Scalp Flap Research Articles

Management of traumatic scalp arteriovenous fistula: Case report and literature review.

Blunt traumatic arteriovenous fistula (AVF) of scalp, are uncommon and most of them can be secured by simple embolization or surgical ligation of the feeders. Our goal in writing this paper is to show patients with traumatic scalp AVFs how to prevent complications and the likelihood of recurrence. Complete treatment and reduce the recurrence rate of traumatic AVF on the scalp. Traumatic scalp AVF. Transarterial embolization and surgical resection. Complete resection of the AVF and subsequent angiography showed resolution of the contralateral lesion. Combination of endovascular embolization with subsequent surgical removal may reduce intraoperative blood loss compared with surgery alone. In addition, a well-designed scalp flap can be performed based on the angiography findings after embolization.

Transmuscular pocket: a modified technique to overcome thick musculocutaneous flap in cochlear implant surgery

Objective To describe and evaluate a modified cochlear implant surgical procedure for patients with a thick musculocutaneous flap. Materials and Methods A prospective study for cochlear implant surgery in selected patients with a musculocutaneous flap thicker than 7 mm. Results Fourteen patients with a thick scalp flap underwent cochlear implantation between July 2019 and December 2020. The patient age ranged between 17 and 53 years. The flap thickness was between 7 mm and 14 mm. The mean follow uptime post operatively was 16.5 months. The cochlear implant receiver coil was successfully implanted using the transmuscular technique without complications and with normal audiological function. Conclusion The transmuscular pocket modified technique is a safe and effective method to overcome a thick musculocutaneous flap in cochlear implant surgery.

Scalp Flap Surgery - an Efficient Way to Save the Cranial Bone Flaps

Brain surgery often requires wide ecisions to ensure the radicality of the surgical intervention. In this contet, the role of the plastic surgeon becomes essential in the reconstructive stage where outstanding soft tissue defects following life-saving neurosurgical interventions often require creation of large local flaps. By effectively covering the defects with quality tissues, the rapid healing of patients is ensured, as well as obtaining stable results over time. This paper presents the salvage surgical approach in the case of a patient operated for the recurrence of a brain tumor, the rotation scalp flap being the optimal choice for this case.

Unseparated Temporal Muscle and Duramater Cranioplasty Methods Following Decompressive Craniectomy: Technical Note.

Cranioplasty (CP) is used to repair cranial defects after decompressive craniectomy. During this procedure, the temporal muscle can contract or retract toward the base and adhere to the scalp flaps above and/or below the dura. Several complications including functional and cosmetic problems can occur following CP. This study presents the technical notes and outcomes of CP. This retrospective observational study collect data of CP-procedures using unseparated muscle-dura technique performed at our hospital in 2019-2022. Technical note is presented regarding the lack of separation of the temporal muscles from the dura mater. A bone flap or titanium mesh was placed above the temporal muscle layer, which was still attached to the dura mater. Functional outcomes were evaluated using OHIP-14 Questionnaire to assess mastication quality. Twenty-three patients were included in this study. Initial surgeries were mostly caused by trauma (65.2%). Most patients underwent autologous bone flap CP (52.2%), during which the bone flap was stored in either the abdominal subcutaneous pocket or cryoprecipitated. Only one patient experienced mastication problems after CP (p<0.001). Temporal hollowing remained a problem in this technique. However, dissection of the temporalis muscle to reduce temporal hollowing can cause facial nerve injuries and masticatory problems. Due to the lack of temporal muscle manipulation, our patients had minimal mastication problems. CP should be performed to improve functional and aesthetic outcomes. A CP technique with the temporal muscle unseparated from the dura mater can be selected to avoid damage to the muscle and mastication problems after surgery.

Dermatofibrosarcoma Protuberans on the Occipital Scalp Showed Uncommon Presentation: A Case Report

Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue sarcoma, with an incidence of about 0.8% to 5% per million people per year, accounting for 1% of soft tissue sarcomas. In its early stage, DFSP is typically found as a violet or pinkish macule or patch, and it can develop into a palpable mass with ulceration or bleeding. The standard treatment for DFSP is wide local excision of the tumor with a 2- to 3-cm negative margin, and radiation therapy or chemotherapy can be conducted with surgical treatment. A 35-year-old man had a palpable mass on the left side of his occipital scalp without color change, ulceration, or bleeding, which typically are present in malignancy. A magnetic resonance imaging (MRI) scan showed a 3-cm homogenous enhanced mass without adhesion between the scalp and the mass. Unexpectedly, a biopsy revealed the round mass to be DFSP. A wide excision and rotation of the scalp flap were performed. The patient recovered without any complications and received adjuvant radiotherapy at a dose of 60 Gray (Gy) for six weeks. There was no recurrence through six months of follow-up. Here we report this unique case of DFSP with atypical presentation.

Reconstruction methods for large cranial-nasal communications: surgeons’ concerns about proper anterior skull base reconstruction

Purpose: Skull base reconstruction is one of the most difficult reconstructive surgical procedures. Due to its complexity, most surgeons have modified the reconstruction methods to minimize the postoperative complications and mortality rate. In the past, flap surgery was not usually performed, but it has recently become more common due to advances in medicine. In this study, we analyzed successful flap surgery methods in skull base reconstruction for large cranial-nasal communications.Methods: Patients who underwent skull base reconstruction from April 2015 to January 2024 were eligible for this study. Of these patients, we included those who underwent reconstruction using a volumetric flap. Reconstructions that only used the conventional galeal flap, allograft skin, or bone substitute were excluded. The reconstruction methods used local flaps and free flaps.Results: In total, 22 patients underwent skull base reconstruction. The most frequently used local flap was the bilateral reverse temporalis muscle flap (seven of 11 cases), and the most frequent free flap was the anterior lateral thigh flap (10 of 11 cases). Other local flap operations used the modified temporalis muscle flap and scalp flap. A rectus myocutaneous flap was also used. There were no cases of flap necrosis.Conclusion: Flap surgery is needed for skull base reconstruction in patients with large cranial-nasal communications. As long as the flap volume is large enough to block and fill the defect, either a local flap or a free flap can be used for reconstruction.

The Use of the Galea Flap for the Reconstruction of Forehead Defects

The forehead, a vital anatomical unit of the face, is delimited by the anterior hairline superiorly and by the nasal root, eyebrows, and a horizontal line through the lateral canthus inferiorly. Malignant tumors like basal cell carcinomas frequently afflict this region, necessitating meticulous reconstruction techniques to preserve aesthetics and functionality. This article presents an in-depth exploration of the galea flap graft’s efficacy in addressing tissue defect on the forehead, especially in cases of basal cell carcinomas. The surgical procedure involves a wide excision with a 1 cm safety margin, including the frontal muscle and periosteum, followed by exposing the frontal bone. A meticulous approach is taken in tracing the midline, marking the hairline, and planning the left hemi coronal incision to ensure optimal outcomes. The galea flap, vascularized by branches of the superficial temporal artery, is meticulously lifted and transposed downwards to cover the tissue defect, while ensuring the viability of the flap. Postoperative monitoring reveals no signs of cutaneous or vascular damage, with preserved sensory and motor functions attributed to the preservation of the frontal branch of the facial nerve. The discussion delves into the intricate anatomy of the forehead, emphasizing its vascularization, innvervation, and aesthetic subunits such as the glabella and eyebrows. Various surgical techniques, including direct suturing, directed healing, skin grafts, advancement flaps, and two-stage scalp flaps, are examined in light of their efficacy and limitations in forehead reconstruction. The galea flap emerges as a preferred option due to its reliable vascular supply, ease of lifting, and versatility in covering tissue defects while preserving aesthetics. Future research directions are suggested, focusing on refining surgical techniques to achieve optimal outcomes in forehead tissue reconstruction, balancing esthetic results with functional integrit.

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.

Raney Clip Free Coronal Scalp Flap: Case Series

The coronal scalp flap is a useful surgical approach that provides access to the upper and middle third of the skull and can be utilized to repair fractures of the upper and middle face. Intraoperative hemostasis is usually achieved with Raney clips. This case series report discusses the literature on the conventional use of Raney clips during coronal flaps elevation and compares it to the technique used by the Oral and Maxillo-facial department at Memorial Hermann Hospital where use of clips are replaced by an electrosurgical cutting and coagulation device, LigaSure. This technique was used by the department on 21 patients treated at MHH. Use of LigaSure was found to decrease intraoperative bleeding as well as reduce alopecia commonly associated with coronal scalp flaps.

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.

Management of head & neck sarcomas in adults: A retrospective study

The research purpose is to review the surgical approach and evaluate the results in adult patients with head and neck sarcomas.The histopathology varied, including two leiomyosarcomas, six malignant fibrous histiocytomas, two malignant peripheral nerve sheath tumors, four dermatofibrosarcomas protuberans, three osteosarcomas, two angiosarcomas, one liposarcoma, one Ewing sarcoma, one synovial sarcoma, two unclassified/non-differentiated sarcomas and one solitary fibrous tumor. Surgical resection included maxillectomy, mandibulectomy, craniectomy, parotidectomy, scalp resection, face skin resection and laminectomy. The reconstruction was performed with one rectus abdominis flap, four radial forearm flaps, two latissimus dorsi flaps, two vascularized fibula flaps, two pectoralis major myocutaneous flaps, two trapezius flaps, two temporalis flaps, seven scalp flaps and two nasolabial flaps.The total patient number was 24. The hospitalization was uncomplicated, followed by postoperative radiotherapy in the majority of cases. In a mean 15-year follow-up period, 11 patients are still alive and disease-free. There were four recurrences treated with palliative radiotherapy.The surgical approach for head and neck sarcomas, including the achievement of a functionally acceptable result by organ sparing techniques, remains challenging. Wide resection combined with the appropriate reconstruction, particularly with microsurgical techniques, and followed by adjuvant radiotherapy or chemotherapy offer improved prognosis and quality of life.

A Descriptive Study on Imperiled Cochlear Implant Salvage Using Double Flap Cover-What We Learned in 6 Years.

Cochlear implant surgery is the standard of care for severe sensorineural hearing loss. Infection followed by implant extrusion is an infrequent complication of this surgery. The ideal treatment is explantation of the implant. However, implant removal and reimplantation is a challenging surgery and may have poor speech reception outcomes. The cost of a new implant especially in developing countries is also a deterrent. Our study dwells on the feasibility of salvaging exposed cochlear implants by a combination of pericranial flaps followed by a scalp flap cover. The study was done in a tertiary care hospital over a period of six years. Out of 303 cochlear implant surgeries, 12 patients had implant exposure and extrusion. Patients having meningitis and sepsis were excluded from the study. All patients underwent debridement and cover with double flap (Pericranial flaps and scalp rotation flap). The average operating time was 2.17h. The surgery is technically simple with a short learning curve. It brings in rich blood supply and there is fair amount of tissue mobility. In 11 patients we were able to salvage the implant. Patients were followed for a period of 01year post operatively. Our study suggests that salvage of infected implant should be attempted as it is feasible, durable and effective in appropriate patients.

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.

Mini-Craniotomy With Endoscopic Approach for Acute Subdural Hematoma Evacuation in a Patient With Complex Scalp Flap Defect: A Case Report

BACKGROUND AND IMPORTANCE: Acute subdural hematoma (aSDH) is one of the most common pathologies resulting from head trauma. Surgical management often involves a large craniotomy for hematoma evacuation. Prior complex cranial reconstructive surgery can complicate incision planning or limit craniotomy size. CLINICAL PRESENTATION: In this report, we describe a 61-year-old woman with a history of squamous cell carcinoma of the scalp, which previously required complex flap reconstruction and left a residual skull defect, who presented with an aSDH after a fall. Prior surgery and poorly vascularized skin significantly limited the available area for craniotomy. We used a mini-craniotomy with endoscopic adjunct to achieve appropriate visualization and complete evacuation of the hematoma. CONCLUSION: In cases of aSDH in which a mini-craniotomy is desirable and the potential location of the incision is limited, an endoscopic approach should be considered.

회전 두피 피판과 머리 덮개 피판을 이용하여 구제한 인공 와우 노출 치험 2예

Cochlear implant (CI) is an effective surgical option for managing severe sensorineural hearing loss. Among the postoperative complications, implant exposure has been considered as one of the most threatening and serious complications. Conventionally, replacing a new device after a removal of the exposed one has been well known to be performed. Salvaging the exposed implant without explanta-tion can be challenging and beneficial and recently has been reported as an alternative management option. Here, we report our experience salvaging two cases of exposed cochlear implants using a rotational scalp flap reconstruction combined with implant coverage with a galeal flap.

Hair follicle extraction combined with an expanded scalp flap for facial organ reconstruction

Use of scalp skin for facial organ reconstruction represents a mainstream procedure for organ reconstruction. In most cases, adequate amounts of skin can be obtained by using tissue expanders, but harvesting sufficient scalp tissue in patients with low hairlines is challenging. Hair follicular unit extraction (FUE) is one approach to resolve this problem. With FUE, hair follicles are removed from the scalp skin, which can then be prepared as a donor site to obtain sufficient amounts of hairless skin. To evaluate the safety and efficacy of FUE when combined with an expanded scalp flap for facial organ reconstruction. Patients with low hairlines requiring facial organ reconstruction were selected for this study. The area of skin extension and hair removal were determined prior to surgery, a process which was performed in three stages. Stage I consisted of hair follicle removal using the FUE technique at the donor site. Stage II involved expander implantation using water injections. In Stage III facial organ reconstruction was completed. With the use of the FUE technique, hair follicles from the donor scalp were thoroughly removed and the donor scalp tissue was successfully expanded. Postoperatively, no evident scar formation at the reconstruction site or contracture of the expanded flap was observed. All patients were satisfied with the outcome of their reconstruction procedure. FUE provides a means for hair follicle removal from the donor site and can be employed to achieve a safe and effective procedure for facial reconstruction in patients with low hairlines.

Risk of postoperative scalp necrosis in the occipital artery region after posterior cranial fossa surgery.

Ischemia-induced postoperative scalp necrosis in the superficial temporal artery (STA) region is known to occur after STA-middle cerebral artery anastomoses. However, no reports have evaluated the risk of postoperative scalp necrosis in the occipital artery (OA) region. This study examined the surgical procedures that pose a risk for postoperative scalp necrosis in the OA region following posterior cranial fossa surgery. Patients who underwent initial posterior fossa craniotomy at our institution from 2015 to 2022 were included. Clinical information was collected using medical records. Regarding surgical procedures, we evaluated the incision design and whether a supramuscular scalp flap was prepared. The supramuscular scalp flap was defined as a scalp flap dissected from the sternocleidomastoid and/or splenius capitis muscles. A total of 392 patients were included. Postoperative scalp necrosis occurred in 19 patients (4.8%). There were 296 patients with supramuscular scalp flaps, and supramuscular scalp flaps prepared in all 19 patients with postoperative necrosis. Comparing incision designs among patients with supramuscular scalp flap, a hockey stick-shaped scalp incision caused postoperative necrosis in 14 of 73 patients (19.1%), and the odds of postoperative scalp necrosis were higher with the hockey stick shape than with the retro-auricular C shape (adjusted odds ratio: 12.2, 95% confidence interval: 3.86-38.3, p = 0.00002). In all the cases, ischemia was considered to be the cause of postoperative necrosis. The incidence of postoperative necrosis is particularly high when a hockey stick-shaped scalp incision is combined with a supramuscular scalp flap.

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.

An Orientational Harvesting Occipital Artery Technique via far Lateral Approach: A Cadaveric Study

To provide further information on the identification of the occipital artery (OA) and suggest an improved approach to its anterograde dissection technique for harvesting. Six cadaveric specimens were prepared for surgical simulation, and the anterograde approach was used to harvest the OA; a hockey stick incision was made from the C2 spinous process through the nuchal ligament to the mastoid tip. By retracting the scalp flap from the posterior arch of C2 to the transverse process, the suboccipital triangle was reflected by a single myocutaneous flap from the inferior nuchal line. In addition, 70 head computed tomography angiography scans were assessed bilaterally (n= 140) to study the running pattern of the OA. The mean total length of the mobilized OA was 11.8 ± 0.7cm, with a diameter of 1.5 ± 0.1-2.1 ± 0.2mm at the suboccipital segment and 1.3 ± 0.1mm at the upper edge of the surgical incision. The average distance of OA at the inferior nuchal line to the midline was 2.9 ± 0.3cm, the average distance of OA at the superior nuchal line to midline was 4.1 ± 0.2cm, the average distance of OA at incision edge to midline was 5.2 ± 0.3cm. Orientational anterograde technique for OA harvesting is a fast and easy approach. This approach avoids critical neurovascular structures. The most important step is to identify the OA near the lateral edge of the superior oblique muscle. Subsequently, in conjunction with preoperative computed tomography angiography, an imaginary line that crosses the inferior and superior nuchal lines may be established to assist in the separation of theOA.

Eyebrow Reconstruction in Craniofacial Clefts by Abnormal Hairline Extention.

The absence of eyebrows, whether complete or partial, has been observed in specific types of craniofacial clefts, primarily occurring in Tessier clefts numbers 9 to 13. To address this defect, several techniques have been used to improve eyebrow appearance, such as the island scalp flap and scalp strip grafting technique. However, these methods did not yield satisfactory esthetic results. In this study, the authors present findings from 7 patients with craniofacial clefts, in whom the eyebrows were completely reconstructed through the rotation flap technique, using abnormal frontal hairline extension, in 1 or 2 stages. The result was natural-looking and highly satisfactory, with no associated morbidity.