7 Scalp Reconstruction Vivek V. Gurudutt and Eric M. Genden
Although seemingly straightforward, the reconstruction of the scalp has required creativity and innovation from surgeons throughout medical history. Creating a balance of appropriate coverage of underlying structures and maintaining cosmesis is oftentimes challenging. The range of defects can be of the scalp alone to deficits of the scalp, bone, and dura. Calvarial and scalp defects require managing potential cerebrospinal fluid leaks in addition to contouring the skull asthetically.1 Matching skin thickness and color as well as maintaining hair-bearing skin are goals of therapy that are not always attainable. Beyond trauma and congenital deformities, oncologic resection is a specific aspect of reconstruction that forces surgeons to be resourceful. Delays in treatment can lead to tumor progression and greater reconstructive complexity. Therefore, delaying resection to allow for tissue expansion is not often recommended.2,3 Scalp reconstruction should provide durable coverage, preserve blood supply, and allow proper wound drainage without breakdown and calvarial exposure.3 The challenge of patients with previous surgical scars, pre- and postsurgical radiation, and dural invasion requires much thought before treatment to fulfill these ideals. The scalp can be a limiting factor in reconstruction. It is difficult to match in terms of thickness, color, and density of hair follicles. As a result, the best tissue type for scalp reconstruction is the scalp itself.1 Management historically focused on primary closure and the use of skin grafts to cover areas of granulation. Preservation of the pericranium allowed for better take of grafted skin. As early as the 1600s, calvarial perforation was suggested as a method of promoting granulation formation. The development of local flaps allowed for closure of defects and preserving hair formation and skin thickness. In the late 1960s and early 1970s, Orticochea4,5 described a four-flap and eventually a three-flap technique for closing large scalp defects. These flaps enabled greater success at wound closure and preservation of hair-bearing tissue. For nononcologic reconstruction, the use of tissue expansion has allowed closure of large defects and maintaining some hair-bearing potential. Regional flaps were found
to be useful for reconstruction of occipital defects, but are limited in cosmesis. The challenges of reconstruction in the oncologic patient as well as a method of covering large surface areas of the skull were met with the development of microvascular reconstruction. Free tissue transfer has enabled surgeons to correct for previous surgeries, wound breakdown, and radiation therapy and still manage to cover entire scalp defects.
â—† RELEVANT ANATOMY The scalp is composed of five distinct layers: skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and the periosteum of the skull. The skin is the thickest compared with that on other areas of the body. The subcutaneous tissue contains most of the blood supply and lymphatics. The galeal layer is the strength layer and provides the most limitation of scalp movement. It attaches to the fascia overlying the frontalis muscle anteriorly, the temporoparietal fascia laterally, and the occipitalis muscle fascia posteriorly. Deep sutures at this level help alleviate tension along the skin.6 Epicranial muscles lie between the loose areolar tissue and the galea.7 Mobility is greatest at the parietal regions of the scalp where the temporoparietal fascia overlies the temporalis fascia.1 Advancement from this area allows the most gain for rotational flaps. To help increase length, galeotomies can be used. Galeotomies at 1-cm intervals can decrease tension by 40% and gain 1.67 mm per incision.8 The cuts should be parallel to the blood supply to avoid devascularization, as the vessels are immediately superficial to the galea.6,9,10 Compromise of blood supply can lead to alopecia as well as necrosis of reconstructive flaps.10 The blood supply of the scalp is composed of branches of the internal and external carotid arteries. The anterior scalp receives its vascularization from the supraorbital and supratrochlear arteries. The superficial temporal artery and the posterior auricular artery supplies the scalp laterally and
133
Genden_5763_Chapter7_main.indd 133
2/24/2012 6:44:18 PM
M
Reconstruction of the Head and Neck posterolaterally, respectively. The superficial temporal artery supplies the greatest region in the scalp and branches into frontal and parietal vessels.7 The posterior aspects of the scalp receive its blood supply from the occipital artery above the nuchal line. Below this area is supplied by the perforators of the trapezius and splenius capitis muscles. Collateralization between these distinct territories is extensive. The use of local flaps should incorporate one of these major vessel systems to ensure adequate vascularization. Venous drainage from the frontalis, parietal, and occipital veins matches their corresponding arteries and drains the frontal, lateral, and posterior scalp into the external jugular vein.7 Neural innervation of the scalp is derived from a combination of cranial and cervical nerves. The anterior aspect is supplied by the first branch of the trigeminal nerve through the supraorbital and supratrochlear nerves. Laterally, the zygomaticotemporal, auriculotemporal, and the lesser occipital nerves provide innervation from the second and third branches of the fifth cranial nerve. Along the posterior scalp, cervical branches from C2 and C3 provide branches for the lesser and greater occipital nerves. Superiorly, the scalp is supplied by the third occipital nerve and is a branch of C3. In general, the pericranium of the vertex of the skull is less sensitive than the inferior areas. Neither the bones nor the veins of the skull receive any proprioception or nociception.7
â—† CLASSIFICATION OF DEFECTS
M
The size, depth, and location of the defect have the greatest impact as to what type of reconstruction should be used for scalp reconstruction. Although no one staging system exists, various algorithms have been suggested throughout the literature. Beasley et al11 describe a staging system based on size and suggest potential reconstruction options. Scalp defects less than 200 cm2 are classified as stage IA. Stage IB defects are the same size as stage IA, but they are associated with associated risk factors for failure, such as heavy trauma, infection, previous radiation, or a history of failed closure. Stage II defects are 200 to 600 cm2 in size. Stage III defects are larger than 600 cm2. Primary closure or local flaps are recommended only for stage IA defects, whereas free flaps are recommended for all other stages.11 Leedy et al1 differentiate defects by size and location. Anterior defects that are small and do not affect the hairline can be closed primarily. Rotational flaps are recommended to preserve or restore the hairline. Moderate (up to 25 cm2) and large defects (>25 cm2) can be closed with rotational advancement flaps and temporoparietal flaps, respectively. Tissue expansion and Orticochea flaps are also useful. For larger parietal defects, tissue expansion is required. Skin grafting over muscle and rotational flaps are other viable options. For large occipital lesions, Orticochea flaps and tissue expansion are useful as well as rotational flaps for smaller lesions that cannot be closed primarily. For vertex lesions, Leedy et al recommend primary closure for small lesions. For lesions less than 4 cm in width, closure with galeal scoring or a pinwheel flap is suggested. Otherwise, large rotational or advancement flaps
with back grafting or tissue expansion are needed. Leedy et al recommend free tissue transfer for patients with neartotal scalp defects. Iblher et al2 reviewed defects from oncologic resections and created an algorithm for closure based on size and location as well. For defects less than 3 to 4 cm in size, primary closure is recommended. If the defect is less than 6 to 8 cm (4 to 5 cm near the hairline), a split-thickness skin graft or local flap is advocated. Defects less than 8 to 10 cm necessitate free flap closure. If the larger defect is occipital, regional flaps are potential candidates for reconstruction. Although opinions vary on when to use which reconstructive option, a thorough understanding of each is necessary before tailoring a treatment plan for an individual patient.
â—† OPTIONS FOR RECONSTRUCTION If primary closure cannot be achieved, even with the aid of galeotomies, several options are available to aid in reconstruction. Healing by secondary intention and allowing granulation of a defect is one method of closure. This technique requires meticulous care of the defect over several weeks of healing. However, it requires no additional surgery, does not require a vascular pedicle, and allows easy detection of tumor recurrence.12 This technique is useful in patients with multiple medical comorbidities that may impede wound healing. Split- or full-thickness skin grafting can be used over the granulation bed. Skin grafting over the defect is another method of closure. It is helpful to graft over areas of granulation, intact pericranium, or muscle to allow for the greatest chance for the graft to take. Burring down the outer layers of the calvaria and revealing the diploic space can be useful to help with vascularization if the pericranium is not viable.3 The ideal area to graft are nonirradiated defects with a good vascular bed and no need for postoperative radiation.3 Split-thickness skin grafts can cover a large wound area and allow for easy detection of tumor recurrence.11,12 Thinner grafts have a better chance of survival due to less nutritional requirements; however, they are not as durable as other modalities of closure. To improve graft survival on previously radiated bone that granulates slowly, galeal flaps can be used. These flaps rotate or transpose galea from sites adjacent to the defect and improve skin graft take by providing a vascular bed.13 Split grafts often are not cosmetically advantageous, with poor color and poor thickness matching. If meshing of the graft can be avoided, the appearance can be improved, but will sacrifice coverage surface area. Tissue expanders follow the tenet of replacing scalp with scalp and are useful in patients not limited by time constraints for reconstruction. As a result, the oncologic patient is not the best candidate for the weeks necessary to allow adequate expansion time.2,3 The process involves implanting an expander and inflating the device over several weeks. A fibrous capsule forms around the expander, allowing an increase in blood supply to the scalp.6 The expanders must be 2 to 2.5 times the size of the defect to be reconstructed.14 The shape of the expander can affect the amount of tissue gained. Round, crescentic, and rectangular expanders allow
134
Genden_5763_Chapter7_main.indd 134
2/24/2012 6:44:18 PM
7 Scalp Reconstruction for 25%, 32%, and 38% tissue gain, respectively.15 Expanders are considered for planning of reconstruction or large defects of up to 50% of the scalp.16 The use of expanders enables maintaining the normal hair pattern by expanding the hairbearing scalp. It is useful in tissue in which local flaps are inadequate secondary to the size of the defect, the trauma to tissue, or unacceptable alopecia or hairline distortion.1 Although the area of skin is increased with expansion, the number of hair follicles remains the same. As a result, the density of follicles is decreased the more the scalp is expanded.6 Complications rates can be higher than 20% and are more likely to occur in infected or radiated tissue.3,11,17,18 Intraoperative rapid expansion allows a small increase in tissue gain by taking advantage of the mechanical creep of the tissue and with galeotomies may allow primary closure of larger defects of up to 5 cm at the vertex.10,14 External tissue expansion utilizes negative pressure on the scalp surface to increase the surface area for closure. External expander thickness ranges from 2 to 5 cm. The process takes 3 to 6 weeks and is associated with minimal risks.19 Local flaps transpose, advance, or rotate viable surrounding scalp into the defect for closure. They consist of skin, subcutaneous tissue, and galea. They enable closure of defects that cannot be managed with primary closure and provide excellent cosmesis. Combining the technique with skin grafting the donor sites allows for better coverage in more cosmetic areas. Relocating hair-bearing skin to more visible areas increases the overall aesthetic appeal of this technique. Attempts at preserving the natural orientation of the hair follicles also should be made. Local flaps are useful in defects less than 6 to 8 cm in size away from the hairline and up to 4 to 5 cm near the hair border.2 The art of local tissue transfer requires experience and ingenuity for the surgeon to achieve acceptable closure and aesthetics. Various types of flaps can be utilized for closure of scalp defects and include yin-yang, pinwheel, Orticochea, V to Y, rhombic, Juri, and H flaps (Figs. 7.1 and 7.2).1,2,4–6,20 Defects of the forehead and scalp are best managed as separate anatomic units to better preserve the hairline.6 If possible, local flaps should utilize a major arterial vessel to maintain axial blood supply.6 Minimizing tension at the skin with galeal sutures reduces the risk of alopecia along the suture line. Avoiding devascularization and tension of rotational flaps is paramount to avoiding wound breakdown. Skin staples are also helpful to avoid ischemia to hair follicles and can decrease incisional alopecia.1 Dog ears that are formed during closure can be left to resolve over time and eliminate the risk of compromising blood supply during removal.1,6 The use of local flaps for large defects is limited due to the size of the flap necessary for closure as well as the inelasticity and lack of mobility of the scalp.21 Regional flaps for scalp reconstruction are useful for lower occipital or temporal defects. The reach of these flaps are the major limiting factor. Regional flaps are useful in palliative situations or in patients in whom longer procedures would be detrimental to the patient.2 Temporoparietal, trapezius, latissimus dorsi, and pectoralis major pedicled flaps are potentially useful and provide coverage of 8 to 10 cm.2 The aesthetic match of thickness and color is not ideal, and hair coverage is often inadequate; however, when the
Fig. 7.1  Medium-sized scalp defect with planned pinwheel closure.
temporoparietal flap is used with a skin graft, the result can be acceptable. In this approach, the temporoparietal flap is raised and transferred into the defect (Fig. 7.3). The skin graft can then be harvested and applied to the defect over the temporoparietal flap (Fig. 7.4). The long-term results demonstrate that the skin graft provides excellent color match and tone (Fig. 7.5).
Fig. 7.2  Wide undermining of the scalp allows for a pinwheel closure of the defect.
M
135
Genden_5763_Chapter7_main.indd 135
2/24/2012 6:44:19 PM
Reconstruction of the Head and Neck
Fig. 7.3 An extensive defect of the lateral scalp and forehead managed with a temporoparietal flap transferred into the defect.
Free tissue transfer has enabled the reconstruction of the most complex defects. Near-total scalp defects, a history of prior radiation, scarring from previous surgeries, and failure of previous closure are difficult clinical dilemmas best closed with free flap coverage.1,10,20 Hussussian and Reece21 noted 90% of delayed free flap reconstruction was secondary to radiation therapy. The use of bone with free flaps can aid in
M
Fig. 7.4 The skin graft is placed over the vascularized temporoparietal flap.
Fig. 7.5 Three-month follow-up demonstrates a healed defect with an acceptable color match.
closure of calvarial defects, and watertight closure of the skin paddle allows closure of dural defects when positioned appropriately.10 Free tissue transfer can be limited in cosmesis secondary to thickness and color matching difficulty as well as the lack of hair-bearing skin. The superficial temporal as well as the occipital vessels can be used for anastomosis.1,11,21 If these vessels are not amenable, vessels in the neck are then explored. The length of the pedicle can pose issues for reconstruction and interposed vein grafts can be helpful in this situation.11,21 The latissimus dorsi flap allows a large size, low donor-site morbidity, and ease of harvest.22 The muscle has minimal bulk and a long pedicle, and can be used with or without skin.2,3,10 Adding the serratus anterior muscle allows for even greater scalp coverage.1 The largest scalp defects can be covered with two latissimus dorsi free flaps. Rectus muscle flaps also allow large areas to be covered with limited thickness. Adding a skin graft to latissimus or rectus muscle eliminates a contour issue; however, flap monitoring, color matching/cosmesis, and durability of the skin is decreased.23 The radial forearm is useful for smaller defects, and the anterior lateral thigh is another potential source in patients with limited flap bulk. Serratus anterior muscle and omentum can be used with skin grafts to gain coverage.24 The serratus flap can be harvested with vascularized rib to address calvarial defects.21,25 Parascapular fasciocutaneous flaps can be considered for reconstruction and offer a good thickness match to the scalp.23 Scapular flaps with skin offer a good substitute for forehead skin in terms of color, texture, and thickness. The length of surgery and recovery in older patients with multiple medical comorbidities can be a limiting factor in free flap reconstruction.23 Balancing patient body habitus, medical conditions, as well as the nature of the defect is necessary in determining the type of flap to be used.
136
Genden_5763_Chapter7_main.indd 136
2/24/2012 6:44:21 PM
7 Scalp Reconstruction
Fig. 7.6 Clinical case of a patient with prior radiotherapy and an infected cranioplasty. The cranioplasty material was removed and the defect washed out.
Techniques such as hair transplantation can be used to improve aesthetics in patients after reconstruction. The results are the most successful if done as a second procedure and if follicular unit grafting is used.1,6 Success rates for hair implantation in free flaps are 90% and can be incorporated into split-thickness skin grafts that overlie myofascial flaps.10 Calvarial defects add to the complexity of a scalp wound. Cranioplasty with the use of titanium mesh provides a solid, malleable, fixable framework, and can be used with methyl methacrylate; however, it can be subject to infection and extrusion9,21,23 (Fig. 7.6). Tissues with radionecrosis or infection are more likely to have complications with alloplastic materials, and may benefit from autologous tissue.21 Infected bone should be removed and cranioplasty delayed26 (Fig. 7.7). Autologous split calvarial defects, split rib, and vascularized rib grafts are all potential reconstructive options. Chang et al27 recommend inclusion of myocutaneous free
Fig. 7.7 A latissimus dorsi flap is elevated with a skin paddle. The long vascular pedicle and the vascularized muscle provide an excellent bed for healing.
Fig. 7.8 The flap is used to reconstruct the defect, and the vascular anastomosis is performed with the facial vessels.
tissue for dural and calvarial defects to eliminate intractable dead space of the wound, decrease osteomyelitis risk, and aid in sealing off the surrounding tissue margin. Morbidity from cranioplasty is related to residual devascularized or infected bone in the wound, inadequate coverage with vascularized tissue, and the type of material used23 (Figs. 7.8 and 7.9). Artificial dermal grafts are another method of helping scalp healing. The outer layer is composed of silicon and provides mechanical protection and moisture modulations. The inner layer is a collagen-glycosaminoglycan matrix that provides a template for cellular growth.28 The artificial dermis is placed and the silicone layer is removed after 3 to
Fig. 7.9 Six-month follow-up demonstrates the well-healed wound.
137
Genden_5763_Chapter7_main.indd 137
2/24/2012 6:44:23 PM
M
Reconstruction of the Head and Neck 6 weeks, and a split-thickness skin graft can be placed. This process reduces operative time, donor-site morbidity, and hospital stay, as compared with flap reconstructions, and increases cosmesis and skin graft take with the regenerated tissue.28 However, a second surgical procedure is required and may not be as successful in patients needing or having completed radiation therapy.28 The reconstructive surgeon must be aware of potential pitfalls in scalp surgery. Patients who have undergone multiple resections and reconstructions have less tissue pliability and compromised vascularity of the scalp.2 Newman et al3 noted complications to be significantly higher in anterior scalp repair compared with other subsites. Thinner skin anteriorly provides less protection to bone or alloplastic materials and may contribute to this phenomenon. Contamination from the frontal sinus may also play a role in failure.3 Postoperative complications are more often encountered in patients with cerebrospinal fluid leaks and in those undergoing adjuvant chemotherapy or radiation.3 Radiation to the scalp induces fibrosis and reduces elasticity. It is imperative to limit tension on the wound and preserve vascularity to decrease breakdown risk.1 The use of vascularized tissue is essential to provide durable and reliable results.
◆ CONCLUSION Scalp reconstruction can be achieved using a variety of options ranging from a skin graft to a regional flap to free tissue transfer. Determining the optimal approach to reconstruction is predicated on the defect size and the patient’s history of prior radiotherapy. A careful preoperative history and a discussion with the patient related to goals and expectations can help guide the surgical options. Extensive defects of the scalp continue to represent a challenge; however, free tissue transfer provides a dependable option.
References 1. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg 2005;116:54e–72e PubMed 2. Iblher N, Ziegler MC, Penna V, Eisenhardt SU, Stark GB, Bannasch H. An algorithm for oncologic scalp reconstruction. Plast Reconstr Surg 2010;126:450–459 PubMed 3. Newman MI, Hanasono MM, Disa JJ, Cordeiro PG, Mehrara BJ. Scalp reconstruction: a 15-year experience. Ann Plast Surg 2004;52:501– 506, discussion 506 PubMed 4. Orticochea M. Four flap scalp reconstruction technique. Br J Plast Surg 1967;20:159–171 PubMed
5. Orticochea M. New three-flap reconstruction technique. Br J Plast Surg 1971;24:184–188 PubMed 6. Lee S, Rafii AA, Sykes J. Advances in scalp reconstruction. Curr Opin Otolaryngol Head Neck Surg 2006;14:249–253 PubMed 7. Janfaza P, ed. Surgical Anatomy of the Head and Neck. Philadelphia: Lippincott Williams & Wilkins; 2001 8. Raposio E, Santi P, Nordström RE. Effects of galeotomies on scalp flaps. Ann Plast Surg 1998;41:17–21 PubMed 9. Hurvitz KA, Kobayashi M, Evans GRD. Current options in head and neck reconstruction. Plast Reconstr Surg 2006;118:122e–133e PubMed 10. Blackwell KE, Rawnsley JD. Aesthetic considerations in scalp reconstruction. Facial Plast Surg 2008;24:11–21 PubMed 11. Beasley NJP, Gilbert RW, Gullane PJ, Brown DH, Irish JC, Neligan PC. Scalp and forehead reconstruction using free revascularized tissue transfer. Arch Facial Plast Surg 2004;6:16–20 PubMed 12. Cherpelis BS. Scalp reconstruction procedures, 2010. Available from http://emedicine.medscape.com/article/1828962-overview. 13. Tardy ME, Kastenbauer ER, eds. Head and Neck Surgery, vol I, 2nd ed. Chapter 3: Surgical Management of Skin Defects of the Scalp, Forehead, Cheeks, and Lips. pg 62, New York: Thieme Medical Publishers; 1995 14. Hoffmann JF. Tissue expansion in the head and neck. Facial Plast Surg Clin North Am 2005;13:315–324, vii PubMed 15. van Rappard JH, Molenaar J, van Doorn K, Sonneveld GJ, Borghouts JM. Surface-area increase in tissue expansion. Plast Reconstr Surg 1988;82:833–839 PubMed 16. Manders EK, Graham WP III, Schenden MJ, Davis TS. Skin expansion to eliminate large scalp defects. Ann Plast Surg 1984;12:305–312 PubMed 17. Cunha MS, Nakamoto HA, Herson MR, Faes JC, Gemperli R, Ferreira MC. Tissue expander complications in plastic surgery: a 10-year experience. Rev Hosp Clin Fac Med Sao Paulo 2002;57:93–97 PubMed 18. Soma PF, Chibbaro S, Makiese O, et al. Aggressive scalp carcinoma with intracranial extension: a multidisciplinary experience of 25 patients with long-term follow-up. J Clin Neurosci 2008;15:988–992 PubMed 19. Lasheen AE, Saad K, Raslan M. External tissue expansion in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2009;62:e251–e254 PubMed 20. Ibrahimi OA, Jih MH, Aluma-Tenorio MS, Goldberg LH, Kimyai-Asadi A. Repair of scalp defects using an H-plasty type of bilateral advancement flap. Dermatol Surg 2010;36:1993–1997 PubMed 21. Hussussian CJ, Reece GP. Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstr Surg 2002;109:1828–1834 PubMed 22. Furnas H, Lineaweaver WC, Alpert BS, Buncke HJ. Scalp reconstruction by microvascular free tissue transfer. Ann Plast Surg 1990;24:431–444 PubMed 23. McCombe D, Donato R, Hofer SO, Morrison W. Free flaps in the treatment of locally advanced malignancy of the scalp and forehead. Ann Plast Surg 2002;48:600–606 PubMed 24. McLean DH, Buncke HJ Jr. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 1972;49:268–274 PubMed 25. Ueda K, Harashina T, Inoue T, Tanaka I, Harada T. Microsurgical scalp and skull reconstruction using a serratus anterior myo-osseous flap. Ann Plast Surg 1993;31:10–14 PubMed 26. Oishi SN, Luce EA. The difficult scalp and skull wound. Clin Plast Surg 1995;22:51–59 PubMed 27. 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;30:13–18 PubMed 28. 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;115:1010–1017 PubMed
M
138
Genden_5763_Chapter7_main.indd 138
2/24/2012 6:44:24 PM