Reconstruction of large defects on the scalp and forehead as an interdisciplinary challenge: Experience in the management of 39 cases

Modified Keystone Perforator Island Flap Techniques for Small- to Moderate-Sized Scalp and Forehead Defect Coverage: A Retrospective Observational Study

We aimed to demonstrate the effective application of keystone perforator island flap (KPIF) in scalp and forehead reconstruction by demonstrating the authors' experience with modified KPIF reconstruction for small- to moderate-sized scalp and forehead defects. Twelve patients who underwent modified KPIF reconstruction of the scalp and forehead from September 2020 to July 2022 were enrolled in this study. In addition, we retrospectively reviewed and evaluated the patient's medical records and clinical photographs. All defects (size range, 2 cm × 2 cm to 3 cm × 7 cm) were successfully covered using four modified KPIF techniques (hemi-KPIF, Sydney Melanoma Unit Modification KPIF, omega variation closure KPIF, and modified type II KPIF) with ancillary procedures (additional skin grafts and local flaps). All flaps (size range, 3.5 cm × 4 cm to 7 cm × 16 cm) fully survived, and only one patient developed marginal maceration that healed with conservative management. Furthermore, through the final scar evaluation with the patient satisfaction survey and Harris 4-stage scale, all patients were satisfied with their favorable outcomes at the average final follow-up period of 7.66 ± 2.14 months. The study showed that the KPIF technique with appropriate modifications is an excellent reconstructive modality for covering scalp and forehead defects.

Finding the Optimal Surgical Incision Pattern-A Biomechanical Study

The closure of wounds and subsequent optimal wound healing is essential to any successful surgical intervention. Especially on parts of the body with limited possibilities for local reconstruction, optimal distribution of load is essential. The aim of the present study was therefore to examine three different incision patterns, conventional straight, Lazy-S and Zigzag, with regard to their biomechanical stability and mode of failure on a porcine skin model. Our results demonstrate the superior biomechanical stability of Lazy-S and Zigzag incision patterns with perpendicular suture placement. This holds true, in particular, for Zigzag incisions, which showed the highest values for all parameters assessed. Moreover, the observed superior stability of Lazy-S and Zigzag incision patterns was diminished when sutures were placed in tensile direction. The conventional straight incision represents the standard access for a large number of surgical procedures. However, we were able to demonstrate the superior biomechanical stability of alternative incision patterns, in particular the Zigzag incision. This is most likely caused by an improved distribution of tensile force across the wound due to the perpendicular placement of sutures. Moreover, this technique offers additional advantages, such as a better overview of the operated area as well as several cosmetic improvements. We therefore advocate that the surgeon should consider the use of a Zigzag incision over a conventional straight incision pattern.

Scalp Reconstruction after Mohs Cancer Excision: Lessons Learned from More Than 900 Consecutive Cases

BACKGROUND

Scalp reconstruction has evolved over time. Given the large surface area, location, and high likelihood of sun exposure, the scalp is particularly prone to sun damage and skin cancer. Resection of scalp cancers often leaves a large defect that can be challenging for reconstruction. The authors present objective data and recommendations based on more than 10 years of consecutive scalp reconstructions performed by the senior author (J.F.T.). In addition, the authors describe each method of reconstruction and delineate an algorithm based on the senior author's approach and the cases assessed.

METHODS

The authors conducted a retrospective review of patients who underwent scalp reconstruction after Mohs cancer excision over a 10-year period. Each case was evaluated for key patient characteristics, defect location, defect size, defect composition, reconstructive modality, and complications.

RESULTS

The senior author (J.F.T.) performed 913 scalp reconstruction procedures. Defects most commonly involved the forehead or vertex of the scalp, with a wide range of sizes. A significant majority of the patients' defects were repaired with the use of adjacent tissue transfer or Integra dermal regeneration templates. There were 94 complications (12.5 percent) noted, ranging from graft loss to cancer recurrence.

CONCLUSIONS

Reconstruction of scalp defects after Mohs cancer excision presents the plastic surgeon with numerous patient and defect preoperative variables to consider. Each defect should be evaluated, and a plan based on composition of the defect and the needs of the patient should be developed. Scalp reconstruction is safe to perform in an outpatient setting, even in elderly patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Multimodality imaging and treatment strategy for malignant scalp neoplasms in adults

Malignant scalp masses deserve much attention as they have the potential to destroy local structures, recur and metastasize to distant organs. Moreover, malignant scalp lesions are known to be more aggressive in behavior than their counterparts elsewhere in the body. Multimodality imaging is essential in narrowing the differential diagnoses of scalp masses, as well as in differentiating benign from malignant masses. Furthermore, imaging is important in (1) evaluating the extent of tumor invasion in the scalp, (2) staging the disease, (3) guiding surgical biopsy and/or resection of the tumor, (4) preoperative planning and post-treatment surveillance of scalp tumors. An interdisciplinary treatment approach is crucial for the management of scalp malignancies given their complex and aggressive nature. This review seeks to describe the unique clinical and imaging characteristics of various types of malignant scalp masses, as well as to review their current treatment strategies.

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.

Aggressive cutaneous squamous cell carcinoma of the scalp

Cutaneous squamous cell carcinoma (cSCC) is the second most common nonmelanoma skin cancer, and its incidence is increasing globally. In Korea, there were 12,516 diagnosed cases of cSCC between 1999 and 2014. Surgical treatment, for which several options are available, is the standard of care for cSCC and securing a sufficient surgical resection margin is always important. cSCC of the scalp sometimes exhibits unusually aggressive behavior. In this article, we report a case of cSCC of the scalp with invasion into the skull and dura mater.

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.

[Case report of frontobasal reconstruction and volume augmentation using a free gracilis muscle flap and autologous fat grafting: utilising the free flap as a scaffold for fat transplantation]

This case report shows the interdisciplinary treatment of a 28-year-old woman suffering from a pronounced frontal volume defect after severe craniocerebral trauma. The combination of cranioplasty using a polymethylmethacrylate (PMMA) implant, free gracilis muscle flap transfer for soft tissue coverage and serial autologous fat grafting into the muscle flap for subsequent contouring enabled both an adequate and aesthetic reconstruction. This example demonstrates the feasibility of treating increasingly complex composite defects in a multidisciplinary setting, when plastic surgeons are involved.

Sebaceous Nevus of the Scalp

Excisions of scalp nevus sebaceous (NS) presents a unique challenge due to limited soft tissue laxity, hair-bearing skin, and convex surfaces which often leave the surgeon and patient underwhelmed with the reconstructive outcome. In this study, the authors conducted an institutional review board-approved retrospective review of patients who underwent excision of pathologically proven scalp primary NS from 2003 to 2017 at our institution to better define the reconstructive outcomes and options for treatment of pediatric scalp NS. 92 patients were included in the study, 54 males (58.7%) and 38 females (41.3%). The average age at surgery was 7.24 years (0.5-16.0; SD 4.7). Local tissue undermining/galeal scoring with primary closure (LTUGS) was used for lesions with average surface area of 3.6 cm, rotational or transposition flaps (RF/TF) for lesions averaging 4.3 cm, completed serial excision for lesions averaging 13.9 cm, and tissue expansion (TE) for lesions averaging 21 cm (P <0.001). One or more poor outcomes were experienced by 35 patients (38%), with a significant difference between the surgical groups; LTUGS 37.2% (29/78), RF/TF 60% (3/5), serial excision 100% (3/3), TE 0% (0/6) (P = 0.022). Univariant binary regression analysis within the LTUGS and RF/TF groups showed that lesion size was a significant predictor of poor outcomes (P = 0.012). All specimens in this study were negative for carcinoma. Therefore, most pediatric nevus sebaceous of the scalp can be managed by a single-phase procedure though risk of poor outcomes increase with nevus size with high rates of poor outcomes even with small lesions.

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.

Pre-Expanded Latissimus Dorsi Myocutaneous Flap for Total Scalp Defect Reconstruction

Scalp defects can be caused by various factors, and reconstruction options for scalp defects include skin grafts, local flaps, tissue expanders, and free flaps. However, currently, it is widely accepted that the use of free flaps is the most feasible method for extensive scalp defect reconstruction. While multiple flaps have been used to reconstruct scalp defects, the reconstruction of total scalp defects still remains challenging. Pre-expansion of free flaps offers several advantages, including increasing flap size and thinning of the tissue for better contour, and is particularly important in scalp reconstruction. This report describes the successful management of total scalp defect reconstruction that involved the entire frontal, parietal, occipital, and temporal regions using a pre-expanded latissimus dorsi myocutaneous flap in a 40-year-old female patient. Over 2 years of follow-up, the transplanted flap survived well and the patient eventually achieved excellent cosmetic appearance, with satisfactory durable coverage. She was able to wear a hairpiece and hat without any wound breakdown. Our report indicates that microsurgery using pre-expanded latissimus dorsi myocutaneous flap transfer is a reliable and safe choice for total scalp reconstruction, allowing reconstruction with a single-flap, an excellent aesthetic effect, and abrasive resistance.

The Role of the Visor Flap in Scalp Reconstruction: A Case Series of 21 Patients

BACKGROUND

Full-thickness scalp defects pose a reconstructive problem, especially in the setting of infection, chemotherapy/radiation, and underlying cranial defects. Current options include dermal matrices, skin grafts, and local flaps. Local flaps often fail, requiring subsequent microvascular free flap reconstruction.

OBJECTIVE

To describe the visor flap, a novel bipedicled advancement flap design, and its role in reconstruction of scalp defects.

METHODS

A retrospective review of 21 adult patients who developed scalp defects reconstructed using the visor flap from 2013 to 2017. The visor flap is a large bipedicled advancement flap design with a triangular extension at the base, which allows redistribution of a large surface area of the scalp.

RESULTS

All 21 patients achieved complete and viable soft tissue coverage of the recipient site, but 19.0% developed complications unrelated to flap viability, requiring reoperation (infected bone flap, epidural hematoma, and recurrent glioblastoma with subdural abscess). Only 1 patient required conversion to free flap reconstruction due to cerebrospinal fluid leak. Etiologies included cancer (76.1%), cerebrovascular disease (19.0%), and traumatic brain injury (4.8%). Preoperative radiation (42.9%), bone/hardware exposure (57.1%), and previous craniotomy (85.7%) were widely prevalent. Defect size ranged from 3 to 50 cm2 (mean, 16.9 cm2), and flap size ranged from 90 to 500 cm2 (mean, 222 cm2).

CONCLUSION

The visor flap provides an innovative solution for closure of scalp defects. This technique optimizes immediate closure of tissue compromised by infection or chemotherapy/radiation without burning bridges to more complex reconstructive options.

Application of the pinwheel flap for closure of a large defect of the scalp

A 74-year-old man had a resultant large oval scalp defect of 12×6 cm (72 cm²) following an excision of a stage IIIA melanoma. We decided to cover the defect with the pinwheel flap, with the aim to provide a good cosmetic result, preservation of hair follicles and minimal donor-site morbidity. This local flap has been traditionally used for much smaller defects. Four L-shaped flaps were designed at equal distances on the vertical and horizontal axes of the defect. The L-shaped flap had a length of 1.5 times the half diameter of the defect (4.5 cm). The incision was made through galea aponeurosis and subsequently undermined at least 3 cm to assist flap advancement. Z-plasties increased the rotation of the flap when it was required. This yielded an excellent reconstructive result at 1-year follow-up, demonstrating the usefulness of the pinwheel flap in large defects on the scalp region.

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.

Comparison of Musculocutaneous and Fasciocutaneous Free Flaps for the Reconstruction of the Extensive Composite Scalp and Cranium Defects

Composite scalp and cranium defects, which require microsurgical reconstruction, result from tumor resection, radiation, trauma, severe burn injuries, and rarely vasculitic disorders. In the current study, the authors aim to compare the outcomes of the fasciocutaneous flaps and musculocutaneous free flaps used for the reconstruction of extensive composite scalp and cranium defects. From 2010 to 2017, 21 patients who underwent composite scalp and cranium defect reconstruction with a free flap were retrospectively identified. Eighteen patients had squamous cell carcinoma, 2 patients had meningioma, and 1 patient had Ewing sarcoma. Thirteen musculocutaneous free flaps including latissimus dorsi and vertical rectus abdominis flaps and 9 free fasciocutaneous flaps including radial forearm and anterolateral thigh flaps were used. Only 1 flap loss was encountered. No neurologic impairment in postoperative period was reported. The mean length of stay in the hospital, the duration of surgery, and total volume of blood transfusion for the fasciocutaneous flap group were significantly shorter than those for musculocutaneous flap group. No flap atrophy was reported in fasciocutaneous flap group. Reconstruction of the composite scalp and cranium defects with fasciocutaneous free flaps allows shorter hospitalization, less blood transfusion and less flap atrophy than those of musculocutaneous flaps. To this respect, their usage should be prioritized in such challenging patients.

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.

Scalp reconstruction: A 10-year retrospective study

Scalp reconstruction is a challenging task for the reconstructive surgeon. In consideration of the anatomical and cosmetic characteristics, the defect depth and size, an armamentarium of reconstructive procedures ranging from skin grafts over local flaps to free tissue transfer has been described. In this 10-year retrospective study, 85 operative procedures for scalp reconstruction were performed at our department. The underlying entity, defect size/depth, reconstructive procedure, complications, and mean hospital stay were analyzed. In most cases, scalp reconstruction was necessary after oncologic resection (67%) or radiation therapy (16%). A total of 85 operative procedures were performed for scalp reconstruction including local flaps (n = 50), free tissue transfer (n = 18), and skin grafts (n = 17). Regarding the complication rate, we could detect an overall major complication rate of 16.5% with one free flap loss. Briefly, local flaps are an adequate and safe procedure for limited scalp defects. In the case of extensive scalp defects affecting the calvarium, prior multiple surgical interventions and/or radiation, we prefer free tissue transfer.

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.

The fusion of craniofacial reconstruction and microsurgery: a functional and aesthetic approach

BACKGROUND

Reconstruction of large, composite defects in the craniofacial region has evolved significantly over the past half century. During this time, there have been significant advances in craniofacial and microsurgical surgery. These contributions have often been in parallel; however, over the past 10 years, these two disciplines have begun to overlap more frequently, and the techniques of one have been used to advance the other. In the current review, the authors aim to describe the available options for free tissue reconstruction in craniofacial surgery.

METHODS

A review of microsurgical reconstructive options of aesthetic units within the craniofacial region was undertaken with attention directed toward surgeon flap preference.

RESULTS

Anatomical areas analyzed included scalp, calvaria, forehead, frontal sinus, nose, maxilla and midface, periorbita, mandible, lip, and tongue. Although certain flaps such as the ulnar forearm flap and lateral circumflex femoral artery-based flaps were used in multiple reconstructive sites, each anatomical location possesses a unique array of flaps to maximize outcomes.

CONCLUSIONS

Craniofacial surgery, like plastic surgery, has made tremendous advancements in the past 40 years. With innovations in technology, flap design, and training, microsurgery has become safer, faster, and more commonplace than at any time in history. Reconstructive microsurgery allows the surgeon to be creative in this approach, and free tissue transfer has become a mainstay of modern craniofacial reconstruction.

Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review

This article aims to demonstrate an individualized approach to an elderly patient requiring scalp reconstruction, to describe the methodology in flap selection, lessons learned, and report outcomes. A retrospective review of a single surgeon's experience of scalp reconstruction (E. D. R.) using free tissue transfer from 2005 to 2011, in patients older than 70 years, was completed. A total of eight patients met the inclusion criteria, five males and three females, with a mean age of 80.4 years (range, 73-92). Free tissue transfer achieved 100% soft tissue coverage. Six of the eight patients required cranioplasty. The mean size calvarial defect was 92 cm(2) (range, 35-285 cm(2)). The mean flap size was 117.6 cm(2) (range, 42-285 cm(2)). Free flaps included three ulnar, three anterolateral thigh, one latissimus dorsi, and one thoracodorsal perforator flap. The mean follow-up time was 18.4 months (range, 3-46 months). Donor site morbidity was minimal. Mortality was 0%. Immediate flap failure was 0%. Other complications occurred in six of the eight patients. Mean revisionary procedures were 1.25 procedures per patient. It was concluded that chronological age does not increase mortality or catastrophic flap complications; however, morbidity is increased in the elderly and revisionary surgery is likely.

Reconstruction of the scalp, calvarium, and frontal sinus

Scalp and cranial deformities are common after trauma or ablative surgery. Local flaps and free flaps may be used in reconstruction of soft tissue defects, and autogenous bone or alloplastic bone substitutes may be used for cranioplasty procedures. Injuries to the frontal sinus, particularly when complicated by leak of cerebrospinal fluid or obstruction of the nasofrontal outflow tract, represent special challenges. Further studies are recommended to improve the multidisciplinary management of these complex, debilitating conditions, in anticipation of enhanced function and cosmesis, reduced donor site morbidity, and improved surgical outcomes.

Reconstruction of scalp defects with the radial forearm free flap

BACKGROUND

Advanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap.

PATIENTS AND METHODS

A retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes.

RESULTS

The patients were primarily male (n = 34), with a mean age of 67 years (25-91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02).

CONCLUSION

Advanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects.

Half forehead reconstruction with a single rotational scalp flap for dermatofibrosarcoma protuberans treatment

Background

Dermatofibrosarcoma protuberans (DFSP) is a soft tissue neoplasm of intermediate to low-grade malignancy. Although metastasis rarely occurs, DFSP has a locally aggressive behavior with a high recurrence rate. In the head and neck area, resection involving a wide margin of healthy tissue can be difficult because of functional and cosmetic considerations. We describe a novel reconstructive method for half forehead defects with an innovative single local wide scalp flap following excision of DFSP with a 3 cm margin of healthy tissue.

Methods

Two patients underwent wide resection of forehead DFSP and reconstruction with a single rotational scalp flap. The scalp flap blood supply was provided from three main vessels: the superficial temporal artery, occipital artery and posterior auricular artery.

Results

No early or late complications were observed in either patient with no local recurrence after 18 months of follow-up. The donor area could be closed primarily in both cases and the flaps survived completely.

Conclusion

This innovative technique allowed a radical excision of forehead DFSP with sufficient healthy margins, thus potentially decreasing tumor recurrence rate. Reconstruction was achieved avoiding microsurgery, skin expanders and large skin grafts. Moreover, all main reconstructive criteria, such as functional and cosmetic tissue characteristics, were completely fulfilled.

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.

Can we put a simplified algorithm for reconstruction of large scalp defects following tumor resection?

Background

Reconstruction of large scalp defects after tumor resection is a challenging problem. We aimed at putting an algorithm for reconstruction of those defects.

Methods

Forty-two patients with scalp malignancies were enrolled in this study. Tumors were resected to a 1 cm negative margin and defects were reconstructed according to their size and to patient general condition.

Results

No peri-operative mortality was encountered. Usage of free flaps was superior in cosmoses and function with an acceptable rate of complications.

Conclusion

for scalp defects wider than100 cm², the best tool of reconstruction is free flaps. Pedicled distant flaps are reserved if free flaps are not feasible or failed. Split thickness skin grafts are cosmetically inferior and not suitable for recurrent and irradiated tumours and better reserved for patients who cannot tolerate major operations.

Reconstruction of the scalp with a calvarial defect

PURPOSE

To review our clinical cases and devise a protocol for selecting the best operative methods to reconstruct the scalp with a calvarial defect.

METHODS

We reviewed the original disease, the areas and depths of the scalp and calvarial defects, the methods of reconstruction, and complications in 20 patients.

RESULTS

The defect was caused by secondary cranial infection following decompressive craniectomy for intracranial hemorrhage (ICH) in 11 patients; extensive removal of the scalp and calvaria for resection of a malignant tumor in 6 patients; and by secondary cranial infection following removal of a malignant tumor in 3 patients. Cranial infection was frequently associated with abscess formation around the fixation screws and plates, suggesting that artificial materials induced the infection. We reconstructed the defect using free flaps in 15 patients and using local flaps in 5 patients.

CONCLUSIONS

When restoring the calvaria in the primary operation, the use of metal screws and plates should be minimized to prevent cranial infection and subsequent scalp and calvaria defects. Local flaps are appropriate for reconstructing relatively small defects (<20 cm(2)), whereas free flaps are better for reconstructing relatively large defects (>25 cm(2)).

Invasive giant basal cell carcinoma of the head: case report, reconstruction choice and literature review

It is unusual to find a giant invasive basal cell carcinoma in the occipital region of the head. We are presenting a case of basal cell carcinoma invading and eroding occipital bone, managed with an unusual scalp reconstruction method. A 69-year-old female presented with a 16x19 cm diameter tumour in the occipital region. Preoperative biopsy revealed a basal cell carcinoma. A complete surgical excision of the tumour was performed in one-step surgery and tissue defect was reconstructed by a pedicle latissimus dorsi musculocutaneous flap. Our case shows that this distant pedicle flap is safe and reliable, and should be revised as the option for the occipital region reconstruction.

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.