Clinical Review & Education
Review
Scalp Reconstruction An Algorithmic Approach and Systematic Review Shaun C. Desai, MD; Jordan P. Sand, MD; Jeffrey D. Sharon, MD; Gregory Branham, MD; Brian Nussenbaum, MD
IMPORTANCE Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area. OBJECTIVE To review the current literature and describe a novel algorithm to help guide the reconstructive surgeon in determining the optimal reconstruction from a cosmetic and functional standpoint. Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, as well as the reconstructive ladder, are also discussed.
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EVIDENCE REVIEW A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence. FINDINGS Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer. CONCLUSIONS AND RELEVANCE Ideal reconstruction of scalp defects relies on a comprehensive understanding of scalp anatomy, a full consideration of the armamentarium of surgical techniques, and a detailed appraisal of patient factors and expectations. The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity.
Corresponding Author: Brian Nussenbaum, MD, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8115, St Louis, MO 63110 ([email protected]).
LEVEL OF EVIDENCE NA.
JAMA Facial Plast Surg. 2015;17(1):56-66. doi:10.1001/jamafacial.2014.889 Published online November 6, 2014.
T
he scalp covers the calvarium and is therefore critical not only for normal cosmesis but also for protecting the intracranial structures. It requires reconstruction when damaged by various causes, including benign or malignant tumor excision, infection, trauma, radiation necrosis, thermal or electrical burns, congenital lesions, or renovation of a cosmetically unappealing scar or alopecia. Modern surgical techniques have allowed the reconstructive surgeon to repair most scalp defects with success and prevent potentially disastrous complications from exposed bone, such as calvarial desiccation, sequestration, and sepsis.1 Use of the reconstructive ladder is highly pertinent to the repair of scalp defects. On each successive step of the ladder, the surgeon balances the complexity of the reconstruction against its necessity. In other words, the simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity.
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Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri.
Scalp Anatomy Scalp Layers As with surgery in any location, a detailed understanding of the anatomy is key to planning a successful reconstruction. The layers of the scalp are frequently described by the mnemonic “SCALP.” This stands for Skin, subCutaneous tissue, galea Aponeurotica, Loose areolar tissue, and Pericranium (Figure 1). The scalp contains the thickest integument on the body, ranging from 3 to 8 mm in depth.2,3 When considering reconstruction, the unique characteristics of scalp skin and its hair-bearing nature must be considered, to provide an aesthetically pleasing reconstruction.4 The scalp’s blood vessels, lymphatic system, and nerves run superficial to the galea aponeurotica in the subcutaneous tissues. This is an important consideration when planning local flaps, since raising a flap superficial to the galea can impair flap vascularity.
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Figure 1. Layers of the Scalp and Temporoparietal Region
Subcutaneous tissue
Skin
Galea Loose areolar tissue Pericranium Calvarium
Calvarium Pericranium Temporal muscle with deep and middle temporal artery Temporalis fascia Temporoparietal fascia with STA Subcutaneous tissue Skin Superficial layer temporalis fascia Frontal branch facial nerve
Deep layer temporalis fascia Superficial temporal flat pad
Zygoma Deep temporal fat pad Masseter
SMAS Parotidomasseteric fascia
Mandible
Parotid gland
SMAS indicates superficial muscular aponeurotic system; STA, superficial temporal artery.
The galea aponeurotica provides strength to the overlying integument and blends with several other scalp structures. The galea is continuous anteriorly with the frontalis muscle fascia, posteriorly with the occipitalis muscle fascia, and laterally with the temporoparietal fascia. The galea itself is very inelastic and provides the reason for the “tight” and “loose” portions of the scalp (Figure 2). From the scalp vertex traveling caudally, the galea is fully formed, and the skin is tight and inelastic. Conversely, where the galeal edges blend into the temporoparietal fascia and scalp musculature fascia, the skin has improved mobility and can be more easily rearranged. It is important to note that the galea also fuses with the pericranium at the linea temporalis in the lateral frontal region.5 This is a key point for reconstruction because many local flaps seek to mobilize scalp from these looser locations and may require release of ligamentous attachments or considerable undermining depending on the location of the donor site tissue.1 Below the galea there is a loose connective tissue responsible for much of the mobility of the overlying scalp skin. This layer is also known as the subgaleal fascia, the innominate fascia, or the subaponeurotic plane.6,7 Scalp flaps are most frequently raised within this layer because it is easily dissected, and the critical neurovascular jamafacialplasticsurgery.com
structures remain superficial and unharmed. The cranial periosteum is tightly adherent to the calvarium and is the deepest layer of the scalp’s soft tissue. This layer is typically kept intact during scalp reconstruction and can serve as a vascularized surface for skin grafting depending on the reconstructive plan. Not infrequently, however, the scalp defect might include the absence of the pericranium. The pericranium is critically important for maintaining blood supply to the underlying calvarial bone. The calvarium is composed of frontal, parietal, temporal, occipital, and sphenoid bones. These bones are generally composed of 3 layers, including an outer table, a central diploic space, and an inner table. The tables vary in thickness depending on the location and age and genetic characteristics of the patient. Pediatric calvarium is typically very malleable and useful in terms of providing source material for a number of reconstructive grafts.8 Alternatively, skull bone of elderly individuals is hard, brittle, and less adaptable to manipulation. The anatomy of the temporal region is more complex than the rest of the scalp and deserves additional attention. Above the temporal line, or the superior attachment of the temporalis muscle, the scalp layers are as described herein. Just below the attachment of JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
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Figure 2. Tight and Loose Layers of the Scalp
Tight scalp
Loose scalp
Once this artery reaches the superior helix of the ear, it branches to form an anterior-frontal division and a posterior parietal division. Vascular supply to the posterior portion of the scalp differs based on the nuchal line. Superior to the nuchal line, the occipital arteries provide vascular supply. Inferior to this line, perforating musculocutaneous branches through the trapezius and splenius capitis muscles are the main supply.1 The relatively small posterolateral area is supplied by the posterior auricular artery, also arising from the external carotid artery. An understanding of the main arterial supply of the scalp is important when designing local flaps of the scalp because axial blood supply must be incorporated. Lymphatic drainage of the scalp is also located in the subcutaneous plane and typically follows the venous drainage. However, cutaneous malignant neoplasms of the scalp can have highly variable patterns of spread, as shown with lymphoscintigraphy studies for sentinel lymph node biopsies for scalp melanomas. These studies show that lymphatic drainage can be found in the parotid, postauricular, suboccipital, posterior cervical, and jugulodigastric lymph nodes.13,14
Innervation
the temporalis muscle, the skin, subcutaneous fat, and galea remain the same. However, traveling inferiorly over the muscle, the galeal layer transforms into the temporoparietal fascia. This fascia is attached to the subcutaneous tissues and is continuous with the frontalis muscle fascia anteriorly and the superficial muscular aponeurotic system inferiorly. This layer provides the mobility of the looser areas of the scalp. The temporal branch of the facial nerve and superficial temporal artery are located within the temporoparietal fascia.9 Underneath the temporoparietal fascia exists a loose areolar tissue separating it from the temporalis fascia of the temporalis muscle. This temporalis fascia, however, splits into a deep layer and superficial layer around the superficial temporal fat pad a few centimeters superior to the zygomatic arch. Although originating as individual layers, the superficial layer of the deep temporal fascia, the temporoparietal fascia, and the periosteum fuse to form a single dense immobile layer at the level of the zygomatic arch. It is at this point that the frontal branch of the facial nerve is most vulnerable while it travels over the middle third of the zygomatic arch to innervate the frontalis and corrugator muscles on their deep surface. Dissection in this area, such as during elevation of a hemicoronal or bicoronal scalp flap, is frequently performed in the plane deep to the superficial layer of the deep temporal fascia to prevent facial nerve injury.9
Vascularity and Lymphatics The scalp is a highly vascular organ supplied by cutaneous arteries arising from 4 separate systems from both the internal and external carotid arteries (Figure 3).4,10 These vessels run in the subcutaneous plane superficial to the galea to form a vast system of collateralization that can even allow for a single artery replantation of a totally avulsed scalp.11,12 Anteriorly, the scalp is fed by the paired supraorbital and supratrochlear arteries originating from the ophthalmic artery from the internal carotid system. The lateral or temporoparietal scalp is the largest and is supplied by the superficial temporal artery, the terminal portion of the external carotid artery. 58
Innervation to the scalp is provided by the trigeminal nerve, the cervical spinal nerves, and branches from the cervical plexus. The supraorbital and supratrochlear nerves supply the skin of the forehead, the anterior hairline region, and the frontoparietal scalp. The zygomaticotemporal nerve provides sensation to the region lateral to the brow up through the temporal line. The auriculotemporal nerve provides much of the sensation to the lateral scalp. Posteriorly, sensation is transmitted through both the greater and lesser occipital nerves. These nerves are formed from the dorsal rami of the cervical spinal nerves and the cervical plexus, respectively. The greater occipital nerve typically emerges from the semispinalis muscle about 3 cm below the occipital protuberance and 1.5 cm lateral to the midline.15
Patient and Technique Selection Reconstructive planning for a scalp defect must take into account the extrinsic and intrinsic factors of the patient (Box). The surgeon should assess the overall health of the patient and his or her social situation, ability and commitment for wound care, and expectations for reconstructive surgery.16 Patient factors such as diabetes mellitus, smoking, corticosteroid use, previous surgical incisions, and prior or anticipated future scalp irradiation must be carefully evaluated and included in the treatment planning. Prior scalp irradiation produces skin fibrosis and can lead to intrinsic changes in the integument, creating a propensity for nonhealing wounds.17 This is a critical point because local flaps or wound closures under tension, which could survive in a nonirradiated scalp, may ultimately have disastrous outcomes in patients with a radiation history. In a retrospective review18 of 73 scalp procedures, preoperative scalp radiation, neoadjuvant or postoperative chemotherapy, and cerebrospinal fluid leak were all noted to be statistically significant on univariate analysis (P < .05) as risk factors for developing major complications. Potential need for postoperative radiation should also be considered when planning reconstruction, and greater consideration should be given to free tissue transfer over local flaps.18,19
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4. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ. The surgical anatomy of the scalp. Plast Reconstr Surg. 1991;87(4):603-612.
23. Nordström REA. Punch hair grafting under split-skin grafts on scalps. Plast Reconstr Surg. 1979; 64(1):9-12.
5. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105(4):1475-1490.
24. Limmer BL, Buchwach KA. Hair transplantation using follicular unit micrografting. Facial Plast Surg. 1999;7(4):523-535.
6. Elliott LF, Jurkiewicz MJ. Scalp and calvarium. In: Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S, eds. Plastic Surgery: Principles and Practice. St Louis, MO: Mosby; 1990:419-440. 7. Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE. Clinical applications of the subgaleal fascia. Plast Reconstr Surg. 1991;87(4):615-626. 8. Ducic Y. Reconstruction of the scalp. Facial Plast Surg Clin North Am. 2009;17(2):177-187. 9. Hoffmann JF. Reconstruction of the scalp. In: Baker SR, ed. Local Flaps in Facial Reconstruction. St Louis, MO: Mosby; 2007:638. 10. Seery GE. Surgical anatomy of the scalp. Dermatol Surg. 2002;28(7):581-587. 11. Miller GDH, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg. 1976;58(2):133136. 12. Kaplan HY, Yaffe B, Borenstein A. Single artery replantation of totally avulsed scalp. Injury. 1993;24 (7):488-490. 13. Cappello ZJ, Augenstein AC, Potts KL, McMasters KM, Bumpous JM. Sentinel lymph node status is the most important prognostic factor in patients with melanoma of the scalp. Laryngoscope. 2013;123(6):1411-1415. 14. Close LG, Goepfert H, Ballantyne AJ, Jesse RH. Malignant melanoma of the scalp. Laryngoscope. 1979;89(8):1189-1196. 15. Mosser SW, Guyuron B, Janis JE, Rohrich RJ. The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches. Plast Reconstr Surg. 2004;113(2):693-697. 16. Becker GD, Adams LA, Levin BC. Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngol Head Neck Surg. 1999;121(6):751-754. 17. Goessler UR, Bugert P, Kassner S, et al. In vitro analysis of radiation-induced dermal wounds. Otolaryngol Head Neck Surg. 2010;142(6):845-850. 18. Newman MI, Hanasono MM, Disa JJ, Cordeiro PG, Mehrara BJ. Scalp reconstruction: a 15-year experience. Ann Plast Surg. 2004;52(5):501-506. 19. Hussussian CJ, Reece GP. Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstr Surg. 2002;109(6):1828-1834. 20. Sittitavornwong S, Morlandt AB. Reconstruction of the scalp, calvarium, and frontal sinus. Oral Maxillofac Surg Clin North Am. 2013;25 (2):105-129. 21. Chang KP, Lai CH, Chang CH, Lin CL, Lai CS, Lin SD. Free flap options for reconstruction of complicated scalp and calvarial defects: report of a series of cases and literature review. Microsurgery. 2010;30(1):13-18. 22. Barrera A. The use of micrografts and minigrafts for the treatment of burn alopecia. Plast Reconstr Surg. 1999;103(2):581-584.
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25. Snow SN, Stiff MA, Bullen R, Mohs FE, Chao WH. Second-intention healing of exposed facial-scalp bone after Mohs surgery for skin cancer: review of ninety-one cases. J Am Acad Dermatol. 1994;31(3, pt 1):450-454. 26. Subotic U, Kluwe W, Oesch V. Community-associated methicillin-resistant Staphylococcus aureus-infected chronic scalp wound with exposed dura in a 10-year-old boy: vacuum-assisted closure is a feasible option: case report. Neurosurgery. 2011;68(5):1481-1483. 27. Powers AK, Neal MT, Argenta LC, Wilson JA, DeFranzo AJ, Tatter SB. Vacuum-assisted closure for complex cranial wounds involving the loss of dura mater. J Neurosurg. 2013;118(2):302-308. 28. Marathe US, Sniezek JC. Use of the vacuum-assisted closure device in enhancing closure of a massive skull defect. Laryngoscope. 2004;114(6):961-964. 29. Brenner M. Scalp reconstruction. In: Branham G, ed. Facial Soft Tissue Reconstruction. Shelton, CT: Peoples Medical Publishing House; 2011:120. 30. Fang RC, Galiano RD. A review of becaplermin gel in the treatment of diabetic neuropathic foot ulcers. Biologics. 2008;2(1):1-12. 31. Harrison-Balestra C, Eaglstein WH, Falabela AF, Kirsner RS. Recombinant human platelet-derived growth factor for refractory nondiabetic ulcers: a retrospective series. Dermatol Surg. 2002;28(8): 755-759. 32. Hershcovitch MD, Hom DB. Update in wound healing in facial plastic surgery. Arch Facial Plast Surg. 2012;14(6):387-393. 33. Raposio E, Nordström RE, Santi PL. Undermining of the scalp: quantitative effects. Plast Reconstr Surg. 1998;101(5):1218-1222.
42. Tufaro AP, Buck DW II, Fischer AC. The use of artificial dermis in the reconstruction of oncologic surgical defects. Plast Reconstr Surg. 2007;120(3): 638-646. 43. Komorowska-Timek E, Gabriel A, Bennett DC, et al. Artificial dermis as an alternative for coverage of complex scalp defects following excision of malignant tumors. Plast Reconstr Surg. 2005;115(4): 1010-1017. 44. Koenen W, Goerdt S, Faulhaber J. Removal of the outer table of the skull for reconstruction of full-thickness scalp defects with a dermal regeneration template. Dermatol Surg. 2008;34(3): 357-363. 45. Gonyon DL Jr, Zenn MR. Simple approach to the radiated scalp wound using INTEGRA skin substitute. Ann Plast Surg. 2003;50(3):315-320. 46. Khan MA, Ali SN, Farid M, Pancholi M, Rayatt S, Yap LH. Use of dermal regeneration template (Integra) for reconstruction of full-thickness complex oncologic scalp defects. J Craniofac Surg. 2010;21(3):905-909. 47. Jung SN, Chung JW, Yim YM, Kwon H. One-stage skin grafting of the exposed skull with acellular human dermis (AlloDerm). J Craniofac Surg. 2008;19(6):1660-1662. 48. Wilensky JS, Rosenthal AH, Bradford CR, Rees RS. The use of a bovine collagen construct for reconstruction of full-thickness scalp defects in the elderly patient with cutaneous malignancy. Ann Plast Surg. 2005;54(3):297-301. 49. Seyhan A, Yoleri L, Barutçu A. Immediate hair transplantation into a newly closed wound to conceal the final scar on the hair-bearing skin. Plast Reconstr Surg. 2000;105(5):1866-1870. 50. Frodel JL, Mabrie D. Optimal elective scalp incision design. Otolaryngol Head Neck Surg. 1999; 121(4):374-377. 51. Orticochea M. Four flap scalp reconstruction technique. Br J Plast Surg. 1967;20(2):159-171. 52. Orticochea M. New three-flap reconstruction technique. Br J Plast Surg. 1971;24(2):184-188.
34. Ibhler N, Ziegler MC, Penna V, Eisdenhardt SU, Stark GB, Bannasch H. An algorithm for oncologic scalp reconstruction. Plast Reconstr Surg. 2010;126 (2):450-459.
53. Horch RE, Stark GB. The contralateral bilobed trapezius myocutaneous flap for closure of large defects of the dorsal neck permitting primary donor site closure. Head Neck. 2000;22(5):513-519.
35. Cox AJ III, Wang TD, Cook TA. Closure of a scalp defect. Arch Facial Plast Surg. 1999;1(3):212-215.
54. Uğurlu K, Ozçelik D, Hüthüt I, Yildiz K, Kilinç L, Baş L. Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure. Plast Reconstr Surg. 2004;114(2):339-350.
36. Worlicek C, Kaufmann R. Divided full-thickness skin graft for closure of circular and oval scalp defects. J Dtsch Dermatol Ges. 2012;10(4):274-276. 37. Kuwahara M, Hatoko M, Tanaka A, Yurugi S, Mashiba K. Simultaneous use of a tissue expander and skin graft in scalp reconstruction. Ann Plast Surg. 2000;45(2):220. 38. Terranova W. The use of periosteal flaps in scalp and forehead reconstruction. Ann Plast Surg. 1990;25(6):450-456. 39. Molnar JA, DeFranzo AJ, Marks MW. Single-stage approach to skin grafting the exposed skull. Plast Reconstr Surg. 2000;105(1):174-177. 40. Mehrara BJ, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol. 2006;94(6):504-508. 41. Yeong EK, Huang HF, Chen YB, Chen MT. The use of artificial dermis for reconstruction of full thickness scalp burn involving the calvaria. Burns. 2006;32(3):375-379.
55. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The lower trapezius musculocutaneous flap revisited: versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery. Plast Reconstr Surg. 2002;109(2):444-450. 56. Tanaka Y, Miki K, Tajima S, Akamatsu J, Tsukazaki Y, Inomoto T. Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap. Br J Plast Surg. 1998;51(3): 250-254. 57. Har-El G, Bhaya M, Sundaram K. Latissimus dorsi myocutaneous flap for secondary head and neck reconstruction. Am J Otolaryngol. 1999;20(5): 287-293. 58. Kim JC, Hadlock T, Varvares MA, Cheney ML. Hair-bearing temporoparietal fascial flap
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Box. Considerations for Patient and Technique Selection
be closed with mini or micro hair grafts.9,22-24 Further discussion on hair transplantation is beyond the scope of this article.
Medical and functional status of the patient Patient preferences Radiation history or need for postoperative radiation
Reconstructive Ladder
Defect thickness, size, and location
Secondary Intention
Prior surgical procedures and previous incision placement
Secondary intention can be an acceptable option for reconstruction in selected clinical scenarios as long as certain criteria are met. Secondary intention works optimally when there is a pericranial layer present, generally on a concave surface, and in patients with lighter skin. Disadvantages include longer healing time, which can sometimes delay adjuvant therapy, tenuous coverage with contour mismatch, alopecia, and prominent telangiectasias (Table). However, one retrospective study16 of 205 consecutive patients with Moh wounds of the scalp followed 38 patients with exposed bone (defined as no periosteum or pericranial layer) who healed with no intervention except local wound care. The mean area of the exposed bone area was 1074 mm2, with all 38 patients healing their wounds without any signs of infection or tissue breakdown. The mean time to epithelialize if at least pericranium was present was 7 weeks, whereas bare bone took 13 weeks to heal. The authors16 concluded that secondary intention is a viable and safe option in selected patients even if the pericranial layer is not present. Other authors25 have reported similar experiences.
Status of pericranium and calvarial defects Type of malignant neoplasm Exposed dura with or without cerebrospinal fluid leak Hair status and patient’s hair expectations Alloplastic materials or grafts used in cranioplasty
are frequently reconstructed with custom-fabricated alloplastic cranioplasty prostheses with polyetheretherketone, hard-tissue replacement materials like polymethylmethacrylate or kryptonite bone cement, bone grafts, resorbable materials, or titanium plates.20 Cranioplastic reconstructions require coverage with well-vascularized tissue. Dural defects with possible cerebrospinal fluid leakage are also important to consider because wound healing may be compromised from fluid accumulation and possible infection.21 In patients with complicated wounds with multiple variables, such as calvarial deficiencies, dural defects, or cerebrospinal fluid leaks, a well-vascularized free flap may be the ideal choice to improve the reconstructive outcome.21 The hair-bearing scalp is a highly visible and unique tissue, which lacks a donor site that can closely approximate its characteristics. Great care should be applied to aesthetic reconstructive techniques with preservation of the patient’s hairlines and the scalp tissue’s normal hair-bearing characteristics. High-tension wound closure or liberal use of cautery may lead to follicular destruction and alopecic scars. This is particularly true when cautery is monopolar and is used above the level of the galea in the vicinity of hair follicles.
Reconstructive Goals The main goals in scalp reconstruction are 2-fold: functional and cosmetic. Functional considerations include protection of the calvarium to prevent desiccation and infection by providing an adequate blood supply via vascularized tissue.1 Such protection should provide adequate coverage to implant hardware (eg, alloplastic implants), and to limit donor site morbidity. In addition to the usual tenets of plastic surgery, including replacing “like with like,” cosmetic considerations unique to scalp reconstruction include maintaining an appropriate hairline and limiting alopecia and scar appearance with aesthetically placed incisions and attention to hair growth patterns. The concept of replacing “like with like” includes attention being paid to skin color match and thickness. Hair transplantation has gained increased popularity and is a useful adjunctive therapy or second revision procedure to areas of alopecia created from the defect or from the reconstruction itself. Alopecia created from incisional scars, skin grafts, or wounds closed under excessive tension can 60
Wound Vacuum-Assisted Closure Wound vacuum-assisted closure (ie, “wound VAC”) was introduced in the late 1990s as a potential wound care option for patients with nonhealing wounds, such as pressure ulcers. However, several studies have reported its used in scalp reconstruction in both the pediatric and adult populations in difficult wounds. Subotic et al26 reported a difficult case of a pediatric patient who had a scalp and calvarial defect with exposed dura that closed with a wound VAC over several weeks. Other authors27,28 have used this method as a temporizing measure for complex defects until further reconstruction can be performed. Vacuum-assisted closure is thought to promote tissue granulation and decrease wound volume by debriding devitalized tissue, decreasing bacterial colonization, promoting blood flow, and removing excess serous fluid that might inhibit wound healing.26,28,29 Contraindications to its use in the head and neck include grossly contaminated wounds, malignant neoplasm in the wound bed, necrosis, and osteomyelitis.29 In rare cases of large, extensive wounds in patients who are not good candidates for other options, hyperbaric oxygen therapy might be beneficial, although there are limited data on this topic. Growth factor therapy with becaplermin gel (Regranex; OrthoMcNeil Pharmaceutical) is also a potential option for patients with complicated scalp wounds as an adjunct to healing by primary intention. Becaplermin or recombinant human platelet-derived growth factor (rhPDGF) is currently approved by the US Food and Drug Administration for treatment of neuropathic diabetic ulcers.30 Off-label use of rhPDGF has been described in the successful treatment of a chronic scalp wound.31 However, this product is contraindicated in patients with known neoplasms at the site of application because there is an unknown increased risk of malignant disease.32 Ultimately, this material should be used with caution in patients with a known neoplasm.
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Table. The Reconstructive Ladder of the Scalp Reconstructive Ladder
Advantages
Disadvantages
Secondary intention
1. Does not require procedure to reconstruct
1. Alopecia of defect 2. Contour deformity, hypopigmentation, and tenuous covering 3. Need base of viable tissue present (eg, pericranium) 4. Longer healing time and prolonged wound car
Primary closure
1. Quick procedure 2. Limited alopecia with good contour and color match 3. Technically more straightforward 4. Easy to monitor site for tumor recurrence
1. Limited usually to defects
Review
Scalp Reconstruction An Algorithmic Approach and Systematic Review Shaun C. Desai, MD; Jordan P. Sand, MD; Jeffrey D. Sharon, MD; Gregory Branham, MD; Brian Nussenbaum, MD
IMPORTANCE Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area. OBJECTIVE To review the current literature and describe a novel algorithm to help guide the reconstructive surgeon in determining the optimal reconstruction from a cosmetic and functional standpoint. Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, as well as the reconstructive ladder, are also discussed.
Journal Club Slides at jamafacialplasticsurgery.com CME Quiz at jamanetworkcme.com and CME Questions page 72
EVIDENCE REVIEW A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence. FINDINGS Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer. CONCLUSIONS AND RELEVANCE Ideal reconstruction of scalp defects relies on a comprehensive understanding of scalp anatomy, a full consideration of the armamentarium of surgical techniques, and a detailed appraisal of patient factors and expectations. The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity.
Corresponding Author: Brian Nussenbaum, MD, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8115, St Louis, MO 63110 ([email protected]).
LEVEL OF EVIDENCE NA.
JAMA Facial Plast Surg. 2015;17(1):56-66. doi:10.1001/jamafacial.2014.889 Published online November 6, 2014.
T
he scalp covers the calvarium and is therefore critical not only for normal cosmesis but also for protecting the intracranial structures. It requires reconstruction when damaged by various causes, including benign or malignant tumor excision, infection, trauma, radiation necrosis, thermal or electrical burns, congenital lesions, or renovation of a cosmetically unappealing scar or alopecia. Modern surgical techniques have allowed the reconstructive surgeon to repair most scalp defects with success and prevent potentially disastrous complications from exposed bone, such as calvarial desiccation, sequestration, and sepsis.1 Use of the reconstructive ladder is highly pertinent to the repair of scalp defects. On each successive step of the ladder, the surgeon balances the complexity of the reconstruction against its necessity. In other words, the simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity.
56
Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri.
Scalp Anatomy Scalp Layers As with surgery in any location, a detailed understanding of the anatomy is key to planning a successful reconstruction. The layers of the scalp are frequently described by the mnemonic “SCALP.” This stands for Skin, subCutaneous tissue, galea Aponeurotica, Loose areolar tissue, and Pericranium (Figure 1). The scalp contains the thickest integument on the body, ranging from 3 to 8 mm in depth.2,3 When considering reconstruction, the unique characteristics of scalp skin and its hair-bearing nature must be considered, to provide an aesthetically pleasing reconstruction.4 The scalp’s blood vessels, lymphatic system, and nerves run superficial to the galea aponeurotica in the subcutaneous tissues. This is an important consideration when planning local flaps, since raising a flap superficial to the galea can impair flap vascularity.
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Figure 1. Layers of the Scalp and Temporoparietal Region
Subcutaneous tissue
Skin
Galea Loose areolar tissue Pericranium Calvarium
Calvarium Pericranium Temporal muscle with deep and middle temporal artery Temporalis fascia Temporoparietal fascia with STA Subcutaneous tissue Skin Superficial layer temporalis fascia Frontal branch facial nerve
Deep layer temporalis fascia Superficial temporal flat pad
Zygoma Deep temporal fat pad Masseter
SMAS Parotidomasseteric fascia
Mandible
Parotid gland
SMAS indicates superficial muscular aponeurotic system; STA, superficial temporal artery.
The galea aponeurotica provides strength to the overlying integument and blends with several other scalp structures. The galea is continuous anteriorly with the frontalis muscle fascia, posteriorly with the occipitalis muscle fascia, and laterally with the temporoparietal fascia. The galea itself is very inelastic and provides the reason for the “tight” and “loose” portions of the scalp (Figure 2). From the scalp vertex traveling caudally, the galea is fully formed, and the skin is tight and inelastic. Conversely, where the galeal edges blend into the temporoparietal fascia and scalp musculature fascia, the skin has improved mobility and can be more easily rearranged. It is important to note that the galea also fuses with the pericranium at the linea temporalis in the lateral frontal region.5 This is a key point for reconstruction because many local flaps seek to mobilize scalp from these looser locations and may require release of ligamentous attachments or considerable undermining depending on the location of the donor site tissue.1 Below the galea there is a loose connective tissue responsible for much of the mobility of the overlying scalp skin. This layer is also known as the subgaleal fascia, the innominate fascia, or the subaponeurotic plane.6,7 Scalp flaps are most frequently raised within this layer because it is easily dissected, and the critical neurovascular jamafacialplasticsurgery.com
structures remain superficial and unharmed. The cranial periosteum is tightly adherent to the calvarium and is the deepest layer of the scalp’s soft tissue. This layer is typically kept intact during scalp reconstruction and can serve as a vascularized surface for skin grafting depending on the reconstructive plan. Not infrequently, however, the scalp defect might include the absence of the pericranium. The pericranium is critically important for maintaining blood supply to the underlying calvarial bone. The calvarium is composed of frontal, parietal, temporal, occipital, and sphenoid bones. These bones are generally composed of 3 layers, including an outer table, a central diploic space, and an inner table. The tables vary in thickness depending on the location and age and genetic characteristics of the patient. Pediatric calvarium is typically very malleable and useful in terms of providing source material for a number of reconstructive grafts.8 Alternatively, skull bone of elderly individuals is hard, brittle, and less adaptable to manipulation. The anatomy of the temporal region is more complex than the rest of the scalp and deserves additional attention. Above the temporal line, or the superior attachment of the temporalis muscle, the scalp layers are as described herein. Just below the attachment of JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1
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Figure 2. Tight and Loose Layers of the Scalp
Tight scalp
Loose scalp
Once this artery reaches the superior helix of the ear, it branches to form an anterior-frontal division and a posterior parietal division. Vascular supply to the posterior portion of the scalp differs based on the nuchal line. Superior to the nuchal line, the occipital arteries provide vascular supply. Inferior to this line, perforating musculocutaneous branches through the trapezius and splenius capitis muscles are the main supply.1 The relatively small posterolateral area is supplied by the posterior auricular artery, also arising from the external carotid artery. An understanding of the main arterial supply of the scalp is important when designing local flaps of the scalp because axial blood supply must be incorporated. Lymphatic drainage of the scalp is also located in the subcutaneous plane and typically follows the venous drainage. However, cutaneous malignant neoplasms of the scalp can have highly variable patterns of spread, as shown with lymphoscintigraphy studies for sentinel lymph node biopsies for scalp melanomas. These studies show that lymphatic drainage can be found in the parotid, postauricular, suboccipital, posterior cervical, and jugulodigastric lymph nodes.13,14
Innervation
the temporalis muscle, the skin, subcutaneous fat, and galea remain the same. However, traveling inferiorly over the muscle, the galeal layer transforms into the temporoparietal fascia. This fascia is attached to the subcutaneous tissues and is continuous with the frontalis muscle fascia anteriorly and the superficial muscular aponeurotic system inferiorly. This layer provides the mobility of the looser areas of the scalp. The temporal branch of the facial nerve and superficial temporal artery are located within the temporoparietal fascia.9 Underneath the temporoparietal fascia exists a loose areolar tissue separating it from the temporalis fascia of the temporalis muscle. This temporalis fascia, however, splits into a deep layer and superficial layer around the superficial temporal fat pad a few centimeters superior to the zygomatic arch. Although originating as individual layers, the superficial layer of the deep temporal fascia, the temporoparietal fascia, and the periosteum fuse to form a single dense immobile layer at the level of the zygomatic arch. It is at this point that the frontal branch of the facial nerve is most vulnerable while it travels over the middle third of the zygomatic arch to innervate the frontalis and corrugator muscles on their deep surface. Dissection in this area, such as during elevation of a hemicoronal or bicoronal scalp flap, is frequently performed in the plane deep to the superficial layer of the deep temporal fascia to prevent facial nerve injury.9
Vascularity and Lymphatics The scalp is a highly vascular organ supplied by cutaneous arteries arising from 4 separate systems from both the internal and external carotid arteries (Figure 3).4,10 These vessels run in the subcutaneous plane superficial to the galea to form a vast system of collateralization that can even allow for a single artery replantation of a totally avulsed scalp.11,12 Anteriorly, the scalp is fed by the paired supraorbital and supratrochlear arteries originating from the ophthalmic artery from the internal carotid system. The lateral or temporoparietal scalp is the largest and is supplied by the superficial temporal artery, the terminal portion of the external carotid artery. 58
Innervation to the scalp is provided by the trigeminal nerve, the cervical spinal nerves, and branches from the cervical plexus. The supraorbital and supratrochlear nerves supply the skin of the forehead, the anterior hairline region, and the frontoparietal scalp. The zygomaticotemporal nerve provides sensation to the region lateral to the brow up through the temporal line. The auriculotemporal nerve provides much of the sensation to the lateral scalp. Posteriorly, sensation is transmitted through both the greater and lesser occipital nerves. These nerves are formed from the dorsal rami of the cervical spinal nerves and the cervical plexus, respectively. The greater occipital nerve typically emerges from the semispinalis muscle about 3 cm below the occipital protuberance and 1.5 cm lateral to the midline.15
Patient and Technique Selection Reconstructive planning for a scalp defect must take into account the extrinsic and intrinsic factors of the patient (Box). The surgeon should assess the overall health of the patient and his or her social situation, ability and commitment for wound care, and expectations for reconstructive surgery.16 Patient factors such as diabetes mellitus, smoking, corticosteroid use, previous surgical incisions, and prior or anticipated future scalp irradiation must be carefully evaluated and included in the treatment planning. Prior scalp irradiation produces skin fibrosis and can lead to intrinsic changes in the integument, creating a propensity for nonhealing wounds.17 This is a critical point because local flaps or wound closures under tension, which could survive in a nonirradiated scalp, may ultimately have disastrous outcomes in patients with a radiation history. In a retrospective review18 of 73 scalp procedures, preoperative scalp radiation, neoadjuvant or postoperative chemotherapy, and cerebrospinal fluid leak were all noted to be statistically significant on univariate analysis (P < .05) as risk factors for developing major complications. Potential need for postoperative radiation should also be considered when planning reconstruction, and greater consideration should be given to free tissue transfer over local flaps.18,19
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4. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ. The surgical anatomy of the scalp. Plast Reconstr Surg. 1991;87(4):603-612.
23. Nordström REA. Punch hair grafting under split-skin grafts on scalps. Plast Reconstr Surg. 1979; 64(1):9-12.
5. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105(4):1475-1490.
24. Limmer BL, Buchwach KA. Hair transplantation using follicular unit micrografting. Facial Plast Surg. 1999;7(4):523-535.
6. Elliott LF, Jurkiewicz MJ. Scalp and calvarium. In: Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S, eds. Plastic Surgery: Principles and Practice. St Louis, MO: Mosby; 1990:419-440. 7. Carstens MH, Greco RJ, Hurwitz DJ, Tolhurst DE. Clinical applications of the subgaleal fascia. Plast Reconstr Surg. 1991;87(4):615-626. 8. Ducic Y. Reconstruction of the scalp. Facial Plast Surg Clin North Am. 2009;17(2):177-187. 9. Hoffmann JF. Reconstruction of the scalp. In: Baker SR, ed. Local Flaps in Facial Reconstruction. St Louis, MO: Mosby; 2007:638. 10. Seery GE. Surgical anatomy of the scalp. Dermatol Surg. 2002;28(7):581-587. 11. Miller GDH, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg. 1976;58(2):133136. 12. Kaplan HY, Yaffe B, Borenstein A. Single artery replantation of totally avulsed scalp. Injury. 1993;24 (7):488-490. 13. Cappello ZJ, Augenstein AC, Potts KL, McMasters KM, Bumpous JM. Sentinel lymph node status is the most important prognostic factor in patients with melanoma of the scalp. Laryngoscope. 2013;123(6):1411-1415. 14. Close LG, Goepfert H, Ballantyne AJ, Jesse RH. Malignant melanoma of the scalp. Laryngoscope. 1979;89(8):1189-1196. 15. Mosser SW, Guyuron B, Janis JE, Rohrich RJ. The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches. Plast Reconstr Surg. 2004;113(2):693-697. 16. Becker GD, Adams LA, Levin BC. Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngol Head Neck Surg. 1999;121(6):751-754. 17. Goessler UR, Bugert P, Kassner S, et al. In vitro analysis of radiation-induced dermal wounds. Otolaryngol Head Neck Surg. 2010;142(6):845-850. 18. Newman MI, Hanasono MM, Disa JJ, Cordeiro PG, Mehrara BJ. Scalp reconstruction: a 15-year experience. Ann Plast Surg. 2004;52(5):501-506. 19. Hussussian CJ, Reece GP. Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstr Surg. 2002;109(6):1828-1834. 20. Sittitavornwong S, Morlandt AB. Reconstruction of the scalp, calvarium, and frontal sinus. Oral Maxillofac Surg Clin North Am. 2013;25 (2):105-129. 21. Chang KP, Lai CH, Chang CH, Lin CL, Lai CS, Lin SD. Free flap options for reconstruction of complicated scalp and calvarial defects: report of a series of cases and literature review. Microsurgery. 2010;30(1):13-18. 22. Barrera A. The use of micrografts and minigrafts for the treatment of burn alopecia. Plast Reconstr Surg. 1999;103(2):581-584.
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25. Snow SN, Stiff MA, Bullen R, Mohs FE, Chao WH. Second-intention healing of exposed facial-scalp bone after Mohs surgery for skin cancer: review of ninety-one cases. J Am Acad Dermatol. 1994;31(3, pt 1):450-454. 26. Subotic U, Kluwe W, Oesch V. Community-associated methicillin-resistant Staphylococcus aureus-infected chronic scalp wound with exposed dura in a 10-year-old boy: vacuum-assisted closure is a feasible option: case report. Neurosurgery. 2011;68(5):1481-1483. 27. Powers AK, Neal MT, Argenta LC, Wilson JA, DeFranzo AJ, Tatter SB. Vacuum-assisted closure for complex cranial wounds involving the loss of dura mater. J Neurosurg. 2013;118(2):302-308. 28. Marathe US, Sniezek JC. Use of the vacuum-assisted closure device in enhancing closure of a massive skull defect. Laryngoscope. 2004;114(6):961-964. 29. Brenner M. Scalp reconstruction. In: Branham G, ed. Facial Soft Tissue Reconstruction. Shelton, CT: Peoples Medical Publishing House; 2011:120. 30. Fang RC, Galiano RD. A review of becaplermin gel in the treatment of diabetic neuropathic foot ulcers. Biologics. 2008;2(1):1-12. 31. Harrison-Balestra C, Eaglstein WH, Falabela AF, Kirsner RS. Recombinant human platelet-derived growth factor for refractory nondiabetic ulcers: a retrospective series. Dermatol Surg. 2002;28(8): 755-759. 32. Hershcovitch MD, Hom DB. Update in wound healing in facial plastic surgery. Arch Facial Plast Surg. 2012;14(6):387-393. 33. Raposio E, Nordström RE, Santi PL. Undermining of the scalp: quantitative effects. Plast Reconstr Surg. 1998;101(5):1218-1222.
42. Tufaro AP, Buck DW II, Fischer AC. The use of artificial dermis in the reconstruction of oncologic surgical defects. Plast Reconstr Surg. 2007;120(3): 638-646. 43. Komorowska-Timek E, Gabriel A, Bennett DC, et al. Artificial dermis as an alternative for coverage of complex scalp defects following excision of malignant tumors. Plast Reconstr Surg. 2005;115(4): 1010-1017. 44. Koenen W, Goerdt S, Faulhaber J. Removal of the outer table of the skull for reconstruction of full-thickness scalp defects with a dermal regeneration template. Dermatol Surg. 2008;34(3): 357-363. 45. Gonyon DL Jr, Zenn MR. Simple approach to the radiated scalp wound using INTEGRA skin substitute. Ann Plast Surg. 2003;50(3):315-320. 46. Khan MA, Ali SN, Farid M, Pancholi M, Rayatt S, Yap LH. Use of dermal regeneration template (Integra) for reconstruction of full-thickness complex oncologic scalp defects. J Craniofac Surg. 2010;21(3):905-909. 47. Jung SN, Chung JW, Yim YM, Kwon H. One-stage skin grafting of the exposed skull with acellular human dermis (AlloDerm). J Craniofac Surg. 2008;19(6):1660-1662. 48. Wilensky JS, Rosenthal AH, Bradford CR, Rees RS. The use of a bovine collagen construct for reconstruction of full-thickness scalp defects in the elderly patient with cutaneous malignancy. Ann Plast Surg. 2005;54(3):297-301. 49. Seyhan A, Yoleri L, Barutçu A. Immediate hair transplantation into a newly closed wound to conceal the final scar on the hair-bearing skin. Plast Reconstr Surg. 2000;105(5):1866-1870. 50. Frodel JL, Mabrie D. Optimal elective scalp incision design. Otolaryngol Head Neck Surg. 1999; 121(4):374-377. 51. Orticochea M. Four flap scalp reconstruction technique. Br J Plast Surg. 1967;20(2):159-171. 52. Orticochea M. New three-flap reconstruction technique. Br J Plast Surg. 1971;24(2):184-188.
34. Ibhler N, Ziegler MC, Penna V, Eisdenhardt SU, Stark GB, Bannasch H. An algorithm for oncologic scalp reconstruction. Plast Reconstr Surg. 2010;126 (2):450-459.
53. Horch RE, Stark GB. The contralateral bilobed trapezius myocutaneous flap for closure of large defects of the dorsal neck permitting primary donor site closure. Head Neck. 2000;22(5):513-519.
35. Cox AJ III, Wang TD, Cook TA. Closure of a scalp defect. Arch Facial Plast Surg. 1999;1(3):212-215.
54. Uğurlu K, Ozçelik D, Hüthüt I, Yildiz K, Kilinç L, Baş L. Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure. Plast Reconstr Surg. 2004;114(2):339-350.
36. Worlicek C, Kaufmann R. Divided full-thickness skin graft for closure of circular and oval scalp defects. J Dtsch Dermatol Ges. 2012;10(4):274-276. 37. Kuwahara M, Hatoko M, Tanaka A, Yurugi S, Mashiba K. Simultaneous use of a tissue expander and skin graft in scalp reconstruction. Ann Plast Surg. 2000;45(2):220. 38. Terranova W. The use of periosteal flaps in scalp and forehead reconstruction. Ann Plast Surg. 1990;25(6):450-456. 39. Molnar JA, DeFranzo AJ, Marks MW. Single-stage approach to skin grafting the exposed skull. Plast Reconstr Surg. 2000;105(1):174-177. 40. Mehrara BJ, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol. 2006;94(6):504-508. 41. Yeong EK, Huang HF, Chen YB, Chen MT. The use of artificial dermis for reconstruction of full thickness scalp burn involving the calvaria. Burns. 2006;32(3):375-379.
55. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The lower trapezius musculocutaneous flap revisited: versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery. Plast Reconstr Surg. 2002;109(2):444-450. 56. Tanaka Y, Miki K, Tajima S, Akamatsu J, Tsukazaki Y, Inomoto T. Reconstruction of an extensive scalp defect using the split latissimus dorsi flap in combination with the serratus anterior musculo-osseous flap. Br J Plast Surg. 1998;51(3): 250-254. 57. Har-El G, Bhaya M, Sundaram K. Latissimus dorsi myocutaneous flap for secondary head and neck reconstruction. Am J Otolaryngol. 1999;20(5): 287-293. 58. Kim JC, Hadlock T, Varvares MA, Cheney ML. Hair-bearing temporoparietal fascial flap
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Box. Considerations for Patient and Technique Selection
be closed with mini or micro hair grafts.9,22-24 Further discussion on hair transplantation is beyond the scope of this article.
Medical and functional status of the patient Patient preferences Radiation history or need for postoperative radiation
Reconstructive Ladder
Defect thickness, size, and location
Secondary Intention
Prior surgical procedures and previous incision placement
Secondary intention can be an acceptable option for reconstruction in selected clinical scenarios as long as certain criteria are met. Secondary intention works optimally when there is a pericranial layer present, generally on a concave surface, and in patients with lighter skin. Disadvantages include longer healing time, which can sometimes delay adjuvant therapy, tenuous coverage with contour mismatch, alopecia, and prominent telangiectasias (Table). However, one retrospective study16 of 205 consecutive patients with Moh wounds of the scalp followed 38 patients with exposed bone (defined as no periosteum or pericranial layer) who healed with no intervention except local wound care. The mean area of the exposed bone area was 1074 mm2, with all 38 patients healing their wounds without any signs of infection or tissue breakdown. The mean time to epithelialize if at least pericranium was present was 7 weeks, whereas bare bone took 13 weeks to heal. The authors16 concluded that secondary intention is a viable and safe option in selected patients even if the pericranial layer is not present. Other authors25 have reported similar experiences.
Status of pericranium and calvarial defects Type of malignant neoplasm Exposed dura with or without cerebrospinal fluid leak Hair status and patient’s hair expectations Alloplastic materials or grafts used in cranioplasty
are frequently reconstructed with custom-fabricated alloplastic cranioplasty prostheses with polyetheretherketone, hard-tissue replacement materials like polymethylmethacrylate or kryptonite bone cement, bone grafts, resorbable materials, or titanium plates.20 Cranioplastic reconstructions require coverage with well-vascularized tissue. Dural defects with possible cerebrospinal fluid leakage are also important to consider because wound healing may be compromised from fluid accumulation and possible infection.21 In patients with complicated wounds with multiple variables, such as calvarial deficiencies, dural defects, or cerebrospinal fluid leaks, a well-vascularized free flap may be the ideal choice to improve the reconstructive outcome.21 The hair-bearing scalp is a highly visible and unique tissue, which lacks a donor site that can closely approximate its characteristics. Great care should be applied to aesthetic reconstructive techniques with preservation of the patient’s hairlines and the scalp tissue’s normal hair-bearing characteristics. High-tension wound closure or liberal use of cautery may lead to follicular destruction and alopecic scars. This is particularly true when cautery is monopolar and is used above the level of the galea in the vicinity of hair follicles.
Reconstructive Goals The main goals in scalp reconstruction are 2-fold: functional and cosmetic. Functional considerations include protection of the calvarium to prevent desiccation and infection by providing an adequate blood supply via vascularized tissue.1 Such protection should provide adequate coverage to implant hardware (eg, alloplastic implants), and to limit donor site morbidity. In addition to the usual tenets of plastic surgery, including replacing “like with like,” cosmetic considerations unique to scalp reconstruction include maintaining an appropriate hairline and limiting alopecia and scar appearance with aesthetically placed incisions and attention to hair growth patterns. The concept of replacing “like with like” includes attention being paid to skin color match and thickness. Hair transplantation has gained increased popularity and is a useful adjunctive therapy or second revision procedure to areas of alopecia created from the defect or from the reconstruction itself. Alopecia created from incisional scars, skin grafts, or wounds closed under excessive tension can 60
Wound Vacuum-Assisted Closure Wound vacuum-assisted closure (ie, “wound VAC”) was introduced in the late 1990s as a potential wound care option for patients with nonhealing wounds, such as pressure ulcers. However, several studies have reported its used in scalp reconstruction in both the pediatric and adult populations in difficult wounds. Subotic et al26 reported a difficult case of a pediatric patient who had a scalp and calvarial defect with exposed dura that closed with a wound VAC over several weeks. Other authors27,28 have used this method as a temporizing measure for complex defects until further reconstruction can be performed. Vacuum-assisted closure is thought to promote tissue granulation and decrease wound volume by debriding devitalized tissue, decreasing bacterial colonization, promoting blood flow, and removing excess serous fluid that might inhibit wound healing.26,28,29 Contraindications to its use in the head and neck include grossly contaminated wounds, malignant neoplasm in the wound bed, necrosis, and osteomyelitis.29 In rare cases of large, extensive wounds in patients who are not good candidates for other options, hyperbaric oxygen therapy might be beneficial, although there are limited data on this topic. Growth factor therapy with becaplermin gel (Regranex; OrthoMcNeil Pharmaceutical) is also a potential option for patients with complicated scalp wounds as an adjunct to healing by primary intention. Becaplermin or recombinant human platelet-derived growth factor (rhPDGF) is currently approved by the US Food and Drug Administration for treatment of neuropathic diabetic ulcers.30 Off-label use of rhPDGF has been described in the successful treatment of a chronic scalp wound.31 However, this product is contraindicated in patients with known neoplasms at the site of application because there is an unknown increased risk of malignant disease.32 Ultimately, this material should be used with caution in patients with a known neoplasm.
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Table. The Reconstructive Ladder of the Scalp Reconstructive Ladder
Advantages
Disadvantages
Secondary intention
1. Does not require procedure to reconstruct
1. Alopecia of defect 2. Contour deformity, hypopigmentation, and tenuous covering 3. Need base of viable tissue present (eg, pericranium) 4. Longer healing time and prolonged wound car
Primary closure
1. Quick procedure 2. Limited alopecia with good contour and color match 3. Technically more straightforward 4. Easy to monitor site for tumor recurrence
1. Limited usually to defects
