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Year : 2019 | Volume : 7 | Issue : 3 | Page : 77 - 80  


Original Articles
A study of various reconstructive options and their complications and management of scalp defects

Sushrut Tated1, Imran Ahmed 2, Sheikh Sarfaraz Ali 1, Asif Iqbal Sheikh 1, Kunal Mokhale 1, Girish Sharma 1

1Resident, 2Professor, Department of Plastic Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, UP, India

Correspondence:

Dr. Sushrut Tated                                                                                                                                               

E-mail: sushrut.tated@gmail.com                                                                                                   

Abstract:

Background: Scalp defects are mainly caused due to trauma, tumour resection and burns. The repair of such defect is dependent upon their location, size and depth

Objectives: To study various reconstructive options and their complications and to provide a framework for management of scalp defects

Methods: This was a prospective study done on patients who have had scalp defects requiring surgery. Total of 30 patients were included in the study. Tumor histology was confirmed by the pathology department. All patients were followed for 3 to 6 months post operatively. Free Flap was done in six patients.  Anterolateral thigh flap and Radial Forearm Free Flap were done. STSG was applied in 9 patients. Tissue expander was applied in 3 patients. Local flaps like rotation, transposition etc was done in 12 patients.

Results: Etiology found was   Road Traffic accident in majority of patients i.e. 10. Burn and basal cell carcinoma was etiology in 6 patients each. Squamous cell carcinoma was found in 5 patients. Fall from height was etiology in 4 patients.  Males were more than females. Free flap was done in six patients. Split thickness skin graft was done in nine patients. Tissue expander was used in three patients. Local flap was used in twelve patients. Three patients had tip necrosis and two patients had infection. Out of three having tip necrosis, two were operated by using free flap with conservative approach. Local flap was used in one patient. Out of two patients with infection, local flap was used in one patient and STSG was used in one.

Conclusion: In small to medium sized defect with exposed bone, local flaps are a good option. In large and extensive defects, free flaps should be used.

Key words: reconstructive, complications, management, scalp defects

INTRODUCTION: 

Scalp defects are mainly caused due to trauma, tumour resection and burns. The repair of such defect is dependent upon their location, size and depth. 1-3

Excision of malignant tumors such as squamous cell cancer, basal cell carcinoma, or angiosarcoma, and irradiation necrosis can cause large scalp or forehead defects. Elderly patients are involved in the majority of these cases, whereas the age range of patients suffering from scalp defects acquired by trauma or burns is usually younger. Other causes of scalp defects include congenital lesions and infections. In scalp the repair of even small defects is complicated. 1

In cases where the pericranium is intact a split thickness skin graft is a simple treatment since direct closure is often not possible due to the lack of elasticity of the scalp. If the periosteum is denuded or in cases with skull defect, local or free flaps are necessary for a sufficient coverage. Various local flaps and free flaps including bone are available for reconstruction. Rotation, advancement and transpositioning scalp flaps are the reference for reconstructing these defects. The correct design of such flaps includes preservation of the original hairline, acceptable redirectioning of the hair follicles, the incorporation of large vascular pedicles, and wound closure without excessive tension. 3 These flaps in turn may require skin grafts to cover the donor zone. 1

Another option is the employment of tissue expanders either prior to resection in certain cases. 4 Knowledge of scalp anatomy is essential for preparing these flaps. 4 The pericranium (skull bone) is covered by skin, subcutaneous tissue, partially diverse muscles, the galea, and loose connective tissue. Due to the tight galea aponeurosis, which forms a fibrous connection between the frontalis muscle anteriorly and the occipitalis muscle posteriorly, the scalp is relatively inelastic.

Present study was carried out to study various reconstructive options and their complications and to provide a framework for management of scalp defects

METHODS:

Study design: This was a prospective study

Study period: from 2017 to 2018

Settings: Department of Plastic Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh

Sample population: Present study was done on patients who have had scalp defects requiring surgery. Total of 30 patients were included in the study.

Ethical considerations: Institutional Ethics Committee permission was obtained before the study was initiated. Written informed consent was obtained from all patients.

Inclusion criteria:

  1. patients who have had scalp defects requiring surgery
  2. willing to participate in the study

Exclusion criteria:

  1. seriously ill patients
  2. not willing to participate

Methodology:

Tumor histology was confirmed by the pathology department. All patients were followed for 3 to 6 months post operatively. Free Flap was done in six patients.  Anterolateral thigh flap and Radial Forearm Free Flap were done. STSG was applied in 9 patients. Tissue expander was applied in 3 patients. Local flaps like rotation, transposition etc was done in 12 patients.

Statistical analysis:

The data was entered in the Microsoft Excel worksheet. Appropriate statistical test was applied. 

RESULTS: 

Table 1: Distribution of study subjects as per etiology of scalp defect

Etiology of scalp defect

Number

%

Road traffic accident

10

33.3

Burns

06

20

Basal cell carcinoma

06

20

Squamous cell carcinoma

05

16.7

Fall from height

03

10

Etiology found was   Road Traffic accident in majority of patients i.e. 10. Burn and basal cell carcinoma was etiology in 6 patients each. Squamous cell carcinoma was found in 5 patients. Fall from height was etiology in 4 patients. 

Table 2: Patient characteristics Characteristic

Gender

Number

%

Male

19

63.3

Female

11

36.7

Males were more than females.

Table 3: Distribution as per surgery performed

Surgery performed

Number

%

Free flap

6

20

Split thickness skin graft

9

30

Tissue expander

3

10

Local flap

12

40

Free flap was done in six patients. Split thickness skin graft was done in nine patients. Tissue expander was used in three patients. Local flap was used in twelve patients.

Table 4: Distribution as per complications and management

Complications

Surgery

Number of Pt.

Management

Tip necrosis

Free flap

2

Conservative

Local flap

1

Conservative

Infection

STSG

1

Conservative

Local flap

1

Conservative

Three patients had tip necrosis and two patients had infection. Out of three having tip necrosis, two were operated by using free flap with conservative approach. Local flap was used in one patient. Out of two patients with infection, local flap was used in one patient and STSG was used in one.

DISCUSSION:

Although the soft tissue of scalp is highly vascularized, there is limited elasticity due to underlying galea and pericranium. Therefore, option of primary closure is possible in limited number of small defects. 6 Primary closures is usually possible for defects less than 3 cm. 6

Skin grafting is excellent option in cases of good vascular bed of nonirradiated tissue. It is easy to perform .However; it results in a suboptimal cosmetic outcome. Also, it may not be durable as normal skin. 7 Tissue expansions cause minimal cosmetic deformity. However, immediate skin expansion is not possible in the oncologic patients. In addition, use of the technique is associated with complication and multiple hospital visits. 8

Local flaps with or without STSG are the mainstay of scalp reconstruction. They are more durable and help in healing in wound of small to medium defects. It has advantage of short surgical time, simplicity of procedure and minimum morbidity. They are of same color and texture. Donor and recipient site is in one operative field.  However they cannot be used in extensive defects.  Numerous free flaps have been described for scalp reconstruction. Free flaps have become the treatment of choice for extensive scalp defects. They can be used in previously irradiated, infected and traumatized areas where local flaps cannot be used. 9

CONCLUSION:

Road traffic accident is most common etiology followed by burns and skin malignancy. Ideal treatment depends on size of defect and patient factors. If peri-cranium and good vascular bed is available, then STSG is a viable option. In small to medium sized defect with exposed bone, local flaps are a good option. In large and extensive defects, free flaps should be used.

REFERENCES:

  1. Frodel JL, Ahlstrom K. Reconstruction of complex scalp defects: the banana peel revisited. Arch Facial Plastic Surg 2004 Jan 1;6(1):54-60.
  2. Demir Z, Velidedeoglu H, Çelebioglu S. VYS plasty for scalp defects. Plastic Reconstruct Surg 2003 Sep 15;112(4):1054-8.
  3. Mehrotra S, Nanda V, Shar RK. The islanded scalp flap: a better regional alternative to traditional flaps. Plastic Reconstruct Surg. 2005 Dec 1;116(7):2039-40.
  4.  Lutz BS, Wei FC, Chen HC, Lin CH, Wei CY. Reconstruction of scalp defects with free flaps in 30 cases. Br J Plastic Surg 1998 Jan 1;51(3):186-90.
  5.  Newman MI, Hanasono MM, Disa JJ, Cordeiro PG, Mehrara BJ. Scalp reconstruction: a 15-year experience. Annals Plastic Surg 2004 May 1;52(5):501-6.
  6. Raposio E, Nordström RE, Santi P. Undermining of the scalp: quantitative effects. Plastic Reconstruct Surg 1998 Apr;101(5):1218-22.
  7. Hoffman JF. Management of scalp defects. Otolaryngol Clin North Am. 2001;34:571-582.
  8. Hussussian CJ, Reece GP. Microsurgical scalp reconstruction in the patient with cancer. Plastic Reconstruct Surg. 2002 May;109(6):1828-34.
  9. Patel MP, Spinelli HM. The scalping flap for reconstruction of upper cranial and cranial base defects. Plastic Reconstruct Surg. 2004 Jul 1;114(1):186-9.
  10. Lutz BS. Scalp and forehead reconstruction. Seminars Plastic Surg 2010;24(2):171-180

Figure 1: Local transposition flap with split thickness skin graft for small defect due to electric burn

 

Figure 2A: Case of squamous cell carcinoma  of scalp

 

Figure 2B: Flap marking for anterolateral thigh flap

Figure 2C: Flap inset in to recipient defect

 

D) Post operative photograph after 2 weeks

 

Figure 3A: Hair loss due to burn

 

Figure 3B: Placement of sialistic expander in subgaleal plane

Figure 3C: Postoperative after 3 months

 

Figure 4: Split thickness skin graft done for scalp defect

 

 





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