Aesthetic reconstruction of the vertex area of the scalp. Case report

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.

The management of non-melanocytic skin malignancies of the scalp and calvarium

Background:

The management of advanced cutaneous malignancies has been controversial. Thirteen patients with nonmelanoma skin neoplasias that had invaded the bone of the calvarium and scalp were treated in our centre.

Objective:

The purpose of this study was to evaluate our experience in treating these malignancies with scalp resection and full or partial thickness cranium reconstruction.

Patients and Methods:

From June 2008 to March 2012, thirteen patients with locally advanced tumours of the scalp invading the calvarium were treated with wide local excision of the scalp combined with an underlying craniectomy and dural resection if needed.

Results:

Using histopathological diagnosis eleven patients were diagnosed with basal cell carcinoma and two patients with squamous cell carcinoma. A full thickness cranium resection was performed in seven patients and partial in six patients.

Conclusion:

These large cancers occasionally invade adjacent structures, as well as bone, presenting a challenging surgical problem. In general, giant rotational or island scalp flaps and free tissue transfers are needed to close the area. Finding clean margins are an important part of treating patients with bone involvement and can usually be attained using outer tabula curettage thus preventing unnecessary morbidity.

Reconstruction of scalp and forehead defects

Reconstruction of scalp and forehead defects is a complex field with a broad variety of reconstructive options. The thought process and techniques used for reconstruction of scalp and forehead defects are the subject of this article.

Scalp and Forehead Reconstruction

The reconstruction of defects that involve the scalp and forehead presents unique aesthetic and functional challenges. This article reviews the surgical anatomy of these regions and presents an algorithm for decision making in reconstructive surgery. Nonmicrosurgical techniques are briefly reviewed. The microsurgical reconstruction of scalp and forehead defects differs from the more common oropharyngeal reconstructions in several ways, including flap choices, choices for recipient vessels, and the opportunity to use conventional and microsurgical techniques simultaneously to improve outcomes. Each of these considerations is reviewed and the authors' preferred techniques presented.

Reconstruction of Complex Scalp Defects

OBJECTIVE

To demonstrate the use of multiple, large, local flaps in the reconstruction of large scalp defects.

METHODS

A retrospective review of 4 cases in which the "banana peel" method of scalp reconstruction, originally described by Orticochea, was used as a method for closure of moderately large to extensive scalp defects.

RESULTS

In all 4 cases, closure of the scalp defects was accomplished. Major morbidity included hair-bearing skin in the forehead in 1 patient, an inconsequential small flap dehiscence requiring closure in the same patient, and a partial loss of a small skin graft to a donor site defect in 1 patient.

CONCLUSIONS

While other techniques may be optimal for the management of most scalp defects, such as 1- to 2-flap rotation-advancement flaps in small to moderate-size defects and microvascular free tissue transfer and secondary tissue expansion for larger defects, we conclude that the multiple-flap reconstruction method as described by Orticochea may be useful in a small subset of patients. The latter includes older, severely debilitated patients who would be optimally treated with microvascular tissue transfer but cannot tolerate lengthy general anesthesia and young patients who will not accept a significant area of alopecia that might exist with other techniques, such as secondary intention, skin grafts, or free flaps.