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Review | Journal Club

Scalp Reconstruction An Algorithmic Approach and Systematic Review

Shaun C. Desai, MD1; Jordan P. Sand, MD1; Jeffrey D. Sharon, MD1; Gregory Branham, MD1; Brian Nussenbaum, MD1
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
JAMA Facial Plast Surg. 2015;17(1):56-66. doi:10.1001/jamafacial.2014.889.
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Importance  Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area.

Objective  To review the current literature and describe a novel 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, as well as the reconstructive ladder, are also discussed.

Evidence Review  A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence.

Findings  Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer.

Conclusions and Relevance  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.

Level of Evidence  NA.

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Figures

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Figure 1.
Layers of the Scalp and Temporoparietal Region

SMAS indicates superficial muscular aponeurotic system; STA, superficial temporal artery.

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Figure 2.
Tight and Loose Layers of the Scalp
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Figure 3.
Vasculature of the Scalp
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Figure 4.
Small Scalp Vertex Defect

A, Small scalp vertex defect with exposed calvarium. B, O → Z Rotational flaps for small scalp vertex defect in a bald patient.

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Figure 5.
Large Scalp Defect

A, Large scalp defect in a patient with history of radiation and exposed calvarium. B, Anterolateral thigh flap with anastomosis of the left superficial temporal artery and vein. Note that the donor vessel was traced more proximally into the parotid gland to achieve a higher-caliber vessel for anastomosis. C, Closure of scalp defect with Penrose drain in place. Photographs courtesy of Bruce H. Haughey, MBChB.

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Figure 6.
Algorithm for the Reconstruction of Various Scalp Defects

Algorithm for the reconstruction of various scalp defects based on size and location. See the section Algorithmic Approach to Defect for further details.aIdeal reconstruction refers to the surgical option that could achieve an optimal functional and aesthetic outcome; however, often that reconstructive option may not be feasible.bLocal flaps include advancement, rotation, and transposition flaps.

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