Nodular Basal Cell Carcinoma Arising in a Split-Thickness Skin Graft of the Scalp

Nodular basal cell carcinoma on an autologous split-thickness skin graft after melanoma surgery

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Integra in Scalp Reconstruction After Tumor Excision: Recommendations From a Multidisciplinary Advisory Board

Integra is a dermal regeneration template used in the reconstruction of burns, traumatic injuries, or excision lesions in patients who present particular risk factors for traditional surgical procedures. A multidisciplinary advisory board of expert dermatologists and plastic surgeons have discussed the use of Integra in the reconstruction of scalp defects after tumor excision, focusing on the evidence derived from literature and on their experience in the treatment of approximately 400 patients. In this position paper, the authors summarize the main evidence discussed during the board, and the common practice guidelines proposed by the experts. The use of Integra is recommended in elderly patients with multiple comorbidities who have a higher risk for potential complications in traditional surgery; these patients may in fact benefit from a lower anesthetic risk, a less complicated postsurgical care and limited morbidity at the donor site obtained with the dermal template. Integra should also be used in the reconstruction of large and complex wounds and in case of bone exposure, as it helps to overcome the challenges related to wound healing in difficult areas. Notably, Integra has proven to be effective in patients who have undergone previous surgical procedures or adjuvant radiation therapy, in which previous incisions, scarring and radiation damages may hamper the effectiveness of traditional procedures. Finally, Integra is recommended in patients with recurrent and aggressive tumors who need closer tumor surveillance, as it gives easy access to the tumor site for oncologic follow-up examination.

Reconstruction of Complex Full-Thickness Scalp Defects After Dog-Bite Injuries Using Dermal Regeneration Template (Integra): Case Report and Literature Review

PURPOSE

The purpose of this article is to review the current applications of dermal regeneration templates in reconstruction of full-thickness scalp defects, most commonly resulting from oncologic surgery, and show its success in reconstruction of a complex full-thickness scalp defect resulting from a dog-bite injury.

MATERIALS AND METHODS

A systematic review conforming to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines was completed. A PubMed search was completed using key terms including Integra, dermal regeneration template, full-thickness scalp defects, dog-bite injuries, and scalp. Eligible articles were selected based on the characteristics of defect size, procedural protocol, and reconstruction modality. Outcomes reported were based on reports of follow-up, complications, and percentage graft take. The case report presents reconstruction of a complex full-thickness scalp defect due to a dog-bite injury with a dermal regeneration template.

RESULTS

Fifteen articles were included. Reported ages ranged from 2 to 93 years. The mean defect size ranged from 6 to 610 cm², with 67% of defects averaging more than 50 cm². All articles reported the 2-stage approach to Integra (Integra LifeSciences, Plainsboro, NJ)-based reconstruction with follow-up ranging from 5 to 23 months, with only 2 articles reporting less than 90% graft take.

CONCLUSIONS

Acellular dermal matrix provides an alternative reconstructive mechanism to free tissue transfer and flap reconstruction and offers a unique advantage in the medically complex patient, as well as in pediatric and geriatric populations. Successful Integra-based reconstruction of full-thickness complex scalp defects is well reported in the literature in relation to reconstruction of Mohs surgical defects, as well as burns of the trunk and extremities; however, reports of reconstruction of post-traumatic soft tissue defects of the head and neck are limited. On the basis of the reported successes from the reviewed literature, as well as the clinical outcome of the reported case, we believe Integra to be a valuable reconstructive tool in the algorithm for repair of post-traumatic, full-thickness, complex scalp defects when used appropriately.

Integra-based Reconstruction of Large Scalp Wounds: A Case Report and Systematic Review of the Literature

Background:

Large complex scalp wounds that have traditionally required free vascularized tissue transfer have been successfully reconstructed with skin substitutes such as Integra. Although there are multiple reports of Integra-based reconstructions of scalp wounds, there has not been a comprehensive assessment of this body of literature that critically examines this method. Our goal was to conduct a systematic review to determine the effectiveness of Integra-based reconstructions of scalp wounds, with emphasis on large defects.

Methods:

A comprehensive systematic review was completed using key search terms, including Integra, dermal regeneration template, bovine collagen, skin substitute, forehead, and scalp. Selected articles reported characteristics of patients and their reconstructions. The primary outcome measures were wound complications and percent graft take.

Results:

Thirty-four articles were included in this systematic review. Wound sizes ranged from 5.7 to 610 cm², with 35.3% of articles reporting a mean defect size >100 cm². Thirty-two articles reported mean percent take of skin graft ≥90%. Sixteen articles reported a minor complication. There were no major complications associated with the reconstructions.

Conclusions:

There is a substantial evidence base for the use of Integra to reconstruct scalp wounds. To date, the dermal regeneration template is generally reserved for salvage procedures or when the patient cannot tolerate free tissue transfer. Based on the findings of this systematic review and the authors’ clinical experience, Integra can be used to achieve predictable results in large complex scalp defects.