Scalp and Forehead Reconstruction

Recipient site scalp necrosis: A rare postoperative complication of hair transplantation

BACKGROUND

Recipient area scalp necrosis is considered a potential complication of hair transplantation, but has rarely been reported. A small number of patients have developed scalp necrosis after hair transplantation with the widely used Follicular unit excision (FUE) technique. There are no guidelines to prevent and manage this complication. The aim of this study was to provide an insight into the pathogenesis, prevention, and management of scalp necrosis following hair transplantation.

METHODS

From 2012 to 2021, among more than 10 000 patients who underwent hair transplantation, only three developed scalp necrosis in our clinical experience, besides, one patient transferred to our hospital because of scalp necrosis after undergoing hair transplantation. According to the disease etiology and patients' symptom, a combination of wound management and antimicrobial therapy was employed. This study was approved by the institutional ethics committee of Nanfang Hospital.

RESULTS

Of the four patients, three received timely treatment and had a good prognosis. Necrosis became confined and healed within 2-3 weeks. Grafts in the lesion area partially survived. In case 4, due to improper treatment at the early stage, the lesion developed extensively and deeply, which not only delayed wound healing, but also resulted in complete loss of grafts.

CONCLUSION

Preoperative prophylaxis, timely diagnosis, and immediate treatment of scalp necrosis can prevent serious complications and reduce morbidity after hair transplantation.

Full-thickness versus split-thickness skin graft reconstruction of scalp defects with and without calvarium exposure

OBJECTIVE

Compare full-thickness skin grafts versus split-thickness skin grafts in scalp reconstruction.

STUDY DESIGN

Retrospective chart review of patients who underwent scalp reconstruction with skin grafts performed at a single institution from 2011 to 2016.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

LEVEL OF EVIDENCE

3b.

The 1-2-3 cm Advancement Flap Rule in Scalp Reconstruction

Background Defects of the scalp are surgically challenging for several reasons: anatomical convexity limits tissue displacement, resistance to advancement is different at different points on the scalp, and there is also interindividual variation. For many patients, the idea of undergoing an advanced surgery such as a free flap is not preferred. Hence, a simple technique with a favorable outcome is needed. We hereby introduce our new technique: the 1-2-3 scalp advancement rule. Objectives The objective of this study is to discover a novel way to reconstruct scalp defects secondary to trauma or cancer, without having the patient undergo a big procedure. Material and Methods A total of nine cadaveric heads were used to test the idea of achieving greater advancement and increased scalp mobility to cover a 4×8 cm-sized defect using our proposed 1-2-3 scalp rule. Three steps performed were advancement flap, galeal scoring, and removal of the outer table of the skull. The measurement of advancement was recorded after each step, and the results were analyzed. Results The mobility of the scalp was calculated from the sagittal midline with identical arcs of rotation. With zero tension, we found that the total distance of advancement with a flap had a mean of 9.78 mm, while the advancement for the same flap after galeal scoring had a mean of 20.5 mm, and after removing the outer table, the mean advancement was 30.2 mm. Conclusion To create a tension-free closure necessary for optimal outcome for scalp defects, our study showed that increased distances were possible using galeal scoring and outer table removal, increasing the distance of advancement by 10.63 mm and 20.42 mm, respectively.

Expanded scalp flap combined with laser hair removal to reconstruct facial defects around the hairline

BACKGROUND

Congenital and acquired facial lesions around the hairline can bring huge physical and psychological trauma to patients. At present, reconstruction of this area remains a challenge. In this study, we present an alternative technique to reconstruct the aesthetic units using an expanded scalp flap combined with laser hair removal.

METHODS

We retrospectively reviewed 25 cases of facial lesions around the hairline reconstructed with this surgical technique between May 2014 and May 2020. Expander was implanted under the scalp as designed before the operation. After the expander was fully expanded, the lesion was removed and the scalp flap was transferred. Laser hair removal was performed on the transplanted skin flap 2 weeks after flap transfer.

RESULTS

There were ten cases of postburn scar, nine cases of congenital nevus, four cases of traumatic scar, one case of haemangioma, and one case of nevus sebaceous. The median times of laser treatment was 3 (range, 1-8). The median follow-up time was 11 months, ranging from 1 to 27 months. The colour and texture of expanded flaps were similar to adjacent tissue in all cases. The direction of reserved hair in transferred flaps was consistent with the direction of hair in the recipient area or contralateral hair. There were no complications, such as infection, blistering, discolouration, and ulceration. All patients were satisfied with the appearance of the reconstructed hairline and the surgical outcomes.

CONCLUSIONS

The expanded scalp flap combined with laser hair removal is a feasible and effective technique to reconstruct both sides of the hairline simultaneously from a single donor site with a good colour match and a similar texture and thickness.

Extended Scalp Flaps for Extensive Soft Tissue Scalp Defects as a Day Surgery Procedure Under Local Anesthetic: A Single Centre Experience

Background  Cutaneous malignancies are on the rise, associated with an increased number in scalp cancers that require wide local excision (WLE) to ensure clearance; the inelastic nature of the scalp poses a particular challenge when dealing with such large defects. Case presentation  A series of 68 cases with large scalp defects following WLE for the clearance of squamous cell carcinoma, atypical fibroxanthoma, dermatofibrosarcoma protuberans, and melanoma skin cancers are presented. These cases were treated in one center under local anesthesia and underwent extended scalp flaps to close the resulting defect primarily without the use of skin grafts for the flap donor site on the scalp. Conclusion  Extended scalp flap is a safe and reproducible solution for extensive scalp defects, which results in quicker wound healing with cosmetically superior results, and can be performed safely and comfortably under local anesthesia in the day case setting.

Complex Multidisciplinary Cranial and Scalp Reconstruction for Patient Salvage

OBJECTIVE/BACKGROUND

Patients can develop scalp and cranial defects as a result of neoplasm, trauma, or infection. Reconstruction of these defects can be difficult in some patients and may require a multidisciplinary approach using creative solutions usually used for disease processes in other areas of the body, such as severe burns.

METHODS

A series of 9 patients were treated using multidisciplinary techniques for reconstruction of complex cranial and scalp defects. Data on patient characteristics, initial treatment, and preparatory and definitive reconstructive treatment were retrospectively collected. Outcomes were measured as full solution, partial solution, or failure.

RESULTS

Three patients had a full solution/wound closure, 5 had a partial solution, and 1 failed reconstructive attempt. Full solution patients tended to be younger, received reconstruction treatment modalities for longer periods of time, and had more definitive surgeries. Initial and preparatory surgeries did not tend to promote a full solution, though having fewer preparatory surgeries that were not related to wound vacuum-assisted closure use tended to be associated with a better outcome. Infection of the scalp or cranium did not tend to change the result.

CONCLUSIONS

Reconstructive salvage of complex cranial and scalp defects takes time, so patience and earlier recognition of need for atypical reconstruction is beneficial. Patient characteristics may influence outcomes, but judicious choice of materials and techniques is more critical to patient success. Use of a multidisciplinary approach to complex cranial and scalp reconstruction is a beneficial option for many patients for whom standard reconstruction methods are not viable.

Single Stage Reconstruction of Large Calvarial Exposure after Tumor Resection: A 3-Year Experience

BACKGROUND

We aimed to review the treatment and outcome of patients’ undergone reconstruction of large full thickness scalp defects with exposed calvarium after oncologic resection with the combined local flap and split-thickness skin graft (STSG) technique.

METHODS

A retrospective review of 45 patients with scalp defects secondary to tumor extirpation was performed at the Plastic Surgery Department, Tanta University Hospital, Tanta, Egypt from Nov 2016 to Nov 2019. Patients, with large (>50 cm2) and full-thickness (exposed calvarium) scalp defects, who underwent scalp reconstruction with the combined local flap and STSG technique and had completed their medical records were enrolled.

RESULTS

Only 38 met the inclusion criteria. Thirty-three were male (86.8). The mean age was 61.5 years. The lesions removed were BCC in 30 cases (78.9%) and SCC in 8 cases (21.1%). Defect sizes ranged from 55 to 196 cm2. There was complete survival of all flaps. Complications were noticed in 5 patients (13.2%);2 developed small hematomas, 2 suffered from partial graft losses and one had wound infection. The follow-up period ranged from 6 to 27 months. Overall, 34 patients were satisfied with the functional and cosmetic results (89.5%), while 4 female patients weren't satisfied with the esthetic results (10.5%).

CONCLUSION

The combination of local flap and skin graft technique is highly reliable, easy to perform and safe single-stage reconstructive modality of large skull exposed scalp defects, providing durable coverage and favorable esthetic outcome.

O to T Flap for Central Forehead Defect Reconstruction

The reconstruction of central forehead defect is challenging because of the paucity of the adjacent extensible tissue and aesthetic importance of the area. Reconstruction of this region should be done keeping in mind brow symmetry and natural hairline. Camouflaging the final scar lines in wrinkles or hairline should be the final goal. Even small resections in this region can be surprisingly difficult owing to resistance offered by galea to advancement despite significant undermining due to its inelastic composition and position over the skull's natural convexity. Following, we present a case report wherein we describe a technique for the reconstruction of central forehead defects using simple Burrow's triangles.

Scalp reconstruction: A 10-year experience

Background

The scalp is an important functional and aesthetic structure that protects the cranial bone. Due to its inelastic characteristics, soft-tissue defects of the scalp make reconstruction surgery difficult. This study aims to provide an improved scalp reconstruction decision making algorithm for surgeons.

Methods

This study examined patients who underwent scalp reconstruction within the last 10 years. The study evaluated several factors that surgeons use to select a given reconstruction method such as etiology, defect location, size, depth, and complications. An algorithmic approach was then suggested based on an analysis of these factors.

Results

Ninety-four patients were selected in total and 98 cases, including revision surgery, were performed for scalp reconstruction. Scalp reconstruction was performed by primary closure (36.73%), skin graft (27.55%), local flap (17.34%), pedicled regional flap (15.30%), and free flap (3.06%). The ratio of primary closure to more complex procedure on loose scalps (51.11%) was significantly higher than on tight scalps (24.52%) (p= 0.011). The choice of scalp reconstruction method was affected significantly by the defect size (R = 0.479, p< 0.001) and depth (p< 0.001). There were five major complications which were three cases of flap necrosis and two cases of skin necrosis. Hematoma was the most common of the 29 minor complications reported, followed by skin necrosis.

Conclusion

There are multiple factors affecting the choice of scalp reconstruction method. We suggest an algorithm based on 10 years of experience that will help surgeons establish successful surgical management for their patients.

Combining Rotation and V-Y Design for Lower Forehead and Temporal Region Reconstruction With Myocutaneous Frontal Flap: Our Experience on 27 Consecutive Cases

BACKGROUND

Because of direct sun exposure, lower forehead and temporal area are anatomical regions with frequently observed skin tumors. The resulting defects after oncological ablations are usually treated, especially in older patients, by split thickness skin grafting or A-to-T and O-to-T flaps if facing small defects. On specific sites that expose bone or periosteum as well as when a skin graft is best avoided for cosmetic reasons, alternative reconstructive procedures should be considered. An excellent option is the use of myocutaneous frontal flap with rotation and V-Y design, which provide a reliable coverage of defects especially of the temporal area, dispensing appropriate like-tissue by its wide arc of rotation.

METHODS

Between 2010 and 2019, 27 patients underwent myocutaneous frontal flap with rotation and V-Y design reconstruction of medium-to-large-sized soft-tissue defects of the lower forehead and temporal area after tumor excision. The malignant skin lesions involved were basal cell carcinoma (n = 17), squamous cell carcinoma (n = 9), and melanoma (n = 1). Twenty one patients were male, and 6 were female with an average age of 64 (54-86) years.

RESULTS

All defects were successfully resurfaced with no local recurrences.

CONCLUSIONS

The authors present a modification to myocutaneous frontal flap harvesting, with emphasis on its extensive arc of rotation with a V-Y design to minimize donor-site morbidity. The advantages of myocutaneous frontal flap with rotation and V-Y design include a good contour with excellent color, texture, and thickness match and good to excellent aesthetic results.

Cryopreserved amniotic membrane and umbilical cord for a radiation-induced wound with exposed dura: a case report

An 87-year old male received surgical excision of scalp melanoma and subsequent radiotherapy due to metastasis to the skull. A radiation-induced wound developed with osteoradionecrosis that required necrotic bone excision resulting in a 7.5x8.5cm wound over the exposed dura, which remained non-healing despite many attempts by local wound care management. Due to the refractory nature of the wound, strips of cryopreserved umbilical cord (cUC) allograft were applied over the exposed dura resulting in significant vascular granulation tissue formation in the central wound bed within four weeks. Re-epithelialisation around the wound perimeter was further promoted by injection of particulate amniotic membrane umbilical cord matrix (AMUC) at the 16th week, and completed by another application of cUC strips and injection of AMUC proximal to the necrotic bone at the 21st week. Vascularisation of the necrotic bone was further promoted by application of cUC and AMUC injection directly into the bony margins at 29 weeks and 34 weeks, respectively, followed by application with an AMUC-hydrogel paste, applied four times over an eight week interval. By 96 weeks, healthy re-epithelialised tissue had formed under the necrotic bony margins. This report highlights the unique regenerative capabilities of cUC and AMUC in promoting wound healing over exposed dura in a long-standing full-thickness, radiation-induced scalp and skull wound.

Hand Doppler flowmetry for surgical planning of pedicled flap in extensive full-thickness scalp reconstruction

Reconstruction of scalp defects can be performed with local flaps for medium to large defects (2-25 cm²) and microvascular free flaps for extensive full-thickness scalp reconstruction greater than 25 cm². Doppler flowmetry with its ability to exactly mark the course of arteries on the overlying skin, is a useful tool for the surgical planning of large local flaps. In our retrospective study conducted on 38 patients (all patients had malignancies or post-traumatic scalp defects), consisting of 39 total surgical procedures, we studied the impact of doppler ultrasonic flowmetry in the surgical planning for pedicled flaps in extensive full-thickness scalp reconstruction (>25 cm²) by evaluating overall flap survival rate. Nine different types of local flaps were employed in the scalp reconstruction: Superficial temporal artery (STA) pedicled rotation flap, STA pedicled transposition flap, STA islanded flap, bipedicled STA flap, bipedicled fronto-occipital flap, Supraorbital/Supratrochlear artery rotation flap, Supraorbital/Supratrochlear artery transposition flap, Occipital artery (OA) pedicled rotation flap, OA pedicled transposition flap. Before each surgical procedure a hand held doppler Huntleigh Diagnostic flowmeter with a 8 MHz probe was used to identify and follow the course of the arteries. Flap survival rate was 100%. No postoperative complications related to the flap were reported, while in two patients a partial skin graft failure occurred.

Reconstructing the Face of War

Introduction

Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites.

Methods

A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images.

Results

Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed.

Conclusion

While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

Soft Tissue Reconstruction for Head and Neck Ablative Defects

Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.

Percutaneous Mesh Expansion: A Regenerative Wound Closure Alternative

BACKGROUND

Puncture wounds in the 1-mm range usually heal without scars. Stacking rows of these punctures offers a scarless method to generate tissue by mesh expansion. The authors developed a percutaneous mesh expansion procedure and present their experience for its wound closure application.

METHODS

Over a 6-year period, the authors applied percutaneous mesh expansion to 65 consecutive patients aged 58 to 101 years (mean, 72 years) with 67 full-thickness calvarial defects ranging in size from 2.5 × 3 cm to 7 × 8 cm (mean, 14 cm) that would have all required flaps for closure. Thirty-six were still anticoagulated, and 20 had prior scalp resections. After tumescent epinephrine anesthesia, the authors temporarily approximate the wound by placing it under strong tension. Using 1.1-mm cutting point needles that selectively sever tissues under tension, the authors inflict rows of staggered alternating punctures over a distance five times the defect width. This results in 20 percent expansion of the meshed area, generating the tissue necessary for defect coverage. When the tension is completely released, closure is performed with simple sutures or staples. The authors avoid overmeshing, especially close to the wound edges, and perform no undermining or additional incisions.

RESULTS

At 6-week follow-up, all defects were healed with only a straight resection scar. However, of the 10 defects larger than 5 × 5 cm, five had wound healing delay and three required a small skin graft. No other complication was observed.

CONCLUSIONS

Percutaneous mesh expansion is a minimally invasive procedure that harnesses the body's natural capabilities to regenerate across small gaps. It sums these regenerated gaps in a mesh pattern that expands tissues to close complex wounds without flaps or additional incisions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Pedicle Temporalis Fascial Flap with Axial Scalp Flap Obviates Need of Free Flap in Extensive Scalp Wound

Extensive scalp defect with exposed bone is best reconstructed with flaps. Majority of these wounds are now routinely reconstructed with free flaps in many centers. Free flaps however require lengthy operative time and may not be available to all patients, where possible less extensive options should thus be encouraged. A sixty-eight-year-old patient presented to us with a Marjolin's ulcer on the vertex of the scalp. After wide local excision a defect of about 17 cm and 12 cm was left. The defect was successfully covered with a combination of an ipsilateral pedicle temporalis fascial flap and an axial supraorbital scalp flap with good outcome. In conclusion wide defects of the scalp can be fully covered with a combination of local flaps. The axial scalp flap and the pedicle temporalis fascial flap where applicable provide an easy and less demanding option in covering such wounds. These flaps are reliable with good blood supply and have got less donor side morbidity.

Usage of a rotational flap for coverage of a large central forehead defect

Background: The forehead is a donor site for facial reconstruction but has no generous donor site for its coverage. All options of the reconstructive ladder can be used. A large rotation flap was used to reconstruct a big central forehead defect following failed previous repair in an elderly diabetic patient after a motor car accident. Case presentation: A 64-year-old diabetic man presented with an extensive central forehead defect after failed previous repair following a motor car accident. Coverage of the defect was performed using a flap based around the ear on one side in a rotation movement. An accepted functional and esthetic result was achieved after 3 months of follow-up. Conclusion: A rotation flap based on arteries around the ear can be used for coverage of a difficult lesion in the central forehead. Level of evidence: Level V, therapeutic study.

Microsurgical Forehead Reconstruction

Reconstruction of the forehead remains challenging. Especially in cases of large or even complete forehead defects, local flaps and skin grafting may not be an option, necessitating free flap coverage. The aim of this retrospective case series was to develop an algorithmic surgical approach as well as to evaluate surgical and aesthetic outcomes of microvascular-based forehead reconstructions, using gracilis muscle or anterolateral thigh flaps in 15 cases. The mean size of the defects was 84.6 (range: 25-160, ±44.1) cm, all with significant area of bone exposure. The free flap reconstructions included 7 gracilis muscle flaps, covered with 1.2-mm-thick unmeshed split-thickness skin grafts, and 8 anterolateral thigh flaps with a mean size of the free flaps of 160 (range: 56-300, ±78.6) cm. In all patients, wound healing at the donor site was uneventful. Minor complications occurred in 3 patients and required small revision procedures. This case series demonstrates that microsurgical reconstruction of multiple entities of forehead defects poses a reliable method, especially in large and complex defects. In our opinion, given low risks for major complications and superior aesthetic results, the gracilis muscle flap covered with unmeshed split-thickness skin graft is ideally suited to reconstruct the forehead and should be one of first choices.

Misdiagnosed microcystic adnexal carcinoma on the lateral forehead and challenges in reconstruction of a large and bone-deep defect

BACKGROUND

Microcystic adnexal carcinoma (MAC) is a rare cutaneous malignancy characterized by aggressive local infiltration, including a high propensity for perineural invasion. Histologically it can be easily confused with benign adnexal tumors, which often leads to inappropriate initial treatment. As a consequence delayed surgical excision often requires removal of large cutaneous masses which can be followed by challenges in reconstruction.

METHODS

We report the case of a challenging reconstruction of a large forehead defect by a modified AT flap with central Burow's triangle grafting and previous wound conditioning using hyaluronic acid after complete micrographic removal of MAC.

RESULTS

A 80-year-old healthy female presented with an almost six year history of an asymptomatic slowly progressing skin mass previously biopsied and diagnosed as benign syringoma five years in advance. Deep biopsies confirmed MAC. She underwent staged surgical excision with Tübingen torte technique with removal of the frontal periostium. A skin substitute of esterified hyaluronic acid was applied for three weeks to the bone-deep 6 × 7 cm defect leading to good granulation tissue above the bone. Final reconstruction was achieved by an AT flap combined with full thickness skin transplantation of the central dog ear. The cosmetic outcome was satisfactory, no recurrence was observed within 18 months follow-up.

CONCLUSIONS

We confirm the histological difficulties in the diagnosis of this tumor entity and the large extension of MAC due to delay in diagnosis and treatment. Deep tumor removal including the periostium might be necessary to achieve tumor free margins. Fast granulation tissue above the frontal bone might be achieved by applying hyaluronic acid products. The combination an AT flap with transplantation of the adjacent Burow's triangles gives optimal skin texture and color matching and seems to be a good option to close even large defects of the front especially for supra brow defects.

Scalp reconstruction: an algorithmic approach and systematic review

IMPORTANCE

Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area.

OBJECTIVE

To review the current literature and describe a novel algorithm to help guide the reconstructive surgeon in determining the optimal reconstruction from a cosmetic and functional standpoint. Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, as well as the reconstructive ladder, are also discussed.

EVIDENCE REVIEW

A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence.

FINDINGS

Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer.

CONCLUSIONS AND RELEVANCE

Ideal reconstruction of scalp defects relies on a comprehensive understanding of scalp anatomy, a full consideration of the armamentarium of surgical techniques, and a detailed appraisal of patient factors and expectations. The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity.

LEVEL OF EVIDENCE

NA.

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.

Scalp and forehead reconstruction

The treatment of scalp and forehead defects is challenging. There are few cases in which an untreated scalp defect can heal by secondary intention. However, lack of adequate treatment can also lead to fatal consequences. Adequate judgment and treatment of a defect on the scalp are therefore mandatory. There are many options to reconstruct a scalp defect. Each option has its role in the reconstruction repertoire. Various factors need to be considered when choosing the method to be used. These factors include etiology and the size of the defect, age and general health of the patient, as well as the situation at the hospital/unit where the treatment is performed. In this article, different reconstruction methods are presented, and guidelines for the selection of the various options are provided.

Forehead reconstruction using a modified dual-plane A to T flap

Forehead defects often present myriad challenges for the reconstructive surgeon. Many options exist for forehead reconstruction, from primary closure to free flaps. To optimally match colour, contour and texture, the best approach replaces 'like with like'. When primary closure is not possible due to size limitations, and colour or depth is not suitable for grafts, then locoregional flaps become the mainstay of repair. The authors present three cases in which a dual-plane modified A to T flap is used to reconstruct central and lateral forehead defects up to 8 cm in size with excellent aesthetic results. This technique applies principles of the periglabellar flap, with modifications designed to encompass larger defects as well as defects of the lateral forehead.

Principles of Skull Base Reconstruction After Ablative Head and Neck Cancer Surgery

“Resection of malignancies of the skull base can result in significant functional and cosmetic morbidity as well as mortality. Reconstructive efforts provide not only functional and cosmetic rehabilitation, but also allow for the avoidance of potentially disastrous complications such as cerebrospinal fluid leak or meningitis. The optimal reconstruction is determined both by a patient based approach and a defect based approach. Skull base defects can be addressed by the separate components of the craniofacial skeleton in which they involve, and therefore the individual reconstructive issues which must be addressed. In this article, we describe an approach to skull base reconstruction and the technical aspects of the available reconstructive options.

Options for the management of forehead and scalp defects

Forehead and scalp reconstruction comprises a diverse and complex set of defects. Repair must be performed with minimal disturbance to surrounding structures, such as the eyelid, eyebrow, and hairline. Care must be taken to maintain symmetry between sides. This article addresses the options for the management of forehead and scalp defects, including secondary intention healing, skin grafting, local flaps, free flaps, tissue expansion, and negative pressure treatment. When possible, special consideration is given to addressing the advantages and disadvantages of each repair option, while providing a framework from which to plan scalp and forehead reconstruction.

Advances in scalp reconstruction

PURPOSE OF REVIEW

The present review summarizes traditional and advanced techniques used to reconstruct defects of the scalp. These deformities range from small defects that can be closed primarily to significant defects, which require free tissue transfer.

RECENT FINDINGS

Increased use of tissue expanders, advancement rotational flaps, and hair transplantation has resulted in improved cosmetic outcomes for larger defects of the scalp. Free tissue transfer has provided a revolutionary method of reconstructing subtotal and total defects of the scalp, in particular those associated with neoplasms.

SUMMARY

New advances in techniques of scalp reconstruction have provided improved outcomes in terms of cosmetic appearance and decreased morbidity for scalp reconstruction.