A clinical study on the various methods of reconstruction of scalp defects

INTRODUCTION : The scalp being the superior border of the body, is many a times exposed to insults from the environment. As the scalp usually lacks clothing coverage, it is more commonly susceptible to burns and other trauma that cause extensive disfigurement and scarring. It is also the site for a variety of benign and malignant neoplasms, due to prolonged sun exposure. The factors influencing decision making in the repair of scalp defects are their size, depth and location. Another vital factor in deciding the management is the nature of the defect. In case of a tumour excision the bone may be removed sometimes requiring a complex reconstructive technique. The type of flap needed to cover the defect is also influenced by the integrity of the surrounding scalp tissue. Advancement, transposition and rotation flaps are the work horse flaps for reconstructing these defects. The design of these flaps should consider the preservation of the hairline, aesthetic re-directioning of the hair follicles, the inclusion of major vascular pedicles, and tensionless wound closure. AIM OF THE STUDY: 1. To analyze scalp defects and to discuss the various established reconstructive options available and their application. 2. To evaluate the outcomes of various surgical procedures following scalp reconstruction. MATERIALS & METHODS: A clinical study was conducted in the Department of Plastic Reconstructive and Maxillofacial Surgery, Madras Medical College and Rajiv Gandhi Government Hospital over a period of 28 months from October 2010 to January 2013. The study population in the present study were the patients who visited the hospital for scalp reconstruction. Inclusion Criteria - The patients with scalp defects due to trauma, infection, burns and cancer resection were included in the study. Exclusion Criteria - Those patients who were not willing to participate were excluded from the study. Ethical Clearance - The ethical clearance was given by the Institutional Ethics committee, Madras Medical College. Informed and Written Consent - Informed and written consent was obtained from all patients prior to the start of the study. Sample Size - A sample size of 20 patients requiring scalp reconstruction procedures was taken. OBSERVATION AND RESULTS: A total no of 20 patients were included in the study over a period of 28 months between October 2010 to January 2013. Patient related, defect related and treatment related parameters were collected. Age in years, gender and comorbid illnesses were noted as patient related parameters. Wound aetiology was recorded as defect related factors. Phase of coverage, the mode of reconstruction and complications were taken as treatment related factors. Among twenty patients, two patients were had diabetes mellitus and were taking regular medications, four patients were smokers, and one patient had the habit of consuming alcohol. In the present study highest number of flaps was done in the chronic phase (75%) and least flaps were done in the acute phase (10%). CONCLUSION The following conclusions can be made from the present study: Certain factors are likely to influence the selection of reconstructive technique like the size and location of the defect in the scalp, whether the pericranium is intact to take up skin grafts, and quality of the adjacent scalp tissue. As the elastic property of the scalp tissue is limited, primary closure of scalp wounds should be done only for defects measuring less than 3 cm. In certain cases, if the pericranium is viable or the outer cortex is removed and the diploic space is exposed a skin graft can be used over the bone. Tissue expansion needs good amount of tissue that can be expanded, patient compliance for multiple procedures, and the calvarial cover should be stable in the expansion period. The vascular distribution within the scalp tissue should be taken into account when planning local scalp flaps. A good design for a local scalp flap should include major vascular pedicles. The flaps should be broad based and wound closure should be tension free. Microvascular reconstruction may be the most reliable option for reconstruction of large scalp defects, especially those that occur in compromised tissues. The perfect reconstruction for every defect never exists; therefore, the reconstruction for every defect must be tailored to each case to perfection. A good knowledge of the anatomy, the individual patient, and the resurfacing choices that are available is the beginning, but the surgeon's success needs creativity to add all these elements together to give a satisfactory result for the patient