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Scalp Recon Grand Rounds

The document discusses principles of scalp reconstruction, presenting two cases of basal cell carcinoma defects. It covers the anatomy of the scalp, surgical assessment of defects, and various reconstructive techniques including secondary intention healing, skin grafting, tissue expansion, and local or free flaps. The goal is to eradicate disease while optimizing aesthetic outcomes and addressing any associated neurological or structural issues.

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Paul Marji
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100% found this document useful (1 vote)
206 views81 pages

Scalp Recon Grand Rounds

The document discusses principles of scalp reconstruction, presenting two cases of basal cell carcinoma defects. It covers the anatomy of the scalp, surgical assessment of defects, and various reconstructive techniques including secondary intention healing, skin grafting, tissue expansion, and local or free flaps. The goal is to eradicate disease while optimizing aesthetic outcomes and addressing any associated neurological or structural issues.

Uploaded by

Paul Marji
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Otolaryngology 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

3/29/17 3
Case Presentation #1

• 69M with h/o BCC of scalp excised 10yr ago


• Presented with recurrent lesion of scalp
• Location: vertex
• Bx: BCC
• Also had a soft-tissue occipital scalp mass
• Pt reported slow growth x4yr

3/29/17 4
Case Presentation #1

• Intraoperative defect:
• 9 x 9cm
• Pericranium intact
• Occipital soft tissue
mass
• 4 x 4 cm

3/29/17 5
Case Presentation #2

• 64M longstanding history of BCC of R temple


• 25 years ago: first BCC removed from area
• 7 years ago: changes to R eye and temple
• Bx: BCC
• Resection: negative margins
• 3 years ago: recurrence
• Re-excision à positive periosteal/bone margins à XRT
• New progressive vision loss OD (LP only)
• Loss of R forehead motion
• PMHx:
• CAD s/p MI with stents, 6-12 EtOH/week, Afib, GERD, HTN
• BCC removed from L arm and flank ~1mo ago

3/29/17 6
Case Presentation

3/29/17 7
Case Presentation

3/29/17 8
Case Presentation

3/29/17 9
Case Presentation

3/29/17 10
Case Presentation

3/29/17 11
Case Presentation

3/29/17 12
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

3/29/17 13
Background: Scalp defects

• Causes of scalp defects


• Surgical wounds related to skin or
other cancers
• Most common: BCC/SCC of skin
• Melanoma: less common
• Risk factors: Sun exposure, age,
immunocompromise
• Trauma
• Shearing injuries: typically involve
loose areolar layer
• Both sources may have associated
neurologic deficit
• Underlying cranial involvement/injury
• Facial nerve function in specific areas

3/29/17 14
History
History

• 1696: Augustin Belloste


• Perforation of bare cranium to
facilitate granulation
• 1871: Netolitzky
• Skin grafting over granulation
tissue
• 1908: Robinson
• Skin grafting over intact
periosteum
• 1953: Kazanjian – galeal scoring
• Orticochea:
• 1967 - four-flap technique
• 1971 – three-flap technique
“The surgeon must move the cutaneous covering
of the skull with the same facility with which a
3/29/17 boy peels a banana.” - Orticochea (1975) 16
History

• 1950s-70s: Tissue Expansion


• 1957: Neumann - First clinical
use of tissue expansion (ear
recon)
• 1978: Radovan - popularizes
tissue expansion for scalp
• 1984 : Manders – tissue
expansion for extensive scalp
defect
• 1976-present: Free tissue
transfer
• 1976: Miller – replantation of
total scalp avulsion

3/29/17 17
Anatomy
Basic Anatomy of the Scalp

• SCALP
• Skin
• SubCutaneous
• Aponeurosis
• Loose connective
tissue
• Pericranium

Source: Leedy et al “Reconstruction of Scalp Defects” 2005

3/29/17 19
Basic Anatomy of the Scalp

• SCALP
• Skin
• SubCutaneous
• Aponeurosis
• Loose connective
tissue
• Pericranium

Source: Jordan “Reconstruction of Scalp Defects.”

3/29/17 20
Temporal Anatomy

Source: Papel et al.

Source: Desai et al.


3/29/17 21
Zones of distensibility

• Defined by thickness
of galea

• Tight areas of scalp


• Thick galea, no
underlying muscle
• Vertex to edge of
temporalis
• Loose areas of scalp
• Thin galea
• Parietal/occipital
areas overlying
muscle
Source: Desai et al 2016

3/29/17 22
Arterial Supply

• ECA system
predominates
• Anteriorly: ICA
• Highly
redundant
• Most vessels lie
within galea/
subcutaneous
layer

3/29/17 Source: Desai et al 2016 23


Sensory Supply

Source: Leedy et al 2005


3/29/17 24
Lymphatic drainage

• Extensive lymphatic
network
• No nodes in scalp

• Drain to adjacent nodal


basins:
• Parotid
• Anterior/posterior
auricular
• Occipital

3/29/17 25
Hair physiology

• Average scalp: more than 100k hairs


• 3 stages:
• Anagen - growth phase
• 90-95% of hairs
• Duration: ~1000 days
• Catagen - involutional phase
• 1-2% of hairs
• Duration: 2-3 weeks
• Telogen - dormant phase
• 5-10% of hairs
• Duration: 2-3 mo
Source: Rompolas et al 2005

3/29/17 26
Patient Assessment
Patient Assessment

• Overall patient health


• Able to tolerate general anesthesia?
• History of/need for radiation
• Prior surgeries
• Defect size
• Pathology
• Defect location
• Associated vascular anatomy
• Distensibility of nearby scalp
• Hair-bearing or not? Involvement of hairline?
• Involvement of adjacent structures

3/29/17 28
Associated Pathology

• Location, Location, Location!


• Intracranial extension of large tumors
• Bony defects
• Neurologic involvement – dural defects, CSF leaks
• Ear involvement
• Status of TM, need for EAC reconstruction
• Sinus involvement
• Frontal obliteration/cranialization
• Facial nerve involvement/injury
• Lesions of temporal/frontal scalp

• Associated deficits may need to be addressed prior to/


concurrent with reconstruction

3/29/17 29
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”

3/29/17 30
Surgical Approach
Reconstructive ladder – scalp defects

• Secondary intention
• Primary closure
• VAC-assisted closure
• Skin grafting
• Tissue expansion
• Local flaps
• Regional flaps
• Free tissue transfer

3/29/17 32
Secondary intention

• Appropriate for: • Disadvantages:


• Small defects • Allopecia
• Bald patients (vertex • Requires underlying
defects) pericranium/muscle
• Prolonged healing time
• Extensive wound care
• Hypopigmentation
• Resultant tissue friable
• Advantages:
• No additional procedures

3/29/17 33
Secondary intention

3/29/17 34
Skin grafting

• Appropriate for: • Disadvantages:


• Defects in non-cosmetic • Alopecia
areas • Requires pericranium/
• Poor medical status granulation for graft take
• Closure of secondary defects • Friable/thin tissue
• Temporary closure for tissue • Not appropriate if post-op
expansion XRT expected
• High risk of recurrence

• Advantages:
• Easy, fast
• Tension-free closure
• Can close large defects

3/29/17 35
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

Source: Jordan “Reconstruction of


Scalp Defects”
3/29/17 36
Skin grafting

Source: Papel et al.


3/29/17 37
Primary closure

• Appropriate for: • Disadvantages:


• Defects <3cm • Limited size
• Hair-bearing areas • Requires extensive
• Hairline undermining
• Dog ears
• May distort hairline

• Advantages:
• Limited alopecia
• Favorable contour/color
match
• Fast/simple

3/29/17 38
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)

• Dog ears: may not require


revision

3/29/17
Source: Leedy et al.
Local flaps

• Appropriate for: • Disadvantages:


• Medium-sized defects • Large incisions/extensive
• Select large defects undermining necessary
• Medically complex patients • Closure may be under
tension
• Creation of secondary
defects
• Advantages:
• Single-stage
• Good contour/color match

3/29/17 40
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

3/29/17 41
Local flaps: Rotational flaps

• Main workhorse for scalp


reconstruction
• Technique:
• Bevel incisions to parallel
hair growth
• Keep in mind vascular
anatomy
• Galeal relaxing incisions
• Graft secondary defect

• Disadvantage: long incision


• Length = 4-6x width of defect
Source: Jordan “Reconstruction of
Scalp Defects”
3/29/17 42
Local flaps: Rotational flaps

Source: Leedy et al.

3/29/17 43
Local flaps: Rotational flaps

• Multiple rotation flaps


• Distributes tension over scalp
• Smaller flaps required
• May allow recruitment from more
elastic areas
• Disadvantage: more incisions

• Examples:
• O-Z flap

• Pinwheel flap

Source: Jordan “Reconstruction of


3/29/17 Scalp Defects” 44
Local flaps: Rotational flaps

• Multiple rotation flaps


• Distributes tension over scalp
• Smaller flaps required
• May allow recruitment from more
elastic areas
• Disadvantage: more incisions

• Examples:
• OàZ flap
• Defects <5cm, vertex
• Pinwheel flap

Source: Jordan “Reconstruction of


3/29/17 Scalp Defects” 45
Local flaps: Rotational flaps

• Multiple rotation flaps


• Distributes tension over scalp
• Smaller flaps required
• May allow recruitment from more
elastic areas
• Disadvantage: more incisions

• Examples:
• O-Z flap

• Pinwheel flap

3/29/17 Source: Desai et al. 46


Local flaps: Rotational flaps

Pre-op 1wk Post 2wk Post

6mo Post
6wk Post

47
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

• Can be used on defects up to


9x12cm
• Provides hair-bearing tissue
Source: Orticochea M. “Flaps of the
Cutaneous Covering of the Skull.”
3/29/17 48
Local flaps: Orticochea flap

3/29/17 Source: Leedy et al. 49


Local flaps: Orticochea flap

Source: Orticochea M. “Flaps of the


Cutaneous Covering of the Skull.”
3/29/17 50
Local flaps: Visor flap

• Described by Hwang et al.

• Technique: Bipedicled
advancement flap
• V-V donor site
• May allow for closure at
both primary and donor
site.
• Defect size: 3-50 cm2

Source: Hwang et al. 2016


3/29/17 51
Tissue expansion

• Appropriate for: • Disadvantages:


• Hair-bearing scalp • Duration of expansion
• Larger defects • Multiple procedures
• Non-malignant processes • Disfigurement during
• Compliant patients expansion
• Risk of infection/extrusion
• May require grafting for
temporary coverage
• Advantages:
• Good contour/color match
• Recruits hair-bearing tissue
• Versatile

3/29/17 52
Tissue expansion

• Long-term tissue expansion


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computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

• Relies on biologic creep


• Duration:
• Begin inflation 2 weeks after
implantation
• Inflation: 4-8 weeks
• Areas with thin skin require
slower expansion
• Inflate until overlying skin is The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your
computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

indurated or until patient


discomfort
• If blanching occurs, deflate
slightly

• Intraoperative tissue
expansion
• Relies on mechanical creep
• Inflate until pale/indurated
• Deflate after 3min, repeat
Source: Papel et al

3/29/17 53
Tissue expansion

Net tissue effect:


• Blood flow - increases
• Dermis – thins, increased
fibroblasts
• Epidermis – thickens,
increased mitotic activity
• Fat – thins up to 50%
• Muscle – decreased mass,
maintains function

3/29/17 Source: Leedy et al 54


Tissue expansion

3/29/17 Source: Papel et al 55


Tissue expansion

Can replace defects up to


50% of scalp

Galeal scoring - may decrease


• Expansion time
• Patient discomfort

Expander base = 2.5x


width of defect
• Net gain by shape:
• Round: 25%
• Crescent: 32%
• Rectangle: 38%

3/29/17 Source: Leedy et al 56


Regional flaps The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your
computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

• Ideal for:
• Occipital/temporal defects
• h/o XRT
• TPF flap: can provide tissue for
grafting

• Common flaps used:


• Trapezius
• Lattisimus dorsi
• Temporoparietal

• Disadvantages:
• Donor site morbidity
• Not hair-bearing

3/29/17 57
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

3/29/17 58
Free Tissue Transfer

• Common donor sites: • Common recipient vessels:


• Latissimus Dorsi • Facial vessels
• Anterolateral thigh • STA/STV
• Radial forearm

3/29/17 59
Free tissue transfer – ALTFF

Source: Desai et al

3/29/17 60
Free tissue transfer - RFFF

3/29/17 61
Free tissue transfer – Latissimus Dorsi + STSG

3/29/17 62
Free tissue transfer – Total scalp defect
Algorithm for approach to defects
3/29/17 Source: Desai et al 65
Small defects (<9cm2)

• Considerations:
• Location
• Involvement of hairline

• Reconstructive options:
• Primary closure
• Local flaps

3/29/17 Source: Desai et al 66


Medium defects
(9-30cm2)

• Considerations:
• Location
• History of/need for XRT
• Involvement of hairline

• Reconstructive options:
• Local flaps
• Tissue expansion
• Free tissue transfer (XRT)

3/29/17 Source: Desai et al 67


Large defects
(>30cm2)

• 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

3/29/17 Source: Desai et al 68


Case Presentations
Case Presentation #1

• Considerations:
• 9 x 9cm vertex defect
• Bald area of scalp
• 4 x 4 cm occipital mass
• Recurrent tumor – may
require XRT

3/29/17 70
Case Presentation #1

• Reconstruction: O-Z
• Wide undermining
• Galeal scoring
• Resection of
subcutaneous mass
• “Tissue expander”

3/29/17 71
Case Presentation #1

• Reconstruction: O-Z
• Wide undermining
• Galeal scoring
• Resection of
subcutaneous mass
• “Tissue expander”

3/29/17 72
Case Presentation #1

3/29/17 73
Case Presentation #1

3/29/17 74
Case Presentation #2

3/29/17 75
Case Presentation #2

• Extensive defect involving:


• R orbit/maxilla
• R ethmoid/maxillary/frontal
sinuses
• Inner and outer table of skull
• Resection of dura
• Reconstruction: Left ALTFF
• Musculocutaneous free flap
• Anastamosis: R ECA and EJ
• Cranial/Orbital reconstruction
• Dura-Matrix synthetic dura
• Titanium mesh cranioplasty
• Titanium mesh orbital
reconstruction
• Frontal sinus obliteration

3/29/17 76
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

3/29/17 77
Case Presentation #2

• Re-resection
• Partial removal of previous
flap
• Right ALTFF
• Anastamosis: contralateral
facial vessels

3/29/17 78
Conclusions: Scalp reconstruction

• May run the gamut of reconstructive ladder


• Anticipation of associated pathology/
defects is paramount
• “Load the Boat”
• Key considerations in reconstruction:
• Defect size, location
• Involvement of hairline
• History of/anticipation of XRT

3/29/17 79
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.

3/29/17 80
Thank you!
Special thanks to Dr. Heffelfinger and Dr. Krein

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