Intraoperative expander-assisted scalp reduction

Improved Scalp Reduction Results with Prolonged Acute Tissue Expansion (PÂTÉ)

The purpose of this study was to develop a method to remove greater amounts of bald tissue during scalp reduction than has been previously reported with acute tissue expansion, by prolonging local anesthesia as well as the time period of acute tissue expansion. A new method for prolonging the local anesthetic effect was developed, and a tissue expander was placed under the hair- bearing scalp and attached to a tissue compliance measuring device in three patients. Through cyclic loading of the expander for an extended period of time, and with precise pressure monitoring, a marked improvement in scalp reduction results was achieved. All three patients responded dramatically to the procedure, with a 100% increase in the amount of scalp tissue that was removed in Patient 1, a 90% increase in Patient 2, and a 118% increase in Patient 3. Postoperative markings demonstrated minimal stretch-back. Prolonged acute tissue expansion (PÂTÉ) was demonstrated to be an extremely useful adjunct to scalp reduction.

Nevus Sebaceus of Jadassohn

The nevus sebaceus of Jadassohn (SNJ) is a hamartomatous disorder of the skin and its adnexa pertaining to the group of "organoid nevi,'' most frequently involving the face and scalp. During adulthood, patients with SNJ have a 10% to 20% risk of the development of cutaneous or adnexal neoplasia, so that prophylactic excision before puberty is recommended by most authors, and tissue expansion is considered to be the best method of reconstruction. It has been largely demonstrated in literature that most of the lesions that have been interpreted as basal cell carcinoma (BCC) are actually examples of primitive follicular induction or trichoblastomas, not authentic BCCs. A literature review on histopathologic findings associated with SNJ and a retrospective chart review of two cases occurring in young females are presented. In one case, the lesion was treated by intraoperative expander-assisted reduction and scalp graft (Case 1); in the other one, a primary closure with adjacent tissue was performed (Case 2). No signs of malignant degeneration or residual pathology have been found. For treatment of the biggest lesions, when preoperative tissue expansion cannot be performed, intraoperative one, transfer of a scalp graft has been shown to be a good reconstructive method. For the smallest lesions, a primary closure with adjacent tissue is sufficient.

The "modified" winch stitch

BACKGROUND

The methods described to achieve intraoperative tissue expansion have drawbacks.

OBJECTIVE

To report an intraoperative tissue expansion technique using standard suture material and hemostats to create a "modified" winch stitch.

METHODS

A continuous running suture is placed with both ends left free. A "fixed" hemostat is placed above the skin at one end. After pulling at the other end with a second hemostat, a third hemostat is placed proximal to this hemostat just above the skin, which is left in place to produce stretching. The second and third hemostats are then used in an alternating pulling and holding fashion.

RESULTS

This method produces significant tissue expansion. If the desired degree of approximation is achieved, the ends of the suture can be tied together, as in the previously described winch stitch.

CONCLUSION

The modified winch stitch is a simple and inexpensive means to facilitate closure of wounds under a significant amount of tension.

Management of scalp defects

This article presents a systematic approach to the reconstruction of scalp defects, which includes a review of the anatomy of the scalp as it pertains to reconstruction, and a discussion of the various reconstructive options for scalp defects, such as grafts and flaps. Further, scalp flap selection, design, and execution are outlined. Finally, adjunctive techniques of tissue expansion and hair transplants are included to enhance the final aesthetic result.