Local Scalp Flaps Research Articles

Reconstruction of Scalp and Forehead Defects: Options and Strategies.

Background Aesthetic reconstruction of scalp and forehead defects with local flaps and minimal donor site morbidity is the primary goal of coverage. While selecting the coverage technique, essential factors such as size, location, and components of a defect, hair-bearing or non-hair-bearing nature of skin, status of the exposed skull, need for radiation, patient condition, availability of local tissue, and the potential for hairline distortion should be kept in mind. Materials and methods This is a retrospective analysis in which 54 patients who underwent soft tissue reconstruction of the scalp and forehead defects were included. The defect size was categorized into four groups: small: <4 cm2, medium: 4-50 cm2, large: 50-200 cm2,and very large: >200 cm2. Reconstruction of all defects was done according to the defect's size, location, and depth. All patients were regularly followed at intervals of two weeks, six weeks, and three months, respectively. The outcome was evaluated in terms of flap survival, flap coverage scale, the requirement of secondary treatment, postoperative complications, and final aesthetic appearance. Results In 54 consecutively treated patients with scalp and forehead defects, the male-to-female ratio was 2:1, and the overall mean age of participants was 34.8 years, ranging from 0.5 to 66 years. The most common etiology of the defect was trauma (16; 29.6%), and the most common location of the defect was combined (16; 29.6%). Rotation flap and primary closure were the most commonly performed procedure, each 12 (22.2%) in number. Out of 12 primary closure cases, two patients developed wound dehiscence because of infection. All cases ofskin grafting healed well. All cases of transposition flap with skin grafting at the donor site went uneventful, and the dog ear at the base was revised later. One case of the bipedicle flap in which partial graft loss occurred at the donor area was managed with regrafting. Two cases of single rotation flap, one double rotation flap, and one free latissimus dorsi muscle flap developed distal necrosis. The excellent aesthetic outcome was found in all cases of primary closure and single and double rotation flaps. Conclusions Local flaps have an architecture similar to the recipient site, and low donor site morbidity results in an aesthetically more pleasant outcome. In our experience, scalp defects up to 50 cm2 were covered with the local scalp flaps with primary closure of the donor area. Defects ranging from 50 to 200 cm2 required local scalp flap with skin grafting at the donor area.Free tissue transfers are usually needed when the defect is very large, devoid of the periosteum, or with the calvarial defect.

An Algorithm for Reconstruction of Electrical Injuries of the Scalp.

Electrical injuries of the scalp are a frequent occurrence in developing countries. Burns can be contact or conductive and result in extensive tissue damage. The authors present their experience with treatment of scalp and calvarial electrical injuries and propose a management algorithm. This was a retrospective cohort study comprising all patients with electrical injuries of the scalp treated at the authors' center between January of 2010 and December of 2016. Noncontrast computed tomography scans were obtained to assess viability of the calvarium in patients who presented more than 2 weeks after injury. Single-stage débridement and reconstruction were performed. All nonviable soft tissue and bone was removed. Soft-tissue reconstruction was performed with skin grafts, local scalp flaps, pedicled trapezius flaps, and free flaps (anterolateral thigh, latissimus dorsi, and scapular). Cranioplasty was performed in a delayed manner with autologous bone grafts. Over a 7-year period, a total of 52 patients underwent scalp reconstruction for high-voltage (44 patients) and low-voltage (eight patients) electrical injury. All patients underwent successful soft-tissue reconstruction. Osteomyelitis with draining sinuses developed in three patients; these patients underwent flap re-elevation and bone débridement, which resulted in a healed wound and stable reconstruction. Cranioplasty was performed with split calvarial grafts in two patients and split rib grafts in four patients. One patient underwent scalp tissue expansion for hair restoration. The authors propose an algorithm for reconstruction of electrical injuries of the scalp. Thorough débridement of the calvarium is the most important determinant of a successful outcome. Therapeutic, IV.

Salvaging Exposed Cochlear Implants.

Background:The cochlear implant (CI) procedure is one of the most efficient surgical options for the management of patients suffering from severe bilateral sensorineural hearing loss. Notably, CI exposure is one of the most commonly reported complications. Herein, we report our experience in the management of three patients with CIs complicated by implant exposure.Methods:We present a retrospective review-based case series of three patients with exposed CIs requiring soft tissue coverage who were referred to plastic surgery care. These patients underwent their CI procedures at a university hospital specializing in ear, nose, and throat, after which they were referred for plastic surgery care at our university hospital for reconstruction after exposure. Each patient was managed through different surgical techniques based on the size, site, and condition of the surrounding tissue. The management options are discussed in this article.Results:Three patients with exposed cochlear implants were treated with different surgical techniques. During the 1-year follow-up period, the patients made an uneventful recovery with fully functional cochlear implants.Conclusions:The management of CI extrusion with local scalp flaps can constitute an effective and reliable option to salvage CI with a good prognosis and a lower incidence of exposure recurrence. Optimal results for establishing effective soft tissue coverage can be achieved by choosing the appropriate technique according to the clinical presentation.

Reconstruction of chronic scalp erosion after deep brain stimulation surgery

To investigate the reconstructive effectiveness for chronic scalp erosion after deep brain stimulation (DBS). Deep brain stimulation (DBS) is an effective treatment for Parkinson's disease. However, this surgery is not exempt from hard-ware related complications, especially scalp erosions on scalp. Scalp erosions usually accompanied with chronic infection and wound contamination. If not arrested, infections may spread through the entire equipment which would endanger the patient's life. Along with review of previous literatures, we summarized our experience in the management of scalp erosion and implemented a systemic treatment plan for reconstruction. We retrospectively analyzed the clinical data of patients with chronic scalp erosion after DBS in the past 40 months. The treatment plan was composed of three sequential major steps, including wound care and conservative methods, debridement and local flap, and revaluation of the wound. In each of the cases, wound debridement and local scalp flap repair were conducted, and assisted by negative pressure wound therapy (NPWT) device and double cannula irrigation. The local scalp flap survived in all 6 patients. The chronic scalp erosions all healed without refractory. The DBS devices still functioned properly after the treatments in all patients. The average follow-up period was 13.33 months (range: 4 to 23 months), and no infection recurrence or re-erosion of the scalp flap was reported. A combination of wound debridement, local scalp flap repair, the use of NPWT device and double cannula irrigation provides effective treatment method for chronic erosion post DBS surgery.

Management of scalp defects due to high-voltage electrical burns: a case series and proposed algorithm to treat calvarium injury

Multiple modalities to manage scalp and underlying skull defect due to high-voltage electrical burns have been discussed. We aimed to describe our experience and to propose an algorithm for the management of skull injury which could be helpful in decision-making. A retrospective study of patients who sustained electrical burns to the head from May 2007 to April 2012 was carried out. Sex, age, size of scalp defect, and method of reconstruction and management were analyzed. Thirteen patients were identified. Out of 13, 11 patients had scalp defects which were covered using local scalp flap. Free latissimus dorsi (LD) muscle flap and pedicle trapezius flap were used in two patients. The largest defect covered with local scalp flap was the size of 80 cm2. Free LD flap was used to cover a defect of 144 cm2. Of the nine patients who presented early (immediately after injury), seven required debridement of the outer table and the other two patients required full-thickness excision of the skull. The remaining four patients who presented late (after 3 months) were found to have osteomyelitic segments which required full thickness excision of the skull. Most of the soft tissue defects of the scalp due to high-voltage electrical burns can be managed with local scalp flaps. However, if the local tissue is injured or not sufficient to close the defect, then free flap should be considered. In management of calvarium injury, the emphasis should be debridement of necrotic bone to provide infection-free site followed by soft tissue cover. Level of Evidence: Level IV, therapeutic study.

Head Injury by Bear Mauling: A Case Report

Animal bites posses a great challenge for the surgeon to restore back what is normal. These attacks occur to be sudden and cause a life threatening injuries. They even cause facial disfigurement with distressing physical and psychological consequences. This manuscript reports a case of 65 year old man who was mauled by bear and also illustrates about the myths and management of head injury by bear attacks. Bear inflicted head injuries are rare and very few reported in literature. The wound was managed by a local scalp flap with restoration of esthetics.

Scalp Reconstruction Following High Voltage Electric Burn

Background: Scalp reconstruction following high voltage electric burn can be challenging. A useful Reconstructive algorithm is lacking. The purpose of this study was to evaluate our experience and to identify an appropriate reconstructive strategy. Methodology: This was a prospective observational study, conducted in the Burn unit of Dhaka Medical College Hospital &amp; Department of Burn &amp; Plastic Surgery,Sir Salimullah Medical College &amp; Mitford Hospital over a period of five years. Reconstructive procedures, independent factors and outcomes were evaluated. A total of 7 procedures were performed in 30 patients. Techniques for reconstruction included skin grafting, outer table drilling &amp; skin grafting, Bipedicle flap, Single rotation flap, Double opposing rotation flap, Transposition flap, Tissue expansion &amp; primary closure. Conclusion: Important tenets for successful management of scalp defects are durable coverage, adequate debridement, preservation of blood supply, and proper wound drainage. Local scalp flaps with skin grafts remain the mainstay of reconstruction in most instances. DOI: http://dx.doi.org/10.3329/bdjps.v3i2.18251 Bangladesh Journal of Plastic Surgery July 2012, 3(2): 49-52

Reply to Dr. Henderson et al.’s comments

We thank Henderson et al. for the insightful comments. Although, they have echoed most of our opinions, we think two facts may merit further comments. One, the fact that local scalp flaps may not be reliable in neonates is underscored by Dr. Henderson’s team’s experience. We tend to fully agree with them that in patients with a large scalp defect parental allografts should be considered as a first-line measure rather than as a salvage procedure pending definitive autografting. Two, in our case, the maternal autograft stayed on, and the entire wound healed without the need for auto grafting, even though the epidermis peeled off after a month. The auto graft was done for a limited area of breakdown much later (after a year!!). We believe that specifically maternal autograft is preferable due to the perinatal transmission of maternal T cells to the neonate. It confers in many cases, a type of immunological tolerance [1] and hence improves the probability of the duration and extent of survival of the graft. Of course, more experience is needed on this issue. In our patient, the wait to see the fate of the calvarial bone is adding to our anxiety as we are unclear if dura was intact as the infant presented to us with eschar and granulation. We await further follow-ups.

Exposed Titanium Mesh and Dura Persisting for 8 Years After Cranioplasty

Cranial defects and their reconstructions may be challenging in neurosurgery and plastic surgery practice. In this article, we present a patient who had an infection on the scalp with exposed titanium mesh and dura for 3 months. The patient had undergone craniectomy and cranioplasty with titanium mesh plate with local scalp flap 8 years ago due to skin tumor invasion to the skull. After the titanium mesh was removed at the operation, a considerably wide osteoneogenesis and a small bone defect (1.5 × 2 cm in size) were detected under the titanium mesh plate (10 × 10 cm in size), and computed tomography substantiated our observations. On the basis of our observation, titanium mesh plates could be recommended in patients who need cranioplasty instead of materials that are occupying and inhibiting osteoneogenesis in cranioplasty applications.

The Shoelace Method in Congenital Aplasia of the Scalp and Skull

Aplasia cutis congenita (ACC) is an uncommon skin disorder characterised by the absence of some or all layers of the skin. It may involve any part of the body, but is most common in the scalp. Some scalp lesions are associated with a defect of the underlying skull or even dura. Small superficial lesions heal spontaneously. Options available for larger defects and those involving the skull include conservative management, skin grafts, composite grafts, local scalp or pericranial flaps, and free microvascular transplants. This case report presents a delayed primary closure of a scalp and skull defect with the shoelace method and a temporary skin graft. The method is simple, gives an excellent cosmetic result, and can be used in moderately sized defects, where a direct suture is not possible.

Scalp reconstruction: a 15-year experience.

Scalp reconstruction after ablative surgery can be challenging. A useful reconstructive algorithm is lacking. The purpose of this study was to evaluate the authors' experience and to identify an appropriate reconstructive strategy. This was a retrospective review of all patients treated by the authors' service for scalp defects during a 15-year period. Reconstructive methods, independent factors, and outcomes were analyzed. A total of 73 procedures were performed in 64 patients. Techniques for reconstruction included primary closure, grafts, and local and distal flaps. A correlation between reconstructive technique and complications could not be demonstrated. However, an increased incidence of complications was correlated with a history of radiation, chemotherapy, cerebrospinal fluid leaks, and an anterior location of the ablative defect (P < 0.05). Important tenets for successful management of scalp defects are durable coverage, adequate debridement, preservation of blood supply, and proper wound drainage. Local scalp flaps with skin grafts, and free tissue transfer remain the mainstay of reconstruction in most instances.

Management of acute calvarial burns in children.

Although rare, head burns involving the calvarium are a serious complication of burns and electrical injury, and present therapeutic challenges to the surgical burn care team. We evaluated our experiences and compared available strategies to address this challenge. Records of all burned children between January 1986 and December 2000 were reviewed. Twenty-seven children (15 boys and 12 girls) with scalp burns extending at least into the outer table of bone were identified and compared with a matched group of 30 patients admitted for acute thermal burns without skull injury. Flame burn was the injury mechanism in 78% of these patients and electrical injury was the injury mechanism in 22%. The incidence of calvarial burns in our patient population was 1.2% for thermal burns and 5.6% for electrical injuries during the study period. The age distribution was biphasic, with maximums in infancy for thermal burns and in puberty for electrical injuries. Eight of 27 patients (29.6%) developed full-thickness calvarial bone defects. In 23 patients, calvarial burn wound coverage was achieved with bone debridement and immediate or delayed placement of autograft skin. In four patients (all with electrical injury), local scalp flaps were required for closure. The length of hospital stay and overall number of acute operative procedures significantly increased for patients with calvarial burns. Acute calvarial burns are safely managed by bone debridement in combination with staged autografting or early flap coverage. Although flap coverage reduces the number of required procedures, the extensive wound size in thermal burns restricts acute flap procedures primarily to electrical injuries. Compared with patients without skull injury, length of hospital stay and the number of acute operative procedures are tremendously increased in patients with calvarial burns.

Reconstruction of extensive head defects by local scalp flaps

Reconstruction of extensive head defects by local scalp flaps

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.

후이부 피하조직-측두두정근막피판을 이용한 유양동절제술후 생긴 이후부 피부결손의 복구

Severe postmastoidectomy wound infection infrequently leaves large skin and soft tissue defects over postauricular area, which is ususlly quite difficult to repair by primary closure. Using “Retroauricular subcutaneous tissue-temporoparietal fascia flap” whose main vessel of blood supply is posterior auricular artery, such defects could be successfully repaired in two patients who underwent revision mastoidectomy. In this axial pattern local scalp flap, distal semilunar potion of the flap had only subcutaneous tissue and temporoparietal fascia, which was slid into the postauricular defect area. This new flap approach can be useful in repairing postauricular skin and soft tissue defects following radical mastoidectomy.

Reconstruction of massive defects of the scalp, cranium, and dura after resection of scalp neoplasms

Massive defects of the scalp, cranium, and dura can be covered with local rotation, transposition scalp flaps. Five cases of massive defects of up to 300 square centimeters resulting from resection of scalp neoplasms were reconstructed by this technique. Excellent cosmetic and functional results were obtained in all cases. Although the emphasis in the recent literature has been on free flap coverage of these massive defects, our series demonstrates that these extensive scalp defects can be reconstructed using large local scalp flap transposition.

The extended temporoparietal fascia "non-free" flap.

The extended temporoparietal fascia flap is a logical variation of previously accepted extended free tissue transfers, which are unique in that the recipient and donor vessels are identical. This local scalp flap permits adequate distant ipsilateral skull coverage with minimal patient inconvenience. If desired, retrograde fascial perfusion from cephalad collaterals allows the completion of long interposition vein graft microanastomosis to the superficial temporal vessels before creating any recipient site defect without fear of flap warm ischemia time. Although the patient described had complications, the concept of the extended temporoparietal fascia flap has been proved to be an intriguing option for head and neck reconstruction.