reconstruction of scalp defects - missoto · scalp reconstruction • local flaps- > 2 cm, hair...
TRANSCRIPT
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Reconstruction of Scalp Defects
J Randall Jordan, MD, FACS
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Disclosures
• Financial- None
• These are my opinions based on my experience- there are a number of different ways to deal with scalp defects that may differ from my experience, i.e. EBM = level 5 or > !
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Scalp!
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3 Dimensional Anatomy
Tardy E . Rhinoplasty- The Art and the Science;Vol I
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Scalp defects can be challenging!
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Reconstruction of Scalp Defects
A challenge due to poor mobility Some scalps more mobile than others!!
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Galeal attachments
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Scalp Anatomy
• Vascular supply lies just superficial to Galea
• Galea is relatively inelastic
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Neurovascular Anatomy
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Scalp Reconstruction- Small to Moderate
• Primary Closure
• Second Intention
• Skin Graft
• Local Flaps
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Scalp Reconstruction- Large
• Free Tissue Transfer (FTT)
• Integra™ + STSG
• Tissue Expansion
• Negative Pressure Wound Care ( Wound Vac)
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Scalp Reconstruction
• Partial thickness can heal by second intention
• Excellent for bald scalp
• Can be slow process
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Primary Closure
• Primary Closure- typically less than 3 cm Diameter
• Undermine superficial to Galea
• No buried sutures- just 3-0 Prolene vertical mattress sutures or staples (only if minimal tension)
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Scalp Reconstruction - Flaps
• Rotation Flaps
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Rotation Flaps
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Scalp Reconstruction - Flaps
• Ying-Yang or O to Z
• Best for midline vertex defects not larger than 5 cm
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O to Z
• Excellent for hair bearing scalp
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O to Z
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Scalp Transposition Flaps
• Calvarial defects
• Reliable
• Leave Pericranium at donor site
• STSG donor site
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Orticochea Banana Peel Flap
• Large scalp defects • 3-5 flaps • Undermine and release
lateral attachments to periosteum
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Scalp Reconstruction- FTT
Courtesy of Dr Issam Eid
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Scalp Reconstruction
• Free Tissue Transfer- Rotation Flap Combo
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Scalp Reconstruction
• Tissue Expansion
• Lengthy course
• Relatively high complication rate
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Scalp Reconstruction
• Wound Vacuum Devices
• Secure dressing
• Still takes a long time!
• Fairly expensive
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Scalp Reconstruction with Integra™
Full thickness scalp defects can be reconstructive challenges
Skin grafts do not take well on bare bone
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Integra™ Bilayer Matrix Wound Dressing
• Off the shelf product • Can be placed over
bare bone • Allows for skin
grafting at 21 days over full thickness defects
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Integra™ Bilayer Matrix Wound Dressing
• Collagen Matrix with Glycosaminoglycans
• Silicone outer sheet provides moisture barrier
• Dermal regeneration?
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Technique - Integra™
Integra™ trimmed to fit wound
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After 3 weeks
Healthy bed at 3 weeks Silicon layer removed
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Large MAC Resection margins
Scalp Reconstruction with Integra™
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Technique - Allevyn™ dressing
Allevyn™ trimmed slightly smaller than wound 2nd layer stapled over first
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Dressing
• Allevyn™ is a semipermeable dressing by Smith – Nephew
• Variety of shapes and thicknesses
• I soak in Gentamicin irrigation for this use
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At end of first stage 3 weeks; prior to STSG
Scalp Reconstruction
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1 week postop 5 months postop
Scalp Reconstruction
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Indications and Contraindications
• Full thickness scalp defects not amenable to local tissue transfer or free flaps
• Smokers? • Radiation Therapy? • Known sensitivity to
bovine collagen
Indications Contraindications
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Pros and Cons
• Pro • Allows relatively
simple option for reconstruction of difficult defects
• Shortens operative time (and hospital stay compared to FTT)
• Can be done under MAC
• Con • Expensive product • Requires 2nd trip to
OR at 3 weeks for STSG
• Aesthetic appearance ?
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Scalp Reconstruction
• Primary closure- less than 2 cm, mobile scalp
• Second Intention- bald scalp,< 4cm,partial thickness, older, sedentary
• Skin graft- partial thickness, bald scalp, > 4 cm
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Scalp Reconstruction
• Local Flaps- > 2 cm, hair bearing, aesthetic
• Integra + STSG- full thickness, bald, > 2 cm
• FTT- Calvarial defect, large, RT Hx or planned postop
• Special situations- consider tissue expansion , Wound Vac
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Thanks!
• Any Questions??
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Reconstruction of Scalp Defects
J Randall Jordan, MD, FACS