Scalp Recon Grand Rounds
Scalp Recon Grand Rounds
Principles of Scalp
Reconstruction
Code: ZUTHEG
March 29, 2017
Candace Mitchell, MD PGY-4
Advisors: Dr. Heffelfinger, Dr. Krein
Overview
Outline: Scalp Reconstruction
• Case Presentation
• Background
• History
• Anatomy
• Preoperative Assessment
• Surgical Technique
• Algorithm for approach to scalp defects
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Case Presentation #1
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Case Presentation #1
• Intraoperative defect:
• 9 x 9cm
• Pericranium intact
• Occipital soft tissue
mass
• 4 x 4 cm
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Case Presentation #2
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Case Presentation
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Case Presentation
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Case Presentation
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Case Presentation
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Case Presentation
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Case Presentation
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Case Presentation
• Considerations:
• What is the expected defect?
• What associated deficits might we encounter?
• How does his medical history affect our surgical plan?
• XRT
• Recent forearm surgery
• What reconstructive options are available?
• Goals:
• Eradicate disease
• Provide coverage for vital structures
• Optimize aesthetic outcomes
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Background: Scalp defects
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History
History
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Anatomy
Basic Anatomy of the Scalp
• SCALP
• Skin
• SubCutaneous
• Aponeurosis
• Loose connective
tissue
• Pericranium
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Basic Anatomy of the Scalp
• SCALP
• Skin
• SubCutaneous
• Aponeurosis
• Loose connective
tissue
• Pericranium
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Temporal Anatomy
• Defined by thickness
of galea
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Arterial Supply
• ECA system
predominates
• Anteriorly: ICA
• Highly
redundant
• Most vessels lie
within galea/
subcutaneous
layer
• Extensive lymphatic
network
• No nodes in scalp
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Hair physiology
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Patient Assessment
Patient Assessment
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Associated Pathology
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Associated Pathology
• Bony defects
• Goals: provide contour, protect brain
• Monocortical defects:
• May cause scalp deformity
• Some may not require additional
reconstruction
• Calcium hydroxyapatite cement for
larger defects
• Full-thickness defects:
• Small defects: Calcium
hydroxyapatite +/- mesh
• Larger defects:
• Split cranial bone, acrylic/titanium
mesh Source: Blackwell “Reconstruction of
Cutaneous Malignancies of the Scalp
and Lip”
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Surgical Approach
Reconstructive ladder – scalp defects
• Secondary intention
• Primary closure
• VAC-assisted closure
• Skin grafting
• Tissue expansion
• Local flaps
• Regional flaps
• Free tissue transfer
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Secondary intention
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Secondary intention
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Skin grafting
• Advantages:
• Easy, fast
• Tension-free closure
• Can close large defects
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STSG – wound preparation
• Full-thickness wounds
• Options:
• Burr down outer table
• Integra – collagen-GAG wound
matrix with silicone outer layer
• Stimulates granulation formation
• Can be used as a temporizing
measure
• Other materials
• Typically wait 3 weeks to allow
granulation to form
• Advantages:
• Limited alopecia
• Favorable contour/color
match
• Fast/simple
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Primary closure: Technique
• Technique:
• Ellipse - 3:1 ideal ratio
• Wide undermining in subgaleal
plane
• Score galea to achieve relaxation
• Closure:
• Close galea first (minimize tension)
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Source: Leedy et al.
Local flaps
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Local flaps: Advancement flaps
• Scalp: minimal
distensibility
• No RSTLs exist in scalp
• Advancement flaps
therefore less useful
• Single/double advancement
may be useful for:
• Small defects
• Temporal defects
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Local flaps: Rotational flaps
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Local flaps: Rotational flaps
• Examples:
• O-Z flap
• Pinwheel flap
• Examples:
• OàZ flap
• Defects <5cm, vertex
• Pinwheel flap
• Examples:
• O-Z flap
• Pinwheel flap
6mo Post
6wk Post
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Local flaps: Orticochea flap
• Described by Miguel
Orticochea in 1968
• Initially 4-flap technique
• Revised to 3-flap technique in 1972
• Technique: Multiple
transposition flap
• 2 lateral flaps: STA
• 1 posterior flap: occipital
• Galeal releasing incisions
• Technique: Bipedicled
advancement flap
• V-V donor site
• May allow for closure at
both primary and donor
site.
• Defect size: 3-50 cm2
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Tissue expansion
• Intraoperative tissue
expansion
• Relies on mechanical creep
• Inflate until pale/indurated
• Deflate after 3min, repeat
Source: Papel et al
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Tissue expansion
• Ideal for:
• Occipital/temporal defects
• h/o XRT
• TPF flap: can provide tissue for
grafting
• Disadvantages:
• Donor site morbidity
• Not hair-bearing
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Free Tissue Transfer
• Ideal for:
• Disadvantages:
• Extensive defects
• Long operative time, hospital
• History of XRT stay
• Defects involving skull/dura • Donor site morbidity
• Chronic infection • Not hair-bearing, color/
contour mismatch
• Advantages:
• Robust coverage
• High success rate
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Free Tissue Transfer
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Free tissue transfer – ALTFF
Source: Desai et al
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Free tissue transfer - RFFF
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Free tissue transfer – Latissimus Dorsi + STSG
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Free tissue transfer – Total scalp defect
Algorithm for approach to defects
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Small defects (<9cm2)
• Considerations:
• Location
• Involvement of hairline
• Reconstructive options:
• Primary closure
• Local flaps
• Considerations:
• Location
• History of/need for XRT
• Involvement of hairline
• Reconstructive options:
• Local flaps
• Tissue expansion
• Free tissue transfer (XRT)
• Considerations:
• Location
• History of/need for XRT
• Involvement of hairline
• Reconstructive options:
• Orticochea flap
• Tissue expansion
• Free tissue transfer
• Regional flap
• Total scalp:
• Free tissue transfer
• Considerations:
• 9 x 9cm vertex defect
• Bald area of scalp
• 4 x 4 cm occipital mass
• Recurrent tumor – may
require XRT
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Case Presentation #1
• Reconstruction: O-Z
• Wide undermining
• Galeal scoring
• Resection of
subcutaneous mass
• “Tissue expander”
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Case Presentation #1
• Reconstruction: O-Z
• Wide undermining
• Galeal scoring
• Resection of
subcutaneous mass
• “Tissue expander”
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Case Presentation #1
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Case Presentation #1
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Case Presentation #2
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Case Presentation #2
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Case Presentation #2
• Successes of reconstruction:
• Good contour
• Coverage of defect
• Tension-free closure
• Single-stage
• Minimal distortion of hairline
• Drawbacks:
• Poor color-match
• Hair-bearing donor tissue
• Ultimately, noted to have
recurrence along suture line
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Case Presentation #2
• Re-resection
• Partial removal of previous
flap
• Right ALTFF
• Anastamosis: contralateral
facial vessels
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Conclusions: Scalp reconstruction
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References
• Desai, S.C., et al., Scalp reconstruction: an algorithmic approach and systematic review. JAMA Facial Plast
Surg, 2015. 17(1): p. 56-66.
• Leedy, J.E., J.E. Janis, and R.J. Rohrich, Reconstruction of acquired scalp defects: an algorithmic approach.
Plast Reconstr Surg, 2005. 116(4): p. 54e-72e.
• Baker, S.R. and N.A. Swanson, Local Flaps in Facial Reconstruction. 1995: Mosby.
• Pasha, R. and J.S. Golub, Otolaryngology : head and neck surgery : clinical reference guide. 3rd ed. 2011, San
Diego ; Oxford: Plural Pub. xxiii, 598 p.
• Hwang, L., et al., The Visor Flap: A Novel Design for Scalp Wound Closure. J Craniofac Surg, 2017. 28(2): p.
e146-e148.
• Steiner, D., et al., Scalp reconstruction: A 10-year retrospective study. J Craniomaxillofac Surg, 2017. 45(2): p.
319-324.
• Orticochea, M., Discoveries and methods in plastic surgery. 1996, Colombia: Consultario Especialistas
Columbia. pp. 161-73.
• Badhey, A., et al., Multiflap closure of scalp defects: Revisiting the orticochea flap for scalp reconstruction.
Am J Otolaryngol, 2016. 37(5): p. 466-9.
• Papel, I.D., Facial plastic and reconstructive surgery. 2nd ed. 2002, New York: Thieme. xviii, 910 p.
• Jordan, JR. “Reconstruction of Scalp Defects.” Accessed at - http://missoto.org/uploads/
JRJordan_Friday_MSO_6_2014_Reconstruction_of_Scalp_Defects.pdf
• Blackwell, K. “Reconstruction of Cutaneous Malignancies of the Scalp and Lip.” Powerpoint presentation, 2006.
• Rompolas, P., K.R. Mesa, and V. Greco, Spatial organization within a niche as a determinant of stem-cell fate.
Nature, 2013. 502(7472): p. 513-8.
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Thank you!
Special thanks to Dr. Heffelfinger and Dr. Krein