cranioplasty plate. On an average, the patients who did not need to remain in the hospital for other reasons were discharged after two days. All patients reported subjective improvements in function post-operatively and that they were satisfied with the procedure. This study suggests that large bipedicled scalp flaps with skin graft to the donor site are reliable, with positive patient-related outcomes and few post-operative complications. This technique is well suited for reconstructing long elliptical scalp defects created after the insertion of a cranioplasty plate. This procedure provides a robust alternative to patients who are unsuitable for free tissue transfer and those who may benefit from the short operative time and quick recovery time associated with a local flap.

Suprapterional keyhole approach for anteromedial skull base lesions: How I do it

BackgroundFor a minimally invasive treatment approach to the anteromedial part of the anterior cranial fossa (ACF), a small incision and craniotomy of the posterolateral part of the ACF are preferable.MethodWe described the concept and technique of suprapterional keyhole approach (SPKA), which uses an exoscope and endoscope to treat ACF lesions.ConclusionThe SPKA enables ACF observation from the lateral direction; the endoscope’s extended viewing angles enable the observation of the anteromedial part of the ACF, including the bilateral olfactory groove. Facial skin and large scalp incisions are avoided, making this approach efficient for ACF lesions.

Non-surgical management of severe aplasia cutis congenital accompanied by a bone defect – a case study

Background and objectives. Aplasia cutis congenita (ACC) is a rare developmental disorder that is not fully understood. It is part of a diverse group of conditions characterized by the congenital absence of THE epidermis, dermis, and occasionally subcutaneous tissues or bone, often affecting the crown of the scalp. It frequently presents as an isolated condition but can also be associated with a syndrome. Among patients, scalp involvement is common; however, large scalp defects with skull involvement are uncommon. Materials and methods. We report the case of a newborn delivered at full term by cesarean section, 3200g, in Mangalia Municipal Hospital, later transferred to the Constanta Neonatology Department, Neonatal Intensive Care department, for 3 injuries with lack of substance, both in tegument and bone, of different sizes, at the level of the vertex and the occiput. Results. Given the fragile age, a conservative management approach was chosen. The wound was meticulously cleaned daily using sterile water, and a self-adhesive absorbent dressing with hydrocolloid was applied. This dressing promoted granulation and epithelialization, adjusting dynamically to the lesion size. The newborn remained hospitalized for 35 days until the closure of the most extensive skin lesion at the vertex. Conclusions. Aplasia cutis congenita can be managed using various treatment approaches, but a consensus on the optimal strategy remains elusive. While conservative treatment has been proposed, several authors have highlighted its limitations. The choice between conservative and surgical management should be personalized, considering factors such as lesion size, location, underlying etiology, and related abnormalities.

Retracted: Treatment of Large and Complicated Scalp Defects with Free Flap Transfer.

[This retracts the article DOI: 10.1155/2020/2748219.].

Adaptability of bipedicled scalp advancement flap for coverage of huge scalp defects after tumor resection

BackgroundSeveral reconstructive techniques have been used to reconstruct scalp defects. Numerous researchers have studied the utilization of bipedicled scalp advancement flaps for scalp defect coverage. In this study, we will assess the adaptability of a bipedicled scalp advancement flap for coverage of huge scalp defects after tumor resection. MethodsThis study was performed at the Plastic Surgery Department, Fayoum University Hospital, on 20 patients with huge scalp tumors treated by adequate excision and reconstructed using a bipedicled scalp advancement flap from December 2021 to July 2023. ResultsThe study was conducted on 20 patients: 16 (80%) were men and 4 (20%) were women presenting with large scalp tumors. The mean age was 57.4 years (33–68 years). The sites of the tumors were 10 (50%) occipital, 6 (30%) parietal, and 4 (20%) parieto-occipital. No major complications occurred postoperatively, and the bipedicled flaps survived well in all cases, with no necrosis. ConclusionHuge scalp defects after tumor resection can be safely reconstructed with a large versatile bipedicled advancement scalp flap, either transversely or longitudinally oriented, with favorable functional results and accepted aesthetic results, apart from the alopecic area over the grafted donor site, which can be treated by tissue expansion if desired later.

Reconstruction of a large scalp defect secondary to a rare cutaneous metastasis from urothelial bladder carcinoma using intact fish skin xenografts.

Reconstruction of a large scalp defect secondary to a rare cutaneous metastasis from urothelial bladder carcinoma using intact fish skin xenografts.

Salvage of the cochlear implant in cases of skin breakdown over the receiver/stimulator in children

Objective and method: Skin breakdown over receiver/stimulator (RS) after cochlear implantation poses a serious challenge. We report our experience using a one-stage reconstruction and implant salvage approach. Results: Between the years 2005 and 2017 five children, all females, with congenital- bilateral sensorineural hearing loss were identified. In all cases, a temporoparietal fascia flap (TPFF) and a large scalp flap were used to provide a two-layer coverage to the exposed RS. In the first three cases, a split-thickness skin graft was used to cover the donor site defect. In the latter two cases, a larger rotation flap was used, and a skin graft was not required. One case required revision due to the dehiscence of the wound and exposure of the RS. In another case, an accidental electrode array explantation occurred and the patient underwent a revision cochlear implantation. All patients had achieved complete healing and no change in hearing thresholds with the implants. Conclusions: We demonstrate our one-stage salvage technique with TPFF that saves the implant and prevents a two-stage procedure. The success rate can be improved with special care at reconstruction and with better protection of the implant during the procedure.

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

ObjectiveHospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to...

A case report of spontaneous superficial temporal artery hemorrhage following COVID-19 infection

Post-COVID syndrome and COVID-19 have been related to autonomic changes and the appearance of endothelial dysfunction. Current research has discovered vasculitis-like occurrences in patients previously without evidence of endothelial dysfunction or autoimmune states. Additionally, COVID-19 and post-COVID syndrome have been hypothesized to induce flares of vascular dysfunction. Here, we present a patient with a large hematoma of the right scalp following spontaneous superficial temporal artery hemorrhage after uncontrolled hypertension, tachycardia, and generalized weakness three months after COVID-19 infection. This patient’s bleed was successfully managed with a pressure bandage and did not require neurosurgical embolization; moreover, he had no prior hemorrhages or indications for vessel rupture. Our case study represents a patient with chronic changes in blood pressure and heart rate following a prior COVID-19 infection that led to a large superficial scalp hematoma over the right frontotemporal bone with active extravasation from the right superficial temporal artery.

"Decoding a Decade: The Daring Dance of Over inflation in Tissue Expanders – Unveiling Our Unique Journey."

Background: Reconstruction of large scalp defect like post burn alopecia, post traumatic alopecia and congenital naevi require not only well-vascularized skin but also hair bearing scalp for better aesthetic outcome. Tissue expansion has always been the valuable reconstructive option in scalp reconstruction and is superior to any other option as it provides hair-bearing scalp. We have changed the traditional way of tissue expansion by using over expansion to two to three times of its recommended expansion to prevent multiple expansions. Methodology: This prospective case series was conducted from January 2013 - December 2022. Patients requiring scalp expansion for reconstruction of post burn alopecia , congenital melanotic naevi and post traumatic alopecia were included in this study. Flap advancement for covering the percentage area of the scalp defect was assessed as the outcome. Results: 13 patients were included, 6 (46%) patients required 2 expanders and 7(54%) patients required single tissue expander. Average flap advancement was 9 cm. Average tissue expansion was 650 ml, over expanded twice to thrice the recommended volume. No patient had any expander complication, wound breakdown or flap necrosis. Hair density was adequate on visual analogue scale. Conclusion: two to three times over expansion in tissue expander is valuable and safe tool for covering large area of alopecia without the need of expansion multiple times. Keywords: Tissue expansion, scalp alopecia, post burn scalp defects, congenital melanotic nevus scalp

Large aplasia cutis congenita of the vertex conservative management.

Aplasia cutis congenita (ACC) of the vertex with bone defect is a rare and begnin anomaly that can involve the epidermis, dermis, and subcutaneous tissues of the scalp with significant bone defect Bajpai and Pal (J Pediatr Surg 38(2):e4, 2003). When associated with skull defect, this rare malformation carries the risk of severe complications such as rupture of the superior sagittal sinus or infections. We report a case of aplasia cutis congenita of the scalp with skull defect measuring 9 × 10cm and an exposed sagittal sinus in a newborn. Both conservative and surgical methods have been proposed to treat this condition. In our case, conservative treatment was planned led to complete epithelization and the patient was healing well at 5years of follow-up. ACC of the vertex with a large scalp defects present a management dilemma Rocha et al. (Clin Case Rep 3(10):841-4, 2015). Based on a review of the literature, we report this case to demonstrate that even for the largest skin and bone defects, an initial conservative approach may allow for complete wound closure without the need for early surgical intervention.

Full-thickness versus split-thickness skin graft reconstruction of scalp defects with and without calvarium exposure

Compare full-thickness skin grafts versus split-thickness skin grafts in scalp reconstruction. Retrospective chart review of patients who underwent scalp reconstruction with skin grafts performed at a single institution from 2011 to 2016. χ2 or Fisher exact tests were used to compare graft integration and complication rates. The effects of graft type, defect type, graft size, and patient comorbidities on the likelihood of graft success and complications were analyzed using multivariate logistic regression. A hundred and twenty-five full-thickness and 93 split-thickness grafts were performed in 200 patients, including 68 defects (31.2%) with exposed calvarium. Full-thickness grafts required fewer average reconstructions (P=0.002). A 92.8% of full-thickness grafts had complete graft integration compared with 78.5% of split-thickness grafts (P=0.002). This difference was more evident in defects with exposed calvarium (87.2% vs. 47.6%, P≤0.001). Despite higher rates of minor debridement, full-thickness grafts had less postoperative bone exposure and wound breakdown than split-thickness grafts on intact pericranium and exposed calvarium defects. Preoperative radiation, immunosuppression, and increased graft sizes were significant predictors of graft outcomes. Skin grafts, especially full-thickness, provide a versatile, reliable, and simple approach for reconstructing medium to large scalp defects in the appropriate patient. Even on defects with bare calvarium, full-thickness grafts can succeed when a vascularized recipient bed is prepared. Defects with exposed bone, larger graft sizes, preoperative radiation, and immunosuppression may result in decreased graft take and increased complications. 3b.

Comparison of Antero-Lateral Thigh Flap and Vastus Lateralis Muscle Flap for the Treatment of Extensive Scalp Defects-A Retrospective Cohort Study.

Free flap reconstruction is the standard of care for extensive defects of the head and neck area. In this study, two types of free flaps, the antero-lateral thigh flap (ALT) and the vastus lateralis muscle flap, were compared. The primary endpoint was flap success, secondary endpoints were complication rates, hospitalization and surgery time. Cases with defect situations of the scalp and consecutive microvascular free flap reconstructions using either ALT flaps or vastus lateralis muscle flaps between 2014 and 2022 were retrospectively analyzed. Indications, perioperative handling and outcomes were compared. Twenty patients were included in the analysis. Ten patients (50%) received a free flap reconstruction using an ALT flap and ten patients (50%) received a vastus lateralis flap. A simultaneous two-team approach was possible in each case and the flap success rate was 100% with the need for one successful anastomosis revision. The mean defect size in our cohort was 147 ± 46 cm2. There were no significant differences in surgery time, duration of hospitalization or complication rate between both cohorts. Both free flaps, the ALT and the vastus lateralis flap, are suitable for the closure of large scalp defects. They provide high success rates, short surgery times without the need for patient repositioning and low donor-site morbidity. The vastus lateralis muscle flap bares the advantage of being perforator-independent and allows for the preparation of long vessels for anastomosis if needed while baring the disadvantage of a prolonged period of healing via granulation or the need for secondary surgery in terms of covering by split-thickness skin grafts which may interfere with necessary adjuvant treatment in oncological patients.

Application of a jigsaw puzzle flap based on free-style perforator to repair large scalp defects after tumor resection: A case series

BackgroundReconstruction of large scalp defects after tumor resection is common and challenging. Free skin grafting or free flap transfer is always performed. However, these techniques can result in poor functional and cosmetic outcomes. MethodsIn the Second Affiliated Hospital of Soochow University and the Second Affiliated Hospital of Chengdu Medical College, 35 patients underwent jigsaw puzzle flap procedures based on a free-style perforator to repair large scalp defects after tumor resection from May 2013 to November 2022. The key to this procedure was to divide a large defect into several smaller parts that correspond to adjacent free-style perforators around the scalp defect. The free-style perforator flaps were designed in different ways, such as propeller flaps, rotation flaps, and V-Y advancement flaps, which were pedicled with free-style perforators. All of the small flaps were then mobilized to the defect and sutured to each other to create a new, large jigsaw puzzle-like flap to cover the large scalp defect. Finally, all the donor sites were closed directly. ResultsOverall, 35 patients were treated. The average defect size was 72 ​cm2 (range, 25–91 ​cm2). All flaps had a satisfactory appearance after follow-up periods of 6 months–10 years. Local tumor recurrence occurred in one case. ConclusionThe application of a jigsaw puzzle flap based on a free-style perforator is a suitable option for the reconstruction of large scalp defects after resection, yielding satisfactory functional and cosmetic results.

Patch and pulley: A simple and cost-effective approach to surgical management of large scalp defects

Patch and pulley: A simple and cost-effective approach to surgical management of large scalp defects

Outcomes of Calvarial and Soft-Tissue Reconstruction with Latissimus Dorsi-Rib Osteomyocutaneous Free Flap.

The latissimus dorsi-rib osteomyocutaneous free flap (LDRF) has been used for autologous reconstruction of large composite calvarial and scalp defects. In this study, the authors aim to present clinical and patient-reported outcomes after LDRF reconstruction. An anatomical study was conducted to evaluate the distribution of the connecting perforators between the thoracodorsal and intercostal systems. An institutional review board-approved retrospective review of 10 patients who underwent LDRF with one or two ribs for treatment of cranial defects was conducted. Patient-reported outcomes regarding quality of life, neurologic status, and functional status were evaluated using validated surveys. One-way analysis of variance and post hoc Tukey tests were used for anatomical outcomes. Preoperative and postoperative scores were compared using paired t tests. The tenth rib (4.65 ± 2.01) followed by the ninth rib (3.7 ± 1.63) had the highest number of perforators. A combination of the ninth and eleventh ribs exhibited maximal perforator number and pedicle length. All patients had stable LDRF reconstructions. Eight patients completed both preoperative and postoperative questionnaires; Median clinical follow-up was 48 months (range, 34 to 70 months). Scores trended toward improvement but did not reach statistical significance on the Karnofsky Performance Scale ( P = 0.22), the Functional Independence Measure (Motor, P = 0.52; Cognitive, P = 0.55), or the Headache Disability Index ( P = 0.38). The minimum clinically important difference was surpassed, demonstrating improvement of function for 71% of patients on the Barthel Index and 63% on the Selective Functional Movement Assessment test. The LDRF can improve cognitive and physical functional status in complex patients with prior failed reconstructions for composite scalp and skull defects. Therapeutic, IV.

D106. Outcomes of Calvarial and Soft Tissue Reconstruction with Latissimus Dorsi Rib Osteomyocutaneous Free Flap

PURPOSE: The latissimus dorsi-rib osteomyocutaneous free flap (LDRF) has been used for autologous reconstruction of large composite calvarial and scalp defects. In this study, we aim to present patient-reported and clinical outcomes for patients treated with LDRF. METHODS: An anatomical study was conducted to evaluate the distribution of the connecting perforators between the thoraco-dorsal and intercostal system. An IRB-approved retrospective review of ten patients who underwent LDRF and one or two ribs for treatment of cranial defects was conducted. Patient-reported outcomes regarding quality of life, neurological and functional status were evaluated. One-way analysis of variance (ANOVA) and post hoc Tukey’s tests were used for anatomical outcomes. Preoperative and postoperative scores were compared using paired t-tests. RESULTS: The 10th rib (4.65± 2.01) followed by 9th rib (3.7±1.63) had the highest number of perforators. A combination of the 9th and 11th ribs exhibited maximal perforator number and pedicle length. All patients had stable LDRF reconstructions. Eight patients completed both pre and postoperative questionnaires; Median clinical follow-up was 48 [34-70] months. Scores trended toward improvement but did not reach statistical significance on the Karnofsky Performance Scale (p=0.22), Functional Independence Measure (FIM; Motor p=0.52, Cognitive p=0.55), and Headache Disability Index (p=0.38). The minimum clinically important difference (MCID) was surpassed, demonstrating improvement of function for 71% of patients on the Barthel Index and 63% on the Selective Functional Movement Assessment test (SFMA). CONCLUSION: The LDRF can improve cognitive and physical functional status in complex patients with prior failed reconstructions for composite scalp and skull defects.