Scalp and Calvarial Reconstruction

ABSTRACT

Over the past several decades, an improved understanding of the blood supply of local flaps, increased experience with tissue expansion, and the development of techniques for microsurgical transfer of distant flaps have greatly contributed to the ability of plastic surgeons to repair scalp defects. This article will review basic anatomy, principles, and pearls of reconstruction for simple to complex scalp defects. Included will be anatomic considerations, indications and contraindications for reconstruction, and an overview of reconstructive options.

KEYWORDS

Scalp reconstruction - microsurgery - calvarium reconstruction - tissue expansion - scalp anatomy

REFERENCES

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Editor's Comments

Drs. Lin, Hanasono, and Skoracki have written an excellent overview of scalp and calvarial reconstruction, which highlights their extensive experience on these difficult reconstructions.

I would like to add several observations and comments from our own institutional experience. One is the use of outer-table calvarial burring with or without conjunction of the VAC therapy to provide a bed of granulation tissue for split thickness graft coverage. We do not consider this a permanent solution to scalp coverage as the wound is often unstable and unreliable. We will use this technique as bridge coverage for up to 3 to 6 months until suitable long-term coverage can be achieved (for example, to allow for adjacent tissue expansion).

The second point I would like to make is we agree completely that the latissimus dorsi muscle flap is the workhorse flap of scalp reconstruction; however, in the properly selected patient anterior lateral thigh flap (ALT), flaps can provide more durable coverage over a large area, particularly mesh or allopathic implants, and are more resistant to wound breakdown than muscle-only flaps.

In addressing calvarial reconstruction, we echo the authors' comments that alloplastic or autogenous material placed in an infected wound bed yields unacceptably high infection rates. In the cases of infected skull, we will remove all alloplastic or autogenous material and treat with antibiotics until there are no systemic signs of infection, including normalized sedimentation rates. At this point the patient will require a minimum interval of 6 months prior to consideration for reconstruction.

Finally, the use of prefabricated alloplastic implants has greatly simplified our reconstructive algorithm in the appropriate patient. PEEK or PMA implants can be premade from 3D CT scans to precisely match the calvarial defect, providing final cosmetic results superior to acrylic reproductions of the bone plate.

James F. Thornton, M.D.

Figure 1 Near total scalp reconstruction with ALT free flap.

Figure 2 PEEK custom premade calvarial implant.