Scalp Rotation Flap Research Articles

An Approach to Managing Recurrent Cochlear Implant Wound Infection and Skin Breakdown.

We report the case of a cochlear implant patient who developed multiple infections with device extrusion necessitating explanation and reimplantation twice. An approach using a vancomycin washout followed by a temporalis muscle rotation and scalp rotation flap was utilized to salvage the device.

Multiple cutaneous squamous cell carcinoma of the forehead in a patient with skin of color treated by wide local excision with adjuvant radiotherapy: a case report

Cutaneous squamous cell carcinoma is the second most common non-melanoma skin cancer, characterized by the proliferation of keratinocytes, with an increasing incidence worldwide. In cases of perineural invasion, surgical excision followed by adjuvant radiotherapy is the preferred treatment. An intraoperative frozen section is necessary to determine the cancer-cell-free margin. A 80-year-old male presented to the outpatient department of our hospital with two fungating growths over his right forehead (size 2.7×1.2 cm) and right temple region (size 4×1.2 cm) for 5 years. An incisional biopsy of the growths revealed well-differentiated squamous cell carcinoma. There was no evidence of lymphadenopathy. The patient was treated successfully by wide local excision of the growths with an intraoperative frozen section to determine negative margins. Local defects of the forehead and right temple were reconstructed with a scalp rotation flap and a split skin thickness graft, respectively. The final histopathological examination showed moderately differentiated squamous cell carcinoma with resection-free margins. Forehead growth showed perineural invasion. The patient underwent 30 fractions of image-guided adjuvant radiotherapy in view of perineural invasion and to avoid local recurrence. The patient recovered well without any recurrences or complications. Surgical excision and reconstruction followed by adjuvant radiotherapy is the most effective method for treating cutaneous squamous cell carcinomas with perineural or lymphovascular invasion. Intraoperative frozen section is necessary to reduce recurrence rates and metastasis. Ours is a rare case of multiple cutaneous squamous cell carcinomas involving the forehead region.

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.

Results of Split Thickness Skin Grafts after Scalp Rotation Flap Surgeries: A Cross-Sectional Study

Aim: To assess outcome of Split thickness skin grafts after scalp rotation flap Surgeries. Study design: A cross-sectional study Place and Duration:This study was conducted at Patel Hospital Karachi Pakistan fromFebruary 2021 to February 2022. Methodology: This study aimed to assess clinical features, patient demographics, results, and long-term follow-up to identify its effectiveness in other procedures. A total of 15 individuals were incorporated in the present study, those who had combination scalp reconstruction and cranioplasty with anSplit thickness skin graftsfor local donor site covering. Before surgery, five patients (33.3 %) were classified as having "high complexity" scalp abnormalities. Six (40 %) patients were large, while 9 (60 %) were medium size. The remaining grafts were inset over bare Calvarial bone, while 10 (66.7%) were inset over vascularized muscle or pericranium. Results: The authors observed that all Split thickness skin grafts in this group were successful 93.3 % of the time (14/15). Due to poor take, grafts failed were observed in 1 patient. Because of the excellent success rate in this series, no patient risk factors were observed to be associated with transplant failure. Furthermore, whether the graft resided over bone or vascularized muscle/pericranium did not affect the success rate. Conclusion: Cranioplasty poses a challenge to surgeons. Split thickness skin Grafting has shown more promising results with simple techniques than other multifaceted reconstructive methods. Keywords:Calvarial bone, Cranioplasty, Split thickness skin grafts ,Percranium, Skin grafts

Personalized Computational Models of Tissue-Rearrangement in the Scalp Predict the Mechanical Stress Signature of Rotation Flaps.

To elucidate the mechanics of scalp rotation flaps through 3D imaging and computational modeling. Excessive tension near a wound or sutured region can delay wound healing or trigger complications. Measuring tension in the operating room is challenging, instead, noninvasive methods to improve surgical planning are needed. Multi-view stereo allows creation of 3D patient-specific geometries based on a set of photographs. The patient-specific 3D geometry is imported into a finite element (FE) platform to perform a virtual procedure. The simulation is compared with the clinical outcome. Additional simulations quantify the effect of individual flap parameters on the resulting tension distribution. Rotation flaps for reconstruction of scalp defects following melanoma resection in 2 cases are presented. Rotation flaps were designed without preoperative FE preparation. Tension distribution over the operated region. The tension from FE shows peaks at the base and distal ends of the scalp rotation flap. The predicted geometry from the simulation aligns with postoperative photographs. Simulations exploring the flap design parameters show variation in the tension. Lower tensions were achieved when rotation was oriented with respect to skin tension lines (horizontal tissue fibers) and smaller rotation angles. Tension distribution following rotation of scalp flaps can be predicted through personalized FE simulations. Flaps can be designed to reduce tension using FE, which may greatly improve the reliability of scalp reconstruction in craniofacial surgery, critical in complex cases when scalp reconstruction is essential for coverage of hardware, implants, and/or bone graft.

The "Snail Flap": A Rotation Flap in Scalp Reconstruction.

The scalp rotation flap is still the flap of choice for scalp defects as it provides hair-bearing skin, replacing “like with like,” and can be designed to respect hairlines and patterns.1 Conventionally, these flaps are planned to be up to 8 times the diameter of the defect to allow for sufficient recruitment of scalp laxity and allow for primary closure of the secondary defect. Nevertheless, its use is limited by large flap to defect ratios (See Video [online], which displays the surgical technique of the “snail flap”). Video 1. This video displays the snail flap technique demonstrated in the article. From “The Snail Flap: A Rotation Flap in Scalp Reconstruction” Following the creation of the scalp defect, the thickness of the scalp is measured. If it is less than 5 mm, a snail flap is raised, as shown in the video, with a “flap:defect” ratio of 2:1. The tip of the flap is folded onto itself and advanced into the primary defect first. The secondary defect is then closed by spreading the tension across the entire arc. In younger patients, where the scalp thickness tends to be greater than 5 mm and there is increased scalp laxity, a “flap:defect” ratio of 1.5:1 may be chosen as the greater scalp laxity accords ease of closure (Fig. 1).

Challenges of Management of Arteriovenous Malformation of the Pinna in a Low Resource Setting: A Case Report

Arteriovenous Malformation (AVM) is a lesion of vascular development characterized by an abnormal communication between an artery and a vein without an intervening capillary bed. AVM of the pinna is very rare with very few reported cases in Africa. Management of an AVM is often daunting, most especially in a resource challenged centre like ours where facilities for super selective embolization are not available. We present the case of a 17-year-old female with a pulsatile swelling of the left pinna since childhood. Clinical and radiological diagnosis of arteriovenous malformation was made. She was managed surgically with left external carotid artery ligation, partial auricular resection and postauricular scalp rotation flap cover of the cartilage remnant. The aetiopathogenesis, clinical presentation, diagnostic confirmation and treatment options are discussed. We also discuss the challenges of managing AVM in poor resource settings like ours.

Ideal Flap Cover for the Salvage of Exposed/Infected Cochlear Implants: A Case Series and Literature Review.

With an increase in the number of cochlear implant surgeries there is bound to be an increase in the number of complications. A dreaded problem in any implant procedure is the implant exposure and infection. Explantation of the implant leads to an unpleasant situation to the patient and the surgeon owing to the high cost of the device. There are reports in the literature favouring the mandatory relocation or removal of the infected implants. On the other hand, there are convincing reports of implant salvage using skin, muscle or fascial flaps. In this paper we have analysed a series of cases referred to us from the departments of E.N.T for the management of implant exposure/infection. We have also reviewed similar case series reported in the literature. From 2014 to 2017 we operated six cases of exposed cochlear implant. We salvaged the implant in five cases, where we could do two layer coverage consisting of the inner temporoparietal fascial flap and outer scalp skin flap. In one case where the temporoparietal fascial flap could not be done as superficial temporal vessels were found to be injured in the previous surgery, the implant was removed due to persistent infection. All these cases were administered appropriate antibiotics for a minimum period of 3weeks. Early double layer closure with inner temporoparietal fascial flap and outer scalp rotation flap coupled with appropriate antibiotics can salvage an infected, exposed implant.

Reconstruction of composite defects of the scalp and neurocranium\u2014a treatment algorithm from local flaps to combined AV loop free flap reconstruction

BackgroundReconstruction of cranial composite defects, including all layers of the scalp and the neurocranium, poses an interdisciplinary challenge. Especially after multiple previous operations and/or radiation therapy, sufficient reconstruction is often only possible using microsurgical free flap transplantation. The aim of this study was to analyze the therapy of interdisciplinary cases with composite defects including the scalp and neurocranium.MethodsFrom 2009 to 2017, 23 patients with 18 free flaps and 10 pedicled/local flaps were analyzed. First choices for free flaps were muscle flaps followed by fasciocutaneous flaps.ResultsExcept for four patients, a stable coverage could be reached in the first operation. Three of these patients received a local scalp rotation flap in the first operation and needed an additional free flap because the local flap was no longer sufficient for coverage after wound healing deficiency or tumor relapse. The superficial temporal artery or external carotid artery served as recipient vessels. In special cases, venous grafts or an arteriovenous loop (AV loop) were used as extensions for the recipient vessels.ConclusionsIn summary, an interdisciplinary approach with radical debridement of infected or necrotic tissue and the reconstruction of the dura mater are essential to reach a stable, long-lasting reconstructive result. Based on our experience, free flaps seem to be the first choice for patients after multiple previous operations and/or radiation therapy.

Recurrent Adenocarcinoma of External Auditory Canal: A Rare Case Report

Primary carcinoma of the external auditory canal is extremely rare, with an incidence of approximately one per million populations per year. The commonest presenting symptom is reported to be pain followed by signs and symptoms of chronic suppurative otitis media. A 28 year old male patient presented with polypoidal mass in left ear occluding external auditory canal since 3 months. Radical excision was done. The histopathology suggested poorly differentiated adenocarcinoma with surgical margins free. Patient received adjuvant radiotherapy (25 cycles, 50Gy). Patient developed recurrence within 6 months for which wide excision of the mass along with excision of external auditory canal and a scalp rotation flap was performed. Patient was given concurrent chemoradiotherapy. In such cases the need for adequate surgical excision has been stressed by many authors. Parotid gland involvement and perineural involvement are poor prognostic signs, associated with high chances of recurrence after surgical resection.

Scalp Rotation Flap for Reconstruction of Complex Soft Tissue Defects.

Importance Scalp reconstructions may be required after tumor resection or trauma. The inherent anatomy of the scalp presents challenges and may limit reconstructive options. Objective To describe and investigate the scalp rotation flap as a reconstructive technique for complex soft tissue defects. Design Retrospective case series with a mean follow-up of 13 months. Setting Tertiary academic center. Participants A total of 22 patients with large scalp soft tissue defects undergoing scalp rotation flap reconstruction. Interventions The flap is designed adjacent to the defect and elevated in the subgaleal plane. The flap is rotated into the defect, and a split-thickness skin graft is placed over the donor site periosteum. Main Outcomes and Measure Data points collected included defect size, operative time, hospital stay, and patient satisfaction with cosmetic outcome. Results Mean patient age was 71 years. Mean American Society of Anesthesiologist classification was 2.8. Mean defect size was 41 cm(2) (range: 7.8-120 cm(2)), and 19 of 22 defects resulted from a neoplasm resection. Mean operative time was 181 minutes, and mean hospital stay was 2.4 days. There were no intraoperative complications. Three patients with previous radiation therapy had distal flap necrosis. Twenty-one patients (95%) reported an acceptable cosmetic result. Conclusions and Relevance The scalp rotation flap is an efficient and reliable option for reconstructing complex soft tissue defects. This can be particularly important in patients with significant medical comorbidities who cannot tolerate a lengthy operative procedure.

The Reconstructive Management of Hardware-Related Scalp Erosion in Deep Brain Stimulation for Parkinson Disease

The presence of foreign material in deep brain stimulation is a risk factor for infection, and hardware-related pressure under the scalp may cause skin erosion. The aim of this article is to present our experience in the coverage of scalp in relation to underlying hardware. We analyzed 21 patients with Parkinson disease who had undergone deep brain stimulation surgery and developed scalp erosion with hardware exposition during follow-up. Nine patients were programmed for a scalp rotation flap, whereas free tisue transfer was performed in the rest of the patients. Minimum follow-up was 2 years. A hardware-related ulcer appeared in 5 of 9 rotation flap patients. No ulceration or major complications were observed in free flap patients. Free flaps are probably the best option for stable coverage in hardware-related scalp erosion with a high rate of success.

Surgical Management of Recurrent Squamoid Eccrine Ductal Carcinoma of the Scalp

Squamoid eccrine ductal carcinoma (SEDC) is an exceedingly rare tumor that shows both squamous differentiation and adnexal ductal differentiation. As our review of the literature revealed, only a total of 7 cases were reported to date. We report an additional case of SEDC occurring on the scalp of a 53-year-old man. Despite complete excision by conventional technique with clear margin, the lesion recurred within a 3-month period, with regional lymph node metastasis. The tumor was completely removed, and the large scalp defect was reconstructed by using scalp rotation flap. We present a case of recurrent SEDC on the scalp, and we surgically resected this tumor. In addition, the large scalp defect was reconstructed successfully with scalp flap, and no recurrence has been observed in the patient's postoperative follow-ups.

Reconstruction of Temporal and Suprabrow Defects

Large temple and suprabrow lesions can pose a reconstructive challenge. When the lesion extends anterior to the hairline, esthetically acceptable local flaps may be difficult to design. We describe a modified scalp flap (ie, part Converse scalping flap and part scalp rotation flap) that can be tailored to reconstruct a variety of difficult temple and suprabrow lesions while simultaneously maintaining eyebrow position. The modified scalp flap is raised in a subgaleal plane until approximately 2.5 cm above the brow. At this level, dissection proceeds in the subcutaneous plane to protect the frontal branch of the facial nerve and to keep the flap thin. (The key to the modified scalp flap is the dissection plane change that protects the frontal branch of the facial nerve.) The extent of posterior subgaleal dissection is dictated by the amount of anterior rotation necessary. A temporal dog-ear is removed subfollicularly to permit modified flap rotation and preserve the superficial temporal artery. The modified scalp flap has been used to reconstruct temple and suprabrow lesions in 10 patients ranging in age from 4 months to 22 years. There were no complications. Four typical cases are presented. Temple and suprabrow lesions can be excised and successfully reconstructed in one stage using a modified scalp flap that is extended from the hair-bearing scalp onto the glabrous skin of the forehead. This novel modified scalp flap prevents eyebrow/hairline distortion and avoids facial nerve injury.

Repair of Chiari III malformation using cranioplasty and an occipital rotation flap: technical note and review of literature

Background Chiari III malformation (CM3) is rare among Chiari malformations (I-IV). Its definition has been expanded to include caudal medullary displacement and hindbrain herniation into encephaloceles in lower occipital and high cervical regions. Prognosis is recorded as dismal, with respect to survival and functional outcome. Methods We describe the presentation, radiologic evaluation, and repair of this malformation using methyl-methacrylate cranioplasty and an occipital scalp rotation flap for closure. Outcome after surgery is addressed. Results Adequate closure of the defect and protection of underlying structures was achieved without undue stress at incision site. Conclusions This method of closure can be considered in cases of large occipital and cervical encephaloceles with poor skin cover and added osseous anomalies around the foramen magnum.

Extended temporal bone resection for squamous cell carcinoma.

The aim of this study was to assess the surgical results of a series of patients from this unit who underwent extended temporal bone resection for recurrent squamous cell carcinoma as a salvage procedure. The surgical records of 15 patients were analyzed in detail. Each patient had salvage surgery in the form of an extended temporal bone resection with supraomohyoid block dissection, dural grafting, and free microvascular forearm or scalp rotation flap repair for recurrent squamous cell carcinoma in a radical mastoid cavity. Radical surgery yielded a 47% 5-year survival. Twenty-nine percent of the survivors had temporal lobe involvement that necessitated a partial excision of the temporal lobe of the brain. Histologic evidence of local lymph node involvement in the supraomohyoid neck dissection was present in 13% of cases. Those who died did so in the first postoperative year. All those with poorly differentiated tumors died. The survivors had well or moderately differentiated tumors. Radiotherapy alone or partial temporal bone resection, most commonly a radical mastoidectomy with or without preoperative or postoperative radiotherapy is used by the majority of otolaryngologists in treating squamous cell carcinoma of the temporal bone. The 5-year survival rate after this treatment remains depressingly low and the prognosis gloomy, particularly for advanced tumors. The findings in this series of extended temporal bone resections as salvage surgery in recurrent disease is encouraging, and radical surgery combined with radiotherapy from the outset may give much better 5-year survival figures in the future than the conventional partial temporal bone resection and radiotherapy.

Extended temporal bone resection for squamous cell carcinoma

OBJECTIVE: The aim of this study was to assess the surgical results of a series of patients from this unit who underwent extended temporal bone resection for recurrent squamous cell carcinoma as a salvage procedure. DESIGN: The surgical records of 15 patients were analyzed in detail. Each patient had salvage surgery in the form of an extended temporal bone resection with supraomohyoid block dissection, dural grafting, and free microvascular forearm or scalp rotation flap repair for recurrent squamous cell carcinoma in a radical mastoid cavity. RESULTS: Radical surgery yielded a 47% 5-year survival. Twenty-nine percent of the survivors had temporal lobe involvement that necessitated a partial excision of the temporal lobe of the brain. Histologic evidence of local lymph node involvement in the supraomohyoid neck dissection was present in 13% of cases. Those who died did so in the first postoperative year. All those with poorly differentiated tumors died. The survivors had well or moderately differentiated tumors. CONCLUSIONS: Radiotherapy alone or partial temporal bone resection, most commonly a radical mastoidectomy with or without preoperative or postoperative radiotherapy is used by the majority of otolaryngologists in treating squamous cell carcinoma of the temporal bone. The 5-year survival rate after this treatment remains depressingly low and the prognosis gloomy, particularly for advanced tumors. The findings in this series of extended temporal bone resections as salvage surgery in recurrent disease is encouraging, and radical surgery combined with radiotherapy from the outset may give much better 5-year survival figures in the future than the conventional partial temporal bone resection and radiotherapy. (Otolaryngol Head Neck Surg 1997;116:617-23.)

Neurosurgery in Rwanda during a United Nations Peace-Keeping Mission

An analysis of the neurosurgical component of the medical support provided by a United Nations peace-keeping mission in Rwanda is presented. The Australian Defence Force contingent provided medical support to the United Nations and the civilian population. Eight hundred thirty-eight procedures were performed during 12 months. A wide range of surgery was encompassed, with neurosurgery accounting for 17 (2%) of the total operations: compound depressed fractured skull, 5; intracranial pressure monitor, 2; burr holes for acute head injury and chronic subdural hematoma, 2; skull osteomyelitis debridement, 1; rib-graft cranioplasty, 2; scalp rotation flap, 1; congenital myelomeningocele, 2; occipital meningocele, 1; craniofacial approach to Le Fort III fracture, 1. A broad range of neurosurgical procedures have been performed. The overall numbers of neurosurgical operations were small, but they were successfully performed by general surgeons. Familiarity with neurosurgery is necessary in predeployment training of military surgeons working in a remote location with limited resources.

Congenital cutis aplasia of the scalp

Aplasia cutis congenita of the scalp is a congenital anomaly, characterised by a lack of covering tissue on the vertex of the skull. Seventeen patients were treated in Lille CHR from 1964 to 1992. Three patients were of the same family (the father and his two sons). The frequency has probably been underestimated, due to the high under-diagnosis of minor forms (localized alopecia). The defect was purely cutaneous in 10 patients, scalp and bone in 7 patients, among whom 6 had exposure of the sagittal sinus. The size varied from 49 mm2 to 192 cm2. The main area of involvement was medial with parietal extension. Seven children had associated malformations: trisomy 13 with cardiopathy (2), cleft lip and palate (3), limb malformation (2), epilepsy (1), and abnormal ears (2). Three patients had been treated at the time of cicatricial alopecia by excision and suture or tissue expansion. Thirteen patients were treated in the neonatal period. The various methods used were spontaneous healing (1), skin graft (1), excision and suture (4), local T or W plasties (2), scalp rotation flap (5), and 1 patient died before any treatment. Four patients died in neonatal period: 2 trisomies 13, 1 meningitis with septicaemia, and 1 sagittal sinus rupture. One child required a secondary procedure at age 7; this was a cranioplasty and latissimus dorsi muscle free flap. The prognosis is highly conditioned by the associated pathology, e.g. trisomy 13, the size of the bone defect with, in addition, sagittal sinus exposure, and the rapidity of the treatment.

Scalp Flap Rotation with Primary Donor Site Closure

A 57-year-old man with a 7-cm defect of the left temple underwent reconstruction with a large scalp rotation flap that shifted the donor defect to the back of the neck so that it could be closed primarily. This approach, also used successfully in 7 other patients with similar defects, avoided the need for an unsightly skin graft in the donor site while providing tissue with a color and texture that blended well with the surrounding forehead and facial skin. Primary closure of the donor site reduces scalp flap morbidity and improves the overall aesthetic outcome.