JAMA Facial Plastic Surgery
Journal Club Slides:
Dermal Regeneration Template for
Full-Thickness Scalp Defects
Richardson MA, Lange JP, Jordan JR. Reconstruction of
full-thickness scalp defects using a dermal regeneration
template. JAMA Facial Plast Surg. Published online
November 25, 2015. doi:10.1001/jamafacial.2015.1731.
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Introduction
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Large full-thickness scalp defects pose a reconstructive problem and
commonly require microvascular free flap reconstruction.
Herein, a novel alternative reconstructive technique using the application of
Integra bilayer wound matrix followed by delayed split-thickness skin
grafting is presented.
This is a retrospective review (January 1, 2008, to December 31, 2014) of
10 patients who underwent reconstruction of large scalp defects using the
application of Integra bilayer wound matrix followed by delayed splitthickness skin grafting.
The patients in this study had excellent skin graft and wound closure
outcomes. Of the 10 patients, 9 showed a 100% initial take of the skin graft
to the defect site. Only 1 patient showed a 95% to 100% initial take.
Adequate coverage of the wound bed was achieved with acceptable
cosmetic results. One patient experienced radiotherapy-induced wound
breakdown 3.5 months after completion of intensity-modulated radiotherapy.
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Purpose
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The purpose of this study is to describe a novel and effective reconstructive
technique for full-thickness scalp defects that can be performed quickly
without general anesthesia or free flap reconstruction.
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Relevance to Clinical Practice
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Historically, the reconstruction of large full-thickness scalp defects has been
a challenge to surgeons owing to scalp anatomy, limited mobility of the
scalp, and poor vascularity of the calvarium. Techniques for repair have
included primary closure, tissue expansion, skin grafting, local flaps, and
microvascular free tissue transfer. Each of these reconstructive options has
different limitations and complications.
More recently, free tissue transfer with microvascular anastomosis has been
favored for larger defects. This method involves significant risk,
hospitalization, and likely increased financial cost.
The described method of Integra bilayer wound matrix followed by delayed
split-thickness skin grafting is a highly successful and cosmetically pleasing
outpatient alternative for reconstruction of these defects.
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Description of Evidence
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Ten patients underwent reconstruction of large scalp defects using the
application of Integra bilayer wound matrix followed by delayed splitthickness skin grafting from January 1, 2008, to December 31, 2014.
Technique
– Patients underwent full-thickness scalp resection, including removal of
the periosteum overlying the outer table of the skull in 6 of 10 patients.
– After confirmation of clear margins, Integra was placed into the wound
bed with the semipermeable silicon layer on the superficial aspect of the
wound. It was then coated in bacitracin ointment and secured with 2
layers of an Allevyn dressing soaked in gentamicin sulfate solution (160
mg per 200 mL of normal saline solution).
– Patients were taken to the operating room approximately 21 days later
and the Allevyn dressing and semipermeable silicone layer were
removed. A 0.04-cm (0.016-inch) skin graft was harvested and meshed
at a ratio of 1:1.25 and sutured into place. Bacitracin was applied and a
gentamicin-soaked Allevyn dressing was again placed.
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Description of Evidence
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Postoperative care
– All patients returned to the clinic 7 to 10 days postoperatively for
removal of the Allevyn dressing and assessment of the skin graft.
– Patients were instructed to leave the wound uncovered but to apply
bacitracin ointment at least twice daily until the wound was completely
epithelialized.
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Description of Evidence
Reconstructive Technique for Full-Thickness Scalp Defects
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Description of Evidence
Patient Results
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Controversies and Consensus
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Limitations of Technique
– This technique is not recommended in cases that require full-thickness
calvarial resection that results in dural exposure. In these cases,
microvascular free flap reconstruction is usually required.
– This technique results in an area of scalp devoid of hair and therefore is
less suitable for patients with hair-bearing scalps.
– The technique requires 2 surgical procedures and multiple weeks of
wound care, which may be a burden socially or financially for some
patients.
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For some patients, this presents a viable alternative reconstructive option
for large scalp defects.
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Comment
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Future Implications and Research
– We have more recently begun to perform the resection, initial Integra
placement, and second-stage split-thickness skin graft reconstruction
under intravenous sedation with local anesthetic rather than general
endotracheal anesthesia. This potentially results in quicker
postoperative recovery from anesthesia and decreased risk of major
anesthesia-related complications in these sometimes frail and elderly
patients.
– Future studies directed at analyzing the cost of this technique
compared with other alternative reconstructive options are ongoing.
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Conclusions
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In this series, we present a technique for reconstruction of large fullthickness scalp defects that has low morbidity and can be performed on an
outpatient basis with minimal wound care. This technique provides the
surgeon with an alternative to other reconstructive options, including
microvascular free tissue transfer, for repair of large full-thickness scalp
defects with excellent results. The procedure can be performed under
sedation and local anesthesia for patients with risk factors for general
anesthesia.
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Contact Information
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If you have questions, please contact the corresponding author:
– Matthew A. Richardson, MD, Department of Otolaryngology and
Communicative Sciences, University of Mississippi Medical Center,
2500 N State St, Jackson, MS 39216 (marichardson@umc.edu).
Conflict of Interest Disclosures
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None reported.
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