Can we put a simplified algorithm for reconstruction of large scalp defects following tumor resection?

Challenging frontiers in neuroplastic cranial reconstruction: addressing neurosurgical wound healing complications through interdisciplinary collaboration - an observational study

BACKGROUND AND OBJECTIVES

Although rare, complications like skin dehiscence and necrosis after neurosurgery pose significant challenges by increasing the risk of infections spreading to the epidural, subdural, or intracerebral spaces. This retrospective, single-center study aims to assess the prior clinical courses, neuroplastic repair, and outcomes of  patients with skin defects following cranial neurosurgical procedures, and to outline our interdisciplinary reconstructive protocol.

METHODS

A retrospective analysis was performed on cranial surgeries conducted at the Department of Neurosurgery,  spanning from 2017 to 2023. Patients with skin defects requiring the combined expertise of neurosurgery and plastic surgery for effective treatment were included. The sizes of the skin defects were measured using intraoperative photographs analyzed with the freeware ImageJ software, version 2018. All patients provided informed consent for the surgeries. If informed consent was not possible due to neurological deterioration, consent was sought from adult representatives or next of kin except for acute circumstances. All patients admitted to our hospital agree to the pseudonymized use of their medical data and tissue specimens for research purposes in their treatment contract.

RESULTS

A cohort of 24 patients experiencing wound healing complications after neurosurgical procedures underwent a total of 29 interdisciplinary surgeries for the reconstruction of skin, dural, and bone defects.  After the neuroplastic surgery, 8 out of 24 patients (33.3%) developed surgical complications, with 6 of these requiring revision surgeries due to persistent cranial infection.  In all cases,  permanent wound closure was successfully achieved following adherence to the proposed treatment algorithm.

CONCLUSIONS

Our study underscores the necessity of an integrated neurosurgical and plastic surgical approach to effectively manage wound healing complications in a single stage surgery. Key interventions include differentiation between necrosis and gaping lesions, alongside precise management of neurosurgical issues like cerebrospinal fluid fistulas and hydrocephalus. Plastic surgical expertise in assessing the possibilities and limitations of both local and free flap surgeries is essential.

Reconstruction of Scalp and Forehead Defects: Options and Strategies

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.

Scalp and Calvarium Reconstruction

Defects of the scalp and calvarium pose unique reconstructive challenges due to the importance of this area in protecting the brain and its distance from larger donor vessels for free flap transfer. The wide range and complexity of reconstructive options make this a broad topic because the simplest defects are often closed or managed in the outpatient setting and the most complex require multilayer closure in the operating room with a multidisciplinary team and intensive postoperative care. In hair-bearing individuals, the scalp is an esthetically important area due to the importance of hair to self-esteem and sexual attraction.

Squamous Cell Carcinoma of Scalp: Our Experience in a Single Tertiary Care Centre

Cutaneous cancer is a rare entity accounting for less than 1% of all diagnosed cancers in India. In contrast to the West, squamous cell carcinoma is the commonest skin cancer in India, often affecting the scalp. However, due to their rarity, not much is known regarding their biological behavior and prognosis. The present study is a retrospective cohort study undertaken in a tertiary cancer centre on 19 consecutive cases of squamous cell carcinoma of the scalp over a period of 5 years. Patients with non-sqamous histology and those associated with xeroderma pigmentosum were excluded. Nineteen patients were evaluated with a mean age of 52.7 years. Majority presented with a swelling (11 patients; 57.9%) in the parieto-occipital region (13 patients; 68.4%). All patients underwent wide excision with or without excision of underlying bone or dura, depending on involvement. Only 4 (21%) required major reconstruction. On histopathology, 8 (42.1%) were poorly differentiated, while 3 (15.8%) had presence of perineural invasion (PNI). The mean duration of follow-up was 38.14 months. Three of the 4 (75%) and 2 of 3 (66.67%) patients with poorly differentiated histology and PNI respectively developed recurrence, while only 1 of the 6 (16.67%) with close or positive base margin developed recurrence. Hence, to conclude, poorly differentiated histology and PNI are poor prognostic indicators, while in the event the mucoperiosteum is clinically uninvolved, the underlying bone may be preserved in select cases, even if the base margin is close.

Single Stage Reconstruction of Large Calvarial Exposure after Tumor Resection: A 3-Year Experience

BACKGROUND

We aimed to review the treatment and outcome of patients’ undergone reconstruction of large full thickness scalp defects with exposed calvarium after oncologic resection with the combined local flap and split-thickness skin graft (STSG) technique.

METHODS

A retrospective review of 45 patients with scalp defects secondary to tumor extirpation was performed at the Plastic Surgery Department, Tanta University Hospital, Tanta, Egypt from Nov 2016 to Nov 2019. Patients, with large (>50 cm2) and full-thickness (exposed calvarium) scalp defects, who underwent scalp reconstruction with the combined local flap and STSG technique and had completed their medical records were enrolled.

RESULTS

Only 38 met the inclusion criteria. Thirty-three were male (86.8). The mean age was 61.5 years. The lesions removed were BCC in 30 cases (78.9%) and SCC in 8 cases (21.1%). Defect sizes ranged from 55 to 196 cm2. There was complete survival of all flaps. Complications were noticed in 5 patients (13.2%);2 developed small hematomas, 2 suffered from partial graft losses and one had wound infection. The follow-up period ranged from 6 to 27 months. Overall, 34 patients were satisfied with the functional and cosmetic results (89.5%), while 4 female patients weren't satisfied with the esthetic results (10.5%).

CONCLUSION

The combination of local flap and skin graft technique is highly reliable, easy to perform and safe single-stage reconstructive modality of large skull exposed scalp defects, providing durable coverage and favorable esthetic outcome.

A simple technique to reconstruct medium to large scalp defects with exposed bone

Medium to large scalp defects with exposed bone can pose particular challenges to the dermatologic surgeon. Most of the publications pertaining to the repair of such defects are presented in the plastic surgery literature. Dermatologic surgeons may have less experience in this area and be hesitant to pursue surgery when these defects may be encountered. The technique described below is a simple, one-stage reconstruction, with a short healing period, providing adequate cosmesis, and is within the capability of most dermatologic surgeons.

Scarred scalp reconstruction with a rectangular expander

Scalp reconstruction is challenging because the scalp is inelastic, stiff, and has hair follicles. Tissue expansion offers aesthetically pleasing outcomes with minimal donor-site morbidity. However, in a scarred scalp, the extent of possible dissection for the expander insertion may be limited and surgeons must make use of the limited scalp tissue. We successfully reconstructed scarred scalps using rectangular expanders. This report presents two cases: a 4× 3 cm chronic defect with widespread scarring and osteomyelitis and an 11× 7.5 cm scar tissue following a skin graft. Tissue expanders were inserted in the subgaleal plane and were inflated by 195 mL and 400 mL over periods of 2 and 3 months, respectively. Subgaleal elevation of a fasciocutaneous flap was achieved with the expanded tissue. The defects were well covered, with good color, texture, and hair-bearing tissue. There were no complications involving the tissue expanders. Rectangular expanders yield more available tissue than round or crescent-shaped expanders. Moreover, since the base of the flap is well defined, the expander can be easily inserted in a limited space. Therefore, rectangular expanders are recommended for the reconstruction of scarred scalps.

Application of the pinwheel flap for closure of a large defect of the scalp

A 74-year-old man had a resultant large oval scalp defect of 12×6 cm (72 cm²) following an excision of a stage IIIA melanoma. We decided to cover the defect with the pinwheel flap, with the aim to provide a good cosmetic result, preservation of hair follicles and minimal donor-site morbidity. This local flap has been traditionally used for much smaller defects. Four L-shaped flaps were designed at equal distances on the vertical and horizontal axes of the defect. The L-shaped flap had a length of 1.5 times the half diameter of the defect (4.5 cm). The incision was made through galea aponeurosis and subsequently undermined at least 3 cm to assist flap advancement. Z-plasties increased the rotation of the flap when it was required. This yielded an excellent reconstructive result at 1-year follow-up, demonstrating the usefulness of the pinwheel flap in large defects on the scalp region.

Reconstruction of Moderate-Sized Scalp Defects: A 1-2-3 Rule

BACKGROUND AND OBJECTIVE

Excision of cutaneous scalp tumors results in surgical defects that are difficult to repair because of poor distensibility in this area of the body. The main aim of this study was to develop a structured algorithm to help choose the best technique for reconstructing scalp defects.

MATERIAL AND METHODS

Retrospective study of patients who required surgical reconstruction following excision of a cutaneous scalp tumor. We excluded patients with defects that could be closed by simple direct suture and defects for which it was initially decided to use a skin graft or healing by secondary intention. The defects were classified into 5 groups according to the minimum distance between edges. The different reconstruction techniques used were evaluated in each group. The outcomes analyzed were complete defect closure, intraoperative and postoperative complications, and final aesthetic result.

RESULTS

We included 119 patients (102 men and 17 women) with a mean age of 71 years (range, 32-93 years). Mean follow-up was 42 months (range, 6-120 months). Sixty-eight patients had a moderate-sized defect with a distance between edges of 1 to 4cm. Reconstructions started with relaxation incisions in 43 defects and resulted in the successful closure of 22 of them. Defects with a distance of 1 to 2cm required a single relaxation incision. Two incisions were required for defects with a distance of 2 to 3cm, while 3 incisions were required for those with a distance of 3 to 4cm. In the 21 cases in which relaxation incisions were insufficient to close the defect, the incisions were extended to mobilize the flap to achieve closure. Relaxation incisions alone were insufficient for closing defects with a distance greater than 4cm.

CONCLUSIONS

The 1-2-3 rule can help in choosing the best reconstruction technique for moderate-sized defects based on the principle that 1, 2, or 3 initial relaxation incisions are needed depending on the minimum distance between edges (1-2cm, 2-3cm, or 3-4cm). In all cases, incision extension to mobilize the corresponding flaps remains an option.

Myiasis on a Giant Squamous Cell Carcinoma of the Scalp: A Case Report and Review of Relevant Literature

Non-melanoma skin cancer is the most common malignancy amongst Caucasians worldwide with basal cell and squamous cell cancer being the most common. Giant skin cancers are a relatively rare type of skin cancer that are, by definition, greater than 5 cm. This subtype by itself is associated with a significantly increased risk of complications and mortality. Myiasis is defined as infestation of body tissues of humans by dipterous larvae. Myiasis is often associated with malignant skin conditions. We describe a rare case of cutaneous myiasis located on a giant squamous cell carcinoma of the scalp in an elderly female. Myiasis coupled with malignant skin conditions provides a unique surgical challenge. This is especially true if the malignancy is invasive, as in our case, often requiring a multidisciplinary multimodality treatment plan.

Relapsing advanced metatypical basal cell carcinomas (MTBCC) of the face: surgical modalities

Metatypical basal cell carcinoma (MTBCC) represents a high-risk type of cutaneous tumour. We report about three different patients with relapsing advanced large MTBCC: one of the scalp and two of the cheek region. Such patients required in most of the cases a complex surgical approach to achieve a stable and complete remission. In the first presented patient a combination of flaps and grafts has been performed. We describe tailored surgical approaches. By this contrivance it is possible to treat even elderly patients with exposed bone after complete excision effectively and safe. Interdisciplinary team work is for the benefit of these patients.

Evaluation of options for large scalp defect reconstruction: a 12-year experience

OBJECTIVE

Multiple options for reconstruction of scalp defects exist with local tissue advancement and free tissue transfer the mainstay of reconstruction. Over the last 12 years, our tertiary referral hospital has performed more than 150 scalp reconstructions. We reviewed our experience with large scalp defects and evaluated whether free tissue transfer is a viable first option for reconstruction.

METHODS

A retrospective review was conducted of all scalp reconstructions from January 1, 1999, to December 31, 2011. A cohort of patients with defects greater than 50 cm(2) were identified for a total of 64 operations; 10 free flaps, 28 local advancement flaps, and 26 skin grafts. Reoperation rates and complications were compared between groups.

RESULTS

Reoperation rate in the free flap group was 20% (2/10). Both reoperations were within the immediate postoperative period, one for microvascular thrombotic occlusion and the other for postoperative hematoma. The local tissue transfer group had a 14% reoperation rate (4/28), all for debridement of partial flap loss. The skin graft cohort had a 12% reoperation rate (3/26) for 1 complete and 2 partial skin graft failures; all required repeat grafting. Reoperation for free-flap complications did not require rehospitalization. In contrast, the skin graft and non-free flap reoperations frequently required rehospitalization.

CONCLUSION

Though free tissue transfer has a higher occurrence of reoperation within the immediate postoperative period, completion of reconstruction usually occurs within a single hospitalization. Free tissue transfer is a feasible option, and we advocate for its use as a primary method for repairing large scalp defects.

Giant epithelial malignancies (Basal cell carcinoma, squamous cell carcinoma): a series of 20 tumors from a single center

Background:

Among nonmelanoma skin cancer (NMSC), basal cell carcinoma (BCC), and squamous cell carcinoma (SCC) are the most common. Giant NMSCs have occasionally reported in the medical literature with particular problems related to diagnosis and treatment. The aim of this study was to analyze patients, treatment, and outcome with giant BCC/SCC.

Materials and Methods:

We analyzed our files between January 1, 2008, and December 31, 2011, of an academic teaching hospital in the dermatology department. Patients were analyzed according to demographic factors, clinical presentation, histopathology, treatment, and outcome. American Society of Anesthesiology physical status system was used to assess the fitness of patients before surgery.

Results:

The frequency of giant NMSC was estimated as 0.4% for both tumor entities. 80% of giant BCC patients were female and 100% of giant SCC patients were male. The mean age was 81.5 ± 8.5 years for BCC) and 79.5 ± 11.4 years for SCC. The major anatomical site was the scalp. Four of 10 BCCs were classified metatypic (basosquamous). Perineural infiltration was seen in 5 NMSCs. Seventy percent of patients had an ASA score ≥3. Surgery was performed in general anaesthesia in 5 (BCC) and 6 (SCC) patients, respectively. All other patients were operated in local or tumescence anesthesia. Blood transfusions were necessary in five patients. The primary treatment was delayed Mohs technique. Defect closure was realized with rotational flaps in most cases. Neoadjuvant chemoimmune therapy and adjuvant combined cetuximab/radiotherapy have been performed in three patients. We observed three deaths, all unrelated to NMSC. 75% of patients achieved complete remission.

Conclusions:

Giant NMSC is uncommon but not rare. These tumors are high-risk subtypes. Treatment needs an interdisciplinary approach.

Reconstruction of scalp defects with the radial forearm free flap

BACKGROUND

Advanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap.

PATIENTS AND METHODS

A retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes.

RESULTS

The patients were primarily male (n = 34), with a mean age of 67 years (25-91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02).

CONCLUSION

Advanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects.