Reconstruction of Scalp and Forehead Defects

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Anatomy of the scalp and forehead

Knowledge of the anatomy of the scalp and forehead will assist the reconstructive surgeon in the choice of local flap options as well as choosing a potential microsurgical recipient vessels site if needed. Furthermore, such knowledge is important for understanding, evaluating and adequately reconstructing complex full thickness calvarial defects.

The anatomy of the scalp and that of the forehead are very similar and, therefore, the two are often considered a single unit. The main difference

Goals and Priorities

When considering a defect or deformity, the initial question is: what are the goals and priorities? Recognizing that the easiest way to close a defect may not be the best or ideal way, one must ask: is the goal to simply close a wound or to reconstruct the part to obtain the best aesthetic and functional outcome possible? (Table 1).

Considerations include: location and size of defect; depth of defect and surrounding tissue quality; age and health of patient; and status of disease (control or

Primary Closure

Frequently, post-traumatic wounds have the appearance of tissue loss but, on careful inspection, are found to not be missing any tissue. These wounds can usually be closed directly if minimal tissue needs to be debrided (Fig 1). If the defect is smaller then 3 cm in diameter, primary closure with undermining can usually be performed.17 There may be limitations of that approach based on the surrounding tissue quality or exposure of vital structures. Local advancement flaps, undermining the

Local flap reconstruction within the same aesthetic unit

Tissue from the same aesthetic unit provides the best cosmetic results in reconstructing a defect. There are no separate aesthetic units of the scalp, but there is a clear distinction between the hair-bearing scalp and the aesthetic unit of the forehead. When utilizing scalp flaps, consideration needs to be given to the direction of hair growth. A swatch of hair growing in the wrong direction can mar an otherwise excellent reconstruction. The thick, unyielding characteristics of scalp and

Crane Principle and Island Pedicle Flaps

Reconstruction of defects with flaps from outside the aesthetic unit in which the defect is located is often required if there is not enough laxity of tissue within the same aesthetic unit. One of the techniques used crossing the aesthetic units of the scalp and the forehead is the crane principle. In 1969, Millard described the crane principle in which a flap is used as an engineering crane to lift and transport subcutaneous tissue from one area to deposit in another; the pedicle and overlying

Muscle, Musculocutaneous and Fasciocutaneous Flaps

Many reconstructive surgeons will choose to close large scalp and forehead wounds with a free-tissue transfer, even if one could technically be closed with a distant pedicle flap. Their reasoning is that free tissue transfers provides the most robust vascular supply of the flap to the wound, compared to the distal portion of the pedicle flap (which frequently has less robust vascularity). In addition, it is usually easier to inset and tailor free-tissue transfers then pedicle flaps, thereby

Future directions

The future directions of reconstruction are tissue engineering and composite tissue allograft transfer (CTA). Although genetically engineered growth of hair follicles has only been demonstrated in an animal model,59 CTA of other facial parts have been clinically performed in humans.60, 61, 62, 63, 64 Because the standard methods of scalp and forehead coverage and reconstruction are usually able to obtain an acceptable aesthetic result (albeit sometimes only with a wig), isolated scalp and

Summary

As mentioned, reconstruction of scalp and forehead defects is a complex field with a broad variety of reconstructive options. It is important to determine goals and priorities. Is the goal to close the wound or to reconstruct the defect? What is the easiest way to close the defect versus what is the best way to close the defect?

Defining those initial goals and choosing a reconstructive option is influenced by size and location of the defect, etiology and depth of the defect, surrounding tissue

Acknowledgments

The authors want to acknowledge their Neurosurgery and Head and Neck Surgery colleagues as well as all the residents in Plastic and Reconstructive Surgery at the University of Chicago who were all crucial in the care of the patients presented in this manuscript.

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References (64)

  • B. Devauchelle et al.

    First human face allograft: early report

    Lancet

    (2006)
  • S. Guo et al.

    Human facial allotransplantation: a 2-year follow-up study

    Lancet

    (2008)
  • L. Lantieri et al.

    Repair of the lower and middle parts of the face by composite tissue allotransplantation in a patient with massive plexiform neurofibroma: a 1-year follow-up study

    Lancet

    (2008)
  • M.A. Lesavoy et al.

    Management of large scalp defects with local pedicle flaps

    Plast Reconstr Surg

    (1993)
  • D.E. Tolhurst et al.

    The surgical anatomy of the scalp

    Plast Reconstr Surg

    (1991)
  • G.E. Seery

    Surgical anatomy of the scalp

    Dermatol Surg

    (2002)
  • C.B. Cutting et al.

    Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps

    Plast Reconstr Surg

    (1984)
  • J.G. McCarthy et al.

    The spectrum of calvarial bone grafting: introduction of the vascularized calvarial bone flap

    Plast Reconstr Surg

    (1984)
  • D.M. Knize

    Reassessment of the coronal incision and subgaleal dissection for foreheadplasty

    Plast Reconstr Surg

    (1998)
  • S.W. Mosser et al.

    The anatomy of the greater occipital nerve: implications for the etiology of migraine headaches

    Plast Reconstr Surg

    (2004)
  • J.M. Stuzin et al.

    Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad

    Plast Reconstr Surg

    (1989)
  • R.J. Siegle

    Reconstruction of the forehead

  • F.J. Menick

    Facial reconstruction with local and distant tissue: the interface of aesthetic and reconstructive surgery

    Plast Reconstr Surg

    (1998)
  • L.J. Gottlieb et al.

    From the reconstructive ladder to the reconstructive elevator

    Plast Reconstr Surg

    (1994)
  • N.J. Beasley et al.

    Scalp and forehead reconstruction using free revascularized tissue transfer

    Arch Facial Plast Surg

    (2004)
  • E. Raposio et al.

    Effects of galeotomies on scalp flaps

    Ann Plast Surg

    (1998)
  • E.F. Robinson

    Total avulsion of the scalp

    Surg Gynecol Obstet

    (1908)
  • J.M. Pitkanen et al.

    Immediate coverage of exposed, denuded cranial bone with split thickness skin grafts

    Ann Plast Surg

    (2000)
  • E. Komorowska-Timek et al.

    Artificial dermis as an alternative for coverage of complex scalp defects following excision of malignant tumors

    Plast Reconstr Surg

    (2005)
  • W. Koenen et al.

    Removal of the outer table of the skull for reconstruction of full-thickness scalp defects with a dermal regeneration template

    Dermatol Surg

    (2008)
  • W. Terranova

    The use of periosteal flaps in scalp and forehead reconstruction

    Ann Plast Surg

    (1990)
  • L.J. Gottlieb et al.

    The use of tissue expansion techniques in burn reconstruction

    J Burn Care Rehabil

    (1986)

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