Scalp reconstruction
The choice for a reconstruction depends on multiple factors, such as the defect itself, the patient characteristics and surgeon preference.
Attempts were made to reconstruct damaged skulls despite minimal knowledge of neurology, anatomy, and the brain.
[citation needed] Main reasons for scalp reconstruction are divided into two groups: congenital or acquired.
Acquired defects can be caused by burns, blunt, penetrating, or avulsion injuries, tumor invasion, infection, oncologic resection, radiation, or wound-healing difficulties.
By using Mohs surgery the defect can be kept minimal, but nevertheless infiltrative basal-cell carcinoma may have the need to remove a large part of the scalp.
[4] Loose connective tissue between the periosteum and the aponeurosis makes these two rigid structures easily slide over each other and contribute to skin movement.
Thus, if vascular and nervous anatomy is respected, the skin, subcutaneous tissue and galea aponeurotica can be lifted off the skull with minimal bleeding, nerve damage, or chance of necrosis.
Local flaps used for scalp reconstruction must contain at least one of these major arteries, to maintain a reliable blood supply.
From anterior to posterior front to back the nerves are: Dural lesions should be closed to avoid CSF leakage.
These are made from cadaveric dura mater, xenografts (tachosil, duragen, durepair), or synthetic grafts materials (PTFE, neuropatch).
However, (vascularised) autografts (fascia lata, muscle or omentum majus) are preferred in irradiated or severely infected defects.
Skull deformities can result in high intracranial pressure which can cause complaints ranging from headaches to epilepsy-like seizures.
[citation needed] Considering modern aesthetic standards, a better option is the use of split-thickness or full-thickness skin grafts, which is also quicker.
Another option is secondary healing, but this is aesthetically inferior to primary closure in hair bearing areas because of the resulting alopecia.
Free flaps are usually the best solution for reconstruction of large defects that cannot be closed locally and that have unfavourable wound conditions such as severe infection, exposed sinuses, dura or brain tissue, CSF leakage or radiation damage.
Another challenge with the use of free flaps is to achieve an aesthetically pleasing result with good color and contour match, especially if the defect is deep.
Although the forehead is not a highly important aesthetic unit, color mismatch and bulkiness will draw attention quickly.
Free flap reconstruction of the forehead can be bulky and color match is variable and depends on the ethnic and genetic background.
Recipient-site complications include (total or partial) flap necrosis, wound infection, dehiscence, hematoma or skin graft failure.
To avoid major bleeding or sensibility disorders, the anatomy of the scalp must be respected, such as by making incisions parallel to rather than across blood vessels.
Due to the rich perfusion, scalp injuries can lead to serious bleeding, which may be difficult to stem if the cut blood vessels retract into the fat.
