Role of systematic scalp expansion before cranioplasty in patients with craniectomy defects

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.

Tissue Expanders in Staged Calvarial Reconstruction: A Systematic Review

Cranioplasties are common procedures in plastic surgery. The use of tissue expansion (TE) in staged cranioplasties is less common. We present two cases of cranioplasties with TE and systematically review literature describing the use of TE in staged cranioplasties and postoperative outcomes. A systematic review was performed by querying multiple databases. Eligible articles include published case series, retrospective reviews, and systematic reviews that described use of TE for staged bony cranioplasty. Data regarding study size, patient demographics, preoperative characteristics, staged procedure characteristics, and postoperative outcomes were collected. Of 755 identified publications, 26 met inclusion criteria. 85 patients underwent a staged cranioplasty with TE. Average defect size was 122 cm ² , and 30.9% of patients received a previous reconstruction. Average expansion period was 14.2 weeks. The most common soft tissue closures were performed with skin expansion only (75.3%), free/pedicled flap (20.1%), and skin graft (4.7%). The mean postoperative follow-up time was 23.9 months. Overall infection and local complication rates were 3.53 and 9.41%, respectively. The most common complications were cerebrospinal fluid leak (7.1%), hematoma (7.1%), implant exposure (3.5%), and infection (3.5%). Factors associated with higher complication rates include the following: use of alloplastic calvarial implants and defects of congenital etiology ( p  = 0.023 and 0.035, respectively). This is the first comprehensive review to describe current practices and outcomes in staged cranioplasty with TE. Adequate soft tissue coverage contributes to successful cranioplasties and TE can play a safe and effective role in selected cases.

Tissue expansion for challenging DBS hardware erosions in patients with Parkinson's disease

•Consider tissue expanders for challenging DBS cases in PD patients with hardware erosion.•Placement of tissue expander is essential in planning the reconstruction.•MRI-compatibility of the tissue expander is paramount for shortening the total duration of anesthesia.•Role of routine skin biopsies to identify PD patients at additional risk for developing scalp defects should be investigated.

Stepwise Reconstruction of a Large, Self-Inflicted Calvarial Defect

BACKGROUND AND IMPORTANCE

Scalp expansion ensures that tissue similar in color, texture, thickness, and most importantly, hair-bearing quality, is available to resurface the scalp. It is a critical option for reconstruction of large calvarial defects.

CLINICAL PRESENTATION

Over 6 months, a 55-year-old male patient excoriated his scalp into a full-thickness scalp and calvarial wound resulting in dural violation and meningitis. The patient presented with altered mental status and methicillin-susceptible staphylococcus aureus (MSSA) bacteremia, cranial osteomyelitis, and an intracranial abscess secondary to the large scalp defect. The patient underwent immediate debridement and dural coverage with a scalp rotational flap. Several months later he began delayed stepwise cranioplasty with multiple scalp tissue expanders given the deficiency of soft tissue.

CONCLUSIONS

This case is presented to highlight the unusual mechanism of injury and the complex reconstructive approach in surgical management.

A New Type of Three-Dimensional Customized Composite Implant in Reconstruction of Large Skull Defects

ABSTRACT

Large skull defects can result in chronic injury to intracranial tissues as well as psychological trauma for patients, and their repair presents a challenge to surgeons. Hydroxyapatite has been used in reconstructing skull defects for many years, but it is difficult to adjust the shape and size of the material intraoperatively, especially for large defects. With three-dimensional digital technology, a new type of customized composite implant made of epoxide acrylate maleic and hydroxyapatite has been applied in clinical practice. In this retrospective review, 15 patients with large skull defects (4 female and 11 male, at a mean age of 36.4 years, range from 24-65 years) were treated with the novel customized composite implant, reconstructing the large skull defects successfully. During the average 2.2 years follow-up period (range 0.5-4 years), complications including infection, cerebrospinal fluid leakage, intracranial hemorrhage, or implant exposurea were not occured, only 1 patient (6.7%) with a seroma managed non-operatively. The customized implants, which required no intraoperative adjustments and are about a third of the cost of titanium implants, are an excellent alternative for large skull defect repair.

Systematic Review of Tissue Expansion: Utilization in Non-breast Applications

Background

Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances.

Methods

The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed.

Results

A total of 565 publications were identified. Of these, 166 publications described tissue expansion for "less traditional" indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction.

Conclusions

Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

Decompressive craniectomy with scalp expansion graft using a temporary synthetic skin substitute in the pediatric population: case series and review of the literature

INTRODUCTION

The use of decompressive craniectomy in children is controversial and often reserved for patients with refractory intracranial hypertension. Following decompression, skin closure in select cases can be challenging due to brain herniation and swelling through the craniectomy defect. In these cases, partial cortical debridement is sometimes performed.

METHODS

We describe two cases in which a synthetic skin substitute was used to facilitate a tension-free closure, rather than performing a partial lobectomy.

RESULTS

At 6-month follow-up, both patients are at preoperative cognitive baseline, with some residual hemiparesis.

DISCUSSION

We believe that use of a synthetic skin substitute for skin closure after decompression is a suitable option for closure of traumatic scalp wounds and may contribute to improved functional outcome in patients with severe intraoperative brain swelling.

Complications of tissue expansion in the head and neck

BACKGROUND

The authors aim to present a comprehensive review detailing the present state of evidence with regard to complications following tissue expansion in the head and neck.

METHODS

A systematic literature search was conducted to identify all studies reporting complications of tissue expansion in the head and neck between 2000 and 2019. Subgroup comparisons based on expander locations and planes were conducted.

RESULTS

A total of 7058 patients were included. Tissue expansion was associated with an overall complication rate of 8.73% (616/7058). The most common complications were extrusion (207/7009; 3.0%) and hematoma (200/7009; 2.9%). Overall complications were highest in the scalp (65/238; 27.3%) and lowest in the mastoid (347/5688; 6.1%). Complications were more common with expansion in the non-subcutaneous plane (63/590; 10.7%).

CONCLUSION

In the absence of large clinical trials, systematic reviews such as these can help inform clinical guidelines and provide practitioners with an evidence-based reference to improve informed consent.

Multi-stage Preparation for the Repair of Complicated Skull Defects

Cranioplasty following decompressive craniectomy is highly associated with complications. Methods for avoiding these complications have been well-documented; however, approaching reconstruction through the previous incision, especially if it was on or very near the bone defect, can sometimes lead to wound dehiscence and infection, with exposure of the artificial bone. For such complicated cases, we propose a multi-staged preparation that includes creating a delayed skin flap for the actual skull reconstruction. Flap was elevated in three stages, with 4 week intervals between each stage to allow for adequate blood supply. Cranioplasty using custom-made implants was then performed. Four patients (age range, 10–25 years) were prepared for skull reconstruction using this technique. During follow-up period for 12 months, no complications, including infections, exposure of the artificial bone, or flap necrosis, were observed. Despite the multiple stages required, we consider that our technique makes a significant contribution to the literature because it suggests a technique for cranioplasty following decompressive craniectomy that may avoid many of the complications following such cranioplasty using current methods.

Flattening the curvature of synthetic materials to relieve scalp skin tension in cranioplasty

BACKGROUND

Scalp tissue shrinkage and volume contraction is a major problem in cranioplasty, and sometimes a tissue expander must be set before cranioplasty. The procedure for placing scalp expanders is cumbersome. In this study, we present a method for flattening the curvature of synthetic materials to relieve scalp skin tension and discuss the feasibility and limitations of the method.

METHODS

A total of 25 cranioplasty patients were included in this study. The optimal degree of curvature flattening for each piece of bone substitute material was determined based on cosmetic considerations and the extent of encephalomalacia or atrophy due to primary disease. In this series, the correlation between the degree of curvature flattening and the size or location of the bone flap was considered, and the amount of scalp surface area that could be obtained through curvature flattening was estimated.

RESULTS

The median degree of curvature flattening was 5.0 mm. The degree of curvature flattening showed moderate correlation with the rate of change in the area of synthetic material achieved through curvature flattening (p < 0.001). The 21 cases of fronto-temporal craniectomy were divided into two groups according to the distance from the midline. There was a statistically significant difference between these two groups in degree of flattening curvature.

CONCLUSIONS

In the present cranioplasty series using synthetic materials, curvature flattening was a non-invasive and convenient method for skin closure. This method can be beneficial especially in patients requiring a larger craniotomy including convexity regions.

Scalp expansion: Surgical considerations and possible future directions

Introduction

Repairing large scalp defects has always been a difficult task for plastic surgeons. This is because the requirements of such procedures are two-fold: sufficient soft-tissue coverage is required, and to obtain a satisfactory aesthetic outcome, a sufficient number of covering hairs should be ideally provided.

Materials and Methods

Based on the author's experience in this repair technique over a 20-year period, this article presents some technical details of scalp expansion, surgical refinements and possible directions for further technical advancement.

Results

Data and details on relevant scalp anatomy, expander choice, expander placement, subgaleal undermining, galeotomies and acute scalp expansion are provided.

Conclusions

The author hopes that the above-mentioned details may be of some utility in the complex field of scalp expansion.