Scalp and forehead reconstruction

The free anterolateral thigh flap substituted for a pedicled biparietal flap in reconstructing complex frontal defect

Complex scalp defects involving soft and hard tissues pose challenges for plastic surgeons. The solution for each defect must depend on various factors and even the technical development of the infrastructure. We present a case study in which the patient had a significant total frontal defect. The first surgery was a bi-parietal flap as a salvage option to cover the defect. However, aesthetic satisfaction was not achieved. The second surgery used the anterolateral thigh flap to enhance the aesthetic result, and the placement of titanium mesh was an appropriate choice. This case may be an example of how different solutions can lead to variable results and what needs to be considered when dealing with complex scalp defects.

Surgical Management for Hair Restoration: A Review of Contemporary Techniques

BACKGROUND

Hair loss can cause psychological distress for patients, regardless of the etiology or extent of the defect. Many conservative and pharmacological approaches are successful in management, but refractory or severe cases often mandate surgical treatment. Surgical techniques have been refined over the course of a century, and we aim to review the most contemporary strategies.

METHODS

A review of the literature was performed using the databases PubMed, Web of Science, and Embase, in May 2020. Articles were included if they discussed techniques used within the past 10 years, in search of more contemporary strategies and the most widely used approaches.

RESULTS

The use of local flaps, scalp reduction surgery, and hair transplantation techniques are all used for various indications. Modern hair transplantation can be further divided into follicular unit excision and follicular unit transplantation, each with its own advantages. Local flaps are most often used for post-traumatic and reconstructive indication, while hair transplantation can be used for smaller cosmetic lesions or in combination with a variety of other reconstructive techniques.

CONCLUSION

Hair loss continues to be a challenging pathology for both patients and physicians, regardless of etiology. When conservative treatment is inadequate, there exist multiple surgical techniques that can feasibly restore hair, though the exact degree of success may vary between patients. The proper technique is dependent upon etiology, patient specific factors, as well as surgeon experience and comfort.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

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.

Bilayer wound matrix-based cutaneous scalp reconstruction: A multidisciplinary case control analysis of factors associated with reconstructive success and failure

BACKGROUND

Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp.

METHODS

A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes.

RESULTS

In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm², and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 - 26.7, and p<0.012). Additionally, subjects who underwent preoperative radiation were more likely to suffer from reconstructive failure (p<0.040) as well as those who require postoperative inpatient admission (p<0.034).

CONCLUSION

BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure.

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.

Superficial temporal vessels, both anterograde and retrograde limbs, are viable recipient vessels for recurrent head and neck reconstruction in patients with frozen neck

BACKGROUND

Reconstruction of recurrent head and neck malignancy especially in the presence of a frozen neck is challenging. The superficial temporal vessels would be ideal as recipient vessels because they lie out of the previous surgical and radiation field.

METHODS

We conducted a retrospective case-control study based on our database between January 2013 and June 2016. A total of 581 primary cases were selected as controls. The 60 test group patients had (a) recurrent head and neck reconstruction, (b) previous surgery and irradiation, (c) frozen neck, and (d) superficial temporal vessels as recipients.

RESULTS

There was no significant difference between vascular compromise rates of superficial temporal vessels (anterograde and retrograde limbs) and controls (P > .05). Flap success rate of the test and control group is comparable, 95% vs 98% respectively.

CONCLUSION

Superficial temporal vessels, both anterograde and retrograde, should be the first consideration for recurrent intraoral, facial, and scalp reconstruction with frozen necks.

Noncultured epidermal-melanocyte cell suspension and dermal-fat grafting for the reconstruction of an irregular, atrophic, and depigmented forehead scar: an innovative approach

Scars on the face 'eclipse' patient social life and provide challenge for the treating surgeon. 'Forehead' is difficult area on face to re-construct because of the inelastic, relatively immobile skin and subcutaneous tissue. The surgical correction of scar depends upon the site, size, type of scar and general condition of the patient. We describe an innovative approach to treat a depressed, de-pigmented, irregular scar placed vertically in the centre of forehead, in a young girl..

Use of a Dermal Regeneration Template in Complicated Craniotomy Wounds: Review of a Series

BACKGROUND

Surgical wounds after craniotomy heal with primary closure in most cases; however, significant comorbidities, multiple procedures, and history of tumor increase the risk of wound breakdown. Craniotomy wounds often require sophisticated coverage by a plastic surgeon using regional or microvascular flaps to address exposed intracranial contents. Unfortunately, timely treatment of craniotomy wounds may be difficult as a result of limitations of plastic surgery consultation, specialized operating room staffing, and operating room time. Infected wounds may need serial debridement and antibiotic therapy before definitive closure, and patients with dehisced or infected craniotomy wounds may need medical and nutritional optimization.

OBJECTIVE

To present the first case series of 7 neurosurgical patients with craniotomy wound complications who underwent closure with dermal regeneration template (DRT) at the time of urgent surgical debridement.

METHODS

Seven adult patients underwent placement of DRT for dehisced or infected craniotomy wounds after treatment for tumor or trauma. Patients had an average of 5.5 operations before definitive closure. Six patients ultimately underwent delayed free flap transfer after DRT placement, and 1 patient had DRT as definitive coverage.

RESULTS

All patients had healed craniotomy wounds.

CONCLUSION

DRT has a role in treating complicated craniotomy wounds in patients with cancer or trauma either as a bridge or as definitive coverage. Its ease of application does not require advanced or time-consuming techniques. In some cases, it may even be used as a definitive means of closure in surgical wounds.

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.