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Farsi S, Odom JQ, Gardner JR, Held M, King D, Sunde J, Vural E, Moreno MA. Oncological outcomes of partial thickness calvarial resection for locally advanced scalp malignancies. Am J Otolaryngol 2024; 45:104456. [PMID: 39106682 DOI: 10.1016/j.amjoto.2024.104456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 07/30/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE Traditionally, locally advanced scalp malignancies have been managed through composite, full-thickness calvarial resection. The aim of this study is to explore the oncologic outcomes of partial calvarial resection for locally invasive scalp malignancies without medullary space invasion, employing a burr-down approach. STUDY DESIGN Retrospective case series. SETTING Tertiary referral center. METHODS This study analyzed records of 26 adult patients diagnosed with scalp cancer that spread to the calvarial region. Data collected included demographics, medical history, adjuvant therapy details, imaging, surgical outcomes, and postoperative oncological results. RESULTS 26 patients with cancerous scalp lesions necessitating calvarial resection for deep margin control were identified in 22 men and 4 women. Mean age at diagnosis was 72.7 years. The most common histopathological diagnosis was Squamous cell carcinoma (n = 16). Partial removal of the calvarial lesions was achieved in all patients without any intraoperative complications. Twelve patients received adjuvant therapy consisting of the following modalities: radiation (6), chemotherapy (1), immunotherapy (1), a combination of immunotherapy and radiation (2), and a combination of chemotherapy and radiotherapy (2). There was a total of 7 recurrences: local (n = 3,11.5 %), regional (n = 3,11.5 %), distal (n = 1,3.8 %). Long term local control was achieved in (n = 23,88.4 %) of patients. The mean time of follow-up was 19.1 months, and the mean time to recurrence was 15.1 months. CONCLUSION Partial calvarial resection represents a viable, safe, and effective surgical technique for cancerous tissue removal, reducing risks associated with full thickness calvarial resection, and enhancing soft tissue healing when compared to the established gold standard.
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Affiliation(s)
- Soroush Farsi
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America.
| | - John Q Odom
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - J Reed Gardner
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Michael Held
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Deanne King
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Jumin Sunde
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Emre Vural
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
| | - Mauricio A Moreno
- University of Arkansas for Medical Sciences, Department of Otolaryngology - Head and Neck Surgery, 4301 West Markham Street, Slot #543, Little Rock, AR 72205, United States of America
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Zhang M, Fu J, Liu X, Liu B, Mao X, Hu Z. Application of Free Flaps in Reconstruction of Head and Neck Soft Tissue Defects With Bone Exposure. Ann Plast Surg 2024; 93:S11-S14. [PMID: 38896852 DOI: 10.1097/sap.0000000000004000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Reconstruction of head and neck soft tissue defects with bone exposure is both challenging and technically demanding for plastic surgeon. Objectives in head and neck soft tissue defects with bone exposure reconstruction are consistent restoration of functionality while also improving appearance. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 4 years. METHODS A retrospective analysis was conducted from June 2019 to June 2023 on 12 patients treated at our hospital for head and neck soft tissue defects with bone exposure due to various causes. These included 4 cases of trauma from car accidents, 1 burn case, and 7 postoperative malignant tumor removals. The defect sizes ranged from 4 × 6 to 15 × 45 cm. Different free flaps were used for repair based on the defect, including 6 anterolateral thigh flaps, 3 forearm flaps, 2 latissimus dorsi flaps, and 1 dorsalis pedis flap. Flaps were designed and harvested to match the defect size and transplanted via anastomosed vessels. RESULTS All 12 flaps survived successfully. One patient required flap thinning surgery postoperatively. All patients were followed up for over 3 months, showing good color and texture of the transplanted flaps, satisfactory healing, and significant aesthetic improvement. Donor sites showed significant scarring without functional impairment. CONCLUSION Free flap repair for head and neck soft tissue defects with bone exposure is feasible and yields good results.
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Affiliation(s)
- Mingjun Zhang
- From the Department of Plastic and Aesthetic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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Kim TH, Choi JW, Jeong WS. Pushing boundaries: Anterolateral thigh free flaps for extensive scalp defects beyond previous limits, leveraging imaging modalities with ultrasound and indocyanine green. Microsurgery 2024; 44:e31190. [PMID: 38828550 DOI: 10.1002/micr.31190] [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: 12/02/2023] [Revised: 03/28/2024] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Scalp defect reconstruction poses considerable challenges, with ongoing debates regarding the most effective strategies. While the latissimus dorsi (LD) flap has traditionally been favored, the anterolateral thigh (ALT) flap has been well described as a versatile alternative for addressing extensive scalp defects. This study underscores the success of scalp reconstruction using ALT flaps, notably pushing the boundaries of previously reported flap sizes. Our approach leverages the use of indocyanine green (ICG) perfusion to guide precise preoperative planning and vascular modification, contributing to improved outcomes in challenging cases. METHODS We performed 43 ALT flap reconstructions for scalp defects between 2016 and 2023. We collected patients' demographic and clinical data and evaluated flap size and recipient vessels and additional surgical techniques. Detailed preoperative plans with ultrasound and ICG use for intraoperative plans were performed to find perforators location. The cohort was divided into two, with or without complications on flaps, and analyzed depending on its surgical details. RESULTS This study involved 38 patients with extensive scalp defects (mean age: 69.4 ± 11 years) who underwent ALT perforator flap transfers (mean flap size: 230.88 ± 145.6 cm2). There was only one case of unsuccessful flap transfer, and four cases had a few complications. The characteristics of the complication group included a large flap size (303.1 ± 170.9 vs. 214.9 ± 136.6 cm2, P = .211), few perforator numbers without pedicle manipulation, lack of intraoperative indocyanine green administration (75% vs. 25%, P = .607), and the use of superficial temporal vessels as recipient vessels. CONCLUSIONS Scalp reconstruction using large ALT free flaps with the aid of imaging modalities facilitates the optimization of surgical techniques, such as pedicle manipulation, perforator numbers, and vein considerations, thereby contributing to successful reconstruction.
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Affiliation(s)
- Tae Hyung Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong Woo Choi
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Shik Jeong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Moratin J, Dao Trong P, Semmelmayer K, Mrosek J, Zittel S, Bleymehl M, Ristow O, Freudlsperger C, Hoffmann J, Engel M. Comparison of Antero-Lateral Thigh Flap and Vastus Lateralis Muscle Flap for the Treatment of Extensive Scalp Defects-A Retrospective Cohort Study. J Clin Med 2023; 12:6208. [PMID: 37834851 PMCID: PMC10573281 DOI: 10.3390/jcm12196208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/31/2023] [Accepted: 09/23/2023] [Indexed: 10/15/2023] Open
Abstract
Free flap reconstruction is the standard of care for extensive defects of the head and neck area. In this study, two types of free flaps, the antero-lateral thigh flap (ALT) and the vastus lateralis muscle flap, were compared. The primary endpoint was flap success, secondary endpoints were complication rates, hospitalization and surgery time. Cases with defect situations of the scalp and consecutive microvascular free flap reconstructions using either ALT flaps or vastus lateralis muscle flaps between 2014 and 2022 were retrospectively analyzed. Indications, perioperative handling and outcomes were compared. Twenty patients were included in the analysis. Ten patients (50%) received a free flap reconstruction using an ALT flap and ten patients (50%) received a vastus lateralis flap. A simultaneous two-team approach was possible in each case and the flap success rate was 100% with the need for one successful anastomosis revision. The mean defect size in our cohort was 147 ± 46 cm2. There were no significant differences in surgery time, duration of hospitalization or complication rate between both cohorts. Both free flaps, the ALT and the vastus lateralis flap, are suitable for the closure of large scalp defects. They provide high success rates, short surgery times without the need for patient repositioning and low donor-site morbidity. The vastus lateralis muscle flap bares the advantage of being perforator-independent and allows for the preparation of long vessels for anastomosis if needed while baring the disadvantage of a prolonged period of healing via granulation or the need for secondary surgery in terms of covering by split-thickness skin grafts which may interfere with necessary adjuvant treatment in oncological patients.
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Affiliation(s)
- Julius Moratin
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Philip Dao Trong
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany;
| | - Karl Semmelmayer
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Jan Mrosek
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Sven Zittel
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Moritz Bleymehl
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Oliver Ristow
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Christian Freudlsperger
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Jürgen Hoffmann
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Michael Engel
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
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Krishna D, Khan MM, Dubepuria R, Chaturvedi G, Cheruvu VPR. Reconstruction of Scalp and Forehead Defects: Options and Strategies. Cureus 2023; 15:e41479. [PMID: 37551215 PMCID: PMC10404163 DOI: 10.7759/cureus.41479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/09/2023] Open
Abstract
Background Aesthetic reconstruction of scalp and forehead defects with local flaps and minimal donor site morbidity is the primary goal of coverage. While selecting the coverage technique, essential factors such as size, location, and components of a defect, hair-bearing or non-hair-bearing nature of skin, status of the exposed skull, need for radiation, patient condition, availability of local tissue, and the potential for hairline distortion should be kept in mind. Materials and methods This is a retrospective analysis in which 54 patients who underwent soft tissue reconstruction of the scalp and forehead defects were included. The defect size was categorized into four groups: small: <4 cm2, medium: 4-50 cm2, large: 50-200 cm2, and very large: >200 cm2. Reconstruction of all defects was done according to the defect's size, location, and depth. All patients were regularly followed at intervals of two weeks, six weeks, and three months, respectively. The outcome was evaluated in terms of flap survival, flap coverage scale, the requirement of secondary treatment, postoperative complications, and final aesthetic appearance. Results In 54 consecutively treated patients with scalp and forehead defects, the male-to-female ratio was 2:1, and the overall mean age of participants was 34.8 years, ranging from 0.5 to 66 years. The most common etiology of the defect was trauma (16; 29.6%), and the most common location of the defect was combined (16; 29.6%). Rotation flap and primary closure were the most commonly performed procedure, each 12 (22.2%) in number. Out of 12 primary closure cases, two patients developed wound dehiscence because of infection. All cases of skin grafting healed well. All cases of transposition flap with skin grafting at the donor site went uneventful, and the dog ear at the base was revised later. One case of the bipedicle flap in which partial graft loss occurred at the donor area was managed with regrafting. Two cases of single rotation flap, one double rotation flap, and one free latissimus dorsi muscle flap developed distal necrosis. The excellent aesthetic outcome was found in all cases of primary closure and single and double rotation flaps. Conclusions Local flaps have an architecture similar to the recipient site, and low donor site morbidity results in an aesthetically more pleasant outcome. In our experience, scalp defects up to 50 cm2 were covered with the local scalp flaps with primary closure of the donor area. Defects ranging from 50 to 200 cm2 required local scalp flap with skin grafting at the donor area. Free tissue transfers are usually needed when the defect is very large, devoid of the periosteum, or with the calvarial defect.
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Affiliation(s)
- Deepak Krishna
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Manal M Khan
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Rahul Dubepuria
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Gaurav Chaturvedi
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Ved Prakash Rao Cheruvu
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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Shash H, Marzouq S, Alghamdi A, Alrayes M, Alkhaldi SK, Shash H, Abu Quren AM. The 1-2-3 cm Advancement Flap Rule in Scalp Reconstruction. Cureus 2023; 15:e35301. [PMID: 36994305 PMCID: PMC10042496 DOI: 10.7759/cureus.35301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
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.
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Validating a Novel Device to Improve Skin Color Matching for Face Transplants. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4649. [PMID: 36415618 PMCID: PMC9674481 DOI: 10.1097/gox.0000000000004649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/13/2022] [Indexed: 03/08/2023]
Abstract
UNLABELLED Facial vascularized composite allotransplantation (VCA) offers an added layer of complexity when compared to solid organ transplantation. VCAs must account for aesthetic variables such as skin tone and color. The goal of this study is to validate the Nix Color Sensor as a novel tool to be added to the plastic surgeon's armamentarium for evaluating skin color match of the donor and recipient. METHODS A prospective study of 100 individuals was conducted. All participants were photographed and scanned with the Nix Color Sensor. Sixty pairwise comparisons were randomly generated. Skin color analysis was performed using photographs and the Nix Color Sensor. Delta E2000 values were compared to mean evaluator ratings using a Spearman correlation analysis. RESULTS One hundred patients were included. A Spearman's correlation demonstrated a strong inverse correlation between Delta E2000 values and the mean evaluator ratings. The higher the mean evaluator rating for likeness, the lower the delta. A correlation coefficient of -0.850 demonstrates a statistically significant relationship (P < 0.01). CONCLUSIONS When the Delta E2000 rises above 5 there is a significant drop in the mean evaluator ratings. As mean evaluator ratings of 5 and above would be considered adequate for face transplant amongst most plastic surgeons, an E2000 value of 5 or lower should be targeted when matching donors with recipients for face transplant. The Nix Color Sensor positively correlates to the plastic surgeon's perception of skin color and can serve as an adjunct in donor selection for facial VCAs.
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Gupta P, Srivastava S. Reconstruction of Scalp with Local Axial Flaps. Indian J Otolaryngol Head Neck Surg 2022; 74:2265-2272. [PMID: 36452712 PMCID: PMC9702446 DOI: 10.1007/s12070-020-02103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022] Open
Abstract
The scalp is a unique part of the human body and various etiological factors, such as tumour extirpation, infection, burns, or trauma, can lead to scalp defects. Primary closure, skin grafting, local flaps, tissue expansion or free tissue transfer are modalities available for scalp reconstruction. In this article, the authors share their institutional experience using various local flaps concerning the size, location, depth of defect and the quality of surrounding tissue. From September 2017 to January 2020, 54 patients underwent scalp reconstruction with local flaps for a sizeable defect size of 5-150 cm2 in the Department of Plastic Surgery, SMS Medical College, Jaipur. Patients were identified by age, sex, cause of the scalp defect; the location, size, and depth of the defect; condition of surrounding tissue and the type of reconstruction done. The most common cause of scalp defect was excision of malignant tumour (50%). 30 patients had a large sized defect (40-90 cm2) and in 28 patients had 90-150 cm2 defects. Surgical reconstruction was done using local flaps, transposition flap was the most used in 36 patients (66.7%) followed by rotation advancement flap in 11 patients (20.4%). The recovery was relatively quick. Minor complications happened in 5 patients (9.3%) that were managed conservatively. In the present era of microsurgical reconstruction, local options as axial flaps provide a simpler and safer method of scalp reconstruction. A carefully planned scalp flap gives healthy, robust, hair-bearing tissue coverage and requires a shorter healing time for the patients.
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Affiliation(s)
- Pradeep Gupta
- Department of Burns and Plastic Surgery, SMS Medical College, Jaipur, India
| | - Saket Srivastava
- Department of Burns and Plastic Surgery, SMS Medical College, Jaipur, India
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The Role of Resection of the Outer Table of the Cranium in Locally Invasive Primary Squamous Cell Carcinoma of the Scalp. J Craniofac Surg 2022; 33:1860-1864. [PMID: 35816753 DOI: 10.1097/scs.0000000000008696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Nonmelanoma skin cancer is the most common malignancy of the scalp. Of these, squamous cell carcinoma (SCC) is the most troublesome. It poses a challenge to the surgeons caring for these patients as the anatomy of the scalp makes excision and reconstruction difficult. Although more superficial lesions are amenable to Mohs micrographic surgery, more invasive lesions require a different approach. This manuscript is a retrospective review of outer table resection for SCC of the scalp invading to the depth of the pericranium. We include a discussion of full thickness craniectomy for invasive SCC, regardless of depth of invasion, for completeness. METHODS IRB approval was obtained from St. Joseph's Hospital and Medical Center in Phoenix, Arizona. One hundred four potential cases identified based on ICD codes. Ultimately, 23 cases met study criteria and were included in this analysis. Seventeen cases of outer table resection and 6 cases of full craniectomy were discussed. Additionally, the authors' approach for resection and reconstruction is articulated. RESULTS Seventeen patients underwent outer table resection at an average age of 79.3 years. All had invasion of the pericranium with a mean surface area of 42.6 cm2. Eight patients had prior radiation treatment for SCC of the scalp and 12 patients had at least 1 prior surgery to attempt excision of their lesions. Two patients had local recurrence for a local control rate of 88.2% (15/17). One patient with metastasis prior to presentation, died 6 months after his initial surgery for disease-free survival rate of 94.1% (16/17) at a mean of 15.4months. Thirteen patients were able to achieve immediate reconstruction with local flaps with or without additional skin grafting (76.5%). DISCUSSION The data in this study supports that in instances of locally invasive primary SCC of the scalp that extends to the pericranium, excision down to the calvarium with complete circumferential and deep peripheral margin assessment, followed by resection of the outer table, is an excellent option. The low rate of local recurrence and high disease-free survival in this study support that this method allows for optimal oncologic outcome while mitigating the significant morbidity associated with the alternative option of a full thickness craniectomy.
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Knott PD, Alemi SA, Han M, Seth R, Park AM, Heaton CM, Grekin RC, Arron ST, Neuhaus I, Yu SS, Saylor DK, Zhu BZ. Skin Color Match in Head and Neck Reconstructive Surgery. Laryngoscope 2021; 132:1753-1759. [PMID: 34904721 DOI: 10.1002/lary.29959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To quantify the degree of color match achieved during microvascular facial reconstruction, and to describe a novel technique for improving reconstructive skin color match. We hypothesize that split-thickness skin grafts (STSG) placed atop de-epithelialized free tissue produces better facial skin color match than free tissue with intact epithelium. STUDY DESIGN Cross sectional photographic study of reconstructed facial skin color match. METHODS Sixty-eight adults, who underwent head and neck reconstructive surgery, were divided into six categories based on cutaneous reconstructive technique: cervicofacial flap, radial forearm free flap (RFFF), fibula free flap, anterolateral thigh free flap (ALT), STSG over adiopofascial flap (STAFF), and STSG over myogenous flap (STMF). Averaged color samplings of the reconstructed defect and adjacent normal skin were taken from digital photographs. The color difference was calculated using the delta-E calculation. Blinded expert observers also rated the degree of color match. Nonparametric cohort contrast and correlation statistical analyses were performed. RESULTS The mean delta-E's and 10-point Likert ratings for the ALT, fibula, RFFF, STAFF, STMF, and cervicofacial flaps were 11.6, 10.0, 7.7, 6.3, 8.8, and 4.7, and 5.1, 6.4, 2.4, 3.2, 2.7, and 1.1, respectively. Likert scale inter-rater correlation was strong, with coefficient = 0.80. CONCLUSIONS On average, STSG over de-epithelialized myogenous and adipofascial free tissue transfers produced a better color match than the skin paddles of donor sites, with the exception of the radial forearm donor site. Delta-E values obtained from photos correlated well with expert ratings of color match. This reliable technique for quantifying color match may be used in future studies. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Philip Daniel Knott
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Sean A Alemi
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Mary Han
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Rahul Seth
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Andrea M Park
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Chase M Heaton
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Roy C Grekin
- Department of Dermatology, University of California, San Francisco, California, U.S.A
| | - Sarah T Arron
- Department of Dermatology, University of California, San Francisco, California, U.S.A
| | - Isaac Neuhaus
- Department of Dermatology, University of California, San Francisco, California, U.S.A
| | - Siegrid S Yu
- Department of Dermatology, University of California, San Francisco, California, U.S.A
| | - Drew K Saylor
- Department of Dermatology, University of California, San Francisco, California, U.S.A
| | - Bovey Z Zhu
- Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center, Honolulu, Hawaii, U.S.A
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Trends and Outcomes of Cranioplasty Alone Versus Single-Stage Composite Scalp and Calvarial Reconstruction. J Craniofac Surg 2021; 33:1271-1275. [PMID: 34855630 DOI: 10.1097/scs.0000000000008395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cranioplasty is a critical intervention to restore the calvarium using autologous or alloplastic materials with single-stage composite scalp and calvarial reconstruction reserved for complex cases. This study aims to identify 30-day outcomes in scalp and calvarial reconstruction using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS The authors conducted a retrospective analysis of the 2010 to 2018 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent cranioplasty were identified using current procedural terminology coding and included by exposure type (autologous, alloplastic, composite, or other). Subjects with missing exposure or outcome data were excluded. Primary outcome was 30-day reoperation, whereas secondary outcomes were 30-day unplanned readmission and transfusion. Univariate analysis was completed to assess differences in demographics, comorbidities, and postoperative complications. Multivariable logistic regression was used to control for confounders. RESULTS In total, 1719 patients underwent cranioplasty (mean age 54.7 ± 15.3 years, 43.5% male), including 169(9.8%) autologous, 1303(75.8%) alloplastic, 32(1.9%) composite, and 215(12.5%) other procedures. Cranioplasty procedures were associated with 30-day complication and mortality rate of 16.5% and 2.4%, respectively. Composite cranioplasty was associated with decreased 30-day reoperation (adjusted odds ratios 0.11, 95% confidence interval 0.014-0.94, P = 0.044). There was no statistically significant difference in readmission between cranioplasty groups. Alloplastic cranioplasty was associated with decreased odds of postoperative transfusion (adjusted odds ratios 0.47, 95% confidence interval 0.27-0.84, P = 0.01). CONCLUSIONS Cranioplasty is an increasingly common procedure. Alloplastic cranioplasty is associated with decreased 30-day transfusion requirement, whereas single-stage composite reconstruction is a viable option and associated with decreased 30-day reoperation with no difference in readmission.
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Reconstruction of Large Tissue Defects After the Resection of Brain Tumors Using a Skin Flap With Vascular Pedicle. J Craniofac Surg 2021; 32:2692-2694. [PMID: 34727473 PMCID: PMC8549454 DOI: 10.1097/scs.0000000000007610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The reconstruction of large tissue defects after the resection of brain tumors is challenging for every neurosurgeon. The authors describe the benefits of a skin flap with vascular pedicle in the reconstruction of large tissue defects after the resection of brain tumors. In this retrospective analysis, a skin flap with vascular pedicle reconstruction was used in 5 patients who underwent intracranial tumor resection, accompanied by tissue defects, cerebrospinal fluid leakage and scalp infection. The surgical techniques are described, and the outcomes were discussed. The harvested flaps showed well-vascularized healing of the transplanted skin without partial necrosis in all 5 patients. One patient had cerebrospinal rhinorrhea, which was successfully treated by endoscopic repair. Another patient had cerebrospinal fluid leakage, which was successfully treated by continuous lumbar drainage. A skin flap with vascular pedicle is an effective choice for the reconstruction of large tissue defects after the resection of brain tumors.
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Sleiwah A, Mughal M, Thomas N, Roblin P, Townley W, Jeannon JP. Locally Advanced Scalp Tumors: Clinical and Survival Outcomes of a Tertiary Unit. Ann Plast Surg 2021; 87:271-277. [PMID: 34397516 DOI: 10.1097/sap.0000000000002673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Locally advanced nonmelanoma skin cancers of the head and neck are well described in the current literature. However, data about clinical and survival outcomes are lacking. We present survival data from a tertiary head and neck cancer unit in London. METHODS A retrospective analysis of data collected from a single institution was conducted. All patients with locally advanced cutaneous scalp carcinomas invading the skull between 2011 and 2019 were included. Data included patient demographics, tumor, comorbidities, interventions, flap survival, and metal work exposure. Survival outcomes were examined using Kaplan-Meier analysis. RESULTS Twenty-three patients were identified. The mean age was 72 years. Eighteen patients were male, and 5 were female. Five patients were immunosuppressed. Nineteen patients underwent outer cortex drill-down/full-thickness calvarial resection, followed by reconstruction with free tissue transfer. Six patients had titanium mesh reconstruction after segmental skull resections. Three patients underwent further surgery because of exposed metalwork. Disease-free survival at 3 years after surgery was 60%. CONCLUSIONS Locally advanced nonmelanoma skin cancers invading the bone are sporadic. There are little published data on clinical and survival outcomes in this group. Despite the nature of these skin lesions, a high degree of local control can be obtained by extensive surgical resection, outer table drill-down, and calvarial resection. We conclude that aggressive management of the bony invasion improves disease-free survival and improves local control.
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Affiliation(s)
- Aseel Sleiwah
- From the Plastic Surgery Department, Guy's & St Thomas Hospital
| | - Maleeha Mughal
- From the Plastic Surgery Department, Guy's & St Thomas Hospital
| | | | - Paul Roblin
- From the Plastic Surgery Department, Guy's & St Thomas Hospital
| | - William Townley
- From the Plastic Surgery Department, Guy's & St Thomas Hospital
| | - Jean-Pierre Jeannon
- Ear, Nose and Throat Department, Guy's & St Thomas Hospital, London, United Kingdom
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Clinical and Surgical Outcomes in Extensive Scalp Reconstruction after Oncologic Resection: A Comparison of Anterolateral Thigh, Latissimus Dorsi and Omental Free Flaps. J Clin Med 2021; 10:jcm10173863. [PMID: 34501311 PMCID: PMC8432082 DOI: 10.3390/jcm10173863] [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: 08/01/2021] [Revised: 08/19/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
Microsurgical scalp reconstruction is indicated in patients with large scalp defects. The aim of this study was to compare the outcomes of scalp reconstruction in oncologic patients reconstructed with latissimus dorsi (LD), anterolateral thigh (ALT), and omental (OM) free flaps. Thirty oncologic patients underwent scalp reconstruction with LD (10), ALT (11), and OM (9) flaps. The length of the vascular pedicle, the operation time, the possibility of a two-team approach, the length of hospital stays, the complications, and the aesthetic results were evaluated. The OM flap was the flap with the shortest vascular pedicle length with a mean of 6.26 ± 0.16 cm, compared to the LD flap, which was 12.34 ± 0.55 cm and the ALT flap with 13.20 ± 0.26 cm (p < 0.05). The average time of surgery was 6.6 ± 0.14 h in patients reconstructed with OM, compared to the LD flap, which was 8.91 ± 0.32 h and the ALT flap with 7.53 ± 0.22 h (p < 0.05). A two-team approach was performed in all patients for OM flaps and ALT flaps, but only in two patients reconstructed with the LD flap (p < 0.001). In patients reconstructed with the OM flap, a very satisfactory or satisfactory result was reported in seven patients (77.8%). Eight patients reported a very unsatisfactory or unsatisfactory result with LD flap (80%) and 10 patients with ALT flap (90.9%) (p = 0.002). The mean hospital stay after surgery was not statistically significant (p > 0.05). As for complications, two patients reconstructed with OM flap, five LT flaps, and two ALT flaps developed complications, not statistically significant (p = 0.235). Omental flap, latissimus dorsi flap, and anterolateral thigh flap fulfill most of the characteristics for complex scalp reconstruction. The decision on which flap to use should be based on clinical aspects of the patients taking into account that the three flaps show similar rates of complications and length of hospital stay. Regarding the aesthetic outcome, OM flap or LD flap should be considered for reconstruction of extensive scalp defects.
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The Second Free Tissue Transfer After the First Free Flap Loss for a Complex Scalp Reconstruction: Our Strategy to Success With a Staged Approach. J Craniofac Surg 2021; 33:e109-e111. [PMID: 34260450 DOI: 10.1097/scs.0000000000007941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Scalp reconstruction for a critical neurosurgical patient, as lifesaving efforts continued, can be challenging and a free tissue transfer is often needed to achieve reliable soft tissue coverage. However, the patient's labile perioperative condition may compromise successful reconstruction and perioperative hypotension is one of the major known factors for the failure of free tissue transfer. In this report, the authors encountered such an instance, and present our strategy in overcoming this hurdle toward obtaining successful scalp reconstruction with second free tissue transfer after the first free flap loss. After optimizing the patient's medical condition, the second free tissue transfer was performed in 2 stages with recipient vessel dissection during the first stage and the flap harvest and microvascular anastomoses during the second stage. Our staged approach is warranted to ensure the patient can tolerate the stressor of general anesthesia and to precondition the patient for ultimate successful second free tissue transfer.
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Scalp Reconstruction in Delayed Diagnosed Dermal Leiomyosarcoma Mimicking Keloid Scar. J Craniofac Surg 2021; 32:e620-e622. [PMID: 33654031 DOI: 10.1097/scs.0000000000007600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Leiomyosarcoma (LMS) of the skin is a rare smooth muscle neoplasm of all soft tissue sarcoma. Because of its prognostic importance, early diagnosis is critical for successful treatment. Since several features and clinical manifestations are similar to those of a keloid scar, the differential diagnosis between these two diseases is difficult, especially in the early stages of cancer that do not show any remarkable features in appearance, or when the patient has a history of previous wounds or surgery.In our case report, a 71-year-old female patient who underwent a scalp reconstruction using an anterolateral thigh flap turned out to have, because of delayed diagnosis, a dermal LMS mimicking a keloid scar. The case emphasizes careful physical examination for early intervention, even if a lesion looks like a typical keloid scar. After resection, the appropriate reconstruction method can be selected based on the complexity of the defect site.
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Liu X, Huo D, Wu G. Deep Inferior Epigastric Flap Combined Bilateral-Anterolateral Thigh Flap for the Coverage of Both Lower Extremity Soft-Tissue Defect: A Case Report and a Literature Review. Clin Cosmet Investig Dermatol 2021; 14:153-161. [PMID: 33603432 PMCID: PMC7886084 DOI: 10.2147/ccid.s292053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/18/2021] [Indexed: 11/23/2022]
Abstract
Background/Purpose Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap have been advantageous over traditional myocutaneous flaps as they preserve the integrity of donor site muscles and minimize the damage and complication to donor site structures. Here, we reported the efficacy of free ALTP and DIEP in the repair of large skin area and soft tissue defects on both lower limbs after trauma. Case Report A 19-year-old female traffic accident victim presented with multiple open bilateral fractures to the lower extremities with joint dislocation, massive skin and soft tissue defects, and multiple soft tissue contusion. Wounds on both lower extremities were covered with VSD (Vacuum Sealing Drainage). The tibiofibular and ankle joints on both lower limbs were fixed using external fixators. DIEP and ALTP flap were performed at different times. Results After transfer, the vascular pedicle was anastomosed to the anterior tibial artery, posterior tibial artery, and the accompanying vein. After the operation, the donor site was directly closed and sutured. All flaps survived with a good appearance, leaving only a linear scar at the donor site. Conclusion This case shows that free ALTP and DIEP flaps are ideal for repairing large skin area and soft tissue defects in bilateral lower limbs after trauma.
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Affiliation(s)
- Xilin Liu
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, 130033, People's Republic of China
| | - Da Huo
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, 130033, People's Republic of China
| | - Guangzhi Wu
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, 130033, People's Republic of China
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Fliss E, Zaretski A, Maoz-Halevy ED, Gur E, Yanko R. Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: The Scalp Exchange Procedure. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2020. [DOI: 10.1055/s-0040-1716418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Approximately 70,000 Israelis underwent scalp irradiation for tinea capitis infection during their childhood, as did many other children worldwide. Long-term follow-up data showed that these children had an increased risk of aggressive and multiple nonmelanoma skin cancers, meningiomas, and other malignancies. Resection of these lesions creates a defect of soft tissue, bone, and dura, and requires scalp and skull reconstruction with local or free flaps in the irradiated field.
Methods Sixteen patients with a history of childhood scalp irradiation underwent scalp and skull reconstruction in our department (2000–2018). Data on demographics, oncological status, operative details, and postoperative outcome were retrospectively collected and analyzed.
Results The study group included 11 males and 5 females (average age at surgery, 70 years). The most common lesions were meningiomas (n = 9) and basal cell carcinomas (n = 8), and the most common indication for reconstruction was chronic exposure of deep structures (skull, dura, brain tissue, and titanium mesh; n = 9). Thirteen patients underwent primary free flap reconstruction and three underwent primary local flap reconstruction. Flap failure requiring reoperation occurred in one patient of the free flap reconstruction group (7%) and in all three patients of the local flap reconstruction group.
Conclusion Long-term consequences of childhood depilatory treatments of the scalp by irradiation are now surfacing. Our experience showed that in such cases, surgeons should aim for a more aggressive approach with wide resection and primary free flap reconstruction, and that favorable long-term functional and aesthetic results can safely be achieved using this reconstruction approach.
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Affiliation(s)
- Ehud Fliss
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arik Zaretski
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal D. Maoz-Halevy
- Department of Neurology, Sheba Medical Center affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Gur
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ravit Yanko
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Möllhoff N, Koban KC, Engelhardt TO, Tonn JC, Giunta RE. [Case report of frontobasal reconstruction and volume augmentation using a free gracilis muscle flap and autologous fat grafting: utilising the free flap as a scaffold for fat transplantation]. HANDCHIR MIKROCHIR P 2020; 52:330-334. [PMID: 32823367 DOI: 10.1055/a-1150-7601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
This case report shows the interdisciplinary treatment of a 28-year-old woman suffering from a pronounced frontal volume defect after severe craniocerebral trauma. The combination of cranioplasty using a polymethylmethacrylate (PMMA) implant, free gracilis muscle flap transfer for soft tissue coverage and serial autologous fat grafting into the muscle flap for subsequent contouring enabled both an adequate and aesthetic reconstruction. This example demonstrates the feasibility of treating increasingly complex composite defects in a multidisciplinary setting, when plastic surgeons are involved.
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Affiliation(s)
- Nicholas Möllhoff
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, LMU München
| | - Konstantin Christoph Koban
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, LMU München
| | - Timm Oliver Engelhardt
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, LMU München
| | | | - Riccardo E Giunta
- Abteilung für Hand-, Plastische und Ästhetische Chirurgie, Klinikum der Universität München, LMU München
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20
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Coruh A. High Voltage Electric Burn Repair of the Forehead by Reverse Flow Temporalis Muscle Flap. J Burn Care Res 2020; 40:373-376. [PMID: 30805601 DOI: 10.1093/jbcr/irz024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/12/2018] [Accepted: 02/21/2019] [Indexed: 11/13/2022]
Abstract
Repairing soft tissue defects of the forehead which exposes the bare bone is a dilemma with few reconstructive techniques for plastic surgeons. Forehead is an important aesthetic unit of the face which is covered with the glabrous skin. Due to the relative lack of similar mobile tissue locally, reconstruction of large soft tissue defects of the forehead region by local flaps is demanding. Temporalis muscle flap does not reach to the midline of the forehead region because of the insufficient length of the deep temporal vascular system. During the transfer of the muscle, only a small volume and size of the muscle can reach to the defect, remaining most of the muscle bulk in the pedicle and a relatively limited arc of rotation, thus a small volume of usable tissue at the distal portion of the flap. We successfully used reverse flow temporalis muscle flap for the purpose of eliminating the above-mentioned disadvantage of temporalis muscle flap in a 23-year-old male patient who sustained a high-voltage electrical burn resulting 12 × 8 cm left forehead defect exposing the bare bone.
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Affiliation(s)
- Atilla Coruh
- Burn Unit, Department of Plastic & Reconstructive Surgery, Erciyes University Medical Faculty, Kayseri, Turkey
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21
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Surgical Decision-Making in Microvascular Reconstruction of Composite Scalp and Skull Defects. J Craniofac Surg 2020; 31:1895-1899. [DOI: 10.1097/scs.0000000000006623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Free Flap Reconstruction of Complex Oncologic Scalp Defects in the Setting of Mesh Cranioplasty. J Craniofac Surg 2020; 31:1107-1110. [DOI: 10.1097/scs.0000000000006421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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23
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Hostile Scalp Wound Reconstruction Using Acellular Dermal Matrix for Soft Tissue Augmentation. J Craniofac Surg 2020; 31:e309-e312. [DOI: 10.1097/scs.0000000000006170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ray AC, Philandrianos C, Bertrand B, Mélot A, Roche PH, Jaloux C, Casanova D. Two-stage free flap reconstruction of the scalp and calvaria for large neurosurgical resections. Microsurgery 2019; 40:331-336. [PMID: 31777989 DOI: 10.1002/micr.30538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 09/12/2019] [Accepted: 11/08/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Free tissue transfer is occasionally necessary during reconstruction of large scalp and calvarial bone resections. A single-stage procedure is usually performed but if a flap becomes necrotic it exposes brain tissue or the meninges. Performing a two-stage procedure, the surgeon must preserve flap vitality and manage flap complications before resecting a tumor, and therefore before exposing the brain or meninges. We report here the first series of two-stage free-flap reconstruction during major neurosurgical resection. METHODS From 2012 to 2018, nine free-flaps were performed to eight patients (61 years-old, on average). Average skull resection was 10.1 cm × 15 cm (range 6-18 cm × 9-24 cm). It was performed in all cases due to large malignant tumors. Resection/reconstruction was performed in all case in a two-step procedure: during the first step, the free-flap was harvested and anastomosed to the cranial site; during the second step, resection was performed and the flap was positioned into the defect to assure coverage. RESULTS Average flap size was 11.3 cm × 17.7 cm (range: 7-20 cm × 11-30 cm). Two flap complications occurred after the first stage and one flap did not survive. One patient died before the second stage. Seven patients had the second procedure; no flap complication occurred. All procedures ended in complete wound healing. Follow-up period was 41.5 months on average (range: 10-83 months). Final outcome was total remission for two patients, recurrence for four patients, and two patients died. CONCLUSIONS Our data suggest that the two-stage free-flap reconstruction may be employed for major scalp and calvaria resection.
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Affiliation(s)
- Anne-Claire Ray
- APHM, Plastic Department, Conception University Hospital, Marseille, France
| | | | - Baptiste Bertrand
- APHM, Plastic Department, Conception University Hospital, Marseille, France.,Aix-Marseille University, Marseille, France
| | - Anthony Mélot
- APHM, Neurosurgery Department, North University Hospital, chemin des Bourrely, Marseille, France
| | - Pierre-Hugues Roche
- Aix-Marseille University, Marseille, France.,APHM, Neurosurgery Department, North University Hospital, chemin des Bourrely, Marseille, France
| | - Charlotte Jaloux
- APHM, Plastic Department, Conception University Hospital, Marseille, France.,Aix-Marseille University, Marseille, France
| | - Dominique Casanova
- APHM, Plastic Department, Conception University Hospital, Marseille, France.,Aix-Marseille University, Marseille, France
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Weitz J, Spaas C, Wolff KD, Meyer B, Shiban E, Ritschl LM. A Standard Algorithm for Reconstruction of Scalp Defects With Simultaneous Free Flaps in an Interdisciplinary Two-Team Approach. Front Oncol 2019; 9:1130. [PMID: 31709189 PMCID: PMC6823187 DOI: 10.3389/fonc.2019.01130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022] Open
Abstract
Reconstructions of complex scalp after ablative resection or by post-traumatic tissue loss, can present difficulties regarding recipient vessel selection, functional, and aesthetic outcome. The harvesting method for many microvascular free flaps requires a need for changing patients position during surgery and makes a simultaneous interdisciplinary two-team approach complicated, which is a major disadvantage regarding safety and operation time. The ideal flap for scalp reconstruction has yet to be described, although the microvascular latissimus dorsi flap is frequently referred to as the first choice in this context, especially after resection of large defects. The purpose of this study is to compare two different microvascular free flaps for a simultaneous scalp reconstruction in an interdisciplinary two-team approach applying a standardized algorithm. All consecutively operated complex scalp defects after ablative surgery from April 2017 until August 2018 were included in this retrospective study. The indications were divided into neoplasm or wound healing disorder. Two microvascular flaps (latissimus dorsi or parascapular flap) were used to cover the soft tissue component of the resulting defects. Seventeen patients met the inclusion criterion and were treated in an interdisciplinary two-team approach. Skull reconstruction with a CAD/CAM implant was performed in 10 cases of which four were in a secondary stage. Nine patients received a parascapular flap and eight patients were treated with latissimus dorsi flap with split thickness skin graft. Anastomosis was performed with no exception to the temporal vessels. One parascapular flap had venous insufficiency after 1 week followed by flap loss. One latissimus dorsi flap had necrosis of the serratus part of the flap. All other flaps healed uneventful and could be further treated with adjuvant therapy or CAD/CAM calvarial implants. Regarding overall complications, flap related complications, flap loss, and inpatient stay no statistical differences were seen between the diagnosis or type of reconstruction. The parascapular flap seems to be a good alternative for reconstruction of complex tumor defects of the scalp besides the latissimus dorsi flap. Stable long-term results and little donor site morbidity are enabled with good aesthetic outcomes and shorter operation time in an interdisciplinary two-team approach.
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Affiliation(s)
- Jochen Weitz
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Christophe Spaas
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Ehab Shiban
- Department of Neurosurgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Neurosurgery Department, University Hospital of Augsburg, Augsburg, Germany
| | - Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
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Is Three-Dimensional Virtual Planning in Cranial Reconstruction for Advanced Cutaneous Squamous Cell Carcinoma of the Skull a Feasible Option? J Craniofac Surg 2019; 30:2362-2367. [PMID: 31609941 DOI: 10.1097/scs.0000000000005895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cutaneous squamous cell carcinoma (cSCC) is a common type of malignant skin disorder. An uncommon feature is local bony invasion, as can rarely be seen in lesions on the scalp. The optimal treatment strategy in these rare cases is still under debate. OBJECTIVE The aim of this case report is to present a 1-stage three-dimensional planned surgical resection and reconstruction of a cSCC with bony invasion into the scalp and to discuss the alternative options and potential pitfalls. MATERIALS AND METHODS A patient diagnosed with rT4N0M0 cSCC of the scalp underwent a cranial resection and reconstruction in 1 stage. With the use of computer-assisted design and computer-assisted manufacturing a patient-specific implant (PSI) of poly (ether ether ketone) was manufactured. After the PSI was inserted, it was covered with a latissimus dorsi muscle and a split-thickness skin graft. RESULTS Intraoperatively the resection template generated an accurate resection and accurate and fast placement of the PSI. The reconstruction had a clinical satisfactory esthetic result, but was hampered by the development of a small wound dehiscence was observed over the postoperative course. CONCLUSION Three-dimensional planned resection and reconstruction for composite defects of the skull after resection of a cSCC of the scalp with bony invasion may lead to an accurate and predictable resection and accurate and fast placement of the PSI. However, patient specific characteristics should be considered to assess potential risks and benefits before opting for this one-stage treatment strategy.
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Challenges in Microsurgical Reconstruction for Craniofacial Osteomyelitis With Resultant Osteonecrosis. J Craniofac Surg 2019; 30:1960-1965. [PMID: 31232982 DOI: 10.1097/scs.0000000000005594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton. METHODS/RESULTS The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop. CONCLUSIONS Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels.
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Full-Thickness Skin Grafting for Local Defect Coverage Following Scalp Adjacent Tissue Transfer in the Setting of Cranioplasty. J Craniofac Surg 2019; 30:115-119. [PMID: 30394971 DOI: 10.1097/scs.0000000000004872] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Numerous techniques have been described to overcome scalp deficiency and high-tension closure at time of cranioplasty. However, there is an existing controversy, over when and if a free flap is needed during complex skull reconstruction (ie, cranioplasty). As such the authors present here our experience using full-thickness skin grafts (FTSGs) to cover local defects following scalp adjacent tissue transfer in the setting of cranioplasty. METHODS By way of an institutional review board-approved database, the authors identified patients treated over a 3-year period spanning January 2015 to December 2017, who underwent scalp reconstruction using the technique presented here. Patient demographics, clinical characteristics, technical details, outcomes, and long-term follow up were statistically analyzed for the purpose of this study. RESULTS Thirty-three patients, who underwent combined cranioplasty and scalp reconstruction using an FTSG for local donor site coverage, were identified. Twenty-five (75%) patients were considered to have "high complexity" scalp defects prior to reconstruction. Of them, 12 patients (36%) were large-sized and 20 (60%) medium-sized; 21 (64%) grafts were inset over vascularized muscle or pericranium while the remaining grafts were placed over bare calvarial bone. In total, the authors found 94% (31/33) success for all FTSGs in this cohort. Two of the skin grafts failed due to unsuccessful take. Owing to the high rate of success in this series, none of the patient's risk factors were found to correlate with graft failure. In addition, the success rate did not differ whether the graft was placed over bone verses over vascularized muscle/pericranium. CONCLUSION In contrary to previous studies that have reported inconsistent success with full-thickness skin grafting in this setting, the authors present a simple technique with consistent results-as compared to other more complex reconstructive methods-even in the setting of highly complex scalp reconstruction and simultaneous cranioplasty.
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Forehead reconstruction using supraclavicular flap with microsurgical technique: Free flap and a pedicle supercharged flap. JPRAS Open 2017. [DOI: 10.1016/j.jpra.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Versatility of the Latissimus Dorsi Free Flap during the Treatment of Complex Postcraniotomy Surgical Site Infections. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1355. [PMID: 28740770 PMCID: PMC5505831 DOI: 10.1097/gox.0000000000001355] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/17/2017] [Indexed: 11/26/2022]
Abstract
Background: Some intractable cases of postcraniotomy infection, which can involve compromised skin, an open frontal air sinus, and residual epidural dead space, have been reported. In such cases, reconstructing the scalp and skull is challenging. Methods: Between 2009 and 2016, the author treated 12 patients with recalcitrant postcraniotomy surgical site infections with latissimus dorsi (LD) free flaps. The patients’ ages ranged from 37 to 79 years (mean, 63.5 years), and their underlying diseases included subarachnoid hemorrhaging (n = 5), brain tumors (n = 4), and cerebral arteriovenous malformations (n = 3). Results: The LD free flap was used for scalp reconstruction in 3 cases, scalp reconstruction and separation of the intracranial and nasal cavities in 5 cases, and the obliteration of epidural dead space in 4 cases. Debridement followed by staged cranial reconstruction was carried out in 8 cases, and single-stage cranial reconstruction was conducted in 2 cases. The bone defects of the other 2 cases, which were small, were filled with LD musculo-adipose free flaps. The postoperative local appearance of the wounds was acceptable in every case, and no complications occurred. Conclusions: The LD free flap is a versatile tool for the treatment of complex postcraniotomy surgical site infections. This vascularized muscle flap is useful for controlling local infections because of its abundant vascularity. Moreover, its variety of uses means that it can resolve several problems in cases involving complex cranial wounds.
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Chou PY, Lin CH, Hsu CC, Yang WH, Kane AA, Lin CH. Salvage of postcranioplasty implant exposure using free tissue transfer. Head Neck 2017; 39:1655-1661. [DOI: 10.1002/hed.24813] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 02/04/2017] [Accepted: 03/14/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, and College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Wei-Hsun Yang
- Department of Neurosurgery; Chang Gung Memorial Hospital; Chiayi Taiwan
| | - Alex A. Kane
- Department of Plastic Surgery; University of Texas Southwestern Medical Center; Fort Worth Texas
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; Chiayi Taiwan
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Morice A, Kolb F, Picard A, Kadlub N, Puget S. Reconstruction of a large calvarial traumatic defect using a custom-made porous hydroxyapatite implant covered by a free latissimus dorsi muscle flap in an 11-year-old patient. J Neurosurg Pediatr 2017; 19:51-55. [PMID: 27791703 DOI: 10.3171/2016.8.peds1653] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Reconstruction of complex skull defects requires collaboration between neurosurgeons and plastic surgeons to choose the most appropriate procedure, especially in growing children. The authors describe herein the reconstruction of an extensive traumatic bone and soft tissue defect of the cranial vault in an 11-year-old boy. The size of the defect, quality of the tissues, and patient's initial condition required a 2-stage approach. Ten months after an initial emergency procedure in which lacerated bone and soft tissue were excised, reconstruction was performed. The bone defect, situated on the left frontoparietal region, was 85 cm2 and was filled by a custom-made porous hydroxyapatite implant. The quality of the overlying soft tissue did not allow the use of classic local and locoregional coverage techniques. A free latissimus dorsi muscle flap branched on the contralateral superficial temporal pedicle was used and left for secondary healing to take advantage of scar retraction and to minimize alopecia. Stable well-vascularized implant coverage as well as an esthetically pleasing skull shape was achieved. Results in this case suggest that concomitant reconstruction of large calvarial defects by cranioplasty with a custom-made hydroxyapatite implant covered by a free latissimus dorsi muscle flap is a safe and efficient procedure in children, provided that there is no underlying infection of the operative site.
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Affiliation(s)
- Anne Morice
- APHP, Hôpital Necker Enfants Malades, Service de chirurgie maxillo-faciale, Paris.,Department of Neurosurgery, Necker Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Frédéric Kolb
- Institut Gustave Roussy, Département de cancérologie cervico-faciale, Service de chirurgie plastique, Villejuif
| | - Arnaud Picard
- APHP, Hôpital Necker Enfants Malades, Service de chirurgie maxillo-faciale, Paris.,Université Paris Descartes, Paris.,Centre de références des malformations de la face et de la cavité buccale, Paris; and
| | - Natacha Kadlub
- APHP, Hôpital Necker Enfants Malades, Service de chirurgie maxillo-faciale, Paris.,Université Paris Descartes, Paris.,Centre de références des malformations de la face et de la cavité buccale, Paris; and
| | - Stéphanie Puget
- Department of Neurosurgery, Necker Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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Abstract
Reconstruction of the forehead remains challenging. Especially in cases of large or even complete forehead defects, local flaps and skin grafting may not be an option, necessitating free flap coverage. The aim of this retrospective case series was to develop an algorithmic surgical approach as well as to evaluate surgical and aesthetic outcomes of microvascular-based forehead reconstructions, using gracilis muscle or anterolateral thigh flaps in 15 cases. The mean size of the defects was 84.6 (range: 25-160, ±44.1) cm, all with significant area of bone exposure. The free flap reconstructions included 7 gracilis muscle flaps, covered with 1.2-mm-thick unmeshed split-thickness skin grafts, and 8 anterolateral thigh flaps with a mean size of the free flaps of 160 (range: 56-300, ±78.6) cm. In all patients, wound healing at the donor site was uneventful. Minor complications occurred in 3 patients and required small revision procedures. This case series demonstrates that microsurgical reconstruction of multiple entities of forehead defects poses a reliable method, especially in large and complex defects. In our opinion, given low risks for major complications and superior aesthetic results, the gracilis muscle flap covered with unmeshed split-thickness skin graft is ideally suited to reconstruct the forehead and should be one of first choices.
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Bartella AK, Ghassemi M, Hölzle F, Ghassemi A. Reconstruction of facial soft tissue: comparison between conventional procedures and the facelift technique. Br J Oral Maxillofac Surg 2016; 54:1006-1011. [PMID: 27542312 DOI: 10.1016/j.bjoms.2016.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 07/23/2016] [Indexed: 10/21/2022]
Abstract
We compared the result of replacement using a modified facelift technique with those of other commonly used surgical techniques for the treatment of defects of the soft tissue of the infraorbital and cheek region. We made a retrospective observational study of 86 patients who had defects of the facial soft tissue after excision of malignant tumours. Procedures used for reconstructions included non-vascularised skin grafts, local flaps, facelift technique, and microvascular free flaps, and we evaluated morbidity; duration of hospital stay; the need for, and duration of stay in the intensive care unit (ICU); and functional and aesthetic outcomes. We studied 46 men and 40 women (mean (range) age 71 (8-99) years). We found no significant difference between the methods apart from shorter duration of hospital stay and lower incidence of ectropion in the facelift group. The facelift technique also gave the best aesthetic outcome. However, in defects larger than 60cm2, microvascular free tissue transfer was the only choice. The facelift technique is reliable and safe, and gives excellent aesthetic and functional outcomes, but its use is limited to defects smaller than 60cm2.
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Affiliation(s)
- A K Bartella
- University Hospital RWTH-Aachen, Department of Oral and Maxillofacial Surgery, Pauwelsstraße 30, 52074 Aachen Germany.
| | - M Ghassemi
- University Hospital RWTH-Aachen, Department of Orthodontics, Pauwelsstraße 30, 52074 Aachen Germany
| | - F Hölzle
- University Hospital RWTH-Aachen, Department of Oral and Maxillofacial Surgery, Pauwelsstraße 30, 52074 Aachen Germany
| | - A Ghassemi
- Oral and Maxillofacial Surgery, Academic Hospital of the University of Hanover, Klinikum Lippe, Röntgenstr. 18, 32756 Detmold Germany; Medical Faculty University RWTH, Aachen, Pauwelsstraße 30, 52074 Aachen Germany
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37
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Meaike JD, Dickey RM, Killion E, Bartlett EL, Brown RH. Facial Skin Cancer Reconstruction. Semin Plast Surg 2016; 30:108-21. [PMID: 27478419 DOI: 10.1055/s-0036-1584821] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Nonmelanoma skin cancers are the most common skin cancers in the United States and the most common malignancies afflicting the head and neck region. Reconstruction of resulting defects has significant aesthetic and functional implications, and plastic surgeons are frequently consulted for reconstruction. Reconstruction can be accomplished via a multitude of approaches spanning the reconstructive ladder, and the approach should be individualized based upon both patient-related and defect-related factors. Here the authors propose a simplified approach to facial reconstruction broken down by aesthetic region.
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Affiliation(s)
- Jesse D Meaike
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Ryan M Dickey
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Elizabeth Killion
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Erica L Bartlett
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodger H Brown
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
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Simunovic F, Eisenhardt SU, Penna V, Thiele JR, Stark GB, Bannasch H. Microsurgical reconstruction of oncological scalp defects in the elderly. J Plast Reconstr Aesthet Surg 2016; 69:912-9. [PMID: 27133193 DOI: 10.1016/j.bjps.2016.03.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/04/2016] [Accepted: 03/19/2016] [Indexed: 11/24/2022]
Abstract
The incidence of scalp tumors requiring radical excision increases with age. Free flap surgery is the standard reconstructive option for large defects; however, there is an ongoing uncertainty about its safety in the elderly. We conducted a review of data and report on 19 patients aged ≥75 years and 13 < 75 years. Data regarding patient demographics, types of tumors, surgery, size of defect, flaps used, and prevalence of complications were analyzed. The patients in the elderly group had more accompanying medical conditions and a higher ASA score. Squamous cell carcinoma was the predominant tumor in the elderly and sarcoma in the younger patients. The defect size was similar in both groups. The latissimus dorsi (LD) and the anterolateral thigh (ALT) flaps were flaps of first choice, with temporal vessels most commonly used for anastomosis. Surgery lasted longer in the younger patients. There was no difference in the duration of hospital stay. No significant correlation was found between age and the flap-related or medical complications. Revision surgery was more often required in the younger patients. We conclude that free flap surgery is safe and reliable in the elderly population. The LD and the ALT are the most commonly used flaps. Advanced age should not be considered a risk factor for free flap surgery in these patients.
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Affiliation(s)
- Filip Simunovic
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany.
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - Vincenzo Penna
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - Jan R Thiele
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - G Björn Stark
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - Holger Bannasch
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Freiburg, Germany
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Koshy JC, Seruya M. Reconstructive algorithms in the pediatric population. J Surg Oncol 2016; 113:940-5. [DOI: 10.1002/jso.24200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 01/27/2016] [Indexed: 11/08/2022]
Affiliation(s)
- John C. Koshy
- Division of Plastic Surgery; Baylor College of Medicine; Houston Texas
| | - Mitchel Seruya
- Division of Plastic and Maxillofacial Surgery; USC Keck School of Medicine, Children's Hospital Los Angeles; Los Angeles California
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Las DE, de Jong T, Zuidam JM, Verweij NM, Hovius SER, Mureau MAM. Identification of independent risk factors for flap failure: A retrospective analysis of 1530 free flaps for breast, head and neck and extremity reconstruction. J Plast Reconstr Aesthet Surg 2016; 69:894-906. [PMID: 26980600 DOI: 10.1016/j.bjps.2016.02.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 01/07/2016] [Accepted: 02/01/2016] [Indexed: 12/19/2022]
Abstract
Reconstructive microsurgery is a powerful method of treating various complex defects. However, flap loss remains a possibility, leading to additional surgery, hospitalisation and costs. Consequently, it is important to know which factors lead to an increased risk of flap failure, so that measures can be undertaken to reduce this risk. Therefore, we analysed our results over a 20-year period to identify risk factors for flap failure after breast, head and neck and extremity reconstruction. The medical files of all patients treated between 1992 and 2012 were reviewed. Patient characteristics, surgical data and post-operative complications were scored, and independent risk factors for flap loss were identified. Reconstruction with a total of 1530 free flaps was performed in 1247 patients. Partial and total flap loss occurred in 5.5% and 4.4% of all free flaps, respectively. In all flaps, signs of compromised flap circulation were a risk factor for flap failure. More specifically, the risk factors for flap failure in breast reconstruction were previous radiotherapy, venous anastomosis revision, gluteal artery perforator (GAP) flap choice and post-operative bleeding. In head and neck reconstruction, pulmonary co-morbidity and anastomosis to the lingual vein or superficial temporal artery were risk factors, whereas a radial forearm flap reduced the risk. In extremity reconstruction, diabetes, prolonged anaesthesia time and post-operative wound infection were risk factors. Independent pre-, intra- and post-operative risk factors for flap failure after microvascular breast, head and neck and extremity reconstruction were identified. These results may be used to improve patient counselling and to adjust treatment algorithms to further reduce the chance of flap failure.
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Affiliation(s)
- David E Las
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tim de Jong
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J Michiel Zuidam
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Norbert M Verweij
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Steven E R Hovius
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marc A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Goertz O, von der Lohe L, Martinez-Olivera R, Daigeler A, Harati K, Hirsch T, Lehnhardt M, Kolbenschlag J. Microsurgical Reconstruction of Extensive Oncological Scalp Defects. Front Surg 2015; 2:44. [PMID: 26484347 PMCID: PMC4588120 DOI: 10.3389/fsurg.2015.00044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/21/2015] [Indexed: 12/02/2022] Open
Abstract
Although most small to medium defects of the scalp can be covered by local flaps, large defects or complicating factors, such as a history of radiotherapy, often require a microsurgical reconstruction. Several factors need to be considered in such procedures. A sufficient preoperative planning is based on adequate imaging of the malignancy and a multi-disciplinary concept. Several flaps are available for such reconstructions, of which the latissimus dorsi and anterior-lateral thigh flaps are the most commonly used ones. In very large defects, combined flaps, such as a parascapular/latissimus dorsi flaps, can be highly useful or necessary. The most commonly used recipient vessels for microsurgical scalp reconstructions are the superficial temporal vessels, but various other feasible choices exist. If the concomitant veins are not sufficient, the jugular veins represent a safe back-up alternative but require a vessel interposition or long pedicle. Post-operative care and patient positioning can be difficult in these patients but can be facilitated by various devices. Overall, microsurgical reconstruction of large scalp defects is a feasible undertaking if the mentioned key factors are taken into account.
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Affiliation(s)
- Ole Goertz
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
| | - Leon von der Lohe
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
| | - Ramón Martinez-Olivera
- Neurosurgical Unit, Department of Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
| | - Adrien Daigeler
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
| | - Kamran Harati
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
| | - Tobias Hirsch
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
| | - Jonas Kolbenschlag
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr-University , Bochum , Germany
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Miyamoto S, Fujiki M, Sakuraba M. Clinical analysis of 33 flow-through latissimus dorsi flaps. J Plast Reconstr Aesthet Surg 2015; 68:1425-31. [DOI: 10.1016/j.bjps.2015.05.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 05/29/2015] [Accepted: 05/31/2015] [Indexed: 10/23/2022]
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The Use of Posterior Rectus Sheath Free Flap for Reconstruction of Total Forehead Defects. J Craniofac Surg 2015; 26:1728-9. [PMID: 26167992 DOI: 10.1097/scs.0000000000001843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Sosin M, Chaudhry A, De La Cruz C, Bojovic B, Manson PN, Rodriguez ED. Lessons Learned in Scalp Reconstruction and Tailoring Free Tissue Transfer in the Elderly: A Case Series and Literature Review. Craniomaxillofac Trauma Reconstr 2014; 8:179-89. [PMID: 26269725 DOI: 10.1055/s-0034-1393725] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 02/12/2014] [Indexed: 10/24/2022] Open
Abstract
This article aims to demonstrate an individualized approach to an elderly patient requiring scalp reconstruction, to describe the methodology in flap selection, lessons learned, and report outcomes. A retrospective review of a single surgeon's experience of scalp reconstruction (E. D. R.) using free tissue transfer from 2005 to 2011, in patients older than 70 years, was completed. A total of eight patients met the inclusion criteria, five males and three females, with a mean age of 80.4 years (range, 73-92). Free tissue transfer achieved 100% soft tissue coverage. Six of the eight patients required cranioplasty. The mean size calvarial defect was 92 cm(2) (range, 35-285 cm(2)). The mean flap size was 117.6 cm(2) (range, 42-285 cm(2)). Free flaps included three ulnar, three anterolateral thigh, one latissimus dorsi, and one thoracodorsal perforator flap. The mean follow-up time was 18.4 months (range, 3-46 months). Donor site morbidity was minimal. Mortality was 0%. Immediate flap failure was 0%. Other complications occurred in six of the eight patients. Mean revisionary procedures were 1.25 procedures per patient. It was concluded that chronological age does not increase mortality or catastrophic flap complications; however, morbidity is increased in the elderly and revisionary surgery is likely.
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Affiliation(s)
- Michael Sosin
- Division of Plastic, Reconstructive, and Maxillofacial Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Arif Chaudhry
- Division of Plastic, Reconstructive, and Maxillofacial Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Carla De La Cruz
- Division of Plastic, Reconstructive, and Maxillofacial Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Branko Bojovic
- Division of Plastic, Reconstructive, and Maxillofacial Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Paul N Manson
- Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Eduardo D Rodriguez
- Department of Plastic Surgery, New York University Langone Medical Center, Institute of Reconstructive Plastic Surgery, New York, New York
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Gómez R, Hontanilla B. The Reconstructive Management of Hardware-Related Scalp Erosion in Deep Brain Stimulation for Parkinson Disease. Ann Plast Surg 2014; 73:291-4. [DOI: 10.1097/sap.0b013e318276da63] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Longo B, Laporta R, Pagnoni M, Campanale A, Grippaudo FR, Santanelli Di Pompeo F. Skin grafted latissimus dorsi flap for reconstruction of lateral aesthetic units of the face. Microsurgery 2014; 35:177-82. [DOI: 10.1002/micr.22305] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/22/2014] [Accepted: 07/23/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Benedetto Longo
- Plastic Surgery Unit, NESMOS Department, Sant'Andrea Hospital, School of Medicine and Psychology“Sapienza” University of Rome Italy
| | - Rosaria Laporta
- Plastic Surgery Unit, NESMOS Department, Sant'Andrea Hospital, School of Medicine and Psychology“Sapienza” University of Rome Italy
| | - Marco Pagnoni
- Plastic Surgery Unit, NESMOS Department, Sant'Andrea Hospital, School of Medicine and Psychology“Sapienza” University of Rome Italy
| | - Antonella Campanale
- Italian Ministry of Health, Directorate General for Medical Devices, Pharmaceutical Services and Safety in Health CareRome Italy
| | - Francesca Romana Grippaudo
- Plastic Surgery Unit, NESMOS Department, Sant'Andrea Hospital, School of Medicine and Psychology“Sapienza” University of Rome Italy
| | - Fabio Santanelli Di Pompeo
- Plastic Surgery Unit, NESMOS Department, Sant'Andrea Hospital, School of Medicine and Psychology“Sapienza” University of Rome Italy
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Complications after oncologic scalp reconstruction: A 139-patient series and treatment algorithm. Laryngoscope 2014; 125:582-8. [DOI: 10.1002/lary.24855] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/12/2014] [Accepted: 07/07/2014] [Indexed: 11/07/2022]
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Cöloğlu H, Ozkan B, Sener M, Uysal AÇ, Borman H. The management of non-melanocytic skin malignancies of the scalp and calvarium. Indian J Plast Surg 2014; 47:36-42. [PMID: 24987202 PMCID: PMC4075214 DOI: 10.4103/0970-0358.129621] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Harun Cöloğlu
- Plastic and Reconstructive Surgery Clinic, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Burak Ozkan
- Plastic and Reconstructive Surgery Clinic, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Mesut Sener
- Anesthesiology Clinic, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Ahmet Çağrı Uysal
- Plastic and Reconstructive Surgery Clinic, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Hüseyin Borman
- Plastic and Reconstructive Surgery Clinic, Faculty of Medicine, Baskent University, Ankara, Turkey
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