Reconstruction Of Large Scalp Defects Research Articles

"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

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.

Use of the O-Z flap as an alternative to free tissue transfer for reconstruction of large scalp defects.

The reconstruction of large scalp defects poses both functional and cosmetic challenges. While free tissue transfer remains the standard for defects larger than 30 cm2, prolonged anesthesia and postoperative complications remain significant limitations. The purpose of this study is to evaluate the use of O-Z flaps for the reconstruction of large scalp defects and to describe the techniques employed. This is a retrospective analysis of ten patients who underwent reconstructive surgery using an O-Z flap approach for large scalp defects between July 2017 and June 2019. The parameters included in this study were patient demographics, tumor characteristics, and postoperative management, collected for at least a year after surgery. In this cohort, the mean age was 76.1 years and 90% were male. All patients were treated for neoplastic skin lesions, with 70% located on the vertex and 30% located on the temporoparietal region. The mean size of defect was 52.0 cm2 (range: 38.6 to 63.8 cm2). The maximum hospital stay was two days, and no patients were readmitted within 30 days of surgery. There were no cases of wound infection or flap necrosis. All patients reported pain control with acetaminophen and ibuprofen. Four patients received adjuvant radiation, and there was no delay to receiving treatment following surgery. The O-Z flap is a reliable alternative for the reconstruction of non-irradiated scalp defects in the vertex and temporoparietal regions up to 63 cm2. This technique provides advantages for patients, including hairline preservation, shorter hospital stays, and decreased postoperative complications.

Reconstruction of Full Thickness Defects on the Scalp With Artificial Dermal Regeneration Template: Analysis of Long-Term Results in 68 Cases

Artificial skin substitute templates have been shown to be a reliable solution for the reconstruction of large scalp defects with exposed skull bone, but there is a lack of long-term data. The aim of this retrospective study was to investigate the long-term outcome of the procedure in a large cohort of 68 cases. In total, 58 patients with 68 full thickness scalp defects with exposed skull bone, were included. Mean follow-up time was 24 (±19) months. The mean size of the defects was 63 (±54) cm2. During the follow-up period, no local recurrences occurred. Complications were observed in 13% of the cases including template necrosis (4%), infections (4%), ulcerations (3%), and autograft necrosis (2%). During the final follow-up, 26 patients had died due to internal diseases not associated with the surgery. Cosmetic results were rated good by the patients and an independent observer. The use of a dermal regeneration template for the reconstruction of large, full thickness defects of the scalp with exposed skull bone is a reliable method regarding the complication rate, safety of the procedure, and cosmetic outcome. Limitations of this study are the retrospective and single center design.

Versatility of Bipedicle Flap for Reconstruction of Large Scalp Defects

Background: Reconstruction of Scalp defects is a challenging problem. The unique hair bearing characteristics of scalp impose unique reconstructive challenges for coverage of scalp defects. Size, location and depth of the defect determine the complexity of the procedure. Patients with large scalp defects require reconstruction with broad based large scalp flaps. Objective: To determine the outcome of use of bipedicle scalp flap for coverage of large scalp defects. Study Design: Prospective & Observational study. Settings: Department of Plastic Surgery, Lahore General Hospital and Jinnah Burn & Reconstructive Surgery Centre Lahore-Pakistan. Duration: March 2010 to February 2019. Methodology: Eighteen patients of both genders with scalp defects secondary to trauma, tumor excision and burn injury were operated. Defect size more than 25cm2 were included in the study. Those patients in which residual scalp tissue was traumatized or inadequate for scalp reconstruction were excluded from the study. The variables and outcome measures included size, location of defect, flap survival and donor site complications. Bipedicle flaps designed in different axis depending on location and size of the defect. Results: Out of 18 patients included in this study, 12(66.67%) were male and 6 (33.3%) female. Age ranged from 32 to 78years (mean 48.66). Size of the defect ranged from 5.2x10.4cm to 18x14cm. Postoperatively 14(77%) flaps survived completely while marginal flap necrosis and dehiscence seen in 2(11%) patients. Hospital stay on average was 11 days. Recovery was quick in all patients and wound healing was satisfactory. The mean follow up period was 8 months. Minor complications like hematoma seen in 1(5%) patient. In 3 (16%) patients there was partial graft loss at flap donor site that healed with conservative management. Conclusion: Bipedicle flap provides healthy, durable and hair bearing tissue with good cosmetic outcome. Large defects can be reconstructed with a simple technique.

Free flap reconstruction of scalp after malignant tumor resections

The incidence of malignant scalp tumors which require radical excision increases with age. Reconstructing a multilayer scalp defect is a challenge for the reconstructive teams because of the soft tissue variability and paucity of available tissue. There is a wide range of options for treating scalp defects, from primary closure to free tissue transfer. In this study, nine patients who underwent reconstruction of large scalp defects after malignant tumor resection by using free tissue transfer were evaluated and reported. Eight patients died within two years after the surgery due to local recurrence (%88.9), and only one patient is still alive without any problems with a mean follow-up of 32 months. Many free tissue transfers have been reported on, with varied results. In the postoperative period, local and systemic complications can be seen, which do not correlate with age. Local tumor recurrence is another serious problem. Tumor complications and recurrences are the factors which affect the survival rates in patients. In this study we report on the scalp defect reconstruction after tumor resection with results and survival rates.

Microsurgical Reconstruction of Extensive Oncological Scalp Defects.

Although most small to medium defects of the scalp can be covered by local flaps, large defects or complicating factors, such as a history of radiotherapy, often require a microsurgical reconstruction. Several factors need to be considered in such procedures. A sufficient preoperative planning is based on adequate imaging of the malignancy and a multi-disciplinary concept. Several flaps are available for such reconstructions, of which the latissimus dorsi and anterior-lateral thigh flaps are the most commonly used ones. In very large defects, combined flaps, such as a parascapular/latissimus dorsi flaps, can be highly useful or necessary. The most commonly used recipient vessels for microsurgical scalp reconstructions are the superficial temporal vessels, but various other feasible choices exist. If the concomitant veins are not sufficient, the jugular veins represent a safe back-up alternative but require a vessel interposition or long pedicle. Post-operative care and patient positioning can be difficult in these patients but can be facilitated by various devices. Overall, microsurgical reconstruction of large scalp defects is a feasible undertaking if the mentioned key factors are taken into account.

The role of the anterolateral thigh flap in complex defects of the scalp and cranium

In this study, we introduced scalp reconstruction using free anterolateral thigh (ALT) flaps and evaluated postoperative outcomes in nine patients between March 2000 and April 2012. Five patients had problems of exposed prosthesis, three required reconstruction after resection of scalp tumor and one patient presented with third degree flame burns of the scalp. All flaps survived without re-exploration, except three flaps with tip necrosis requiring secondary procedures of debridement and small Z-plasty reconstructions. The superficial temporal artery and its concomitant vein were used as recipient vessels, apart from two cases where previous surgery and flame burns excluded these choices, for which facial arteries and veins were used instead. Primary closure of the donor-site was possible in six cases; with skin grafting performed for the other three patients. All donor sites healed without complications. The ALT flap offers the advantage of customizable size, option of fascia lata as vascularized dural replacement, and minimal flap atrophy typical of muscle flaps. Indications include very large defects, defects with exposed prosthesis, or defects with bone or dural loss. Our experience lends credible support to the use of customized free ALT flaps to achieve functional and cosmetically superior result for the reconstruction of large scalp defects, especially with bone exposure.

Can we put a simplified algorithm for reconstruction of large scalp defects following tumor resection?

BackgroundReconstruction of large scalp defects after tumor resection is a challenging problem. We aimed at putting an algorithm for reconstruction of those defects.MethodsForty-two patients with scalp malignancies were enrolled in this study. Tumors were resected to a 1 cm negative margin and defects were reconstructed according to their size and to patient general condition.ResultsNo peri-operative mortality was encountered. Usage of free flaps was superior in cosmoses and function with an acceptable rate of complications.Conclusionfor scalp defects wider than100 cm2, the best tool of reconstruction is free flaps. Pedicled distant flaps are reserved if free flaps are not feasible or failed. Split thickness skin grafts are cosmetically inferior and not suitable for recurrent and irradiated tumours and better reserved for patients who cannot tolerate major operations.

Scalp Reconstruction with Inverted Myocutaneous Latissimus Free Flap and Unmeshed Skin Graft

Limited skin paddle size, peripheral thinning, or lack of cerebral expansion after radiotherapy may necessitate secondary sculpting after latissimus free flap reconstruction of large scalp defects. This series presents a novel modification of the myocutaneous latissimus dorsi free flap for use in large scalp defects. After superficial artery isolation, titanium mesh is placed into the calvarial defect to recapitulate the inner table. The myocutaneous latissimus flap is harvested in standard fashion, deepithelialized, and inverted. The skin paddle is placed over titanium mesh to fill the calvarial defect, then sewn over a drain. The inverted latissimus muscle is draped over the defect and extended peripherally beneath the pericranium. The flap is sewn to the scalp internally using a vest-over-pants suture pattern, and the thoracodorsal and superficial temporal vessels are anastomosed and left facing outward. Unmeshed skin graft is draped over the muscle and vessels then sutured loosely. Patients with complex scalp defects whose soft tissue defect exceeded the size of latissimus skin paddle available with primary closure were considered eligible for inverted latissimus free flap reconstruction. Follow-up range was 6 months to 12 months. Over a 2-year period, five patients underwent inverted latissimus free flap reconstruction. Scalp defects ranged in size from 10 × 8 cm to 17 × 11 cm. The calvarial defect was smaller than the soft tissue defect in all cases. All flap donor sites were closed primarily. All five flaps took, and donor site outcomes were acceptable. Aesthetic outcomes were satisfactory with well-contoured, calvarial-shaped results. Cosmesis was most notably limited by skin graft joint lines. No patients underwent secondary surgical revision. The inverted myocutaneous latissimus free flap is a safe and effective method for reconstructing large or irradiated scalp defects.

Integra Application for Reconstruction of Large Scalp Defects

Integra Application for Reconstruction of Large Scalp Defects

Galeal/periosteal flaps for the reconstruction of large scalp defects with exposed outer table

Conflicts of interest: none declared. Large surgical defects of the scalp provide a challenge for the reconstructive surgeon due to the relative inelasticity of scalp skin and the lack of an adjacent tissue reservoir. Often they necessitate a repair utilizing a full‐ or partial‐thickness skin graft. Not uncommonly, however, Mohs extirpation of more extensive or aggressive tumours may necessitate removal of periosteum resulting in exposure of bare bone, which is an avascular bed and may not support a skin graft placed directly upon it.1 The role of cortical bone fenestration in facilitating granulation of such defects to heal by secondary intention has recently been elegantly described by Barry et al.2 We discuss our techniques of utilizing galeal/periosteal flaps (GPFs) to resurface exposed bone, providing a vascular bed for a skin graft and allowing immediate reconstruction of large scalp defects. The procedure is performed under local anaesthetic as a day‐case. Following tumour extirpation, the wound and surrounding scalp are prepared and draped in a standard fashion. A radial incision is made through skin and subcutis only, at least 1·5 times the width of the surgical defect, to permit access to the underlying galea and facilitate dissection of the GPF (Fig. 1a). For smaller defects with exposed bone a single access incision may suffice. More commonly, however, an access incision either side of the defect is required to elevate two tension‐free GPFs and provide adequate bone coverage (Fig. 1b).

Dual transposition flaps for the reconstruction of large scalp defects

Large scalp defects can be challenging to repair because of the inelasticity of the scalp. While there are several methods to close this type of wound, they result in either alopecia or unacceptable scarring. We present a dual transposition flap to close a large defect following Mohs surgery for a basal cell carcinoma on the scalp. We describe and report the case of a man with a basal cell carcinoma on the scalp vertex who had been referred for Mohs micrographic surgery. The surgery resulted in a large scalp defect. A dual transposition flap performed with tumescent anesthesia was used in a delayed closure of a 78.5-cm2 defect. It resulted in minimal alopecia, minimal distortion of the hair orientation, and minimal scar stretch-back. The limitation of this study is that this technique is based on one case report. This dual transposition flap is a good reconstructive option for large, immobile scalp defects. It can be performed under local anesthesia with minimal alopecia and camouflaged scars.

Rationale for Reconstruction of Large Scalp Defects Using the Anterolateral Thigh Flap: Structural and Aesthetic Outcomes

Rationale for Reconstruction of Large Scalp Defects Using the Anterolateral Thigh Flap: Structural and Aesthetic Outcomes

One-stage reconstruction of large scalp defects: Anterolateral thigh flap

Seven patients with large scalp and calvarial defects underwent reconstruction with free tissue transfer. Patients fell into two groups according to etiology: tumoral (five) or traumatic (two). A single type of free flap was used in each patient, i.e., the anterolateral thigh flap. Duraplasties with the flaps' vascularized fasciae were performed in two patients with minor calvarial defects, and nonvascularized fasciae were used in another two, with a cranioplasty using methylmethacrylate. One postoperative death and one venous congestion necessitating exploration were observed. The explored anastomosis revealed occlusion of the venous anastomosis; drainage with a venous graft into the neck veins was performed. Minor tissue loss with secondary healing was observed in the flap. Extensive scalp defects often necessitate challenging reconstructive procedures. Single-stage reconstruction with good qualified tissue is possible with a free tissue transfer. The anterolateral thigh flap provides a large amount of tissue with decreased donor-site morbidity and good cosmetic results.

Rationale for Reconstruction of Large Scalp Defects Using the Anterolateral Thigh Flap: Structural and Aesthetic Outcomes

The advent of free tissue transfer has provided multiple options that allow preservation and maintain both the structural and aesthetic status of the scalp. Since the first report of the anterolateral thigh flap in 1984, it has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. Eleven free anterolateral thigh flaps were used to reconstruct soft-tissue defects of different regions of the scalp. Two of these flaps were used for the occipital region, six for temporal regions, two for the frontoparietal midline region, and the remaining flap for a defect of the forehead. The study consisted of 10 males and one female whose ages ranged from 18 to 82 years (mean age: 52.5 years). Six patients had primary or recurrent cancer, four had acute or subacute wounds resulting from trauma or craniotomy, and one had high-tension electrical burn injury. The size of the flaps ranged from 14 to 27 cm in length and from 6 to 18 cm in width. The overall flap success rate was 100%. In two cases, primary thinning of the flap was performed to reconstruct a tissue defect of the temporal region in one patient and a forehead defect in the other. In two patients, the fascial layer of the flap was used as a source for a vascularized fascial flap to cover defects of the dura mater. No secondary corrections, including debulking procedures or scar revision, were necessary. No infections or hematomas were observed. Six cases underwent split-thickness skin grafting of the donor site and, in the remaining cases, the donor sites were closed directly. No donor-site morbidity was observed. The authors conclude that with its evident structural and cosmetic advantages, the anterolateral thigh flap can be considered an excellent flap option for most scalp defects.

Aesthetic Reconstruction of Large Scalp Defects by Sequential Tissue Expansion Without Interval

Tissue expansion is indicated in the reconstruction of various scalp defects when there is inadequate adjacent tissue to allow either primary closure of the defect or repair with a local flap. It is the most important armamentarium for aesthetic hair-bearing scalp reconstruction in cases of congenital or required defects. This technique was used sequentially without interval to achieve scalp reconstruction for 12 patients with a defect ranging from 30% to 75% of the scalp (average, 55%). For 12 patients, 32 expansion treatments were undertaken between September 1997 and January 2002. The 12 patients included 3 women, 4 men, and 5 children with a mean age of 20 years (range, 45 days to 36 years). All patients had more than one period of treatment. The most common conditions treated were burns (n=7), trauma (n=1), congenital naevi (n=2), and male pattern baldness (n=2). Reconstruction of 12 large scalp defects has been performed with a 3.1% rate of major complications. Results show that tissue expansion is a safe and efficient but time-consuming technique for aesthetic scalp reconstruction, especially in the case of "sideburn" scenario or large defects. There was no significant alteration in ratio of complications although tissue expansions were made sequentially.

Bilateral latissimus dorsi flaps for the reconstruction of extensive scalp defects

The reconstruction of large scalp defects is occasionally required. Several methods of scalp reconstruction have previously been described. This paper presents the authors' experience with two patients in whom traditional methods were not sufficient and in whom bilateral latissimus dorsi free flaps were required. To evaluate the effectiveness of a new technique in reconstructing extensive scalp defects. Two case histories are presented. These include the rationale for the choice of reconstruction used as well as a discussion on the technical features of the surgery. Reconstruction was effective in both cases. However, one patient died in the early postoperative period from a pulmonary embolus. Bilateral latissimus flaps can be safely and effectively used in closing massive scalp defects in selected cases.

Omental free flap reconstruction in complex head and neck deformities.

Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. This article reviews our 25-year experience with omental free tissue transfers. All patients who underwent free omental transfer to the head and neck region were reviewed. Fifty-five patients were included with omental transfers to the scalp (25%), craniofacial (62%), and neck (13%) region. Indications were tumor resections, burn wound, hemifacial atrophy, trauma, and moyamoya disease. Average follow-up was 3.1 years (range, 2 months-13 years). Donor site morbidities included abdominal wound infection, gastric outlet obstruction, and postoperative bleeding. Recipient site morbidities included partial flap loss in four patients (7%) total flap loss in two patients (3.6%), and three hematomas. The omental free flap has acceptable abdominal morbidity and provides sufficient soft tissue coverage with a 96.4% survival. The thickness \and versatility of omentum provide sufficient contour molding for craniofacial reconstruction. It is an attractive alternative for reconstruction of large scalp defects and badly irradiated tissue.