Reconstruction of Scalp Defects Using Non-Microsurgical Techniques

INTRODUCTION
Plastic surgeons reconstruct a wide range of
defects of the scalp and cranial vault. The etiology
of these defects may be due to congenital, traumatic
or neoplastic causes [1]. The goals of reconstruction
of scalp defects are to achieve protection of underlying
central nervous system and obtaining an
aesthetically accepted shape of the scalp [2].
Reconstructive options for these defects include
skin grafts [3], local flaps [4] and free flaps [5].
Defects with intact underlying periostium can be
reconstructed with skin grafts while other wounds
with exposure of underlying calvarial bones, dura
223
matter or brain tissues require flap coverage. Acellular
dermal matrix and skin graft has been used
in scalp reconstruction with successful outcomes
[6].
Tissue expansion was used in reconstruction
of scalp defects successfully [7]. However, it is not
applicable to traumatic cases and we did not include
cases managed by tissue expansion in this study.
The surgical application of free flaps for repair
of scalp defects was documented [8]. This reconstructive
option is not discussed in this article. In
this article, we will focus on the use nonmicrosurgical
techniques that are involved in reconstruction
of scalp defects, their benefits and
limitations.
PATIENTS AND METHODS
This is a retrospective study for 13 cases who
underwent immediate reconstruction of scalp defects
from October 2015 to May 2019. The causes
of scalp defects were congenital, traumatic or after
tumor ablation. Institutional Review Board (IRB)
approval was obtained.
The inclusion criteria included patients with
scalp defects and an informed patient consent was
obtained after explaining the recommended surgical
procedure, its benefits, limitations and expected
outcomes.
The following procedures were done:
- Partial thickness skin grafts: Grafts were used
to repair of scalp wounds when vascularized beds
(periosteum, aponeurosis or subcutaneous tissues)
are available.
- Local flaps with or without skin graft: Different
local flaps configuration were used in scalp
wounds reconstruction including transposition,
rotation Fig. (1) or advancement flaps.
- Pin wheel flaps (multiple rotation and transposition
flaps): This technique was applied to cover
to medium defects especially at the temporal
region or vertex Fig. (2).
- Ortichoa technique: This technique was applied
to reconstruct medium to large defects at the
vertex.
- Drilling of the diplopic space and skin grafting
Fig. (3): To expose the diplopic space, the outer
table of the skull was drilled. After dressing
changes, healthy granulation tissues are formed
and creeped to coat the outer table bones. In a
second surgery, we applied Thiersch skin grafts
224 Vol. 44, No. 1 / Reconstruction of Scalp Defects Using Non-Microsurgical Techniques
were applied to cover the granulation tissues.
Artificial dermal regeneration template (Integra):
Artificial skin was applied to complicated
wound when there is no available flap coverage
and the dura was exposed. After 3 weeks, we
discarded the external silicone layer and a meshed
ultra-thin skin graft was applied to the healthy bed
containing the integrated dermal component of the
Integra.
We recorded the following data for each patient:
Age, sex, cause of scalp defects, site and size of
scalp defects, type of surgery performed and complication
rates.
Fig. (1): Case number 5. (A): Pre-operative photo of a case with congenital scalp defect at the
vertex. (B): Three weeks post-operative view where rotation flap was done.
(A) (B)
Fig. (2): Case number 3. (A): Pre-operative photo of a case with post electrical burn scalp defect
at the temporal region. (B): 2 months post-operative view.
(A) (B)
Egypt, J. Plast. Reconstr. Surg., January 2020 225
RESULTS
In this study, we operated 13 cases, 12 cases
(92%) were males and one case (8%) was female.
The range of the age of our patients was from 2
weeks to 72 years (average 34.1 years). The etiology
of scalp wounds defects was either congenital
in one case (7.7%), traumatic in seven cases (53.8),
in one case electrical burn (7.7%) or after tumor
excision in four cases (30.8%).
The dimensions of the scalp defects were from
20cm X 8cm to 3cm X 4cm. The following regions
of the scalp were affected temporal (8 cases),
parietal (7 cases), occipital (2 cases) and forehead
(one case). The reconstructive procedures were
skin graft (in 5 cases), rotation flaps (utilized in 4
cases), transposition flaps (in 4 cases), drill holes
(in 3 cases), (Integra) artificial dermal regeneration
template (in one case), pinwheel flap (in one case)
and Ortichoa flaps (in one case). Table (1) shows
patients demographic data. Early complication was
delayed wound healing in one case. Late complication
included dog ear formation in one case and
tumor recurrence in one case. An algorithm is
proposed for management of various scalp defects
Fig. (5).
Table (1): Patients’ demographic data.
123456789
10
11
12
13
Tumor meningioma
Tumor fibroma
Electrical burn
Trauma
Congenital
Tumor BCC
Trauma
Trauma
Trauma
Trauma
Trauma
Tumor
Trauma
Age Cause
72
42
25
4
2 weeks
65
25
35
30
52
7
65
21
Sex
MF
MMMMMMMMMMM
Site
Temporal-Occipital-Parietal
Temporal-
Temporal
Parietal-temporal
Parietal
Parietal
Temporal
Temporal
Parietal
parietal-temporal
Temporal-forehead
Parietal
Occipital
Size
20*8
12*7
10*5
18*10
4*3
8*7
5*4
4*3
8*5
12*7
10*4
15*10
5*7
Surgery
Integra-drill holes-skin graft
Skin graft
Pinwheel flaps
Drill holes-transposition flap-skin grafts
Rotation flap
Ortichoa flaps
Rotation flap
Rotation flap
Rotation flaps
Transposition flaps
Drill holes and skin graft
Transposition flaps and skin graft
Transposition flaps
Fig. (3): Case number 4. (A): Pre-operative
photo of a case with traumatic scalp avulsion
with exposed right temporal and parietal bones.
(B): Post-operative view of the first surgery
where transposition flap was done to cover the
parietal bone and graulation tissues was formed
at the temporal bones after performing multiple
drill holes and dressing changes. (C): 6 months
post-operative view of second surgery where
skin grafts were applied to cover granulation
tissues overlying the temporal bones.
(A) (B)
(C)
226 Vol. 44, No. 1 / Reconstruction of Scalp Defects Using Non-Microsurgical Techniques
Fig. (4): Case number 5. (A): Pre-operative photo of a 72 years old male patient who had previous resection of meningioma
in the temporal region. A transposition flap and split rib graft were used to reconstruct the temporal defect. Unfortunately,
ischemic skin flaps and graft failure occurred. (B): Post-operative view of the first operation where debridement of necrotic
tissues and drill holes in the occipital region were done. There is exposed meninges in the temporal region. (C): Post-operative
view of the second surgery where Integra was applied to the exposed meninges. (D): Intraoperative view of the third surgery
where the outer silicone layer of the Integra was removed and successful take of the dermal layer of the Integra was confirmed.
(E): Immediate post-operative view after application of meshed skin grafts. (F): 6 months post-operative view.
Fig. (5): An algorithm for scalp reconstruction.
(A) (B) (C)
(D) (E) (F)
Exposed Carnial Bones,
Meninges, Brain
Intact Periostium or
Aponeurosis
Scalp Defect
Less than 8*8 Cm Less than 20*8 Cm More than 20*8 Cm Skin Graft
Rotation
Flap
Multiple
Rotation Flaps
Exposed
Dura
Exposed
Bones
Free Flap if
Available
Integra Drilling and Skin
Grafts
Egypt, J. Plast. Reconstr. Surg., January 2020 227
DISCUSSION
Coverage of soft tissues wounds of the scalp
is the task of the plastic surgeons [9]. The reconstructive
options include healing by dressing changes
and secondary intention, healing by direct suturing
and primary closure, the use of skin grafts,
local scalp flaps, regional pedicled flaps and microvascular
free flaps [10].
In the current study, we did not include any
free flaps. Free flaps are the best option for covering
total or near total scalp defects. Latissimus Dorsi
[11], omentum [12], radial forearm [13] and anterolateral
thigh [14] free flaps have been utilized
successfully for coverage of scalp defects. However,
there are some disadvantages and limitations.
Extreme of age, presence of co-morbid conditions
and patients willing to have a less extensive surgery
are the major contraindications free flap usage. In
addition, any other tissues in the body cannot match
the unique character of the scalp tissues of having
a dense population of hairs.
Regional flaps like pedicled Latissimus Dorsi
[15] or pedicled trapezius [16] cannot reach all areas
of the scalp specially the vertex and supply tissues
with questionable vascularity. The distal part of
the flap is the most needed tissue for reconstruction
and the tissue most far from the pedicle with the
lowest perfusion.
Skin grafts have the benefits of being an easy
technique with rapid healing properties when applied
to a well-vascularized bed [17]. When we are
not confident about safety margin after tumor
clearance, skin grafts allow early and easy detection
of tumor recurrence. However, it has the limitations
of poor take if applied to exposed cortical bones
and the presence of post-operative alopecia and
donor site morbidity.
Local scalp flaps can reconstruct scalp defects
up to 8 X 8cm with direct closure. The combination
of multiple rotations' flaps with or without skin
grafts can cover extensive scalp defects. The advantages
of usage of local scalp flaps are an easy
rapid technique, short hospital stay and limited
alopecia just at the suture lines. It is major disadvantages
is the long incision lines with extensive
undermining [18].
Healing by direct suture closure is possible
only in limited defect sizes less than 3cm [19].
Healing by secondary intension and dressing changes
is time consuming technique and has a poor
cosmetic outcomes [20]. In this study, we did not
include cases managed by the previous two techniques.
The technique of removal of outer table of skull
to speed the process of granulation tissue formation
and skin grafting has been used in management of
massive scalp loss [21]. We used this technique in
three cases when no local flaps are available to
cover the skull bones and free flap cannot be used
due to extreme of age or anesthesia contraindications.
Despite the need of two surgeries, stable
wound coverage was obtained successfully.
Dermal regeneration template is used successfully
in coverage of complex scalp defects [22].
We used it in one case to cover the exposed dura.
After 3 weeks, a second surgery was needed to
cover the successfully taken dermal component
with partial thickness skin grafts. We did not observe
any tissue breakdown or infection in this
artificial template.
In this study, we succeeded to cover extensive
and complicated scalp defects without the use of
microsurgical techniques. The combination of
different reconstructive solutions can achieve good
results without the exposure of the risks and limitation
to microsurgical reconstruction.
Conclusion:
Efficient scalp reconstruction needs a detailed
and accurate understanding of the anatomy of the
different components of the scalp and mastering
a variety of reconstructive options in order to be
able to manage various scalp defects. When microsurgical
reconstruction is not available or contraindicated,
a number of more simplified techniques
can be used effectively.