Alopecia Treatment With Scalp Expansion: Some Surgical Fine Points and a Simple Modification to Improve the Results

The Efficacy of Anterior Capsulotomy and Basal Capsulectomy Adherent to Expanded Scalp Flap During Alopecia Reconstruction in Pediatric Burned Patients

BACKGROUND

Scalp expansion is an optimal treatment for alopecia resulting from burn injuries, especially in the pediatric population through providing highly vascularized adjacent local tissues with optimal hair density, color matching, texture, and hair-bearing characteristics. The aim of this study was to evaluate the efficacy of anterior capsulotomy and basal capsulectomy adherent to expanded scalp flap during alopecia reconstruction with scalp expansion in pediatric burned patients.

METHODS

The study was conducted on 127 patients with an age range of 5 to 19 years who presented with postburn alopecia accompanied by hairline loss. The patients were divided into 2 groups: group I consisted of 58 patients who were operated on using conventional technique, and group II consisted of 69 patients who were operated using modified technique including basal capsulectomy on the skull side and anterior capsulotomy on the expanded scalp flap.

RESULTS

The Hairdex, a validated questionnaire of Hair-Specific Health-Related Quality of Life measures, showed that percentage of satisfaction concerning outcomes was 91.50%, psychological well-being was 95%, and self-confidence was 84.30% in group II, compared with 63%, 55.70%, and 66.20%, respectively, in group I. This significant values had a great positive effect on patient satisfaction, changing child's behavior and self-confidence.

CONCLUSION

Although physiological background of tissue expansion is the same, proper flap design with anterior capsulotomy on flap undersurface and basal capsulectomy on the skull side improve results of the traditional method significantly and minimize the complication rate. These surgical modifications provide maximum benefits from expanded tissue, with restoration of the hairline and a uniform hair direction.

LEVEL OF EVIDENCE

Level III, case-control study.

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.

[The secondary surgeries after unfavorable results in scalp defects treatment]

The unfavorable results in scalp defects treatment are represented essentially by: local flap necrosis; cicatricial alopecia - calvarial contour defects; wide and poorly positioned scalp's scars. The secondary surgeries dealing with the new scalp defect (necrosis or alopecia) include: readvancement of prior flaps-raising a new local flap-tissu expansion - skin grafts - free flaps, bringing skin, muscle or vascularized bone. Their indications depend on the size of this defect, the presence of pericranium, the vascular condition of the scalp and the general condition of the patient. The secondary calvarial reconstructions are regularly done by alloplastic techniques, but sometimes autologous techniques are used. The presence of well vascularized skin coverage and the absence of local infection are mandatory before this cranioplasty. The scalp's scars can be effectively camouflaged by the classical hair minigrafting techniques. Certain principles must be applied to avoid these unfavorable results: one large axial rotation or transposition flap is better than multiple flaps and numerous scalp incisions, particularly for the beginners; hair growth can hide easily the scars when local flaps are well designed; excessive tension during local flaps closure must be avoided; galeal scoring and skin grafting of the donor site of these flaps are useful for that purpose; secondary tissue expansion can resolve many problems if the design of prior local flaps is correct; primary cranioplasty must be avoided if there is a risk of contamination; when the general condition of the patient is bad, treatment of such defects with simple methods is preferable.

Staged reconstructive treatment for extensive irregular cicatricial alopecia after burn

For extensive irregular cicatricial alopecia after burn, effective and pleasing restoration of hair-bearing scalp remains challenging. In this article, the authors presented staged reconstructive treatment for extensive irregular cicatricial alopecia with the goal to achieve better and reliable results. A retrospective review of staged reconstructive treatment performed in 16 patients with extensive irregular cicatricial alopecia after burn was conducted. In stage 1, final flaps were designed at 1st. Tissue expanders were placed into the subgaleal plane and serially inflated with normal saline. In stage 2, scarring tissues were excised and the expanded hair-bearing flaps were advanced to the defect. Hair grafts were harvested from excessive hair-bearing scalps excised from the flaps and replanted. For patients with less satisfactory results, stage 3 was performed by hair transplantation. Cicatricial area, follicular unit density, survival rate of hair grafts, and patients' satisfaction were measured before and after each stage. Thirteen patients received 3-stage treatment, and 3 received 2-stage treatment. Significant improvements in aesthetics and patient satisfaction were achieved in all the patients. No flap necrosis, implant exposure or hematoma was observed. Ideal, aesthetic, and reliable results could be obtained using staged reconstructive treatment for patients with extensive irregular cicatricial alopecia after burn.

Soft tissue expansion and cranioplasty: For which indications?

PURPOSE

The aim of this study was to better define indications for scalp tissue expansion before cranioplasty, and to describe our methodology for calculate the surface of tissue needed, by combining a preoperative analysis of both the size of the defect and the quality of skin above.

MATERIAL AND METHODS

A retrospective analysis of patients who underwent expansion before cranioplasty between 2009 and 2015 was conducted. Information was collected on the etiology, size and location of the defect, and reasons of skin contracture. Data concerning expansion and cranioplasty were reviewed.

RESULTS

Among 47 patients who underwent operation for cranioplasty, five (10.6%) required previous scalp tissue expansion. The etiology of the bone defect was tumoral in three cases, posttraumatic in one case, and a decompressive craniectomy in one case. The mean surface of the bone defect was 69.6 ± 18.7 cm(2). The locations of the defects were fronto-temporo-parietal, frontal, temporo-frontal, on the vertex, and occipital. The cause associated with the skin contracture was an infection in four cases and a delayed cranioplasty in one case. A round-profile expander and a custom-made porous hydroxyapatite implant were used for all patients.

CONCLUSIONS

The accurate assessment of tissue needed before cranioplasty is as essential as the choice of the material used for bone reconstruction. After previous infected cranioplasty or delayed reconstruction of large defects, scalp tissue expansion should be proposed.

Tissue expansion for correction of baldness in aplasia cutis congenita

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.

Usefulness of scalp expansion for cranioplasty in a case with postinfection large calvarial defect: a case report

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.