JAMA Facial Plastic Surgery
Journal Club Slides:
Scalp Reconstruction
Desai SC, Sand JP, Sharon JD, Branham G, Nussenbaum B.
Scalp reconstruction: an algorithmic approach and systematic
review. JAMA Facial Plast Surg. Published online November 6,
2014. doi:10.1001/jamafacial.2014.889.
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Introduction
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Reconstruction of the scalp after acquired defects remains a common
challenge for the reconstructive surgeon.
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Use of the reconstructive ladder is highly pertinent to the repair of scalp
defects.
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Size, location, radiation history, and potential for hairline distortion are
significant factors in determining the ideal reconstruction.
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Purpose
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The primary purpose is to review the current literature and describe an
algorithm to help guide the reconstructive surgeon in determining the
optimal reconstruction from a cosmetic and functional standpoint.
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Pertinent surgical anatomy, considerations for patient and technique
selection, reconstructive goals, and the reconstructive ladder are
discussed.
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Relevance to Clinical Practice
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The scalp covers the calvarium and is therefore critical not only for normal
cosmesis but also for protecting the intracranial structures.
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The scalp requires reconstruction when damaged by various causes,
including benign or malignant tumor excision, infection, trauma, radiation
necrosis, thermal or electrical burns, congenital lesions, or renovation of a
cosmetically unappealing scar or alopecia.
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Modern surgical techniques have allowed the reconstructive surgeon to
repair most scalp defects with success and prevent potentially disastrous
complications from exposed bone, such as calvarial desiccation,
sequestration, and sepsis.
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Description of Evidence
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A PubMed and Medline search was performed of the entire English
literature with respect to scalp reconstruction, including review articles,
clinical trials, meta-analyses, case studies and reports, and cohort studies.
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Priority of review was given to those studies with higher-quality levels of
evidence.
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Description of Evidence
Algorithm for the Reconstruction of Various Scalp Defects
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Controversies and Consensus
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Size, location, radiation history, and potential for hairline distortion are 4
significant factors in determining the ideal reconstruction.
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The tighter and looser areas of the scalp play a significant role in the
potential for primary or local flap closure.
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Small defects (<9 cm2) of the scalp in any location can usually be closed by
primary closure or a local flap, regardless of radiation history.
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Patients with medium to large defects without a history of radiation and
hairline distortion would ideally benefit from tissue expansion.
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Patients with medium to large defects and a history of radiation will likely
benefit from free tissue transfer.
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Comment
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Several algorithms for scalp reconstruction have been proposed in the
literature based on location, size, and etiology of the defect, quality of tissue
and/or wound environment, structures exposed, and hairline distortion.
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The purpose of this proposed algorithm is to provide a comprehensive view
on how to approach scalp defects while taking into account several key
factors that have been repeatedly described in the literature by experienced
reconstructive surgeons.
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Comment
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The 4 most important factors that have been described in the literature, and
thus have been included in this comprehensive algorithm, include scalp
defect size, defect location, radiation history, and hairline distortion.
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This algorithm refers to the surgical option that could achieve an optimal
functional and aesthetic outcome; however, that reconstructive option may
not always be feasible.
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Given the nature of this clinical question, randomized clinical trials will be
difficult to develop.
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Tissue engineering provides promising alternatives to autologous tissue
reconstruction, but it is beyond the scope of this article.
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Conclusions
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Ideal reconstruction of scalp defects relies on a comprehensive
understanding of scalp anatomy, a full consideration of the armamentarium
of surgical techniques, and a detailed appraisal of patient factors and
expectations.
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The simplest reconstruction should be used whenever possible to provide
the most functional and aesthetic scalp reconstruction, with the least
amount of complexity.
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Contact Information
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If you have questions, please contact the corresponding author:
– Brian Nussenbaum, MD, Department of Otolaryngology–Head and Neck
Surgery, Washington University School of Medicine, 660 S Euclid Ave,
Campus Box 8115, St Louis, MO 63110
(nussenbaumb@ent.wustl.edu).
Conflict of Interest Disclosures
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None reported.
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