Scalp Reconstruction : Role of Tissue Expansion and Flap Reconstruction

Preoperative Assessment

• Patient assessment is aimed to answer three questions:

  • 1.

    Is the tumor resectable ?

  • 2.

    Is the resultant defect reconstructible ?

  • 3.

    Is the patient operable , that is, able to withstand the proposed operation due to status of his or her general health?

• Resectability of the tumors is discussed in ablative chapters of the book.

History

• As in any preoperative assessment, it is critical to consider individual patient characteristics including overall health and level of function to establish their operability. Some patients may benefit from preoperative medical optimization to enable them to tolerate an operation and to optimize their healing potential.

• Patient compliance and personal preference should be taken into consideration prior to embarking on reconstruction that relies heavily on patient participation, such as frequent dressing changes or tissue expansions.

• Other specific patient and treatment characteristics, such as a plan for adjuvant radiation in oncologic patients or concomitant injuries in trauma or burn patients, must also be part of the patient assessment.

Physical Examination

• Characteristics of the defect:

  • 1.

    The most important factors that determine the reconstructive approach are defect size , shape , location , and depth.

  • 2.

    The condition of tissues surrounding the defect and the nature of exposed structures (soft tissue, periosteum, bone, or dura) may significantly influence the reconstructive plan to involve microvascular tissue transfer or calvarial reconstruction.

• Surrounding tissue: As with any defect, control of the wound is an important initial step in the reconstructive process.

  • 1.

    The optimal quality of surrounding tissues must be attained by either serial débridements or one-stage excisional preparation of the reconstructive site, whereby poor quality tissues such as scars , chronic wounds , radiated or damaged scalp are excised, and new wound edges consisting of healthy tissues capable of effective healing are established ( Fig. 164.1A and B ).

    

  • 2.

    In the cases of malignancies, negative margins of resection must be obtained. This issue becomes particularly relevant in the cases of aggressive tumors such as angiosarcoma of the scalp or poorly differentiated carcinomas. In such cases, scouting biopsies are performed first, and often several operations are necessary in order to achieve negative margins on permanent pathologic studies.

  • 3.

    Other important considerations unique to the scalp include the shape and symmetry of the hairline, direction of hair growth, pattern of hair-bearing, or baldness and eyebrows , all of which might be distorted by tissue rearrangement.

• Flap , graft , and recipient vessel availability are determined by the review of previous surgical history, available imaging, and, most importantly, physical examination.

Imaging

• Computed tomography (CT) scan is indicated in:

  • Patients undergoing oncologic reconstruction to ascertain depth of invasion or lymph node involvement

  • Trauma patients to determine the pattern or extent of concomitant injuries

• Magnetic resonance imaging (MRI) useful in

  • Assessment of tumor involvement of the skull

  • Intracranial invasion

• Surgeon-performed duplex ultrasound is the best in mapping out vasculature for free tissue transfer.

Indications

Primary indication for scalp reconstruction is a scalp defect with exposed underlying structures (galea, bone, dura, brain).

Reconstructive choices are largely dictated by the size , condition, and extent of the defect .

• Patients with radiation-related problems (i.e., osteoradionecrosis) or needing postoperative radiation, as well as the ones with large and composite defects, should be treated with microvascular tissue transfer if they can withstand surgical treatment.

• Multiple reports support safety of microsurgery in the older but reasonably healthy patient, demonstrating that age should not be viewed as a contraindication to reconstruction and oncologically sound surgical care.

• In contrast, young and healthy individuals are the patients most likely to heal by secondary intention or with skin grafts. The healing area should be later revised with the help of serial excision and tissue expansion to minimize the sequelae of the scarring and loss of the hair-bearing scalp.