Scalp Reconstruction - Clinical Tree

Synopsis

Scalp defects arise from a variety of etiologies and often have complex presentations. The reconstructive process begins with a thorough defect analysis, including size, location, wound conditions, and possible exposure of underlying structures. Reconstructive options follow the tenets of the reconstructive elevator, though the hair-bearing nature and inelasticity of the galea pose unique challenges for scalp reconstruction. Small defects may be amenable to primary closure or healing by secondary intention. Skin grafting may be an appropriate option for patients who cannot tolerate a more involved procedure, or may be used for coverage of a secondary defect. In less acute settings, tissue expansion may be used to generate additional hair-bearing skin for wound coverage or scalp resurfacing. Larger defects often require local flaps, commonly rotation flaps that recruit tissue from the surrounding regions. For the largest, most complex defects, the latissimus dorsi flap should be considered, because it is the workhorse free flap for reconstruction of extensive scalp wounds. In general, complications of scalp reconstruction include wound breakdown, infection, implant exposure, and graft or flap failure, which may be minimized with close post-operative monitoring and timely management.

Clinical Problem

Presentation and Etiologies

The clinical presentation of scalp defects is broad and varies by causative factor. Etiologies may be congenital or acquired, both of which have been previously enumerated in the literature. Congenital etiologies include aplasia cutis; congenital nevi, vascular malformations, and congenital tumors. Acquired etiologies broadly involve traumatic, oncologic, and infectious causes. Traumatic injuries may be blunt or penetrating, or the result of avulsion or burns. Oncologic defects may be secondary to tumor invasion, resection, and/or therapeutic radiation. Wound healing problems and scarring may also lead to scalp defects.

Associated Conditions

Patients with scalp defects may similarly present with a spectrum of associated conditions. Deformity or absence of a segment of calvarium may accompany soft tissue defects. In these patients, it is critical to consider the necessity and timing of calvarial reconstruction. Scalp soft tissue wounds may demonstrate active infection with or without osteomyelitis of the underlying calvarium, the latter of which is particularly at risk in instances of chronic infection or exposure. Tumors involving the scalp pose several challenges due to a potential need for wide resection, pre- and/or post-operative chemotherapy and radiation, and timely reconstruction to avoid delays with cancer therapy. Margin status is a major consideration in patients for whom resection is intended to be curative, and must be verified as clear before final reconstruction. Cancer patients may also have shortened life expectancy and poor nutrition status that predisposes to impaired wound healing, both of which should factor into reconstructive decision making.

Pre-Operative Management

Physical Examination

In performing the pre-operative history and physical examination, it is necessary to assess the general health of the patient with special attention to medical factors that may affect ability to undergo anesthesia and/or wound healing. Such medical issues include cardiopulmonary health, peripheral vascular disease, diabetes mellitus, immunosuppression, and history of smoking or radiation. Goals of surgery should also be clarified, including cure versus palliation in cases of malignancy, and wound closure versus aesthetics. The physical examination must include a detailed defect analysis, including the location, depth, and size of the anticipated defect; exposure of underlying structures such as bone, prosthetic material, or dura; and the health of the surrounding tissues, which may show evidence of prior radiation, burns, or scar.

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