Scalp Reconstruction Research Articles

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.

"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

Intraoperative Tissue Expansion for Scalp Reconstruction

Intraoperative Tissue Expansion for Scalp Reconstruction

Integra Scalp Reconstruction: Addressing a Full-thickness Scalp Defect with Exposed Calvarium Along Vertex in an Elderly Immunocompromised Patient

Integra Scalp Reconstruction: Addressing a Full-thickness Scalp Defect with Exposed Calvarium Along Vertex in an Elderly Immunocompromised Patient

Spectrum of malignant scalp tumours and its impact on management—a tertiary care cancer centre experience

BackgroundTumours on the scalp are diverse and often exhibit site- and histology-specific characteristics. Reconstructing the scalp after oncological resection has always been challenging because of its unique anatomy.MethodologyA retrospective review of patients with malignant scalp tumour operated on at a single institution over 10 years was performed. Data were collected and analysed regarding the scalp tumour profile, treatment, and the outcome of these procedures.ResultsOf the 66 patients in our study, 33 (50%) had SCC. In addition to this, 21% were sarcomas, 17% were appendageal carcinomas, 11% were BCCs, and 1% was neuroendocrine carcinoma. Cortical erosion was observed in 6 patients in the CT imaging, all with SCC histology. Among the eight patients with pathological nodal involvement, three had angiosarcoma, three had SCC, one had appendageal carcinoma, and one had neuroendocrine carcinoma. The mean surgical defect size was 67.4 cm2. The surgical defect was reconstructed with local flaps in 58% of patients and primary closure in 27%. Local and systemic recurrence was noted in 25% of patients. Tumour size more than 6 cm, tumour histology (SCC & sarcoma), unplanned margin-positive excision, and residual disease in re-excision had higher recurrence, even though the p-value was not significant.ConclusionScalp tumours are heterogeneous in their clinical profiles. Often, its tumour biology and microscopic extent are underestimated. High suspicion, histological diagnosis, and clear surgical margins are all requirements in successfully treating scalp tumours. In order to minimize morbidity and restore an aesthetic and functional outcome, it is critical to use the simplest scalp reconstruction whenever possible.

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.

Delayed skin grafting protocol following Integra™ application for non-radiated scalp reconstruction for decreased wound depth and improved contour.

The clinical use of Integra™ has expanded to include scalp reconstruction since its FDA approval in 1996. Integra™, or dermal regeneration template, can be utilized in patients who are elderly with multiple medical comorbidities. Well-established Integra™ techniques utilize skin grafting 1-2 weeks following evidence of template vascularity. Most studies show the time to graft placement as <30 days, with almost all <52 days. No single article proposes a time frame for applying STSG after neodermis regeneration. Therefore, we aimed to describe our protocol to define a time frame for delaying scalp reconstruction with STSG following dermal regeneration. Over the last several years, the senior author has utilized a delayed reconstruction with skin grafting method where-in Integra™ is applied to either debrided bone or exposed pericranium in selected patients, and allowed to mature for ~6 weeks before performing skin grafting. The results have been predictable, reproducible, and have yielded high levels of patient and provider satisfaction due to the improved contour cosmesis. In this pictorial essay, the authors' novel protocol is detailed.

Reconstruction of Moderately and Severely Atrophic Scalp-A Multicentric Experience in Surgical Treatment of Patients Irradiated for Tinea Capitis in Childhood and Surgical Algorithm.

Background and Objectives: Before the introduction of griseofluvin, the use of X-ray radiation was the treatment of choice for tinea capitis. More than half a century later various types of tumors have been found to be associated with childhood irradiation due to tinea capitis, most commonly cancers of the head and neck, as well as brain tumors. The often unusually aggressive and recurrent nature of these tumors necessitates the need for repeated surgeries, while the atrophic skin with an impaired vascular supply due to radiation often poses an additional challenge for defect reconstruction. We present our experience in the surgical treatment of such patients. Materials and Methods: This is a retrospective cohort study. In this study, 37 patients treated for acquired defects of the scalp with a history of irradiation therapy due to tinea capitis in childhood were included in this study, 24 male and 13 female patients. The mean age at the first appointment was 60.6 ± 7.8, with the youngest included patient being 46 and the oldest being 75 years old. Patients' characteristics, surgical treatment, and complications were analyzed and a reconstructive algorithm was developed. Results: Local flaps were used for reconstruction in 34 patients, direct sutures were used in 10 patients and 20 patients received split-thickness skin grafts for coverage of both primary and secondary defects for reconstruction of flap donor sites. One regional flap and one dermal substitute covered by an autologous skin graft were also used for reconstruction. Complications occurred in 43.2% of patients and were significantly associated with the presence of comorbidities (p = 0.001), aseptic bone necrosis (p = 0.001), as well as skin atrophy in frontal, occipital, and parietal region (p = 0.001, p = 0.042 and p = 0.001, respectively). A significant correlation between major complications and moderate skin atrophy was found only in the parietal region (p = 0.026). Conclusions: Unfortunately, many protocols developed for scalp reconstruction are not applicable in the setting of severe or diffuse scalp skin atrophy associated with high tumor recurrence rate and radiation-induced vascular impairment, such as in tinea capitis patients in Serbia. An algorithm has been developed based on the authors' experience in managing these patients.

Concomitant Reconstruction of Multiple Scalp Defects With One Rotational Flap.

The cornerstones of scalp reconstruction are provisions of adequate skin paired with a satisfactory cosmetic outcome without hairline distortion. Several techniques have been described over the years to reconstruct sizable defects. Currently, an individualized approach, based on the patient's medical status and needs, the defect characteristics, and the local tissue quality and availability, should be considered for an optimal outcome. The reconstruction of multiple scalp defects, by means of a well-planned rotational flap, is proposed as a viable option with many advantages. It enables concurrent reconstruction of the defects, obviates further surgical incisions, and elaborates surgical maneuvers, minimizing operative time and complications risk. A satisfactory esthetic outcome can be achieved.

Affixing a Scalp Dressing With Hairpins.

Affixing a scalp dressing is challenging because of the presence of hair. Many methods have been recommended; their limitations include their effect on aesthetics and discomfort to the patient during the procedure. We describe a method for using hairpins to affix a dressing after scalp surgery or trauma that is sturdy, does not compromise aesthetics, and does not cause additional discomfort.

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.

Reconstruction of Defects on Post Electric Burn Injury Scalp with Bone Exposed: Case Series

Electrical burns typically result in severe tissue damage at a localized area, where the generated heat can lead to necrosis of one or both calvarial tables. This study reports four cases with scalp defects due to electrical burns reconstructed. In all cases, the scalp was the entrance site. A local flap and a skin graft were used to cover scalp defect and secondary defect, respectively. At 5–7 days postoperative, the flap survived with no necrosis or complications; satisfactory cosmesis and preservation of scalp contour were achieved. Successful scalp reconstruction requires meticulous preoperative planning and precise intraoperative execution, thus needing a reconstructive ladder. For scalp reconstruction, local transposition flaps are the best option as the adjacent tissue is of comparable quality to the defect tissue and has good contour preservation, low donor site morbidity, and satisfactory cosmesis.

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.

Cultured Epidermal Autografts as a Bridge to Definitive Reconstruction of the Neonatal Scalp after Infected Cephalohematoma.

Cultured Epidermal Autografts as a Bridge to Definitive Reconstruction of the Neonatal Scalp after Infected Cephalohematoma.

Prognosis-Guided Reconstruction of Scalp and Skull Defects in Neurosurgical Patients.

This study aimed to formulate reconstructive recommendations for neurosurgical patients presenting with scalp and/or skull defects based on outcomes in a large series of patients. An institutional review board-approved retrospective review of patients who underwent scalp and/or calvarial reconstruction was conducted. Complications were divided into minor and major; early, intermediate, and late. Univariate logistic regression models were conducted to identify independent predictors of complications. Mann-Whitney U tests were used to compare survival time. Kaplan-Meier curves were developed to compare exposure of titanium and bone cranioplasties. One hundred seventy-one patients who underwent 418 procedures were included (median 1 [1-3] surgeries per patient). Average age was 55 ± 15 years; 53% of patients were male. Median follow-up was 25.5 months [13.9-55.6 months], and 57 patients (33%) were deceased. Complications occurred following 48% of procedures; most common were titanium hardware exposure (36%), nonhealing wounds (23%), and infection (9%). Titanium cranioplasties became exposed 0.47 months [0.3-4.0 months] postoperatively. Frontal defect location was an independent predictor of major complications (odds ratio, 1.59; 95% confidence interval, 1.06-2.39; P = 0.026). Mortality rate for malignant intracranial neoplasms was 68.4% (median survival, 4.3 months), 39.1% for malignancies of both scalp and skull (7.0 months), 37.5% for scalp cancers (16.0 months), and 16.7% for meningiomas (28.2 months). Neurosurgical patients requiring scalp and/or skull reconstruction are a complex population undergoing multiple procedures with high complication rates. Given high exposure rate of titanium hardware shortly after reconstruction, titanium cranioplasty is recommended for patients with a prognosis less than 2 to 8 months.

Scalp Reconstruction Using the Latissimus Dorsi Free Flap: A 12-Year Experience.

Complex scalp defects are regularly reconstructed using microvascular tissue transfer. The latissimus dorsi free flap is one of the workhorse flaps used in scalp reconstruction. These cases necessitate, particularly in the elderly, a close cooperation between plastic surgeons and neurosurgeons. The purpose of this study was to evaluate the suitability of the latissimus dorsi free flap for complex scalp reconstructions and to analyze potential risk factors. A retrospective study identified 43 patients undergoing complex scalp reconstruction using a latissimus dorsi free flap at our department between 2010 and 2022. The mean patient age was 61 ± 18 years. Defects were mostly caused by oncologic tumor resections (n = 23; 55%), exposure to a cranioplasty (n = 10; 23%) or infection (n = 4; 9%). The most frequent recipient vessels were the superficial temporal artery (n = 28; 65%), external carotid artery (n = 12; 28%) and the venae comitantes (n = 28; 65%), external jugular vein (n = 6; 14%). The reconstructive success rate was 97.7%. There was one total flap loss (2%). Partial flap loss occurred in five cases (12%). Follow-up was 8 ± 12 months. Major complications were seen in 13 cases, resulting in a revision rate of 26%. Multivariate logistic regression identified active tobacco use as the only risk factor for major complications (odds ratio 8.9; p = 0.04). Reconstruction of complex scalp defects using the latissimus dorsi free flap yielded high success rates. Among the potential risk factors, active tobacco use seems to affect the outcome of complex scalp reconstructions.

Temporoparietal Fasciocutaneous Island Flap for Forehead and Anterior Scalp Reconstruction.

Background: Forehead and anterior scalp large defect reconstruction is challenging and often requires skin grafting. Objective: To measure the advancing distance and the survival of the temporoparietal fascia (TPF) island flap in forehead and anterior scalp reconstruction. Methods: The study design was a retrospective case series. Participants included all patients who had undergone TPF island flap for forehead and anterior scalp defects of 3 cm and greater from 2009 to 2021. Flap advancing distance and vascular compromise were analyzed. Results: Patient's average age at time of surgery was 73 (standard deviation [SD] 14) years with more males (n = 24, 67%) than females (n = 12, 33%). Of 36 patients, 24 had forehead and 12 had anterior scalp defects, 26 cases had a full TPF island flap, and 10 cases underwent the partial island modification. Flap edge ischemia occurred in two cases (6%) and complete ischemia occurred in one case (3%). The median flap advancing distance was 3.7 cm (SD 1.2). Conclusions: In this 12-year review, we found that the TPF island flap is able to advance up to 7.5 cm and thus is an effective reconstruction for medium to large forehead and anterior scalp defects.

Hyalomatrix coverage in scalp wounds with exposed cranium and dura

The armamentarium of options available for soft tissue reconstruction of the scalp spans the reconstructive ladder. The purpose of this paper is to describe a case series of patients with exposed cranium and dura who were successfully reconstructed using esterified hyalomatrix (eHAM, Hyalomatrix, Medline Industries Inc., US). After obtaining Institutional Review Board approval, a retrospective review of the senior author's (ALF) patient database was completed. Patients who underwent scalp reconstruction using eHAM were identified. Each patient's chart was reviewed and data collected on demographics, days to skin graft, duration of follow-up, pathology, comorbidities and complications. This case series consisted of five patients aged ≥18 years, with scalp wounds exposing dura or cranium, who were treated with eHAM as a bridge to definitive coverage with a skin graft. Each wound successfully granulated the exposed critical structure with the use of the eHAM. The mean time to skin graft coverage was 41 days, with a range of 13-79 days. Of the series of five patients, four had a follow-up of ≥12 weeks. The mean defect size was 90.2cm2. Complex scalp reconstruction can be accomplished using healing by secondary intention, skin grafts, local flaps, tissue expansion and free tissue transfer. As shown in this case series, another option available in select patients is using a dermal substitute such as eHAM. This is one treatment option available to reconstructive surgeons in multiple specialties.

Scalp Reconstruction Techniques for the General Surgeon – A Case Report

Scalp injuries are extremely common and although most scalp lacerations/ injuries can be primarily repaired, few require flap coverage. This article discusses the various ways in which we have reconstructed the scalp. This article is a case series of six different cases that required flap reconstruction where six different techniques were used to obtain wound cover with good outcomes. Patients who presented to various smaller hospitals/nursing homes with availability of only a general surgeon and no super specialists in Rural Bangalore with the need for scalp reconstruction were considered for the study. The operative outcome of six different methods of scalp reconstruction/ repair that include four different local flaps, a split skin graft with a wig and a pericranium burr hole drilling followed by split skin graft coverage have been studied.&#x0D; All six cases were followed up for a period of one month post intervention and all of them had good functional and cosmetic outcomes with no complications. There was no incidence of surgical site infection, seroma, or flap/graft failure in the 6 cases included in our study. Both grafts and flaps are equally good modalities in scalp reconstruction, but the choice for which to use should be based on the need of the patient and the type of wound. Grafts can be considered in conditions where there is adequate soft tissue cover over the scalp and in wounds with larger surface area. Grafts have the advantage of being technically simpler and are associated with fewer complications/failure but cannot be used in injuries where the bone is exposed. Flaps have better cosmetic outcome but are technically more challenging.

A Scalp Scar-Reducing Procedure for the Hair Transplant Donor Area Using a Columnar Trichophytic Suture: A Case Report

One of the main concerns of patients who undergo hair transplantation surgery such as follicular unit strip surgery is scar widening on surgical sites. Until now, trichophytic suture, double-layer suture, tattoos, follicular unit transplantation on scars are suggested as a solution. A 23-year-old man with frontal hair loss underwent follicular unit strip surgery. To reduce hair donor area scarring, we tried a new trichophytic suture method. After surgery, the patient's hair loss degree was corrected with about C1 in the basic and specific (BASP) classification. Also, there was less scar in the columnar trichophytic suture part, compared with almost 7 mm of scar widening in the simple primary closure part. This study highlights that a columnar trichophytic suture may be useful for patients undergoing scalp surgery for cosmetic purposes.