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.

Copyright restrictions may apply

Introduction

• Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon.

• Use of the reconstructive ladder is highly pertinent to the repair of scalp defects. • Size, location, radiation history, and potential for hairline distortion are significant factors in determining the ideal reconstruction. Copyright restrictions may apply

Purpose

• 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. • Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, and the reconstructive ladder are discussed. Copyright restrictions may apply

Relevance to Clinical Practice

• The scalp covers the calvarium and is therefore critical not only for normal cosmesis but also for protecting the intracranial structures. • 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. • 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.

Copyright restrictions may apply

Description of Evidence

• 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.

• Priority of review was given to those studies with higher-quality levels of evidence. Copyright restrictions may apply

Description of Evidence

Algorithm for the Reconstruction of Various Scalp Defects Copyright restrictions may apply

Controversies and Consensus

• Size, location, radiation history, and potential for hairline distortion are 4 significant factors in determining the ideal reconstruction. • The tighter and looser areas of the scalp play a significant role in the potential for primary or local flap closure. • Small defects (<9 cm 2 ) of the scalp in any location can usually be closed by primary closure or a local flap, regardless of radiation history.

• Patients with medium to large defects without a history of radiation and hairline distortion would ideally benefit from tissue expansion. • Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer.

Copyright restrictions may apply

Comment

• 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. • 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.

Copyright restrictions may apply

Comment

• 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. • 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. • Given the nature of this clinical question, randomized clinical trials will be difficult to develop.

• Tissue engineering provides promising alternatives to autologous tissue reconstruction, but it is beyond the scope of this article.

Copyright restrictions may apply

Conclusions

• 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. • The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity. Copyright restrictions may apply

Contact Information

• 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 ([email protected]).

Conflict of Interest Disclosures

• None reported. Copyright restrictions may apply