Reconstruction Of Scalp Defects Research Articles

Hair Transplantation on the Baldness Region with Free Latissimus Dorsi Flap for Scalp Reconstruction: A Case Report

AbstractScalp reconstruction, particularly with complex defects and infection risks, often favors microvascular free flaps. However, this method can result in unavoidable alopecia and undesirable aesthetics. This report describes a novel case where hair transplantation via follicular unit extraction (FUE) was applied to a free myocutaneous flap. A 44-year-old woman with Moyamoya disease suffered intracerebral hemorrhage a decade ago. Craniotomies and autologous bone cranioplasties led to wound dehiscence, with subsequent failed local flaps and skin grafts, and identification of a methicillin-resistant Staphylococcus aureus infection. The final scalp defect, measuring 13 × 9 cm, was reconstructed using a free myocutaneous latissimus dorsi flap. Nine years post-surgery, a 1,500-unit FUE hair transplantation procedure was conducted. The transplanted hair exhibited robust survival with adequate blood supply, achieving a satisfactory 80 to 85% survival rate at 12 months. This resulted in a notable improvement in the patient's external alopecia, with reported high levels of satisfaction. Free flaps offer a valuable method for scalp defect reconstruction; however, they may not ensure optimal aesthetic satisfaction due to alopecia. Nonetheless, successful FUE hair transplantation on a myocutaneous free flap can yield satisfactory aesthetic results.

Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green.

Scalp defect reconstruction poses considerable challenges, with ongoing debates regarding the most effective strategies. While the latissimus dorsi (LD) flap has traditionally been favored, the anterolateral thigh (ALT) flap has been well described as a versatile alternative for addressing extensive scalp defects. This study underscores the success of scalp reconstruction using ALT flaps, notably pushing the boundaries of previously reported flap sizes. Our approach leverages the use of indocyanine green (ICG) perfusion to guide precise preoperative planning and vascular modification, contributing to improved outcomes in challenging cases. We performed 43 ALT flap reconstructions for scalp defects between 2016 and 2023. We collected patients' demographic and clinical data and evaluated flap size and recipient vessels and additional surgical techniques. Detailed preoperative plans with ultrasound and ICG use for intraoperative plans were performed to find perforators location. The cohort was divided into two, with or without complications on flaps, and analyzed depending on its surgical details. This study involved 38 patients with extensive scalp defects (mean age: 69.4 ± 11 years) who underwent ALT perforator flap transfers (mean flap size: 230.88 ± 145.6 cm2). There was only one case of unsuccessful flap transfer, and four cases had a few complications. The characteristics of the complication group included a large flap size (303.1 ± 170.9 vs. 214.9 ± 136.6 cm2, P = .211), few perforator numbers without pedicle manipulation, lack of intraoperative indocyanine green administration (75% vs. 25%, P = .607), and the use of superficial temporal vessels as recipient vessels. Scalp reconstruction using large ALT free flaps with the aid of imaging modalities facilitates the optimization of surgical techniques, such as pedicle manipulation, perforator numbers, and vein considerations, thereby contributing to successful reconstruction.

The use of bone wax versus dermal regeneration matrix for the reconstruction of scalp defects.

Secondary intention healing is an alternative to consider in large tumors or tumors located in areas of limited skin mobility, such as the scalp. To promote epithelialization, we can use Dermal Regeneration Matrix (DRM) or bone wax. This study aimed to compare the efficacy of DRM and bone wax in secondary intention healing of cutaneous scalp tumors in elderly patients with comorbidities. The medical records of 18 patients with cutaneous scalp tumor healing by secondary intention from February 2022 to April 2023 were analyzed for demographic variables, tumor and surgical characteristics, time from withdrawal of material to complete epithelialization, and need for subsequent surgical intervention. Bone wax was used in 6 patients and DRM in 12. The mean patient age was 84.3 years, and the mean tumor size was 2.7 cm. There were no significant differences in demographics or postoperative complications between the groups. The median time to complete epithelization was 84.5 (60.2-108.7) days in the bone wax group and 105.0 (91.0-126.0) days in the DRM group, with no significant differences (P = 0.15). Bone wax is a simple and economical material that can be used for secondary intention healing of scalp tumors in elderly patients with high surgical risk.

Integra® Dermal Regeneration Template in Complex Scalp Reconstruction.

Background/Objectives: The need for surgical reconstruction of scalp defects following the excision of cutaneous skin cancers is an increasingly common procedure. Particular challenges arise when considering options for reconstruction of large defects not amenable to local skin flap coverage. The use of skin grafts poses the risk of donor site morbidity. This paper investigates the emerging use of Integra®, a synthetic acellular dermal regeneration template, as an alternative or adjunct to skin grafting in scalp reconstruction. Methods: The study presents a retrospective analysis of 101 patients who underwent Integra®-based reconstruction of scalp defects. Demographics, procedure details, complications, need for further surgery, and time to healing were evaluated. Results: The overall success rate of the one-stage Integra®-only procedure was 95%, with a minor complication rate of 30.7%. Anticoagulation medication was identified as an independent risk factor for post-operative infection, while previous head and neck radiotherapy and increased defect depth were associated with the requirement for a second-stage skin graft. Conclusions: These findings support the consideration of Integra® as a safe and viable alternative for both partial and full thickness scalp defects in a select cohort of complex highly co-morbid patients, reducing complications and the need for additional procedures.

Scalp reconstruction with locoregional and free flaps - a retrospective cohort study.

Scalp defect reconstruction requires interdisciplinary cooperation to restore soft tissue and osseous defects. While wound closure and form restoration, often a short-term treatment goal, ensures patient survival, the long-term preservation of the head and neck's integrity and aesthetics is crucial for maintaining quality of life. This study aims to compare, quantify, and establish a safe and reproducible approach to various reconstruction options and the postoperative complication profile for individual scalp defect areas. We retrospectively evaluated patients who underwent scalp reconstruction at our institution between March 2017 and April 2022. The inclusion criterion was the presence of a soft tissue defect at the cranium level. We included 31 patients in the study (17 males, 14 females), with an average age of 61 years (range 17-92 years). Eight patients had received radiotherapy in the affected region. The mean defect size was 72.5±116 cm2 (range 20-441 cm2), and an average of 3±2 surgeries had been performed before the plastic surgical treatment was initiated. Eleven patients had only a soft tissue defect, while 20 patients had an associated bone defect. Fifteen of these patients received a cranioplasty. The rotation flap was the most frequently used (n=23), with or without split-thickness skin grafting, followed by the free latissimus dorsi muscle flap with split-thickness skin grafting (n=5), and the free lateral arm flap (n=2). Revision surgeries were necessary in 38.7% of cases due to wound healing disorders (n=9), bleeding (n=2), and cerebrospinal fluid leaks (n=1). Eventually, all wounds were successfully closed. Complex scalp defects can be closed using local flaps, thereby restoring aesthetics and tissue integrity. Free flaps remain a reliable solution for extensive defects. Moreover, in cases requiring cranioplasty, careful preoperative planning and an uncontaminated wound are essential for successful treatment.

Epidermal cyst protruding from the occipital region of the scalp: a case report

Introduction and importance: Epidermal cysts are the most common subcutaneous tumor typically observed on the scalp, face, neck, back, or trunk. Epidermal cysts conventionally range in size from 1 to 5 cm, with sizes greater than 5 cm rarely reported. Case presentation: Here, we present a case of a 58-year-old female housewife who presented to our surgery outpatient department (OPD) with a history of a mass in the left occipital region. The mass was first noticed 3 years back and was small and associated with mild itching. The mass progressively increased in size over the course of 3 years. Her present complaint was a painful mass associated with itching, headache, and pus discharge when compressed. The pain was relieved by taking medication. Clinical discussion: The epidermal cyst was confirmed on biopsy, and subsequent excision of the cyst was done under general anesthesia; the occipital bone was eroded by the inferior part of the cyst – reconstruction of scalp defect done by rotational scalp flap. Conclusion: Epidermal cysts, being a slow-growing benign tumor, can pose diagnostic difficulties, especially when located in the scalp area. In addition to that, when cranial bones and intracranial structures are affected by the cyst, they can even lead to complications and interventional difficulties.

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.

Reconstruction of Scalp Defects Using Rotational Flaps After Revascularization Surgery in Patients with Moyamoya Disease

Treating scalp defects after revascularization surgery is difficult because the scalp microcirculation is severely compromised. We aimed to review the clinical effects of using rotational flaps in scalp defect reconstruction and explore risk factors for wound-related complications (WRC) after reconstruction surgery. We retrospectively identified patients with scalp defects after combined revascularization surgery who were surgically treated with rotational flap reconstruction at our institution between January 2018 and December 2022. We analyzed treatment results in different surgical technique and revascularization strategy cohorts, including direct bypass superficial temporal artery branch selection, indirect bypass types, and skin incisions. Eleven patients were included. The superficial temporal artery parietal branch was selected for direct bypass surgery in 10 (90.9%) patients, 4 (40%) of whom had WRC after flap reconstruction. Five types of indirect bypass surgeries were performed; three patients treated by encephalo-duro-myo-arterio-perio-synangiosis and 1 patient treated by encephalo-duro-myo-perio-synangiosis had WRC after flap reconstruction. Question mark (n= 6, 54.5%), curved (n= 4, 36.65%), and Y-shaped (n= 1, 9.1%) incisions were used; in the first three incision cohorts, 2 patients in each cohort had WRC after flap reconstruction. Patients had the following commonalities that may be risk factors for WRC after flap reconstruction: 1) wounds with nonviable bone exposure after revascularization surgery; 2) three or more tissues used as donor tissues and donor tissues containing the periosteum; and 3) thin scalp around the defect.

219 Post-Skin Cancer Scalp Defect Reconstruction with Integra® as Single Stage Surgery: A Case Series

Abstract Aim Large post-surgical scalp defects represent a common challenge in skin cancer surgery reconstruction. Despite the multiple options available the patients, often elderly, may prefer to have the least amount of surgery done and/or have comorbidities that may impair adequate wound healing. In order to reduce the number of hospital appointments and the risks of COVID19 exposure for the frail patients we used Integra®, a very versatile Dermal Regeneration Template for the treatment of skin defects. Originally, Integra® was designed to be followed by a second-stage surgery with a full thickness skin graft (FTSG). We retrospectively collected, in our busy OMFS Unit, a 40-case series of post-skin cancer scalp defects reconstructed using Integra® as single-stage approach without any further surgery. Method We have carried out a literature review of its use on the scalp and examined a series of parameters from our experience including:defect sizedressing appointments and total healing timeanticoagulation, peri-operative antibiotics prescribingcomplications Results The total healing time for the scalp wounds treated with Integra® averages 3.8 months, requiring 7.8 hospital appointments for dressings and checkups. Two infections, 3 significant bleeds and 4 failures were reported. Conclusions The Integra® is a valid and optimal substitute for local flaps and FTSG in patients that may prefer a single-staged approach wishing to avoid a second surgical site and minimising hospital attendance. The drawbacks are the longer time to heal compared to flaps/FTSG, the costs and the risk of delaying radiotherapy if complete epithelialisation is not achieved.

Surgical Technique Applying Mosquito Forceps to Galeotomies for Scalp Reconstruction

Reconstruction of scalp defects can be difficult due to the stiffness and inelasticity of the scalp, posing challenges for surgeons. Galeotomies can be applied to allow for this inelastic tissue to stretch, increasing local tissue movement and reducing tension on wound margins, but they generally require large incisions and dissections. Here, we completely repaired scalp defects by applying a surgical technique for galeotomies that only required small incisions of the scalp using simple mosquito forceps. This study included nine patients who underwent scalp reconstruction for defects due to mass excision; all surgeries were performed by the same surgeon. All surgical wounds completely recovered with a satisfactory aesthetic outcome, with no notable complications during a mean follow-up period of 21 months. Taken together, our results showed that galeotomies can be successfully performed even in a confined space using mosquito forceps, offering an effective modality for reconstruction of medium-sized scalp defects with minimal complexity.

Dermal Substitutes and Skin Grafts in the Reconstruction of Post-Traumatic Total Scalp Avulsion: A Case Series.

Although scalp defects can vary in size and thickness, scalp avulsion represents a rare occurrence. This type of lesion may have different origins, but it is usually related to long hair being caught in agricultural machinery. The management of full-thickness scalp defects poses a challenge to the head and neck surgeon due to the possible involvement of neurovascular structures and scar retraction, which can affect the esthetic restoration of the area. Several algorithms for the choice of scalp reconstruction have been proposed in the literature and different techniques are available for extensive scalp defect reconstruction (local soft tissue flap, microvascular free flap, and skin graft combined with dermal substitutes), based upon the scalp defect type. Here we describe six cases of patients with total scalp avulsion, which required a combined reconstruction with a split-thickness skin graft (STSG) and Integra® matrix immediately after the trauma.

Geometric Design and Outcome of Transposition Flaps for Scalp Reconstruction

Background: The scalp is a unique part of the human body and various etiological factors, such as tumor extirpation, avulsion, infection, burns, or trauma, can lead to scalp defects. Primary closure, skin grafting, local flaps, tissue expansion or free tissue transfer is modalities available for scalp reconstruction. Local flap coverage is best option for full thickness loss with exposed bone. Among various local flap transposition flap is reasonable and flexible option with good outcome for scalp reconstruction.
 Objective: The purpose of this study was to evaluate the geometric design of transposition flap for scalp reconstruction concerning the dimension of the defect and outcome the surgery.
 Methods: This was a prospective observational study, conducted in the Burn & Plastic Surgery department of Rangpur medical college hospital, Rangpur and different private hospitals of Rangpur city over a period of three years from June 2018 to July 2021 through purposive sampling. All aged patients having single full thickness scalp wound with loss of pericranium were included in this study. In all cases transposition flaps were used. All the flaps were elevated through sub galeal lose areolar plane. Flap donor site was covered with split thickness skin graft taken from thigh. Surgical technique, patient factors and outcome were evaluated.
 Results: A total 50 patients were operated. The age range was 07-68 years, among them 36% patient were in the age range of 21 – 30 years. 80% patients in this series were male. In this series 64 % patients were construction and electric worker by profession. Electric burn was the main (64%) cause of soft tissue defect of scalp. The majority (46%) of the patients had a wound dimension of 51-70 cm2, smallest was (5x6) = 30cm2 and largest was (9x15) = 135cm2, indicating that extent of soft tissue defects in this series is quite extensive. 12 (24%) patients had complication and all were due to infection, seven patients had infection in flap recipient site, 2 patients had infection in flap donor site and 3 patients developed infection in skin donor site. There was no flap loss in our study.
 Conclusion: Sound knowledge of flap geometry and clear evaluation of the defect is mandatory for successful reconstruction of scalp defect. A local transposition flap with donor site skin grafting is reliable option for reconstruction of full thickness scalp defect in most instances.
 J Rang Med Col. September 2022; Vol. 7, No. 2:52-57

Double hatchet flap for scalp defect reconstruction. A case report

Double hatchet flap for scalp defect reconstruction. A case report

Six-years experience in major scalp defect reconstruction with free flap: analysis of the results.

Introduction:The purposes of this study were to report 10-years experiences in microsurgical reconstruction of major scalp defects, comparing outcomes, evaluating complications.Materials and methods:From November to July 2015, 10 consecutive patients underwent microsurgical procedures for severe scalp defects.Results:The average age was 55,1 years ranging from 6 to 87 years. The mean follow-up was 16.7 months ranging from 12 to 24 months. The size of the lesions ranged from 9x10 to 16x20cm. The average hospital stay was 20 days ranging from 8 to 43 days. Mean operative times was 5.3 h ranging from 5 to 6.45 h. Free flaps included 8 Latissimus Dorsi flaps (LD) and 2 anterolateral thigh flaps (ALT). The superficial temporal vessels were used as recipient vessels in 9 cases while the superior Thyroid artery was used in remaining case.Discussion:For large or complex lesions, the use of free flaps is mandatory. Nowadays LD and ALT flaps are among the most common reconstructive choices for scalp defects reconstructions. Older age does not contraindicate the operation procedure nevertheless in younger patients the size of vessels is proportionately larger and pristine.Conclusion:Microvascular free tissue transfer is the mainstay of scalp defects coverage. In our series early complications are less common and concerning than late complications and in fact reoperations are mainly required to manage these latter. Advanced age should be not consider a contraindication for free flap surgery and the procedure can be considered safe and reliable in both old and young population. (www.actabiomedica.it)

Leukocyte- and Platelet-Rich Fibrin: A New Method for Scalp Defect Reconstruction.

Leukocyte- and Platelet-Rich Fibrin: A New Method for Scalp Defect Reconstruction.

Outcome of latissimus dorsi free flap in-case of large scalp defect a single center study

Reconstruction of scalp and calvarial defects following trauma post burn and after tumor ablation frequently requires prosthetic cranioplasty and soft tissue coverage. Furthermore, patients often have advanced disease and receive perioperative radiotherapy following tumor ablation. We evaluated the outcome of scalp reconstruction in traumatic cases with a free Latissimus dorsi (LD) muscle flap in this setting. The aim of this study was to evaluate outcome of latissimus dorsi free flap in-case of large scalp defect. This prospective non-randomized study was conducted on 10 patients with scalp defects following trauma attended emergency unit and outpatient department of burn and plastic surgery, Dhaka medical college hospital (DMCH) in the period between July 2017 and June 2018. Durability of coverage, flap success, infection and overall satisfaction were studied. The age distribution of the study population shows highest number of patients (60%) were in middle (24-30 years) age group whereas lowest are in older group (30-50 years). The lowest age was 24 years and the highest age was 45 years. Highest number of patients (80%) were standard myocutanous type of flap whereas lowest were in (20.0%) were partial latissimus muscle flap. Outcome of the reconstruction (80.0%) were excellent 10% partial flap necrosis occur and total flap loss in 1 (10%) patient. The reconstruction of scalp defects continues to be a challenge for the reconstructive surgeon, who must achieve a satisfactory functional and aesthetic outcome.

Integra as Firstline Treatment for Scalp Reconstruction in Elderly Patients

Large scalp defects pose a reconstructive problem especially in elderly patients. The purpose of the study is to describe our experience of oncologic scalp reconstruction using a dermal matrix (Integra). We conducted a retrospective cohort study (January 2007 to March 2021) of patients who had undergone scalp tumor excision and reconstruction using Integra and a split-thickness skin graft (STSG). The primary end point was Integra and STSG success (defined by ≥75% percent take) and the secondary end point was postoperative complications. Both end points were assessed by the surgeon during follow-up. Demographic data, tumor characteristics, average defect size, time between stages and full-thickness scalp defects were characterized using descriptive statistics. Univariate and multivariate logistic regression models were used to evaluate the association between variables and end points. The sample included 70 patients with a mean (SD) age of 83.3 (7.0) years, 75.7% men and 92.9% with comorbidities. Mean (SD) defect area was 23 (17.0) cm2 and the mean (SD) first-to-second phase interval was 30.6 (8.4) days. Sixty-four patients (91.4%) underwent outpatient surgery. Integra and STSG success rates were 87.1% (95%CI: 77.69 to 93.74%) and 100%, respectively. The complications rate was 18.6% (95%CI: 9 to 28%). Mean (SD) follow-up was 18 (16.7) months. Univariate and multivariate logistic regression analysis showed no association between variables and the primary and secondary end points. Reconstruction of oncologic scalp defects using Integra can be performed under sedation and local anesthesia. Integra should be considered as firstline treatment for the reconstruction of scalp defects in elderly patients with comorbidities, given the low postoperative major complications rate and Integra and STSG take success.

Reconstruction of scalp defects in electrical burns: Challenges and options

Introduction: Electrical burn injury in India comprises a fair percentage of overall burn injuries, and they cause significant morbidity. Reconstruction of scalp defects often poses challenges to the plastic surgeon regarding the timing of surgery, choice of reconstruction, and postoperative management. The objective of this article is to throw light on various options for reconstruction of scalp defects as the involvement leads to significant morbidity. Materials and Methods: The study was conducted at a tertiary burn care unit. The period of this study was from 2016 to 2019. Retrospective analysis was done. Results: In this study, retrospective analysis of 40 cases of scalp burns was evaluated from 2016 to 2019. Out of these, 6 patients were managed with primary suturing, 8 patients underwent split-thickness skin graft, 24 patients required local flaps, and 2 patients were managed with extracorporeal radial forearm flap. There were no major complications. Minor complications like wound infection were seen in five of the local flap patients which were managed with antibiotics and regular dressing. Two patients had partial flap loss which was revised and managed conservatively. All flaps healed well. There was hair loss patch evident in patients where split-thickness graft was used. Conclusion: Thorough debridement of the wound is necessary in electrical burns. Smaller scalp wounds can be managed with split-thickness skin graft and local flaps, but larger defects should be managed with distant flaps and free flaps. This study shows that local flaps are the ideal choice for reconstruction of scalp defects due to their easy availability, minimal complications, and acceptable cosmesis.

Outcomes of split vs full-thickness skin grafts in scalp reconstruction in outpatient local anaesthetic theatre.

BackgroundSurgical excision remains the cornerstone of simultaneous diagnosis and treatment of suspicious skin lesions, and the scalp is a high-risk area for skin cancers due to increased cumulative lifetime ultraviolet (UV) exposure. Due to the inelasticity of scalp skin, most excisions with predetermined margins require reconstruction with skin grafting.MethodsA retrospective single-centre cohort study was performed of all patients undergoing outpatient local anaesthetic scalp skin excision and skin graft reconstruction in the Plastic Surgery Department at Addenbrookes Hospital over a 20-month period between 1 April 2017 and 1 January 2019. In total, 204 graft cases were collected. Graft reconstruction techniques included both full-thickness and split-thickness skin grafts. Statistical analysis using Z tests were used to determine which skin grafting technique achieved better graft take.ResultsSplit-thickness skin grafts had a statistically significant (P = 0.01) increased average take (90%) compared to full-thickness skin grafts (72%). Using a foam tie-over dressing on the scalp led to a statistically significant (P = 0.000036) increase in skin graft take, from 38% to 79%.ConclusionIn skin graft reconstruction of scalp defects after skin cancer excision surgery, split skin grafts secured with foam tie-over dressings are associated with superior outcomes compared to full-thickness skin grafts or grafts secured with sutures only.

Scalp Reconstruction with Novel Unopposing Double Hatchet Flaps- A Case Series

Though there are regional and distant approaches for acquired scalp defect reconstruction, use of local flaps always have the advantage of retaining the topography of scalp. As in treatment of any other defect the choice of a local flap in scalp wound coverage is dictated by the location, size, and depth of the defect and by the availability of adjacent tissue for reconstruction. The versatile and adaptable triangular hatchet flap with a partial skin and subcutaneous bridged pedicle has great versatility. When used singularly or in pair to cover small and medium sized defects, utilising both rotation and advancement components for its movement, has the benefit of maintaining cosmetic appearance. Double hatchet flaps are used commonly in an opposing manner so as to convert a circular wound to a ‘S’ shaped suture line. In the current case series, with a description of four representative cases, authors have presented a modification of this double hatchet flap in unopposing configuration instead of an opposing pattern to cover scalp defects when the type and extent of injury affecting the scalp prevents in heaving flaps at 180 degree to each other. Authors opine that this technique adds into the ever expanding armamentarium of reconstructive surgeon and can be made use of in the aforementioned conditions wherein the standard pattern cannot be employed to cover moderate sized scalp defects.