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Chim H, Arcelona C, Gosain AK. Scalp Closure in Midline Cutis Aplasia-An Absolute Indication for Preoperative Imaging. J Craniofac Surg 2024; 35:e345-e347. [PMID: 38393191 DOI: 10.1097/scs.0000000000010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
The ideal evaluation and treatment of aplasia cutis congenita remains disputed. We present a case of midline scalp cutis aplasia that healed by secondary intention, leaving an area of residual alopecia. There were no clinical indicators of an underlying calvarial defect. Tissue expansion of the scalp was done in preparation for scalp closure. However, on the removal of the expanders and scalp advancement, an unrecognized midline calvarial defect in which a scar tract of herniated dura was found. This resulted in a dural tear, repaired with minimal hemorrhage. However, manipulation of the sagittal sinus resulted in a right subdural hemorrhage followed by cerebral ischemia and a stroke. On the basis of this clinical scenario, we recommend that all cases of midline scalp cutis aplasia undergo preoperative imaging with thin slices of the calvaria before performing scalp advancement-even if the only clinical indication for surgery is scalp alopecia without a palpable skull defect.
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Affiliation(s)
- Harvey Chim
- Division of Plastic Surgery, University of Florida School of Medicine, Gainesville, FL
| | - Christian Arcelona
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Arun K Gosain
- Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
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Bouali S, Charfeddine SH, Ghedira K, Mechergui H, Abderrahmen K, Kallel J. Large aplasia cutis congenita of the vertex conservative management. Childs Nerv Syst 2024; 40:285-292. [PMID: 37865964 DOI: 10.1007/s00381-023-06190-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Aplasia cutis congenita (ACC) of the vertex with bone defect is a rare and begnin anomaly that can involve the epidermis, dermis, and subcutaneous tissues of the scalp with significant bone defect Bajpai and Pal (J Pediatr Surg 38(2):e4, 2003). When associated with skull defect, this rare malformation carries the risk of severe complications such as rupture of the superior sagittal sinus or infections. METHODS AND RESULTS We report a case of aplasia cutis congenita of the scalp with skull defect measuring 9 × 10 cm and an exposed sagittal sinus in a newborn. Both conservative and surgical methods have been proposed to treat this condition. In our case, conservative treatment was planned led to complete epithelization and the patient was healing well at 5 years of follow-up. CONCLUSIONS ACC of the vertex with a large scalp defects present a management dilemma Rocha et al. (Clin Case Rep 3(10):841-4, 2015). Based on a review of the literature, we report this case to demonstrate that even for the largest skin and bone defects, an initial conservative approach may allow for complete wound closure without the need for early surgical intervention.
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Affiliation(s)
- Sofiene Bouali
- Department of Neurosurgery, National Institute of Neurology"Mongi Ben Hmida", Tunis Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia.
| | | | - Khalil Ghedira
- Department of Neurosurgery, National Institute of Neurology"Mongi Ben Hmida", Tunis Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Haifa Mechergui
- Department of Neurosurgery, National Institute of Neurology"Mongi Ben Hmida", Tunis Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Khansa Abderrahmen
- Department of Neurosurgery, National Institute of Neurology"Mongi Ben Hmida", Tunis Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - Jalel Kallel
- Department of Neurosurgery, National Institute of Neurology"Mongi Ben Hmida", Tunis Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
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Lo AY, Yu RP, Raghuram AC, Cooper MN, Thompson HJ, Liu CY, Wong AK. Tissue Expanders in Staged Calvarial Reconstruction: A Systematic Review. Arch Plast Surg 2022; 49:729-739. [PMID: 36523916 PMCID: PMC9747287 DOI: 10.1055/s-0042-1751104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 03/25/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Andrea Y. Lo
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Roy P. Yu
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Anjali C. Raghuram
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Michael N. Cooper
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Holly J. Thompson
- Wilson Dental Library, Herman Ostrow School of Dentistry of University of South California, Los Angeles, California
| | - Charles Y. Liu
- Department of Neurological Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Alex K. Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California,Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California,Address for correspondence Alex K. Wong, MD 1500 East Duarte RoadDuarte, CA 91010
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Torkamand F, Ayati A, Habibi Z, Nejat F. Extensive aplasia cutis congenita associated with cephalocranial disproportion and brain extrusion. Childs Nerv Syst 2019; 35:1629-1632. [PMID: 31139904 DOI: 10.1007/s00381-019-04188-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
Aplasia cutis congenita (ACC) is a rare congenital disorder which can be linked with a variety of other abnormalities. However, the association of this anomaly with cephalocranial disproportion and brain extrusion is rarely reported. In this report, we present a neonate with an extensive ACC with exposed dura mater and sagittal sinus, who later presented with brain extrusion from the defect and an acrocephalic-like feature required decompressive surgery during the first month of life. Theories regarding etiology and progression of acrocephalic feature and brain protrusion in this case have been discussed.
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Affiliation(s)
- Farbod Torkamand
- Department of Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, No 62, Qarib St., Keshavarz Blvd., Tehran, 1419733151, Iran
| | - Aryan Ayati
- Department of Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, No 62, Qarib St., Keshavarz Blvd., Tehran, 1419733151, Iran
| | - Zohreh Habibi
- Department of Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, No 62, Qarib St., Keshavarz Blvd., Tehran, 1419733151, Iran.
| | - Farideh Nejat
- Department of Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, No 62, Qarib St., Keshavarz Blvd., Tehran, 1419733151, Iran
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Conservative Treatment of Large Aplasia Cutis Congenita of the Scalp With Bone Defect With Basic Fibroblast Growth Factor Application. J Craniofac Surg 2017; 28:e154-e158. [PMID: 28045831 DOI: 10.1097/scs.0000000000003347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The object of this report is to share our experience of conservative management of giant aplasia cutis congenita (ACC) of the scalp with the topical application of basic fibroblast growth factor (bFGF). Complete epithelialization of the 9 × 8 cm sized defect was achieved in 33 weeks. Careful conservative management could eliminate the requirement of surgery for giant ACC defects of the scalp with bone defects and should be tried if surgery is thought to be risky or has consecutive morbidity. Topical bFGF application seems to accelerate healing, also providing a better epithelium for later reconstructive treatments and its usage could be standardized in the future.
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Winston KR, Ketch LL. Aplasia Cutis Congenita of the Scalp, Composite Type: The Criticality and Inseparability of Neurosurgical and Plastic Surgical Management. Pediatr Neurosurg 2016; 51:111-20. [PMID: 26937970 DOI: 10.1159/000442989] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 12/01/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The object of this report is to review the management of patients having the composite type of aplasia cutis congenita in the context of the relevant literature on this condition. METHODS Clinical records, neuroimaging and photographic documentation of identified cases of composite type aplasia cutis congenita, with a comprehensive review of the literature, are the material basis of this report. RESULTS Two neonates with composite type aplasia cutis congenita are described as examples of this disorder, and their management, including complications, is discussed. Both had satisfactory outcomes. CONCLUSIONS Early aggressive surgical management with scalp rotation flaps has a low rate of complications, provides satisfactory functional and esthetic outcome, minimizes hospital stays, and should provide cost-effective care by reduction of the time to secure wound closure. Most bony defects, even large ones, commonly ossify completely. Optimal case management requires a synchronized neurosurgical and plastic surgical team. Intuitive nonsurgical and surgical approaches by the inexperienced can be hazardous.
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Affiliation(s)
- Ken R Winston
- Department of Neurosurgery, University of Colorado Denver School of Medicine, Aurora, Colo., USA
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Udayakumaran S, Mathew J, Panikar D. Dilemmas and challenges in the management of a neonate with Adams-Oliver syndrome with infected giant aplasia cutis lesion and exsanguination: a case-based update. Childs Nerv Syst 2013; 29:535-41. [PMID: 23274636 DOI: 10.1007/s00381-012-1999-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 12/03/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with a variable extent of defective formation of the scalp. Adams-Oliver syndrome is a condition mainly characterized by the congenital absence of skin, known as "aplasia cutis" which is usually limited to the vertex scalp and transverse limb defects. CASE REPORT A 17-day-old term female neonate was referred to us with an infected scalp lesion of the vertex. The lesion which is about 10 × 9 cm had signs of infection with necrotic eschar. We started the neonate on systemic parenteral antibiotics with local dressings. On day 3 of conservative management, the neonate had exsanguination due to bleeding from the midline with severe hemodynamic compromise requiring cardiopulmonary resuscitation. After controlling the bleeding with local tamponade and resuscitating the child, she was taken for early surgery. Debridement and bipedicled rotation flap of the scalp to cover the raw area was performed. On day 18, the flap started showing signs of necrosis. The neonate was taken up for debridement, and subsequently, maternal allograft of split-thickness skin was placed as a temporary wound cover. Meanwhile, the wound showed progressive epithelialization. At 1 year, the patient continued to have a non-healing area, which was later successfully covered with a split-thickness skin graft. We plan to revaluate the need for cranioplasty at around 3-4 years of age. DISCUSSION We discuss the dilemmas and challenges involved in the successful management of a neonate with Adams-Oliver syndrome with infected aplasia cutis and an episode of life-threatening exsanguination. CONCLUSION Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with defective formation of the scalp to a varying extent and severity, requiring various timely strategies.
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Affiliation(s)
- Suhas Udayakumaran
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, PO Ponekkara, Kochi 682041, India.
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Beekmans SJA, don Griot JPW, Niessen FB, Mulder JW. Tissue expansion for correction of baldness in aplasia cutis congenita. Eur J Pediatr 2009; 168:541-4. [PMID: 18633641 DOI: 10.1007/s00431-008-0784-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Accepted: 06/17/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Aplasia cutis is a congenital absence of the skin, usually presenting on the scalp. In 20% of all cases, part of the skull is also absent. A residual area of baldness may still be present some years after surgical or conservative treatment. It is possible to excise the scarred hairless region and cover that area with expanded hair-bearing skin from the rest of the skull. We present three patients who underwent tissue expansion and discuss the indications and pitfalls of this procedure. CONCLUSION Tissue expansion can be used to cover a residual alopecia defect in young children with aplasia cutis congenita and associated bone abnormalities. The quality of the bone appears to be normal in our three patients. We demonstrate that even in young children with aplasia cutis and an underlying bony defect, tissue expansion is a safe and effective modality as a second stage reconstruction procedure.
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Affiliation(s)
- S J A Beekmans
- Department of Plastic, Reconstructive and Hand Surgery, Vrije Universiteit Medical Center, De Boelelaan 1117, 1007 MB Amsterdam, The Netherlands.
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Beekmans SJA, Don Griot JPW, Mulder JW. Split Rib Cranioplasty for Aplasia Cutis Congenita and Traumatic Skull Defects. J Craniofac Surg 2007; 18:594-7. [PMID: 17538324 DOI: 10.1097/scs.0b013e3180576f44] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aplasia cutis is a rare skin defect usually presenting over the vertex of the skull. An underlying bone defect is found in approximately 20% of patients. Most skull defects close spontaneously. However, when there are no signs of ossification, closure is mandatory. We present our experience in three patients. Our first patient had an aplasia cutis with a skull defect. The split rib graft procedure was used without complications, and a good cosmetic and functional result was achieved. The second patient was operated on for cerebral bleeding after an arteriovenous aneurysm, and a bony defect could not be closed after that procedure. At a later stage, the defect was filled with split rib grafts, and sufficient protection was achieved and documented after more than 30 years. The third patient was born with an aplasia cutis congenita with a skull defect. The bony defect was filled with split rib grafts without complications at an age of 5 years. Follow-up shows a functional result with a firm skull. Patients with aplasia cutis may have skull defects that will not close by themselves. We present three patients with a bony defect who were reconstructed with split rib grafts. After a long period of follow-up, there remains good cosmetic and functional results. Defects of the skull in children can be reconstructed with split rib grafts that will accommodate the growing skeleton and give good protection of the brain from an early age on.
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Affiliation(s)
- Sander J A Beekmans
- Department of Plastic and Reconstructive Surgery, Vrije Universiteit Medical Center, Amsterdam, The Netherlands.
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Abstract
Aplasia cutis congenita is a rare congenital disorder of skin and most commonly involves the scalp. The skull and dura underlying the defective skin may also be affected, relative to severity of the disease. The typical lesion is present at birth and ranges in size from 0.5-3 cm. The main complications of larger defects include infection, bleeding and trombosis that may be deadly. Therefore, prompt diagnosis and appropriate treatment are critical for avoiding the adverse outcomes. Controversy exists in the literature regarding the treatment of aplasia cutis congenita; both surgical and conservative treatment modalities have their proponents and opponents. We present a case of full thickness aplasia cutis congenital lesion bigger than 3 cm in diameter that healed with the application of novel wound dressing materials without any complications. The physiopathology, classification and treatment options of the disease are discussed.
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Affiliation(s)
- Yavuz Başterzi
- Mersin University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Mersin, Turkey.
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Miyazawa T, Azuma R, Nakamura S, Kiyosawa T, Shima K. Usefulness of scalp expansion for cranioplasty in a case with postinfection large calvarial defect: a case report. ACTA ACUST UNITED AC 2006; 67:291-5. [PMID: 17320641 DOI: 10.1016/j.surneu.2006.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 04/29/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND We frequently experience difficulty in scalp adaptation on cranioplastic surgery, particularly after wound infection, because of scalp atrophy, poor nutritional condition, and tense suture. CASE DESCRIPTION We report our valuable experience of scalp expansion being effective for cranioplastic surgery due to a postinfection large calvarial defect after the removal of a convexity meningioma. CONCLUSIONS If there is some anxiety about scalp adaptation preoperatively, it may be wise to perform a 2-stage cranioplasty, including tissue expansion with a scalp expander, instead of a hasty 1-stage cranioplasty.
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Affiliation(s)
- Takahito Miyazawa
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan.
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Santos de Oliveira R, Barros Jucá CE, Lopes Lins-Neto A, Aparecida do Carmo Rego M, Farina J, Machado HR. Aplasia cutis congenita of the scalp: is there a better treatment strategy? Childs Nerv Syst 2006; 22:1072-9. [PMID: 16639628 DOI: 10.1007/s00381-006-0074-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aplasia cutis congenita (ACC) is a rare disease of unknown etiology, involving any site of the body. The scalp is the most frequent location, followed by the forearms, knees, both sides of the trunk, and neck, in decreasing order of frequency. Superficial lesions may heal spontaneously and seldom result in morbidity or mortality. However, in patients with large scalp and skull defects, there are risks of infection and bleeding. Conservative treatment has been described and advocated, but some authors have highlighted the disadvantages of this treatment modality. On the other hand, several authors claim that aggressive surgical treatment has an important role for large defects. MATERIALS AND METHODS In this paper, we report three newborns with ACC of the scalp, two large defects and a medium one, respectively, treated conservatively and surgically. CONCLUSION The management of ACC of the scalp is still controversial. Our series suggests that conservative treatment should be performed for initial management in newborns.
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MESH Headings
- Abnormalities, Multiple/diagnosis
- Abnormalities, Multiple/genetics
- Abnormalities, Multiple/mortality
- Bone Transplantation
- Child, Preschool
- Diseases in Twins/diagnosis
- Diseases in Twins/mortality
- Diseases in Twins/surgery
- Ectodermal Dysplasia/diagnosis
- Ectodermal Dysplasia/genetics
- Ectodermal Dysplasia/mortality
- Ectodermal Dysplasia/surgery
- Female
- Humans
- Image Processing, Computer-Assisted
- Imaging, Three-Dimensional
- Infant
- Infant, Newborn
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/surgery
- Postoperative Complications/etiology
- Postoperative Complications/mortality
- Scalp/abnormalities
- Scalp/pathology
- Scalp/surgery
- Skin Transplantation
- Surgical Flaps
- Survival Rate
- Tomography, X-Ray Computed
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Affiliation(s)
- Ricardo Santos de Oliveira
- Division of Pediatric Neurosurgery, Ribeirão Preto School of Medicine, University of São Paulo, Campus Universitário, 14049-900 Ribeirão Preto, Brazil.
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